Indian J Gastroenterol https://doi.org/10.1007/s12664-017-0798-5

ABSTRACTS

Abstracts - Indian Society of Gastroenterology Plenary Session

Departments of Hepatology, Pathology, and Research, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India

PLE-1 First week is the crucial period for deciding the liver transplantation in patients of acute-on-chronic liver failure Ashok Choudhury, M Kumar, Rakhi Maiwal, V Pamecha, Senthil Kumar, M Mahtab, S Rahman, Y K Chawla, S S Tan, Harshad Devarbhavi, H C Duan, Chen Yu, Q Ning, D Amarpurkar, C E Eapen, Ashish Goel, S S Hamid, A S Butt, Wasim Jafri, Kim D J, H Ghazinyan, Gh Lee, Ajit Sood, La Lesmana, Z Abbas, G Shiha, Da Payawal, A K Dokmeci, Mf Yuen, A Chan, G K Lau, Jidong Jia, P Jain, Guresh Kumar, B C Sharma, O Yokosuka, R Moreau Shiv Kumar Sarin for the APASL ACLF working party Correspondence- Shiv Kumar Sarin- [email protected] Background and Aims Acute-on-chronic liver failure (ACLF) is rapidly progressive with high short-term mortality. Early identification, intervention and timely consideration of liver transplant (LT) may improve survival. Aim of present study was to identify the indications, causes of ineligibility and timing for LT. Methods Of total 2312 patients in AARC database between October 2012-July 2015, 1021 patients were analyzed for clinical, severity score and organ failures (OF) at baseline and its dynamic changes to predict 28days survival and transplant eligibility. Results The ACLF cohort with mean age 44 (SD 12.2) yr, predominantly male (81%). At admission 56% needed LT of whom 63% were ineligible due to sepsis, renal failure, prolonged ventilation, shock or presence ≥4 OF. By day 4 maximum recovery from sepsis an/or organ failure was seen but by the end of first week, the multiorgan failure peaked (p<0.01) contributing to 55% of all cause 28 days death. MELD >30 at baseline with new onset HE at day 4, total bilirubin >22 mg/dL, PT-INR >2.5 and presentation with Grade III-IV associated with 80% mortality, whereas persistence of the same at day 4 to 7 lead to 100% mortality at 28 days. Absence of new HE or AKI within first 4 days, a decline in total bilirubin by 0.43mg/dL, creatinine by 0.31 mg/dL, INR by 0.34 by day 7 or bilirubin level <20.5 mg/dL, creatinine <0.94 mg/dL, INR <2.18 and MELD score <27 at any time point in first week was noted among those survived 28 days (p<0.001). The mortality was 12.6%, 23%, 43% and 50% respectively at 4th, 7th, 28th and 90day of admission. Conclusion ACLF is a serious condition, the baseline parameters and their change in first week of diagnosis could identify the patient with universal fatality. Emergent live donor LT or special allocation policy for cadaver should be explored in the first week.

PLE-2 Incidence, predictors and outcomes of transition of acute kidney injury to chronic kidney disease in cirrhosis - A prospective cohort study Rakhi Maiwall, Chhagan Bihari, Archana Rast, Awinash Kumar, Guresh Kumar, Shiv Kumar Sarin Correspondence- Shiv Kumar [email protected]

Background and Aims Studies have suggested an increased incidence of transition from functional to structural kidney damage (CKD) after an episode of acute kidney injury (AKI) secondary to nephron loss and hyperfiltration, vascular insufficiency and maladaptive repair mechanisms which cause incomplete recovery and transition to chronic kidney disease (CKD).We aimed to study the natural course and trajectory of AKI, the incidence and risk factors of progression to CKD and Cystatin C (Cys C) as a biomarker in cirrhotics. Methods Cirrhotics (n=787) were followed up for a year for the development /resolution of AKI. Results Of the 787 cirrhotics, aged 51±11.4 yrs, 76% males 36.5% had AKI at enrolment, 15% had AKI in the last 3 months while 62% developed new episodes of AKI. Structural AKI developed in 148 (27%) at a median follow up of 126 (IQR 9-235) days. Patients who developed CKD more frequently had AKI in the past (p=0.003), multiple AKI episodes (p<0.001), severe AKI (p<0.001), higher peak sCr (p<0.001) and prolonged duration of AKI (p<0.001). Further, these patients had a significant decline in eGFR (p=0.001) from baseline till last follow up. Serum CysC (HR 1.19, 1.03-1.37), severity of the AKI episode; stage 3:2:1(HR 3.06, 1.78-5.27:2.35, 1.35-4.07:1) and MELD score (HR 1.03, 1.018-1.044) predicted CKD. Development of CKD also predicted mortality (HR 3.37, 2.28-4.96). Conclusion Almost 50% of cirrhotics develop new AKI episodes of which one-third progress to CKD which is associated with impaired renal functions and poor outcome. Presence and severity of AKI, S. Cystatin C and severity of liver failure predict transition from functional to CKD in patients with cirrhosis.

PLE-3 Impact of slow albumin furosemide±terlipressin in acute-on-chronic liver failure patients Gaurav Pande, Abhimanyu Nehra, Kamlesh Kumar, Prabhakar Mishra, V P Krishna, Prabhat, Alok Kumar, Manjunath, Amit Goel, Abhai Verma, Samir Mohindra, Praveer Rai, Uday C Ghoshal, Vivek Anand Saraswat Correspondence- Gaurav [email protected] Sanjay Gandhi Postgraduate Institute of Medical Science, Raebareli Road, Lucknow 226 014, India Background and Aims Acute-on-chronic liver failure (ACLF) mortality increases with extrahepatic organ failure(s) (OF). Ascites mobilisation is challenging with OFs. To study the efficacy of slow infusion of furosemide and albumin with or without terlipressin SIFA (T) as per responseguided protocol to achieve complete ascites mobilization. Methods Patients hospitalized at SGPGI, between December 2012 to December 2016 with >Gr 2 ascites and ACLF ≥Grade I as per CLIFSOFA and CVP >10 cmH2O were included. Baseline chemistry and echocardiography and intestinal permeability (IP) assessment with urinary lactulose/mannitol ratio (LMR) were done. Consecutive patients in arm I received SIFA (T); arm I; furosemide 2 mg/h, albumin 2 gm/h; 20-

Indian J Gastroenterol

40 g/d] in addition to standard medical therapy (SMT) for ACLF complications. Furosemide was stepped up by 2 mg/h every 12 hours if UNa+ <80 mmol/d. After 48 hrs, terlipressin was started at 4 mg/24 hrs (max. 8 mg/24 hr) and alternately stepped up if UNa+<80 mmol/d till complete ascites mobilization. Arm II received SMT for ACLF complications as per guidelines including oral dirutics, terlipressin-albumin therapy for HRS. Results Two hundred and twenty-two patients (133 Arm I; 90 in Arm II). The etiology of cirrhosis and acute insult didnot differ significantly (p=NS). Baseline parameters including serum(S) creatinine (1.6±1.01 vs. 1.38±1.14), S. bilirubin (16.4±10.2 vs. 19.4 ±9.8 mg/dL), CTP (1164±1.3 vs. 11.7±1.73); MELD (30.9±8.1 vs. 29.9±7.5); number of OF (1.9±1.2 vs. 1.5±1) and CLIF-SOFA (10.9±1.7 vs. 10.3±1.5) were similar (p=NS). 130/132 in Arm I and 23/90 in Arm II mobilized ascites competely in 15.2±4 vs. 23 ±3.1days. Post therapy Arm I significant increase in urine sodium (34.8±24 to 267±142 mmol/24 hrs), urine output (503±102 to 3531±1508 mL/24 hrs). Survival for ACLF-1/2/ 3 in ArmI vs. II was 87%/90/86.7# vs. 70%/66/52% (p<0.05) with overall survival -100/132 (76.5%) and 46/90(53.2%), (p=<0.001) in arm I and II respectively.

PLE-4 Reduction of breath methane using rifaximin shortens colon transit time and improves constipation: A randomized double-blind placebo controlled trial Uday C Ghoshal, Deepakshi Srivastava, Asha Misra Correspondence- Uday Chand [email protected] Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Objective Gut microbe-derived methane may slow transit causing chronic constipation (CC) and its reduction with antibiotic may improve it. Effect of rifaximin on methane-associated slow transit CC was evaluated. Method Bristol stool form, frequency, colon transit time (CTT) and breath methane were evaluated in 23 patients with CC (Rome III) and methane production compared with 68 non-constipating IBS. Methane-producing CC (basal: >10 PPM and/or post-lactulose rise by >10 PPM) were randomized (double-blind) to rifaximin (400-mg thrice/d, 2-weeks) or placebo. Post-treatment stool forms, frequency, methane and CTT were recorded. Results CC patients tended to be methane-produces more often (13/23 [56.5%] vs. 25/68 [36.5%]; p=0.07) and had greater area under curve (AUC) for methane (2415 [435-23580] vs. 1335 [06562.5], p=0.02) than non-constipating IBS. 8/13 (61.5%). Methane-producers and 5/10 (50%) non-producers had abnormal CTT (marker retention: 36-h: 53 [0-60] vs. 19 [8-56], p=0.06; 60h: 16 [0-57] vs. 13 [3-56], p=0.877). Six (46.2%) and 7/13 (53.8%) methane-producers were randomized to rifaximin and placebo, respectively. Rifaximin reduced AUC for methane more (6697.5 [1777.5-23580] vs. 2617.5 [562.5-19867.5], p=0.005) than placebo (3945 [2415-12952.5] vs. 3720 [502.5-9210, p=0.118) at 1-month. CTT normalized in 4/6 (66.7%) on rifaximin (36-h retention: 54 [44-57] vs. 36 [23-60], p=0.05; 60h: 45 [3-57] vs. 14 [11-51], p=0.09) but none on placebo (p=0.02) (36-h: 31 [0-60] vs. 25 [0-45], p=0.078; 60-h: 6 [0-54] vs. 12 [0-28], p=0.2). Weekly stool frequency (pre vs. post: 3 [19] and 7 [1-14], p=0.05) and forms tended to improve with rifaximin than with placebo. Conclusion Rifaximin improved constipation by reducing breath methane and colon transit time. (Registration number in Clinical Trial Registry India: REF/2012/01/003216).

PLE-5 Combination of increased visceral fat and long segment involvement: Development and validation of an updated imaging marker for differentiating Crohn’s disease from intestinal tuberculosis Saurabh Kedia, K S Madhusudhan, Raju Sharma, Sawan Bopanna, Dawesh P Yadav, Sandeep Goyal, Saransh Jain, Rajesh Padhan, V P Mouli, Prasenjit Das, Siddhartha Dattagupta, Govind Makharia, Vineet Ahuja Correspondence- Vineet Ahuja- [email protected] Departments of Gastroenterology, Radiodiagnosis, and Pathology, All India Institute of Medical Sciences, New Delhi 110 029, India Background Computed tomographic (CT) features (long segment, ileocaecal area involvement and lymph nodes >1 cm) have demonstrated good specificity but poor sensitivity, while visceral to subcutaneous fat ratio on CT (VF/SC >0.63) has moderate sensitivity and specificity in differentiating Crohn’s disease (CD) and intestinal tuberculosis (ITB). Aim To develop and validate an updated model incorporating CT features and VF/SC to improve the diagnostic accuracy of imaging in differentiating CD/ITB. Methods CT features and VF/SC were documented in 2 cohorts [development (n=59, follow up: January 2012–November 2014) and validation (n=69, follow up: December 2014– December 2015)] of CD/ITB patients diagnosed by standard criteria. Patients with normal CT were excluded. Features significantly different between CD/ITB were incorporated into a model. Results In both the cohorts, necrotic lymph nodes were exclusive for ITB (23.1% vs. 0 and 43.3% vs. 0), while long segment involvement (57.6% vs. 7.7%, p<0.001 and 52.6% vs. 16.1%, p<0.001) and VF/SC ratio >0.63 (72.7% vs. 19.2%, p<0.001 and 81.6% vs. 25.8%, p<0.001) were significantly more common in CD. Risk score of 2, based upon long segment involvement and VF/SC ratio >0.63 had excellent specificity of 100% and 100% and sensitivity of 54% and 50% for CD in development and validation cohorts respectively. Based upon these features, in 43% patients with the diagnostic dilemma of CD/ITB, a definite diagnosis based only on imaging could be made. Conclusion Necrotic lymph nodes are exclusive for ITB, and combination of long segment involvement and VF/SC ratio >0.63 is exclusive for CD, and these features can make a definite diagnosis in 43% patients with a CD/ITB dilemma. PLE-6 PTGIS and LYVE1 gene expression predicts response to chemotherapy in Indian colorectal cancer V V Ravikanth2, Aviral Jain2,1, U A Steffie2, Govardhan Bale2, Sasikala Mitnala2 , G V Rao1 , R Pradeep 1, H V V Murthy 2 , C Ramji 2 , D Nageshwar Reddy1 Correspondence- Ravikanth V V- [email protected] 1 Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India, and 2 Asian Healthcare Foundation, 6-3-661, Somajiguda, Hyderabad 500 082, India Background Chemotherapy has been the mainstay of care for advanced colorectal cancer. However, adverse events with no response are seen in few of the treated patients. Currently there are limited tools to identify patients who are likely to benefit from the therapy. Therefore, this study aims to identify differentially expressed gene signature predictive of chemotherapy response in colorectal cancer (CRC) patients. Methods Forty-five (n=45) tumors and corresponding normal tissues (n=45) were collected from patients with CRC, treated primarily by

Indian J Gastroenterol

surgery and subsequent adjuvant chemotherapy (CAPEOX). Patients were categorized as responders or non-responders based on response to treatment. RNA was isolated from the tissues, processed and hybridized (n=10) to Human-Gene 1.1 ST arrays (Affymetrix). Unpaired one-way ANOVA was used to identify dysregulated genes between the groups. Dysregulated genes in the discovery set were replicated in an independent set (n=80; qRT-PCR). Fisher's exact test was used to test the significance of association. AUCs and ROCs were generated (SPSS) and combinatorial analysis was performed (5C3=10) to select combination of genes to predict response to treatment. Results A total of 187 genes were upregulated and 6 downregulated in the discovery set that contained 3 responders and 2 nonresponders. Upon replication of dysregulated genes (5 upregulated and 3 down regulated) in the validation set, upregulation of 5 genes (PTGIS, C3, C7, LYVE1 and CXCL12) was significantly associated with non-responder group and negative response to CAPEOX chemotherapy. Combinatorial and comparison of AUCs identified a significant (p=0.03) increase in the AUC by 15% (95% CI: 0.01–0.29) for a combination of two genes (PTGIS and LYVE1). The sensitivity, specificity, positive and negative predictive values were 88.9%, 100%, 100% and 95.6% respectively. Conclusion Our study identified a two-gene expression signature that is predictive of response to chemotherapy. Young Investigator Award Session YIA-1 Effect of bariatric surgery on non-alcoholic fatty liver disease in morbidly obese patients undergoing bariatric surgery Jagdish Singh1, D Goel2, A Garg1, A Sahney1, S Mazumder1, V P Bhalla2, J C Vij1, R Vats2, H Mahajan3, V Malhotra4, Y Batra1 Correspondence- Yogesh [email protected] Departments of Gastroenterology1, GI Surgery2 and Pathology, 4B L K Superspeciality Hospital, New Delhi, Mahajan Imaging3 , New Delhi Introduction Lifestyle modification and weight reduction are the cornerstone for the management of non-alcoholic fatty liver disease (NAFLD). Bariatric surgery is fast emerging as the definitive management for the morbidly obese. There is limited data in literature on the effect of bariatric surgery on NAFLD. Methods Consecutive patients undergoing bariatric surgery between April 2015 to December 2016 were included. Preoperatively and at 3 and 6 months all patients underwent clinical evaluation and biochemical tests, MRI fat quantification was done for the assessment of steatosis and 2D shear wave elastography (2D-SWE) for the assessment of fibrosis at baseline and 6 months follow up. Liver biopsy (NAS score) was done intraoperatively. Results Forty-four patients were included in the final analysis. At 6 months follow up, the BMI decreased markedly (p<.001) from 46.22±7.5 kg/m2 to 40.29±7.12kg/m2. There was remission of diabetes mellitus and hypertension in 11 (61.11%) and 13 (59.09%). The homeostasis model assessment (HOMA) index declined from 8.76±4.20 to 3.79±1.23. Fasting insulin declined from 34.87±8.94 mU/mL to 20.11±2.95 mU/mL. C–peptide level also declined from 5.74±1.22 ng/mL to 2.98±0.91 ng/mL. The lipid profiles and liver function also showed significant improvement and there was statistically significant improvement in steatosis (MR fat quantification 16.46%±10.05% to 7.09%±6.8%) and fibrosis (SWE 5.13kPa±1.87kPa to 3.53kPa±0.77kPa). Conclusions Following bariatric surgery, there was statistically significant improvement of the metabolic syndrome, steatosis and fibrosis at 6 month follow up.

YIA-2 Urinary potassium is a potential biomarker of disease activity in ulcerative colitis and displays in vitro immunotolerant role Sandeep Goyal, Ritika Rampal, Saurabh Kedia, Sandeep Mahajan, Sawan Bopanna, Devesh P Yadav, Saransh Jain, Amit Kumar Singh, Md. Nahidul Wari, Govind Makharia, Amit Awasthi, Vineet Ahuja Correspondence- Vineet Ahuja- [email protected] Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India, Department of Nephrology, All India Institute of Medical Sciences, New Delhi 110 029, India, Center for Human Microbial Ecology, Translation Health Science and Technology Institute, Faridabad, Haryana 121 001, India, Background There is limited data on the role of potassium on gut immune responses. We evaluated the in-vitro effect of potassium on CD4+T cells and the role of urinary potassium as a potential biomarker of disease activity in patients with ulcerative colitis (UC). Methods This prospective observational cohort study included healthy controls and UC patients with active disease (assessed by Mayo score) from September 2015–May 2016. Twenty-four hours urinary potassium along with fecal calprotectin (FCP) were estimated in UC patients (at baseline and follow up after 3–6 months) and controls. In healthy volunteers, we also assessed the effect of potassium on CD4+T cells differentiated in the presence of Th17 polarizing condition. Results Thirty patients with UC (median age:40 (IQR:28–46) years, 17 males) and 18 healthy controls were included. UC patients had significantly higher FCP (368.2±443.04 vs. 12.44±27.51, p<0.001) and significantly lower urinary potassium (26.6±16.9 vs. 46.89±35.91, p=0.01) levels than controls. At follow up, a significant increase in urinary potassium among patients who had clinical response [n=22, 21.4 (14.4–39.7) to 36.5 (20.5–61.6), p=0.04] and remission [n=12, 18.7 (9.1–34.3) to 36.5 (23.4–70.5), p=0.05] was accompanied with a parallel decline in FCP. On in-vitro analysis, potassium under Th17 polarizing conditions significantly inhibited IL-17 and interferon-γexpression while favoring the induction of Fox P3+T cells. Conclusion Urinary potassium levels were inversely associated with disease activity in UC with in-vitro data supporting an immune-tolerant role of potassium. The potential of urinary potassium as a non-invasive biomarker of disease activity in UC needs to be explored further. YIA-3 Impaired circulating GM-CSF secreting innate response activator B (IRA-B) cells play a major role in mother-to-child transmission of hepatitis-B-virus Ashish Kumar Vyas1, Sharda Patra2, Mojahidul Islam1, Shiv Kumar Sarin3*, Nirupma Trehanpati1* Corrspondence- Shiv Kumar [email protected] 1 Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India, 2Lady Harding Medical College and Smt. S K Hospital, New Delhi, India, 3 Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Background Vertical-transmission of hepatitis-B-virus (HBV) is the main cause of chronic HBV-infection. B-cell-mediated-responses play an important role in innate and adaptive immunity. GMCSF secreting IRA-B cells play an important role in the pathogenesis of infectious diseases. We performed a comprehensive analysis of HBV-specific-B-cells their subsets such as GMCSF-secreting (IRA-B) and regulatory-B-cell-responses in HBV-transmission from mother-to-child-(MTC).

Indian J Gastroenterol

Methods Fifty HBsAg+ve pregnant mothers and their newborns were tested for transmission of HBV (HBsAg, HBV DNA); 22 were positive and rest negative. PBMCs from the transmitting (Gr. A, n=22) and nontransmitting (Gr. B, n=28) mothers were analyzed for B cell and their subsets analysis using flow cytometry. HBV specific responses of B cells were assessed using pooled HBV peptides. Next generation sequencing (NGS) was performed in PBMCs. Results Mothers in Group B had higher frequencies of plasma B and greater HBV specific B cell-mediated protective responses (GMCSF, IFN-? and IL-2 secretion) than Group A mothers. Group A mothers showed increased number of early B (immature) and HBV specific regulatory B cell (IL-10 and TGF-β secreting) frequencies compared to Group B. Genes linked with antibodies secretion, and humoral responses had higher expression (>1.5 fold) in Group B than A. Next, we investigated pathway analysis of B cell specific genes between the groups based on the latest KEGG database. Conclusions Effective inflammatory, IRA-B cells-responses and decreased Breg responses have a protective-role in antiviral immunity and help in-prevention of vertical-transmission of HBV. These cells can be used for therapeutic intervention of vertical transmission. YIA-4 Vitamin A promotes mucosal inflammation by augmenting Th1/ Th17 differentiation in inflammatory bowel disease Ritika Rampal1, Md. Nahidul Wari1, Amit Kumar Singh1, Ujjwalkumar Das2, Sawan Bopanna1, Saransh Jain1, Vipin Gupta1, T Velapandian2, Saurabh Kedia1, Dhiraj Kumar4, Amit Awasthi3, Vineet Ahuja1 Correspondence- Vineet [email protected] 1 Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110 029, India, 2Department of Ocular Pharmacology, Dr. R P Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi 110 029, India, 3Centre for Human Microbial Ecology, Translational Heath Science and Technology Institute, Haryana, and 4 Cellular Immunology Group, International Centre for Genetic Engineering and Biotechnology, New Delhi, India Introduction There is limited human data on contribution of retinoic acid (RA) in modulating gut immunological responses. We investigated the role of RA in promoting mucosal inflammation in Inflammatory bowel disease (IBD) in vivo and in vitro. Methods This prospective cohort study included healthy controls, steroid naïve ulcerative colitis (UC) and Crohn’s disease (CD) patients. Mucosal biopsies and blood were evaluated for RA levels and immunophenotypic profiles (CD4, CD8, MAIT, gd T cells). In healthy volunteers, we assessed the effect of RA on CD4? T cell responses differentiated in the presence and absence of polarizing (Th1/Th17) and inflammatory (LPS induced dendritic cells) conditions. Results Twenty-nine UC patients (35.5±8.3 years), 13 CD patients (37.5 ±11.5 years) and 15 healthy controls (31.7±10 years) were included. IBD patients had an increased tissue (UC: 3.5 vs. 0.7 ng/mL; p<0.0001, CD: 3.4 vs. 0.7 ng/mL; p<0.001) and serum (UC: 1.4 vs. 0.9 ng/mL; p<0.05, CD: 1.7 vs. 0.9 ng/mL; p<0.01) RA levels than controls. Active UC had higher tissue RA levels than patients in remission (4.8 vs. 2.9 ng/mL; p=0.01). This effect was accompanied by significantly increased proinflammatory cytokines IL-17 and IFNg in colonic and serum CD4+, CD8+, MAIT+ and gd+T cells in IBD patients. Further, IL-17 and IFNg positively correlated with tissue RA levels in IBD. Also, in inflammatory conditions, RA primed dendritic cells induced high levels of IFNg and IL-17 in presence of Th1/Th17 conditions. Conclusion This is the first study to estimate RA levels in human gut showing that tissue RA levels are significantly increased in IBD and correlate significantly with proinflammtory cytokines in mucosa as well as serum. Like CD4 cells, MAIT, CD8 and ??/?? T cells propagate

mucosal inflammation by upregulating IL-17 and IFNg. Therefore, Vitamin A exerts a proinflammatory role by modulating Th1/Th17 balance depending on the gut microenvironment in IBD. YIA-5 Ischemic hepatitis is ameliorated by N-acetylcysteine in cirrhotics: A randomized controlled trial Awinash Kumar*, Rakhi Maiwall*, Ajeet Singh Bhadoria, Ankur Jindal, Guresh Kumar, Ankit Bhardwaj, Kapil Jamwal, Jaswinder Singh Maras, Manoj Kumar Sharma, B C Sharma, Shiv Kumar Sarin Correspondence- Shiv Kumar [email protected] Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Background and Aims Ischemic hepatitis (IH) following acute variceal bleed (AVB) in cirrhotics is a consequence of hypotension and hepatic ischemia and carries an ominous prognosis. N-acetylcysteine (NAC), a potent anti-oxidant may prevent IH by improving tissue oxygen delivery. We investigated the efficacy of NAC in the prevention/amelioration of IH and survival. Methods Consecutive cirrhotics with AVB were randomized in a prospective open label randomized control trial to receive either standard of care (SOC) plus NAC for 72 hours [Group A, n=107] or SOC alone [Group B, n=107] at a tertiary care setting. Results Baseline characteristics were comparable in the two groups. Twenty-two patients (10.28%) developed IH (GrA-10, GrB-12, p=0.65) post variceal bleed. These patients had higher baseline MELD scores (26.5±10.5 vs. 21±8.9, p=0.02), plasma lactate (8.1±2.5 vs. 4.1±2.6 mmol/L, p<0.001) and lower mean arterial pressure (54.6±7.3 vs. 78.0 ±14.5 mmHg, p<0.001) than others. Incidence of IH increased with severity of liver disease (p=0.002). Patients in GrA had lower peak AST, ALT, LDH, lactate, bilirubin and INR levels than GrB (p<0.05) with markedly decreased incidence of AKI [19.6% vs. 33.6%, p=0.02] at day five. The mortality was higher in patients who developed IH than others (63.6 % vs. 13.02%, p<0.001) but was not different between the two groups. Conclusions IH develops in 10% of cirrhotics following AVB; more so in Child’s C patients and is associated with higher mortality. NAC therapy significantly ameliorates the development of severe IH and decreases the incidence of AKI, but does not influence mortality. (Clinicaltrials.gov no: NCT 02015403). YIA-6 An innovative technology for bioengineering humanized extracorporeal liver system Sandeep Kumar Vishwakarma, Avinash Bardia, L Chandrakala, B V S Sastry, N Raju, Phanni Bhushan Meka, Md. Aejaz Habeeb, Aleem Ahmed Khan Correspondence- Aleem Ahmed Khan- [email protected] Department of Gastroenterology and Hepatology, Centre for Liver Research and Diagnostics, HLS, Hyderabad 500 058, India Introduction Acute as well as chronic liver failures are major fatal problems which lead up to 60% to 80% mortality every year. In acute condition, systemic inflammation and accumulation of toxic compounds (ammonia) in liver results in multiorgan failure which leads to hepatic encephalopathy. Pharmacological drugs are not enough capable of removing toxins from liver; whereas in chronic condition, liver transplantation is the only option. However, liver transplantation is limited due to timely unavailability of enough donors, post-transplantation complications and high cost involvement. The present study demonstrates a promising strategy of using natural platform of bioartificial extracorporeal liver

Indian J Gastroenterol

support system prepared through decellularization and repopulation of xenogenic liver with human hepatic progenitor cells (hHPCs). Methods Xenogenic liver was decellularized by perfusion method using retrograde change of detergents and other chemicals. Removal of nuclear components, retention of ECM and vascular integrity of whole decellularized liver was identified. DiD-labeled hHPCs were infused to identify the cells distribution and engraftment efficiency. Repopulation of hHPCs within the decellularized liver scaffold was determined by SEM analysis whereas the functional activity of repopulated cells was determined by ammonia detoxification experiment by urea quantification. Results The decellularized liver vascular network was able to withstand fluid flow that entered through a central inlet vessel, branched into an extensive capillary bed, and coalesced into a single outlet vessel. Repopulated hHPCs showed homogeneous distribution within the decellularized liver scaffold showing defined vascular tree with multiple branching and residual niches of proliferating cells. Ammonia detoxification showed the functional activity and future applicability of repopulated humanized liver scaffold as extracorporeal natural organ support system. Conclusion This study demonstrate an innovative technology for bioengineering humanized extracorporeal liver system as better approach for ammonia detoxification as temporary support to the failing liver. Presidential Posters PPLE-01 Fecal calprotectin can diagnose acute severe colitis with a good degree of accuracy Saransh Jain, Saurabh Kedia, Sandeep Goyal, Sawan Bopanna, Dawesh P Yadav, Vikas Sachdev, Peush Sahni1, Sujoy Pal1, Nihar Ranjan Dash1, Govind Makharia, Simon P L Travis2, Vineet Ahuja Correspondence- Vineet Ahuja- [email protected] Departments of Gastroenterology and GI Surgery1, All India Institute of Medical Sciences, New Delhi 110 029, India, and 2Translational Gastroenterology Unit, Oxford, UK Introduction Acute severe colitis (ASC) is conventionally diagnosed by Truelove and Witts’ criteria which are non-specific and can be affected by other pathologic conditions. Fecal calprotectin (FCP) is a gut-specific marker of inflammation which can predict short-term outcomes in patients with ASC. We aimed to define the role of FCP in the diagnosis of ASC. Methods This prospective observational cohort study included adult patients (>18 years) with ulcerative colitis (UC) for whom FCP was measured and were under follow up from April 2015– December 2016. Patients were divided into two cohorts:1) all consecutive hospitalized patients with ASC as defined by Truelove and Witts’ criteria; 2) outpatients with active UC (defined by Mayo score) who did not fulfill Truelove and Witts’ criteria. FCP levels were compared between the two cohorts and a cutoff for FCP to diagnose ASC was determined. Results Of 97 patients, 49 were diagnosed with ASC (mean age: 36.1+11.9 years, 36 males) and 48 with active UC (mean age: 37.9+12.4 years, 25 males). Median FCP levels were significantly higher in patients with ASC [1776(952–3123) vs. 282(43–568) μg/g, p<0.001] than mild to moderately active UC (n=48) or moderatelyactive UC [n=35, 1776 (952–3123) vs. 332 (106–700) μg/g, p<0.001]. A FCP cutoff of 782 μg/g of stool had excellent diagnostic accuracy, with an area under the curve of 0.92 (95% CI:0.87–0.97), sensitivity of 84% and specificity of 88% to differentiate ASC from active UC. Conclusion FCP could differentiate ASC from mild to moderate patients with UC, but requires validation before clinical use.

PPLE-02 Impact of oral nano vitamin D supplementation in reducing disease activity and severity in patients with active ulcerative colitis: A double blind randomized parallel group placebo controlled trial Z Rizwan Ahamed, Vishal Sharma, K K Prasad, Chetana Vaishnavi, Sunil Arora1, Rakesh Kochhar, Usha Dutta Correspondence- Usha [email protected] Departments of Gastroenterology, and Immunopathology1, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Vitamin-D possesses anti-inflammatory properties and studies in IL-10 knock-out mice have shown that supplementation ameliorates colitis. Oral nano vitamin D which is likely to have greater bioavailability in UC is now available. Aim To conduct a double blind randomized parallel placebo trial to assess the impact of oral nano vitamin D3 in reducing clinical, serological, fecal and histological markers of inflammation in patients with active ulcerative colitis (UC). Methods Patients of active UC with UCDAI ≥3 and vitamin D <40 ng/mL were included. They were evaluated for disease activity and severity (UCDAI scores); CRP, ESR and fecal calprotectin at baseline and randomized to receive either oral nano vitaminD/placebo (60000 I.U/day x 8 days) followed by reassessment at 4 weeks. The allocation was concealed and all the investigators were blinded. Response was defined as a 3-point reduction in UCDAI score at 4 weeks; and reduction in all inflammatory markers. Univariate and multivariate analysis was performed and p value of <0.05 was considered significant. Results The median vitamin D levels increased from 15.4 to 40.83 in the vitamin D group (p=<0.001) and from 13.45 to 18.85 (p=0.027) in the placebo group. Response in disease activity and severity was found more often the vitamin D group compared to placebo group (53% vs.13%; p=0.001); (60% vs. 33%; p=0.038) respectively. Increase in vitamin D levels correlated with reduction in UCDAI score (p=<0.001, rho=-0.713), CRP (p=<0.001, rho=0.603), calprotectin (p=0.004, rho=-0.368) and histological activity (p=<0.001, rho=-0.608). Patients who achieved target vitamin D of >40 ng/mL (n=17) more often had reduction in disease activity and severity compared to those who did not (n=43) (76.5% vs. 34.9%; p=0.004). Vitamin D administration (OR=9.17; C.I-2.02, 41.67) and baseline histological activity (OR=1.92;C.I. 1.2,3.08) were independent predictors of response. Mixed linear model showed that reduction in UCDAI over time was significant in the vitamin D group alone. Conclusion Oral nano vitamin D supplementation in active UC is associated with reduction in disease activity and severity which parallels reduction in inflammatory markers and is seen more often in those who achieved a target vitamin D level of 40 ng/ mL. PPLE-03 Endoscopic ultrasound-guided fine-needle aspiration of enlarged adrenals in patients with pyrexia of unknown origin: A single center experience of 52 cases Rinkesh K Bansal,1 Narendra S Choudhary,1 Saurabh K Patle,1 Amit Agarwal1, Gagandeep Kaur,2 Haimanti Sarin,2 Rajesh Puri1 Correspondence- Rajesh Puri- [email protected] Institute of Digestive and Hepatobiliary Sciences1, and Department of Cytopathology2, Medanta The Medicity, Gurugram, India Background Fine-needle aspiration (FNA) of adrenals is needed in patients with pyrexia of unknown origin (PUO) and adrenal enlargement in absence of other diagnostic clues. Adrenals are easily accessible by

Indian J Gastroenterol

endoscopic ultrasound (EUS) due to proximity; however, there is no systemic study available. The aim of this study was to evaluate the diagnostic yield and safety of EUS-FNA of enlarged adrenal in patients with pyrexia of unknown origin (PUO). Methods Data was analyzed from October 2010 to September 2016 at a single tertiary care center in North India. EUS FNA of enlarged adrenals was done in fifty-two patients for the etiological diagnosis of PUO in whom a definitive diagnosis could not be made with other means. Results The mean age was 48±14 years; 36 were males and 16 were females. EUS-FNA was done from left adrenal in 50 patients and from right adrenal in 2 patients. A technical success was achieved in 100% cases. The 19 G needle was used in majority (75%) due to presence of necrotic areas in adrenals; median numbers of passes were 2. The cytopathological diagnoses were tuberculosis (n=36), histoplasmosis (n=13), lymphoma (n=2), and metastasis from undiagnosed neuroendocrine tumor of lung (n=1). Thus a diagnosis could be made in 52/52 (100%) patients. None of the patients had any procedure-related complications. Conclusions EUS-FNA is a safe and effective method for evaluating etiology of PUO in patients with adrenal enlargement. PPLE-04 L-ornithine L-aspartate in acute overt hepatic encephalopathy: A randomized trial Sandeep Sidhu1, B C Sharma2, Omesh Goyal1, Harsh Kishore1, Navpreet Kaur1 Correspondence- Omesh Goyal- [email protected] 1 Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India, and 2Institute of Liver and Biliary Sciences, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction Acute episodes of overt hepatic encephalopathy (OHE) in cirrhotics are associated with significant morbidity and mortality. LOrnithine L-Aspartate (LOLA) acts through mechanism of substrate activation to detoxify ammonia. High quality data on efficacy of LOLA in cirrhotics with acute episodes of OHE are missing. We aimed to evaluate the efficacy of intravenous LOLA in reversal of acute episode of OHE in cirrhotics. Methods In this prospective double-blind randomized placebo controlled trial conducted at two tertiary care institutes in India, 370 cirrhotics with acute OHE were screened. After exclusion, 193 (52.16%) patients were randomized to receive either intravenous infusions of LOLA (n=98), 30 grams daily or placebo (n=95) for 5 days. Standard of care treatment (including lactulose) was given in both groups. Randomization was done centrally through the http://www.sealedenvelope.com. All study personnel were blinded to the treatment assignment. Fasting venous ammonia levels were estimated daily from 0–5 days. Serum tumor necrosis factor α and interleukins were performed at day 0 and 5. Primary outcome was mental state grade at day 5 of treatment. Results The grade of OHE was significantly lower in the LOLA group (compared to placbo) from day 1 to 4, but not on day 5. The mean time taken for recovery was significantly lower in LOLA group compared to placebo group [1.92±0.93 days vs. 2.50±1.03 days, p=0.002 (95% CI-0.852 to -0.202)]. Venous ammonia at day 5 and length of hospital stay were significantly lower in LOLA group. No significant change was seen in Interleukins and TNFα in both groups. Conclusion In patients with acute OHE, intravenous LOLA (compared to placebo) significantly improves the grade of OHE over days 1-4, but not on day 5. Patients who receive LOLA have significantly lower venous ammonia levels, significantly decreased time of recovery and shorter length of hospital stay.

PPLE-05 Gluten sensitivity in Indian patients with progressive cerebellar ataxia Inder Singh1, Anil K Verma2,3, Isha Singh2, Alka Singh2, Varun Suroliya1, Urvashi Hooda2, Mohammed Faruq4, Vineet Ahuja2, Govind K Makharia2, Achal K Srivastava1 Correspondence- Achal Kr. [email protected] 1 Neuroscience Centre, All India Institute of Medical Sciences, New Delhi 110 029, India, 2Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India, 3 Celiac Disease Research Laboratory, Department of Pediatrics, Università Politecnica delle arche, Ancona, Italy, and 4CSIR-Institutes of Genomics and Integrative Biology, New Delhi 110 007, India Background Cerebellar ataxia is a heterogeneous group of disorders which can be familial or sporadic. Sensitivity to gluten has been implicated in the pathogenesis of sporadic cerebellar ataxia. Since there is a lack of data on prevalence of gluten sensitivity in patients with ataxia from Asian countries, we screened a well-defined cohort of patients with cerebellar ataxia for presence of gluten sensitivity. Methods A cohort of 192 well-characterized patients with progressive cerebellar ataxia, familial or sporadic, were screened for presence of gluten sensitivity using IgA anti-gliadin Ab (AGA), IgG-AGA, IgA antitransglutaminase 2 Ab (TG2), and IgA anti-transglutaminase 6 Ab (TG6) using commercially available ELISA kits. The data on their genetic testing for spinocerebellar ataxia (SCA) 1, 2, 3, 12, Friedreich's ataxia (FRDA), and brain imaging were reviewed. Results Of 192 patients, 99 and 77 had sporadic and familial cerebellar ataxia, respectively. Genetic mutation for SCA types 1, 2, 3, 12 and FRDA was confirmed in 76 (40%) patients. Forty-two (21.8%) patients had either one or more serological test positive for gluten sensitivity; 20 (10.4%) patients for IgA-AGA, one of 141 (0.71%) for anti-TG2 Ab and 23 of 186 (12.3%) for IgA anti-TG6 Ab. Twenty of 32 (63%) seropositive patients had cerebellar atrophy on brain imaging. None of 10 patients out of 42, who agreed to undergo duodenal biopsy examination, had evidence of celiac disease. Frequency of IgA-AGA and TG6 were significantly higher in our cohort in comparision to the cohort of other ethnicities. Conclusion Forty-two (21.8%) patients had either one or more serological test positive for gluten sensitivity. This study suggest a role of gluten sensitivity in patients with cerebellar ataxia. Gluten sensitivity in patients with ataxia may be playing a causative role or atleast a disease modifier. PPLE-06 Gastric bacterial flora in patients harbouring Helicobacter pylori with or without dyspepsia Verima Pereira, Philip Abraham, Sivaramaiah Nallapeta,@ Anjali Shetty* Correspondence-Philip Abraham- [email protected] Divisions of Gastroenterology and *Microbiology, P D Hinduja Hospital, V S Marg, Mahim, Mumbai 400 016, India, and @Bruker Daltonics, Bengaluru, India Background The role of the gastric microflora in the production of symptoms in patients with Helicobacter pylori (H. pylori) infection has not been explored. We investigated qualitatively the bacterial flora in the stomachs of patients harbouring H. pylori infection, in order to determine differences, if any, related to presence or absence of dyspepsia. Methods Seventy-four gastric biopsy samples obtained at endoscopy from patients with (n=21) or without (n=53) dyspepsia, and that tested positive by the bedside rapid urease test for H. pylori infection, were studied for detection of H. pylori and non-H. pylori organisms. These

Indian J Gastroenterol

organisms were identified by matrix-associated laser desorption ionization time-of-flight mass spectroscopy (MALDI-TOF MS). Results A total of 115 non-H. pylori isolates (34 from dyspeptic and 81 from non-dyspeptic patients) were obtained from the 74 samples. These were identified by MALDI-TOF MS as Staphylococcus spp, Streptococcus spp, Lactobacillus spp, Micrococcus spp, Enterococcus spp, Pseudomonas spp, Escherichia spp, Klebsiella spp and Bacillus spp; nine isolates (eight in non-dyspeptics and one in dyspeptics) could not be identified from the Bruker Biotyper 2 database. Staphylococcus and Lactobacillus were more commonly identified in dyspeptics and Streptococcus, Pseudomonas, Escherichia coli and Klebsiella pneumoniae more commonly in non-dyspeptics. Conclusions The human stomach harbouring Helicobacter pylori is also host to a wide range of organisms. There is a difference in the spectrum between patients with and without dyspepsia. Their role in the production of symptoms in H. pylori infection needs to be studied, and especially whether this opens an avenue for therapeutic intervention. PPLE-07

Introduction Walled off pancreatic necrosis (WON) is a local complication in late phase of SAP. With advent of minimally invasive therapies paradigm shift has occurred in management of WON. Surgery which was the mainstay is considered now as a salvage therapy. To the best of our knowledge there is no data comparing EUS guided drainage vs. percutaneous drainage in WON. Our aim was to compare surgical step up approach (PCD) vs. EUS guided drainage in management of WON. Methodology We conducted a pilot RCT from January 2016 to June 2017. Trial was registered under CTRI (CTRI/2017/01/007749). Sample size calculated was 20 patients, 10 in each arm. All patients were treated as per protocol. Percutaneous drainage and EUS guided LAMS placement were used as minimally invasive therapies. Surgery used as a salvage therapy. We assessed baseline characteristics, mortality, clinical improvement, length of hospital stay, number of radiological exposures, and complications. Results Out of 68 patients with WON 36 were symptomatic. Fifteen patients were excluded, and using computer generated random numbers, 21 patients were randomized i.e. 10 in EUS guided LAMS and 11 in surgical step up arm. Baseline characteristics were comparable. Results in Table 1.

Management of induced type I duodenal perforations: Clip or surgery? PPLE-09 Amol Sonyabapu Dahale, Siddhartha Srivastav, Sanjeev Sachdeva, Sundeep Singh Saluja, Shivakumar Varakanahalli Correspondence- Siddhartha Srivastav- [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India Introduction Scope induced duodenal perforation (type I Stapfer) of duodenum is life threatening complication and surgery remains standard of care. With advent of over the scope clip (OTSC), scope induced perforations are increasingly managed conservatively though data is scarce. We aimed to compare OTSC and surgery in management of scope induced perforation of duodenum. Methods We retrospectively collected data at G B Pant Hospital, New Delhi, (India) for scope induced duodenal perforation patients between September 2008 to December 2016. Scope induced perforations were identified and treated within 24 hours of procedure were analyzed. Factors considered included epidemiology, etiology, baseline parameters, perforation size, outcome, comorbidities and duration of hospital stay. Results Total 20 patients had type I duodenal perforations, five excluded from analysis due to delayed diagnosis and treatment. Of fifteen, five patients were treated with OTSC placement while rest underwent surgery. Age was comparable and majority were females. Baseline parameters and comorbidities were similar in both groups. Median size of perforation was 1.5 cm in both OTSC group and surgical group. All patients treated with standard of care according to institutional protocol. Patients in OTSC group were started orally after 48 hours of OTSC, in surgery group median time to oral intake was 7 days. Two patients in surgical group died while none in OTSC group (p=0.48). Median hospital in OTSC group was 2 days compared to surgery group median of 22 days (p-0.003). Conclusion OTSC is feasible option in type I duodenal perforation with shorter hospital stay. Though mortality trends are better in OTSC group they didn’t reach statistically significant level. PPLE-08 A pilot randomized controlled trial comparing surgical step up approach with endoscopic ultrasound guided drainage in management of symptomatic walled off pancreatic necrosis Ankush Pawar, Amol Dahale, Ajay Kumar, Sundeep Saluja, Poonam Narang, S Srivastava, S Sachdeva, A S Puri Correspondence- Siddharth [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Terlipressin is superior to noradrenaline in management of acute kidney injury in acute on chronic liver failure Vinod Arora, Rakhi Maiwall, Ashok Choudhury, Priyanka Jain, Guresh Kumar, Shiv K Sarin Correspondence- S K [email protected] Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Hepatorenal syndrome (HRS) carries a high short-term mortality in patients with cirrhosis and acute-on-chronic liver failure (ACLF). We have reported a low response to terlipressin in ACLF patients with HRS. Currently, there are no studies comparing the efficacy of terlipressin (TR) with noradrenaline (NA) in patients with ACLF and HRS. Methods In an open-label RCT (GOV:NCT02573727), consecutive patients with ACLF diagnosed with AKI-HRS as per revised international classification of ascites-AKI (ICA-AKI) criteria were randomized to terlipressin (as continuous infusion) plus albumin (1 g/Kg/day for 2 days followed by 25-50 grams/day) (n=60) versus noradrenaline (0.5-3 mg/hr to achieve target MAP) plus albumin (n=60). Progression and regression were defined as per ICA-AKI criteria. Results Baseline characteristics were comparable in both groups. Baseline serum creatinine (S. Cr) (1.71(.01, 4.71) vs. 1.69 (.04, 5.82), p=0.63), AKI stage (2; 3) (53% vs. 48%, p=0.67; 47% vs. 52%, p=0.84), peak S. Cr. (2.68±1.22 vs. 3.08±1.09, p=0.07) were comparable in both groups. Sepsis-related HRS was also not significantly different between the two groups (47.8 % vs. 52 %, p=0.68). Significantly early response was achieved in terlipressin group compared to NA at Day 4 (26.1% vs. 11.1%, p=.05) and day 7 (41% vs. 15%, p=0.008). Reversal of HRS was also better with terlipressin compared to NA (40% vs. 16.7%), p=.02) with lower requirement of renal replacement therapy (43% vs. 56%, p=.055) and improved 28-day survival (46% vs. 20%, p=0.002). On multivariate analysis, MELD (HR 1.10, CI=1.004-1.20, p=.041) and use of terlipressin or noradrenaline (HR 3.31, CI=.94-6.04, p=.06) were predictors of early response to therapy. Adverse effects limiting use of drugs were higher [14/45, 23.33%] with terlipressin than noradrenaline [5/60 (8.3%), p=0.11] in noradrenaline group. Using multivariate analysis, INR (2.60, 1.38-4.92, p=.003), MELD (1.149, CI=1.05-1.25, p=.001), use of terlipressin or noradrenaline (HR 3.74, CI=1.66-8.41, p=.001), pneumonia (4.68, 1.92-14.68, p=.001), early response to terlipressin or noradrenaline (51.36, 15.09-173.24, p=.0001) were strong predictors of survival.

Indian J Gastroenterol

Conclusions ACLF-AKI carries a high mortality rate. Terlipressin infusion provided higher response rate and improved survival compared to noradrenaline infusion. PPLE-10 Molecular ellipticity of circulating albumin-bilirubin complex predicts mortality in severe alcoholic hepatitis patient Sukanta Das1, Jaswinder Singh Maras1, S M Shasthry2, Md. Shabir Hussain1, Shvetank Sharma1, S Sukriti1, Rakhi Maiwall2, T P Singh3, Shiv Kumar Sarin1,2 Correspondence- S K Sarin- [email protected] 1 Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences/, New Delhi, India, 2Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India, 3Department of Biophysics, All India Institute of Medical Sciences, New Delhi, India Background Severity assessment of alcoholic hepatitis requires several indices, which documents limited reliability. Hyperbilirubinemia and hypoalbuminemia are hallmarks of hepatic dysfunction and their complex could reflect disease severity. Circular dichroism (CD) spectroscopy provides a robust platform for quantitation of molecular ellipticity (ME) of albumin-bilirubin ([A-B]) complex. Methods A total of 240 severe alcoholic hepatitis (SAH) patients were studied. Bilirubin: albumin molar ratio and ME was first determined in the discovery cohort (n=90: survivors=30, nonsurvivors=60) as compared to 60 alcoholic cirrhosis (AC) and 30 healthy controls (HC) and then validated in 150 SAH patients. ME was correlated to albumin binding capacity (ABiC) in SAH. Results Bilirubin: albumin molar ratio was higher in SAH as compared to AC, HC [p<0.05]. SAH documented high ME and had clear difference in their CD/UV spectra as compared to other groups [p<0.01]. ME correlated with severity indices [MELD, DF, ACLF grades, CLIF-COFs and CLIF-CADs (r2>0.3, p<0.01)] and mortality (Hazard-Ratio=1.39, p<0.01) in SAH. Both hazard-ratio and Cindex for 90 days mortality prediction of ME was >10% high over MELD score in SAH. ME with AUROC of 0.84 (0.75-0.93) and cut-off of 2.0 mdeg showed high positive (77%) and negative (90%) predictive value for 90 days mortality of SAH. ABiC in SAH inversely correlated with ME (r2>0.7, p<0.01) and in-vitro experiments show significant reduction in ABiC with increase in bilirubin concentration. Conclusions Determination of ME of [A-B] complex by CD spectroscopy offers a simple and reliable modality for prediction of outcome in SAH. Increased bilirubin loading on albumin in SAH explains a mechanism of reduced albumin functionality. PPLE-11 Assessment of coagulation profile in patients with acute-on-chronic liver failure during systemic inflammatory response and sepsis Madhumita Premkumar,1 Priyanka Saxena,2 Roshni Mirza,2 S Sukriti,3 Priyanka Jain,3 Pooja Bhatia,3 Guresh Kumar,3 Chhagan Bihari,2 Ashok Choudhury,1 Shiv K Sarin1 Correspondence- Shiv [email protected] Departments of Hepatology1, Hematology2, Research3, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background Patients with acute-on-chronic liver failure (ACLF) maintain rebalanced hemostasis in the presence of organ failures. We studied the coagulation profile in ACLF and correlated it with the development of systemic inflammatory response syndrome (SIRS) and sepsis. Methods Consecutive ACLF patients, who had no SIRS or sepsis at presentation, were assessed at baseline, day 3 and 7 for the development of SIRS/ sepsis, changes in coagulation parameters, disease progression and bleeding events.

Results Of 243 ACLF (ethanol 63%) patients, 114 [mean age 44.3±11.7 yr; 90% M] (Cohort A) had no evidence of SIRS (A1, n=39) or had SIRS but no sepsis (A2, n=75) and the remaining had sepsis (Cohort B). In Cohort A1, median time to development of SIRS was 3.4, and sepsis 5.2 days. SIRS was noted in 39 (34.2%), 45 (39.5%) and 46 (40%) patients at days 0, 3 and 7 respectively and sepsis in 28 (24%) and 52 (56.1%) patients at days 3 and 7. Presence of SIRS at presentation (n=39) was associated with progression to sepsis by day 3 (30.6%; OR2.3; CI 1.8-4.5) and 7 (48%; OR2.9 CI 1.84.8). Neither INR (2.24 ±0.7 vs. 2.32 ±0.5), aPTT (45.6 ± 8.4 vs. 43.8±3.4) nor fibrinogen (132.7±28.8 vs.144.2±25.9) could predict onset of sepsis. Protein C, FVIII and vWF levels did not change with onset of sepsis. Bleeding events were seen in 55% patients; skin (39%), gastrointestinal (18.4%) and from multiple sites (39%). Bleeding events increased mortality (OR12.3, CI 2.3-3.4, p=0.000). A deranged TEG at baseline was a predictor of bleeding (OR3.1; p=0.051) and mortality (OR= 2.9; p=0.056). The day 28 and 90 survival in the cohort was 62% and 51% respectively. Conclusions Coagulation failure in ACLF determines the likelihood of bleeding, risk of sepsis and mortality. Composite tests like TEG are useful determinants of coagulation assessment. PPLE-12 Ivabradine in combination with carvedilol improves left ventricular diastolic dysfunction, clinical progression and survival in cirrhosis- A prospective randomized controlled trial Madhumita Premkumar, Devraj Rangegowda, Saggere M Shasthry, Tanmay S Vyas, Ritu Goyal, Jelen K Singh, Sherin S Thomas, Shiv K Sarin Correspondence- Shiv [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background Left ventricular diastolic dysfunction (LVDD) is seen in 30% to 70% cirrhotics and signifies advanced cirrhosis, renal dysfunction, and mortality. This prospective RCT assesses the effect of targeted heart rate reduction (THR), (using carvedilol±ivabradine) on LVDD and complications. Methods Of 260 consecutive cirrhotics screened by ECHO, 189 (72%) patients with LVDD were randomized to either THR (5565 or 20% reduction from baseline) Group A, n=94, (50 ± 9yr; 87% males)] or standard medical care [Group B, n=95; (52±8 yr; 77% males)] without βblockers. Patients were evaluated at 0, 6 and 12 months with ECHO, biochemical and neurohormonal tests. Results Of 189 patients, 52% and, 48% had Grades 1 and 2 LVDD respectively. In Gr. A, THR was achieved in 78 (82.9%) patients (responders=R); 60 (63.8%) with carvedilol alone and 34 (36.1%) with added ivabradine in case of carvedilol intolerance. Median daily doses were carvedilol 9.5 mg (3.125-12.5) and ivabradine 7.5 mg (5-12.5). At the end of 1 year, 21 (11.1%) subjects died, 6 (14%) in Grp A and 15 (18%) in Gr B (p=0.24), with no mortality in R as compared with non responder (NR) (p=0.000). Predominant causes of death were sepsis and liver failure. On echo non-survivors (NS) had higher E/e’ ratio (E-wave transmitral/early diastolic mitral annular velocity [8.7±3.3 (S) vs. 9.1±2.3 (NS), p=0.058], and lower ventricular relaxation time [86.5±15.6 ms (S) vs. 94.2±12.3 (NS), p=0.053]. In Gr A, LVDD reversed in 16 (20.5 %) and improved from grade 2 to grade 1 in 34 (35.4%). E/e' ratio reduced in R vs NR at 1 year which correlated with survival. Conclusions The addition of ivabradine to carvedilol shows improvement in LVDD, reduces risk of HE, AKI, and results in better overall survival.

Indian J Gastroenterol

PPLE-13 Combination of Carvedilol and Probiotic VSL#3 is not as effective as endoscopic variceal ligation for primary prophylaxis of large varices in Carvedilol non-responders- A randomized controlled trial Ankit Bhardwaj2, Chandan Kumar Kedarisetty1, Ankur Jindal1, Rakhi Maiwall1, Guresh Kumar2, Ajeet Singh Bhadoria2, Lovkesh Anand1, Ashok Choudhary1, S M Shasthry1, Manoj Kumar1, Shiv Kumar Sarin1 Correspondence- Shiv Kumar [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aim For primary prophylaxis of large varices, patients non-responsive to nonselective beta-blockers (NSBB), have to undergo endoscopic variceal ligation (EVL). Probiotics have been shown to reduce portal pressure. We compared a combination of carvedilol and VSL#3 with EVL in carvedilol non-responders. Methods Consecutive cirrhotics with large varices, non-responsive to carvedilol, were randomized to a combination of carvedilol and VSL#3 (CV group; n=20) or EVL once in 3 weeks till variceal obliteration (EVL group; n=20). The primary end-point was occurrence of first variceal bleed in one year of follow up. Results Baseline characteristics of patients were comparable. The target heart rate in CV group was 58±3 beats per minute with a mean carvedilol dose of 11.9±2.1mg/day. A higher proportion of patients bled in CV group compared to EVL group (30% vs. 5%, p=0.04); the mean time to first variceal bleed being 10.4 (95% CI 9.2-11.7) and 11.5 months (95% CI 10.5–12.5) respectively, p=0.04. The mean HVPG reduction in CV group from baseline was -5.9% (16.2±4.7 vs. 13.5±4.7 mmHg, p=0.78) while in the EVL group, it increased by 2.1% (16.5±3.7 mmHg and 17.6±4.1 mm Hg, p=0.86). The trial was stopped early after an interim analysis at three years. No major adverse events were observed in either group. Conclusion In primary prophylaxis of large varices non-responsive to carvedilol, a combination of carvedilol and VSL#3 is not effective as EVL in the prevention of first variceal bleed. PPLE-14 Impaired immune reserve in different stages of patients with liver cirrhosis and sepsis Sukriti Sukriti1, Jaswinder Singh Maras1, Ashok Kumar Chaudhary2, Sukanta Das1, Madhumita Premkumar2, Chhagan Bihari3, Guresh Kumar1, Nirupma Trehanpati1, Shiv Kumar Sarin1,2 Correspondence- Shiv Kumar [email protected] 1 Departments of Molecular and Cellular Medicine, 2Hepatology, and 3 Pathology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Introduction Liver cirrhosis is a state of immunodysfunction and leads to increased susceptibility to infection. Aim of the present study was to investigate the baseline immune reserve in different stages of cirrhosis and after development of sepsis. Methods The cellular and functional changes in immune reserve of alcoholic cirrhotics (n=43{Child Pugh A, n=9; B n=12, C n=22); cirrhotics with sepsis (n=20);} disease control - non-cirrhotic portal fibrosis (NCPF, n=8) and healthy controls (HC, n=11). The frequency of innate and adaptive immune cells and hematopoietic stem cells (HSCs) was measured using flow cytometry. The functional assessment of immune cells was done by intracellular cytokines, after LPS stimulation. Serum endotoxin levels were also measured. The dynamics of immune reserve was determined in peripheral blood and correlated with clinical outcomes. Results Frequency of monocytes and HSCs was reduced in Child C than Child A, B but not among Child A vs. B; NCPF vs. HC. Neutrophils were increased (p=0.03; 0.01 in Child A, B; p=0.00 vs. NCPF and HC) but

with lower TNF-α production (p<0.02). However, in sepsis in cirrhotics, a significant reduction in monocytes, HSCs, CD8+T cells, B cells was seen (p<0.03). Functional assessment after LPS stimulation showed monocytes has an increase in frequency in Child C (p=0.04) but not in sepsis. The endotoxin levels in plasma were increased in Child C and B than A and HC (p<0.05), but were comparable between Child B and A. Endotoxin levels correlated with MELD score (r2=0.62; p=0.02) and with Child-Pugh score (r2=0.82; p=0.00). Conclusions Monocytes and HSCs are progressive reduced and functionally impaired in Child C cirrhosis and in sepsis. Neutrophil though increased, are functionally impaired with low TNF-α production. With LPS stimulation, the monocyte frequency and TNF-α production is restored in Child C patients but not in sepsis indicating immune exhaustion. PPLE-15 Determinants of nonadherence to immunosuppression in liver transplant recipients Mayank Jain, Jayanthi Venkataraman, Mettu Srinivas Reddy, Mohamed Rela Correspondence- Mayank Jain- [email protected] Gleneagles Global Health City, Chennai Background Treatment and drug adherence is paramount for success of transplant surgery. There is lack of Indian data on adherence in post transplant setting. Aim To study the determinants of nonadherence to immunosuppressants and nonimmunosuppressant drugs in liver transplant recipients using personalized interview and questionnaire methods. Methods The study was done over a six month period. We included adult liver transplant recipients (both DDLT and LDLT) from the Indian subcontinent who followed up in the Institution post liver transplant clinic. Recipient details included baseline demography, comorbidity, psychological mental status, details of addiction like alcoholism, indication and type of transplant (LDLT/DDLT. Financial support for transplantation, admissions for rejection, infection and post transplant complications were obtained from the hospital records. Adherence questionnaire was completed by direct interview and using a questionnaire. Results Sixty-seven liver transplant recipients (56 males, median age 48.17 years) constituted the study group. Overall 11 patients (16.47%) were nonadherent to the treatment. LDLT recipients were more adherent than DDLT recipients. Recidivism was documented in 4 recipients, 2 each in adherent and nonadherent group respectively. Nonadherent recipients were believers in alternative systems of medicine. Medication related factors like improper dosing, meagre drug knowledge, difficulty in remembering drug dose and timings, economic constraints in continuing medical treatment was statistically significant in nonadherent recipients. Post-transplant complications like acute cellular rejection and infection was statistically significant in nonadherent recipients. Conclusion The prevalence of nonadherence in liver transplant recipients was 16.5%. Determinants of nonadherence were deceased donor liver transplant, use of alternative medications, high regimen complexity, poor knowledge about medications and cost issues with long-term medications. PPLE-16 miRNA profiles and their contribution in ulcerative colitis pathogenesis pre and post therapy Avinash Bardia1, Sandeep K Vishwakarma1, Nagarapu Raju1, Lakki Reddy Chandrakala1, Gollapalli Sravani1, B V S Sastry1, Shaik Iqbal Ahmed1, Safwaan Habeeb1, Aleem Ahmed Khan1, Md. Aejaz Habeeb1* Correspondence- Mohammed Aejaz Habeeb- [email protected] Centre for Liver Research and Diagnostics, HLS, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India

Indian J Gastroenterol

Introduction Differentially expressions of MicroRNAs (miRs) have been concerned in the pathogenesis of various gastrointestinal disorders such as ulcerative colitis (UC). However, the pathogenesis of UC still remains mysterious. The discovery of miRs will offer a novel way to understand the UC and will give rise to new diagnostic and therapeutic strategies. Present study was aim to assess the differential expression of miR in peripheral blood sample of UC patients in order to identify new potential biomarkers for UC. Methods Blood samples were obtained from 50 UC patients and 50 healthy volunteers. Serum was separated by centrifugation (1500 g) from 6 mL of total blood. miR was extracted immediately and followed by cDNA construction. miR-146a, miR-155, miR-181a, miR-21 and miR-7 expression levels were quantified by using qRT-PCR before and after (3, 6 and 12 months) treatment with TNF-Alpha inhibitors. Results We have demonstrated that expression of miR-146 and miR155 was significantly down regulated after 12 month of therapy compare to before (p=0.009) (p=0.006). After 3 month of therapy, miR-181 was down regulated but data did not reveal any statistically significant (p=0.10). miR-21 expression level was down regulated after 3 and 6 month of therapy when compared to before. Study has also demonstrated that the expression level of miR-7 was significantly up regulated after treatment. Conclusion This finding suggests that circulating miRs profiles may indicate a potential role of miRs as noninvasive biomarkers for UC, and inflammation in UC has an impact beyond the mucosa and generating a systemic reaction. PPLE-17 Determinants of post paracentesis acute kidney injury in patients with cirrhosis of liver Vaibhav Patil, Mayank Jain, Uday Sanglodkar, Joy Varghese, Tom Michael, Jayanthi Venkataraman Correspondence - Mayank Jain- [email protected] Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai Background Despite adequate colloidal replacement, a subgroup of patients undergoing paracemtesis develop AKI and the predictors responsible for this injury are yet unknown. Aim of the study To determine the prevalence and predictors of paracentesis induced AKI in patients with liver cirrhosis with normal baseline renal parameters Methods A prospective, observational analytical study undertaken at Gleneagles Global Health City, Chennai between April 2015 to April 2017. All patients undergoing large volume paracentesis were enrolled as per inclusion and exclusion criteria. As per AKIN criteria for acute kidney injury, cohort was divided into AKI and non AKI group based on their reports after 48 hours of paracentesis. All variable were analyzed with these two group with both univariate and multivariate regression to dertermine significant predictors of AKI post paracentesis. Results One hundred and eighty-two patients underwent 859 therapetuic paracentesis. Ninety-four paracentesis resulted in AKI (10.9%). The median number of paracentesis was 10 (range 1-25) and the median volume of fluid drained per paracentesis was 6 L (1-20 L). Hypotension occurred on 30 (30/859; 3.5%) and respiratory distress on 7 (7/859; 0.8%) occasions. By univariate analysis, etiology of cirrhosis, diabetes, hypertension and coronary artery disease were significantly associated with development of AKI. Patients who developed post paracentesis AKI were significantly younger, with higher MELD scores and greater volume of fluid drained. By univariate logistic regression, for each litre of fluid drained during paracentesis, the risk of AKI increased by 1.24 times. By multivariate logistic regression, the significant predictors of AKI were volume of fluid drained and MELD score.

Conclusion The prevalence of post paracentesis AKI is 10.9%. The volume of abdominal paracentesis and MELD score are definitive predictors of paracentesis induced AKI. PPLE-18 Transition zone defects in gastroesophageal reflux disease patientsClinical implications and significance Piyush Bawane, Mayank Jain, Melpakkam Srinivas, Ravi Patel, Jayanthi Venkataraman Correspondence- Mayank Jain- [email protected] Gleneagles Global Health City, 439, Cheran Nagar, Perumbakkam, Chennai Background There is no data regarding transition zone (TZ) defects in gastroesophageal reflux disease (GERD) patients and its significance in clinical practice. Aim To determine the prevalence of TZ defects in GERD patients in and to correlate the size of the defect with patient symptoms and occurrence of distal peristaltic defects. Methods A prospective study was undertaken Gleneagles Global Health City, Chennai from June 2015 to May 2017. Esophageal manometry parameters for GERD cases and healthy controls were obtained. HREM was done in supine position using 16 channel water perfusion system (Ready Stock, Australia). The parametrics and interpretation were reported as per Chicago Classification v 3.0. TZ defects were classified as <5 cm and >5 cm. For each of the two forms of TZ defects their influence on distal breaks and further correlation with GER symptoms was done. Independent sample t-test and chi square tests were used. P value < 0.05 was considered statistically significant. Results One hundred and thirty patients with GERD underwent HREM during the study period. The DCI was significantly lower in cases compared to controls (p=0.03). These patients had significant number of proximal breaks as compared to controls (p=0.002). Of these 130 cases, 87 (66.9%) had TZ defects. The defects were less than 5 cm in 67 (77%) and beyond 5 cm in size in 20 (23%) cases. In patients with large breaks in the transition zone, nearly half had defects in the distal segment of the esophagus as well. In patients with smaller defects in TZ (<5 cm), a significant proportion of patients had smaller distal breaks. Sixty-nine percent of patients with TZ defects reported typical GERD symptoms. Conclusion 2/3 of cases of GERD have TZ defects, which is significantly higher than in healthy individuals. These have an association with distal peristaltic defects and are associated with typical GERD symptoms in Indian patients. PPLE-19 Comparison of non-invasive methods to diagnose non-alcoholic fatty liver disease in morbidly obese patients undergoing bariatric surgery J Singh1, D Goel2, A Garg1, A Sahney1, S Mazumder1, V P Bhalla2, J C Vij1, R Vats2, H Mahajan3, V Malhotra4, Yogesh Batra1 Correspondence- Yogesh [email protected] Departments of Gastroenterology1, GI Surgery2 and Pathology, 4B L K Superspeciality Hospital, New Delhi, Mahajan Imaging3, New Delhi Introduction Recently, a number of non-invasive methods to assess both hepatic steatosis (Fibroscan TE-CAP and MR fat quantification) and fibrosis (Fibroscan TE-E and Shearwave elastography 2D SWE) have been developed. There is limited data comparing the accuracy of these modalities. Methods Consecutive patients undergoing bariatric surgery between April 2015 to December 2016 were included. Preoperatively all patients underwent clinical evaluation and biochemical tests, MRI Fat quantification and TE-CAP for the assessment of steatosis and 2D SWE and TE-E

Indian J Gastroenterol

for the assessment of fibrosis. Liver biopsy (NAS score) was done intraoperatively. Results A total of 52 patients were enrolled of which 44 could be analyzed. 2 D SWE detected any fibrosis (stage 1 or more) with an area under the receiver operating characteristic curve (AUROC) of 0.86 (95% confidence interval [CI], 0.70–1.0), which was higher than that of TE-E (AUROC, 0.75 (95% CI, 0.6-0.91) but did not reach statistical significance. MRI detected any steatosis with an AUROC of 1 (95% confidence interval [CI], 1-1), which was significantly higher than that of CAP (AUROC, 0.441 (95% CI, 0.2-0.61). There was procedure failure rate for TE CAP (9/44) and for TE – E (XL-probe) (4/44). Conclusions MRI-fat quantification is more accurate than CAP in detecting all grades of steatosis in patients with non-alcoholic fatty liver disease. 2 D SWE was similar to TE in identification of liver fibrosis (stage 1 or more), using biopsy analysis as the standard. But there was higher failure rate of TE measurement. PPLE-20 Incidence and clinical implications of Bdisconnected pancreatic duct syndrome^ following endoscopic ultrasound-guided drainage of pancreatic fluid collections with metal stent – A prospective cohort study Partha Pal, Jahangeer Basha, Sundeep Lakhtakia, Mohan Ramchandani, Rajesh Gupta, Rupjyoti Talukdar, Zaheer Nabi, B V N Kumar, Jagadeesh Singh, Rakesh Kalpala, P M Manohar Reddy, G V Rao, Manu Tandan, D Nageshwar Reddy Correspondenc - Partha Pal - [email protected] Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Introduction Concerns have been raised about drainage of pancreatic fluid collection (PFC) with metal stent in the setting of disconnected pancreatic duct (DPD). We aim to assess the frequency of DPD and its clinical significance after endoscopic ultrasound (EUS) guided drainage of PFC with bi-flanged metal stent (BFMS). Methods Patients of acute or chronic pancreatitis with symptomatic PFC, who underwent EUS guided drainage with BFMS between March 2015 to January 2017 were included. All patients underwent MRCP and endoscopic retrograde pancreatography (ERP) between 4 to 8 weeks after drainage to evaluate pancreatic duct (PD) anatomy and confirm resolution of PFC. BFMS was removed in all patients during ERP. The patients were followed at 3 monthly intervals for recurrence of PFC or new clinical event. Results Total 109 patients (92 males, age 10-65 years) had pancreatogram (ERCP and MRCP) which showed following PD abnormalities: DPD-68 (62.4%), leak-8 (7.3%), stricture7 (6.4%), normal PD-23 (21.1%) and calcific pancreatitis-3 (2.8%). The location of DPD was in head 13 (19.1%), genu 17 (25%), body 32 (47.1%) and tail 6 (8.8%). PFC recurred in 12 patients (7 symptomatic, 5 asymptomatic), all of them had DPDS. 4/7 symptomatic recurrence required reintervention (EUS drainage with plastic stent in 3, surgery in 1) and 3/7 resolved spontaneously. 19/68 (27.9%) DPDS patients and 4/37 (10.8%) non-DPDS patients developed pancreatic atrophy/new onset chronic pancreatitis (CP) (p=0.041, OR-4.156). No significant difference in new onset diabetes or left sided portal hypertension were observed between DPDS and non-DPDS group. 22/68 (32.3%) DPDS and 5/41 (12.2%) non-DPDS patients have recurrent pain with or without pancreatitis (p=0.012, OR-6.32). Conclusion DPDS is observed in two-thirds of patients after drainage of PFC, but only small percentage (5.8%) requires re-intervention. DPDS patients are more prone to develop pancreatic atrophy/ CP and recurrent pain compared to non- DPDS patients.

PPLE-21 High resolution esophageal manometry testing in health and gastroesophageal reflux disease: Supine, upright or both? M Srinivas, Mayank Jain, V Jayanthi Correspondence- M [email protected] Institute of Gastrointestinal and Hepatobiliary Sciences, Gleneagles Global Health City, Chennai 600 100, India Background High resolution esophageal manometry (HREM) is the current gold standard to assess esophageal motility. The test is done in supine posture and reported using Chicago Classification. However, most symptoms occur in upright posture, potentially being missed by HREM in supine posture. There is no Indian data comparing the effect of both postures on HREM parameters in healthy and gastroesophageal reflux disease (GERD)] patients. Aim To study and compare the effect of posture (supine and upright) on HREM parameters and Chicago Classification in healthy volunteers and GERD patients. Methods Prospective case control study comparing patients with gastroesophageal reflux symptoms (n=49) and controls comprising healthy volunteers (n=55). HREM was done in supine and upright position using 16channel water perfused system (Readystock, Australia) in both the groups. The HREM parameters were collected and reported using Chicago Classification v3.0. Independent sample t-test and Chi-square test was used to test statistical significance. P value < 0.05 was deemed significant. Results GERD patients were significantly older and had a higher BMI compared to controls. None of the HREM parameters were significantly different in upright and supine positions within the two groups and between the two groups. Concordance of Chicago classification between the two postures was good in healthy controls (kappa 0.67) and moderate in GERD patients (kappa 0.59). Conclusions This first Indian study comparing HREM parameters in supine and upright suggests that test posture does not play a significant role in healthy and GERD patients. A larger sample size is required to confirm this finding especially in GERD patients. PPLE-22 Serum IL-6 combined with SIRS accurately predicts development of organ failure in acute pancreatitis Saransh Jain, 1 Shallu Midha,1 Soumya Jagannath Mahapatra,1 Swatantra Gupta,1 Manish Sharma,2 Baibaswata Nayak,1 Tony George Jacob,2 Shalimar, 1 Pramod Kumar Garg1 Correspondence- Pramod Kumar Garg- [email protected] 1 Department of Gastroenterology and Human Nutrition, 2Department of Anatomy, All India Institute of Medical Sciences, New Delhi 110 029, India Background and Aims Predicting severe acute pancreatitis (SAP) is important for triage, prognosis, and designing therapeutic trials. Persistent systemic inflammatory response syndrome (SIRS) predicts SAP but its diagnostic accuracy is suboptimal. Cytokines mediate organ failure (OF), and might be useful predictors of SAP. We aimed to study if cytokines could improve upon the predictive value of clinical variables for the development of SAP. Methods Consecutive patients with a first episode of acute pancreatitis (AP) were included in a prospective cohort study at tertiary care centre. Serum levels of IL-6, TNF-α, IL-10, MCP-1, GM-CSF, IL-1β were measured at 72 hours of the onset of AP. Variables such as age, comorbidity, etiology, SIRS, and cytokines were modeled to predict SAP by multivariable regression analysis. Genotyping was done to correlate cytokine gene polymorphism with cytokine levels.

Indian J Gastroenterol

Results Of 236 patients with AP, 115 patients admitted within 7 days of onset formed the study group. Thirty-seven of the 115 (32%) patients developed OF. Independent predictors of OF were persistent SIRS (OR 34; 95% CI: 7.2-159) and day 3 serum IL-6 of >160 pg/mL (OR 16.1; 95% CI:1.8–142). IL-6 gene (-174 G/C) GG genotype was associated with significantly higher levels of IL-6 compared to CC/CG genotype. Serum IL-6 >160 pg/mL increased the positive predictive value of SIRS from 45% to 85% and specificity from 60% to 95% for predicting OF without significantly compromising its sensitivity and negative predictive value. Conclusion Serum IL-6 value of >160 ng/mL added significantly to the predictive value of SIRS for the development of OF. PPLE-23 Long-term gastrointestinal consequences are frequent following sporadic acute infectious diarrhea in the tropics: A prospective cohort study M Masudur Rahman, Uday Chand Ghoshal, Shamima Sultana, Md. Golam Kibria, Nigar Sultana, Zeenat Arefin Khan, Faruque Ahmed, Mahmud Hasan, Tahmeed Ahmed, Shafiqul Alam Sarker Correspondence- Uday Chand [email protected] Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh. Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India. Nutrition and Clinical Service Division, International Center for Diarrheal Disease Research, Bangladesh. Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh. Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh. Nutrition and Clinical Service Division, International Center for Diarrheal Disease Research, Bangladesh. Department of Gastroenterology, Dhaka Medical College and Hospital, Dhaka, Bangladesh. Gastroliver Foundation, Dhaka, Bangladesh. Background Though post-infection irritable bowel syndrome (PI-IBS) and functional dyspepsia (PI-FD) are reported mostly from temperate countries, PI-malabsorption syndrome (MAS), which mimics PI-IBS, is reported from the tropics. No report on PI-IBS excluded PI-MAS. We studied, (i) the frequency of continuing bowel dysfunction after acute gastroenteritis (AGE), (ii) predictors of its occurrence, and (iii) frequency of PI-MAS among patients with PI-IBS. Methods Three hundred and forty-five consecutive subjects each with AGE and age- and gender-matched healthy controls presenting to ICDDRB, Bangladesh were followed up 3 monthly for 12 months using a translated-validated Rome III questionnaire. PI-IBS and PI-FD were diagnosed using Rome III criteria; if the duration of the symptoms was >3-month but <6-month, chronic bowel dysfunction (CBD) and dyspeptic symptoms, respectively, were diagnosed. Fecal microbiological studies were performed in 245/345 (71%) patients. PI-IBS patients were diagnosed as PI-MAS if 2/3 tests were abnormal: (i) D-xylose hydrogen breath test, (ii) fecal fat microscopy (Sudan III stain), and (iii) histopathology of duodenal biopsy. Results Patients were comparable to controls in age and gender (female 41% in each group). Patients with AGE more often developed PI-IBS and PI-FD than controls (16.5% vs. 2.6% and 7.4% vs. 0.6%, respectively; p=0.00). Presence of FD was a risk factor for PI-IBS (p=<0.0001) and IBS was a risk factor for PI-FD (p=<0.0001). On multivariate analysis, presence of dyspeptic symptoms, CBD and weight loss were the risk factors for PI-functional gastrointestinal disorders (FGIDs). The frequency of PI-IBS following Vibrio cholera and other bacterial infection was comparable. Malabsorption was present among 2 (9%) of 23 subjects with PI-IBS. Conclusion Bowel dysfunction is common after AGE. Dyspeptic symptoms, CBD and weight loss are the risk factors for PI-FGIDs. AGE caused by Vibrio cholerae is a risk factor for PI-FGID. About 10% patients who fulfil the criteria for PI-IBS had PI-MAS.

PPLE-24 Diagnostic adequacy and safety of endoscopic ultrasound guided fine needle aspiration in patients with lymphadenopathy in a large cohort Correspondence- Rajesh [email protected] Rinkesh K Bansal,1 Narendra S Choudhary1, Saurabh K Patle,1 Mahesh K Gupta,1 Chitranshu Vashishtha,1 Gagandeep Kaur2, Haimanti Sarin2, Rajesh Puri1 Institute of Digestive and Hepatobiliary Sciences1 and Department of Cytopathology2 Medanta The Medicity, Gurugram, India Background Role of endoscopic ultrasound (EUS) guided fine needle aspiration (FNA) in patients with lymphadenopathy in term of diagnostic adequacy and safety in large population is not well defined. Aim of current study was to evaluate diagnostic adequacy and safety of EUS FNA in patients with lymphadenopathy. Methods Retrospective study from October 2010 to September 2015 at tertiary care center in Delhi-NCR. We analyzed data of 1005 EUS guided FNA of lymph node. Results The study cohort comprised 1005 lymph nodes in 865 patients; 68% were males, mean age was 50±14 years. Indications of FNA were to look for etiology of pyrexia of unknown origin or staging of malignancy mainly. FNA was taken from mediastinal nodes (n=528, 52.5%) and intra-abdominal nodes (n=477, 47.5%). Median size of nodes at long axis and short axis was 17 (12-25.7) and 10 (8-15) mm respectively. Adequate material by FNA was obtained in 92.8% cases. The cytopathologic diagnosis were malignancy in 153 (15.2%), granulomatous change in 452 (42%), and reactive lymphadenopathy in 328 (35.6%). There was statistically significant difference seen between groups with pathological and reactive lymph nodes regarding size at long and short axis, all the echofeatures of lymph nodes. Procedure related adverse effects were encountered in 6 patients (0.8%). Four patients had mild mucosal bleeding in chronic liver disease patients and two had mild hepatic encephalopathy related to sedation. Conclusion EUS FNA of lymph nodes has good diagnostic adequacy and safety. PPLE-25 Local mucosal immune effector and regulatory T cells in adult patients with treatment naïve celiac disease Prasenjit Das1, Gaurav P S Gahlot1, Vandana Badola1, Alka Singh2, Sreenivas Vishnubhatla3, Siddhartha Datta Gupta1, Govind K Makharia2 Correspondence- Prasenjit [email protected] Departments of Pathology1, Gastroenterology and Human Nutrition2, and Biostatistics3, All India Institute of Medical Sciences, New Delhi 110 029, India Background Tightly regulated mucosal immunity is crucial for protection against luminal microflora and tolerance to dietary proteins. The aim of this study was to analyze the immune effective and regulatory T cell (Treg) populations in mucosal biopsies obtained from patients with celiac disease (CeD) having different grades of villous abnormalities. Methods In this cross section study a total 234 duodenal biopsies [D2 and D3] (132 control and 102 treatment naïve CeD) were included. Mucosa infiltrating lymphocytes and intra-epithelial lymphocytes (IELs) were examined by dual immunohistochemical staining (IHC) for CD20, CD3:CD4, CD3:CD8, CD4:FoxP3, CD8:FoxP3 and TCRαβ: TCRγδ cells. The density of these lymphoid cell groups were correlated with modified Marsh grades. Results Linear increasing pattern for both CD3+IELs and CD20+B cells in lamina propria were noted with increasing modified Marsh grades. Serum anti-tTG titer also showed a similar linear increasing pattern. Densities of both CD4+T cells in lamina propria and CD8+γδ intra-

Indian J Gastroenterol

epithelial T cells were significantly more in biopsies of treatment naïve CeD, than in controls. While the CD8+FoxP3+iTreg cells were found to be significantly upregulated, the CD4+FoxP3+Treg cells were found deficient in biopsies of CeD, than in control biopsies. Conclusion Lack of immune suppressive CD4+FoxP3+Treg cells in duodenal biopsies of treatment naïve CeD cannot be compensated by upregulated weakly suppressive CD8+FoxP3+iTreg cells, contributing to loss of mucosal tolerance in CeD. Though, both TCRγδ and TCRαβ are present in duodenal mucosa in CeD, TCRγδ+IELs were predominant. PPLE-26 Endothelial nitric oxide synthase: A new potential biomarker for gastric cancer * D Krishnaveni1,2, P Shravan Kumar1, M Umadevi1, K Rajender Rao3, Pratibha Nallari2, A Venkateshwari2 Correspondence- Krishnaveni Devulapalli- [email protected] 1 Department of Gastroenterology, Gandhi Hospital, Secunderabad India, 2 Institute of Genetics and Hospital for Genetic Diseases, Osmania University, Hyderabad, India, and 3National Institute of Nutrition, Tarnaka, Hyderabad 500 007, India

Introduction Gastric cancer (GC) is a multifactorial disorder mediated by genetic, epigenetic and environmental risk factors. Endothelial nitric oxide synthase (eNOS) gene was reported to play an important role in various diseases. The present study is aimed to investigate the association of eNOS 4 b/a 27 bp VNTR polymorphism and its expression with gastric cancer in south Indian population. Methodology A total of 314 controls and 160 GC patients were considered for the study. Genomic DNA was extracted from blood samples by salting out method. Genotyping of the VNTR polymorphism was carried by polymerase chain reaction (PCR). Hardy-Weinberg equilibrium, odds ratio and 95% confidence intervals were calculated to evaluate the association between polymorphism and GC. The RNA was extracted from stomach biopsies using Trizol method and converted to C DNA by Invitrogen kit method. The expression of eNOS gene was evaluated by real-time RT-QPCR with reference to GAPDH using SYBR Green chemistry. The relative gene expression changes were analyzed by ANOVA using SPSS. Results Risk factor profile indicates advanced age, male gender, nonvegetarian diet, addiction to smoking or alcohol, consanguinity, and H. pylori infection were the epidemiological risk factors (p< 0.05). The statistical analyses revealed 2.6 fold enhanced risk of GC with a/a genotype (p= 0.0017) than other genotypes. Interaction analysis showed that a/a genotype caused 6.35 fold risk with male preponderance, 11 fold risk with smoking and 14 fold risk with alcoholism. The eNOS mRNA expression was down-regulated by 3.75-fold in GC cancer tissues and by 0.18 fold in non cancerous tissues of the respective patients in comparison to controls. Conclusion The a/a genotype of eNOS 4a/b polymorphism was significantly associated with down regulation of eNOS mRNA expression in GC cases. Hence, the eNOS gene acts as a new potential biomarker in the etiology of gastric cancer. PPLE-27 Role of diagnostic endoscopic ultrasound in idiopathic acute pancreatitis and acute recurrent pancreatitis in children Srikanth Puttaiah Kadyada1, B R Thapa1, Narendra Dhaka1, Anmol Bhatia2, Jagadeesh Menon3 Correspondence- B R [email protected] 1 Division of Pediatric Gastroenterology, Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, 2Department of Gastroenterology, Postgraduate Institute

of Medical Education and Research, Chandigarh 160 012, India, D i v i s i o n o f P ed i a t r i c G a s t ro e n t e r o l o g y, D e p a rt m e n t o f Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India 3

Objectives Endoscopic ultrasound (EUS) is a minimally invasive real time pancreatic imaging modality for assessing pancreatic and peripancreatic structures. We prospectively evaluated for the biliary (stone, sludge, microlith and anomalies of pancreatico-biliary system) risk factor and morphological changes of pancreatitis in idiopathic acute pancreatitis (IAP) and acute recurrent pancreatitis (ARP). Methods Patients underwent EUS after 2 months of attack of pancreatitis. They were studied for changes of chronicity (according to Rosemont criteria) and risk factors of pancreatitis. Diagnostic yield of transabdominal ultrasonography (TUS) was compared with EUS. Results Among 99 patients evaluated during study period, 45 (18 IAP and 27 ARP) where eligible for EUS. Age and weight (Mean±SD) were 9.1 ±2.6 years, 32.66±12.43 kg and 12.2±3.1 years, 44.84±15.12 kg for IAP and ARP respectively. Overall, 33.33% of IAP and 37.03% of ARP were abnormal (p=0.799). Unequivocal changes of chronic pancreatitis were noted only in ARP (11.11% vs. 0%). Hyperechoic ductal margin (11.10% and 18.15%) and hyperechoic foci (55.5% and 66.66%) were the most common changes seen in IAP and ARP respectively. Risk factor were identified only in ARP (25.9% vs. 0%; p=0.031). Sensitivity, specificity, PPV, NPV among IAP and ARP for detecting changes of chronicityusing TUS as compared to EUS were 28.57%, 90.90%, 66.66%, 66.66% and 63.63%, 100%, 100%, 80% respectively. Conclusions About one-third of IAP and ARP showed changes of chronicity after recovery from acute attack of pancreatitis. Unequivocal changes of CP (11%) and risk factors were seen only in ARP. Sensitivity of TUS t5 detect changes of chronicity was poor in comparison to EUS. PPLE-28 Impact of pancreatic ductal clearance on diabetes in patients with chronic pancreatitis Rupjyoti Talukdar*+, D Nageshwar Reddy*, Manu Tandan*, Rajesh Gupta*, Sundeep Lakhtakia*, Mohan Ramchandani*, Rajesh Kalapala*, Jahangeer Basha*, Zaheer Nabi*, R Pradeep**, G Venkat Rao** Correspondence- Rupjyoti Talukdar- [email protected] * Department of Medical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India, ** Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India, + Wellcome DBT Laboratories, Asian Healthcare Foundation, 6-3-661, Somajiguda, Hyderabad 500 082, India Introduction Chronic pancreatitis (CP) is characterized by pain, exocrine insufficiency and diabetes. Treatment of CP mandates a multimodal approach. The impact of endotherapy and surgery on diabetes is unclear. We evaluate risks of diabetes and effect of pancreatic ductal clearance on its development in CP. Methods A database was generated from 1st August 2011 to 31st July 2012 wherein consecutive patients with CP who visited the Pancreas Clinic were enrolled and prospectively followed. After entering relevant available records, the patients were followed 6 monthly for disease progression for at least 4 years. Patients without complete data and those who were lost to follow up were excluded from the study. Logistic regression was used to assess for independent risk factors for diabetes while Kaplan-Meier analyses and Hazard’s ratio were used to evaluate the effect of ductal clearance on diabetes over time. Results Six hundred and forty-four patients were enrolled into the database, of which 137 were excluded in this study. Five hundred and seven patients were analyzed, of which 312 (61.5%) had idiopathic CP. Two

Indian J Gastroenterol

hundred and eighty-three (55.8%) patients underwent ductal clearance (ESWL with ERCP 232, drainage surgery 27 and ESWL followed by surgery 24), while 190 (37.5%) patients developed diabetes. Alcohol intake and presence of pancreatic ductal calculi were independently associated with the development of diabetes (OR [95% CI] of 2.01 [1.163.47], p=0.03 and 2.04 [1.38-3.01], p<0.0001 respectively). KaplanMeier estimate for diabetes free patients was significantly higher in the patients who underwent ductal clearance in the idiopathic CP group (p=0.001 by Log rank test), with a Hazard ratio (HR, 95% CI) of 2.01 (1.3-3.0), p=0.002. The mean (SD) duration between onset of CP symptoms and ductal clearance was 3.4 (3.2) yrs. Discussion Pancreatic ductal calculi increase the risk of diabetes in patients with idiopathic CP but early ductal clearance of stones could prolong the diabetes free interval. PPLE-29 Hepatic encephalopathy and bilirubin prognosticate in decompensated Wilson’s disease: Does the new Wilson’s index help? Seema Alam Correspondence- Seema [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims Decision about liver transplant is difficult in decompensated Wilson’s disease (WD) patients, especially with conflicting reports about efficacy of new Wilson’s index (NWI). Methods Data of all pediatric (<18 years age) WD cases, managed between January 2011 to January 2017, was retrospectively analyzed. Univariate and multivariate analysis was done to identify risk factors of poor outcome (liver transplantation or death). Results Of the total 85 cases, 74 were either acute-on-chronic liver failure (ACLF) or decompensated chronic liver disease (DCLD) cases. Of these 74 cases, 46 (62.2%) improved and 28 (37.8%) either died (21) or were transplanted (7). Among those with NWI ≥11 (33/74 cases), 12 survived and 21 had poor outcome. On comparison with univariate analysis, HE grade 3 or 4 (OR 35.8 95% CI 8.58-149), bilirubin >20 mg/dL (OR 14.3, 95% CI 3.5857.2), ACLF as presentation (OR 3.07, 95% CI 1.15-8.16), AST (mean difference 160.8, 95% CI 64.8-256), INR (mean difference 1.63, 95% CI 0.93-2.33), NWI (mean difference 5.37, 95% CI 3.67-7.08), and PELD/MELD score (mean difference 11.47, 95% CI 6.7-16.2), were significantly associated with poor outcome. On multivariate analysis, significant association was seen only with HE grade 3 or 4 (adjusted OR 37.8, 95% CI 7.68-186.49) and bilirubin >20 mg/dL (adjusted OR 15.5, 95% CI 2.7-86.8). Conclusion HE grade 3 or 4 and high bilirubin (>20 mg/dL) are independently associated with poor outcome in decompensated WD cases. NWI may not have an independent association with poor outcome. PPLE-30 Vitro score: A novel predictor of esophageal varices, decompensation and mortality in cirrhosis of liver Gaurav Trimbak Ratnaparkhi, B Sukanya, J Nayana, Y Raghavendra, S G Uppin, J Rishabh, C Vineet, N S Ravichandra, A Sumaswi, C Bhushan, Ajit Kumar Correspondence- Gaurav Ratnaparkhi- [email protected] Department of Gastroenterology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Background The role of VITRO score (plasma von Willebrand factor (vWF)/Thrombocyte ratio) in cirrhotic patients is not well established. The aim of this study was to investigate the association of VITRO score

with decompensation and presence of esophageal varices (EVs) in patients with cirrhosis of liver (COL). Methods Patients of cirrhosis of liver were included in this study. Endoscopic assessment of the severity of EVs was done. Child-Pugh (CTP) score was used to define decompensation. Plasma vWF estimation and VITRO score calculation was done. VITRO score was then correlated with CTP class and severity of EVs. Results Total 78 patients of COL were included. Mean+SD VITRO score in cases who had EVs (3.89+2.79) was significantly higher than in cases without EVs (1.25+0.39) (p-0.0026). At cutoff value of 1.69, VITRO score has shown excellent AUC (0.94), sensitivity (87.57%), specificity (90.11%) and likelihood ratio (LR) of 9.5 for prediction of EVs (p value <0.0001). Similarly VITRO score was significantly higher in decompensated ( 3.82+2.77) cirrhotics as compared to compensated cirrhotics (1.13+0.28), hence it is useful in prediction of decompensation. (The two-tailed p value equals 0.0049). Also At cutoff value of 1.69, VITRO score has shown excellent AUC (0.97), sensitivity (86.97%), specificity (100%) and LR (8.5) for prediction of decompensation of liver disease (p value <0.0001). Conclusion The VITRO score represents a highly sensitive, specific, and accurate non-invasive predictor for the presence of decompensation and EVs in liver cirrhosis of any etiology. PPLE-31 Light microscopic and computer-assisted image analysis based classifications for assessment of intestinal mucosal biopsies in adults Prasenjit Das1, Gaurav P S Gahlot1, Ramakant Rawat2, Anil K Verma2#, Gaurav Khanna1, Maitrayee Roy1, Alka Singh2, Archana George1, Ashok Singh1, Aasma Nalwa1, Prashant Ramteke1, Vishnuvatla Sreenivas3, Vineet Ahuja2, Siddhartha Datta Gupta1, Govind K Makharia2 Correspondence- Prasenjit [email protected] Departments of Pathology1, Gastroenterology and Human Nutrition2, and Biostatistics3, All India Institute of Medical Sciences, New Delhi, India (# is currently affiliated to celiac Disease Research Laboratory, Department of Pediatrics, Università Politecnica delle Marche) Introduction The existing histological classifications for small intestinal biopsies are based on qualitative parameters; hence are prone to interobserver disagreements. Methods We calculated intra and inter-observer agreements using Marsh, modified Marsh, Corazza/Villanacci, and Ensari classifications. Both light microscopic (LM) and computer assisted image analysis (CIA) based histological features were assessed in duodenal biopsies of 147 controls and 210 patients with celiac disease (CeD). Receiver operating curve analysis, followed by multivariate and logistic regression analyses were performed to identify parameters which could differentiate biopsies of controls and patients with CeD. Based on quantifiable parameters, we proposed and validated a LM-based and a CIA-based histological classification systems for duodenal biopsies. Results The intra-observer and inter-observer agreements with existing classifications varied between 39.7%-64.5% and 12.9%-48.7%, in our study respectively. The normative features in our control cohort include- C:V-1:2 and normal intra-epithelial lymphocyte (IEL) count 13.4±8.1/100 epithelial cells. On multivariable analysis villous height <33.5 μm, IEL count ≥ 25/100 ECs and villous area ≥750 μm2 were found relevant for differentiation between biopsies from a patient with CeD and controls. We proposed two histological classification systems, based on LM and CIA characteristics respectively. Much higher intraobserver (41.9% to 86.2%) and inter-observer (27.2% to 54.9%) agreements were achieved with our proposed LM-based classification. While the intra-observer agreements with the CIA based classification system were between 22.2% to 81.3%, the inter-observer agreement was variable (4.7% to 35.3%).

Indian J Gastroenterol

Conclusions In comparison to existing histological classifications, the improvised light microscopic and newly proposed CIA-based classification systems are based on quantifiable histological parameters and simple to use. PPLE-32 Prevalence of sarcopenia and its impact on outcome in patients with cirrhosis T K Surakshith, Mandhir Kumar, Piyush Ranjan, Munish Sachdeva, Samarjit Ghuman Correspondence- T K [email protected] Institute of Liver, Gastroenterology, and Pancreaticobiliary Sciences, Sir Ganga Ram Hospital, New Delhi 110 060, India Background and Aims Sarcopenia is an under-recognized complication of cirrhosis which negatively impacts survival, quality of life and response to stress. There is paucity of data regarding the prevalence and its impact on morbidity and mortality in cirrhotics. In this study, we aimed to establish the frequency and clinical significance of sarcopenia in cirrhotic patients. Methods This was a prospective study in which 60 consecutive patients with liver cirrhosis. To define sacopenia, transverse CT image at the middle of third lumbar vertebra (L3) was to measure cross-sectional area of the right psoas muscle and Psoas muscle index (PMI) was calculated. Sarcopenia was defined as PMI <295 mm2/m2 for females and <356 mm2/m2 for males. Fisher’s exact test was used to compare categorical variables and unpaired t-test to compare differences in means of continuous variables. A p-value <0.05 was taken as significant. Results Seventy-three percent were males. Mean age was 54.5±11 years. Etiology of cirrhosis were ethanol (43.3%), NAFLD (28.3%) and viral (16.6). Mean MELD and Child scores were 14.59±9.29 and 8.61±1.85 respectively. Sarcopenia was seen in 51.6 %. More frequent in males (p=0.019), ethanolics (p=0.0016) and hepatic encephalopathy (HE) (p=0.0001). It showed correlation with bilirubin (p=0.026), albumin (p=0.003), INR levels (p=0.0004) and MELD scores (p=0.00001). There was a linear correlation between the PMI and severity of liver disease as assessed by Child and MELD scores (r= -0.68 and -0.36 respectively). Seventy percent of the patients who had sarcopenia required readmission within 6 months of follow-up (p=0.0001). Conclusion Sarcopenia is seen in about half of the patients with cirrhosis. It is more common in males and alcoholic liver disease. Sarcopenia correlates with the severity of liver disease (MELD and Child scores). Patients with sarcopenia have higher incidence of HE and require more re-admission on follow up. PPLE-33 Hepatic fibrosis does not affect the assessment of hepatic steatosis by controlled attenuation parameter in patients with chronic liver disease Gyanranjan Rout1, Shalimar1, Saurabh Kedia1, Baibaswata Nayak1, Rajini Yadav2, Prasenjit Das2, Deepak Gunjan1 Correspondence – Shalimar - [email protected] 1 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110 029, India, 2Department of Pathology, All India Institute of Medical Sciences, New Delhi 110 029, India Background and Aim The gold standard method for measurement of hepatic steatosis is liver histology. Controlled attenuation parameter (CAP) can measure hepatic steatosis noninvasively. We aimed to assess the effect of hepatic fibrosis on the diagnostic accuracy of CAP.

Methods A total of 462 patients (May 2012-January 2017)-89 nonalcoholic fatty liver disease, 182 chronic hepatitis B, 88 chronic hepatitis C and 103 chronic liver disease patients with other etiologies were included. Both CAP and liver biopsy were performed within 4 weeks interval. Steatosis was graded as S0-0–5%, S1-6–33%, S2-34–66% and S3-67– 100% of hepatocytes. Receiver operating characteristic (ROC) curves were plotted to evaluate the accuracy of CAP in detecting steatosis. Predictors of CAP were assessed on multivariate linear regression analysis. Results The mean age (±SD) was 33.8±11.6 years and 296 (64.1%) were males. On liver histology, steatosis grades S0, S1, S2 and S3 were seen in 331 (71.6%), 74 (16.0%), 39 (8.4%) and 18 (3.9%). The median CAP (IQR) values for S0, S1, S2, and S3 steatosis were 206 (176-252) dB/m, 295 (257-331) dB/m, 320dB/m (296-356) dB/m, and 349 (306-363) dB/ m, respectively. For estimation of ≥ S1, ≥S2, and ≥S3, CAP AUROC were 0.879, 0.893, and 0.883, respectively. The optimal CAP cutoff values for hepatic steatosis ≥S1, ≥S2, and ≥S3 were 263dB/m, 287dB/ m, and 296dB/m. The diagnostic accuracy of CAP was similar across the different stages of fibrosis. In multivariate analysis, only BMI (OR 1.18; CI, 1.11-1.26, p<0.001) and grade of hepatic steatosis (grade 1, OR, 3.94; 95% CI, 1.58-9.84, p=0.003; grade 2, OR 42.04; 95% CI, 4.97-355.31, p=0.001 and grade 3, OR 35.83; 95% CI 4.31-297.61, p=0.001) independently predicted CAP. Conclusions CAP detects hepatic steatosis with good diagnostic accuracy across various etiologies and stages of hepatic fibrosis in chronic liver disease. PPLE-34 Relationship of gallbladder stasis and pre-neoplastic lesions of gallbladder in patients with gallstones: A prospective study N A Harish Babu Reddy,1 Lileshwar Kaman,2 Uma Nahar,3 Shalmoli Bhattacharya,4 Arnab Pal,5 Rakesh Kapoor,6 Surinder Singh Rana,1 Harshal Mandhavare,1 Usha Dutta1 Correspondence- Usha [email protected] Departments of Gastroenterology1, Surgery2, Pathology3, Biophysics4, Biochemistry5, and Radiotheraphy6, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Factors which predispose Indian patients with gallstones (GS) for development of gallbladder cancer (GBC) are largely unknown. Prevalence and predictors of pre-neoplastic lesions among patients with GS needs evaluation. To study the prevalence and predictors of premalignant lesions among patients with GS with special preference to S typhi, H pylori and gallbladder stasis and compare it with GBC group and functional dyspepsia group. Methods A prospective study in a tertiary care institution in North India. Patients with symptomatic GSD undergoing cholecystectomy, patients with GBC and those with functional dyspepsia were recruited. All underwent US abdomen, to assess GB pathology and GB function. Sera was analyzed for IgG antibodies to Salmonella typhi Vi and Helicobacter pylori. Patients with GBEF <40% were considered to have GB stasis. GB histopathology was analyzed in detail for preneoplastic lesions of the GB mucosa (metaplasia, dysplasia). Univariate and multivariate analysis were performed to identify predictors of metaplasia. Results Age, gender profile of patients with GBC (n=50), GSD (n=44) and dyspepsia (n=50) were similar across three groups. Patients with GBC and GSD had higher seropositivity for H pylori (54% vs. 54.5% vs. 10%; p<0.001) and S typhi (50% vs. 30% vs. 4%, p<0.001) compared to controls. Patients with GSD more often had stasis compared to controls (82% vs. 52%, p=0.002). On PAS/AB staining, 84% (38/44) had evidence of metaplasia. Intestinal metaplasia was seen in 36/44 (82%) and gastric metaplasia was seen in 20/44 (45%). Patients with metaplasia more often had GB stasis, S typhi positivity, more severe inflammation, were from lower socioeconomic status. On multivariate analysis GB

Indian J Gastroenterol

stasis emerged as a single independent predictor of metaplasia (OR 6.6 (1.03-42.2, p=0.046). Conclusion Patients with gallstones had high incidence of premalignant lesions in GB mucosa in the form of metaplasia. GB stasis is the single independent predictor of gallbladder metaplasia. PPLE-35 Efficacy of G-CSF in the management of steroid non-responsive severe alcoholic hepatitis - A double blind randomized control trial S M Shasthry, M Kumar, S K Sarin Correspondence- Shiv Kumar [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims Severe alcoholic hepatitis (SAH), is the most serious form of alcoholic liver disease and treatment with steroids has limited efficacy. Treatment options for management of steroid nonresponsive (Lille score >0.45) severe AH (Maddrey’s score >32) are limited. We assessed the efficacy of Grannulolyte colony stimulating factor (G-CSF) in such patients (steroid non-responders). Methods Patients with histologically proven SAH, were treated with Prednisolone 40 mg/day and were categorized at day 7 as responder (R) or non-responder (NR) (Lille score >0.45). Responders were continued with prednisolone while NRs were randomized to GCSF (a total of 12 doses of 300 microgram, s.c. in 28 days) or placebo. Results Thirty-three (25%) of 132 SAH patients were steroid nonresponders [mean age 40.2 (S.D.-10.3) years] and were randomized to GCSF or placebo. The baseline characteristics of both groups were comparable. At 3 months, in the G-CSF group, MELD reduced from 24.6±3.9 to 19.4±3.7 (p=0.002), and DF from 74.8±22.8 to 57.4±31 (p=0.26) while these parameters did not improve in placebo group. Infections were less common (28% vs. 71%, p<0.001), with lower mortaility (42.9% vs. 78.6%, p=0.04) in the GCSF than placebo group during a mean follow up preiod of 169 days (S.D.187.9). Cox regression analysis for mortality showed receiving G-CSF (HR 0.37, S.D.-0.14-0.98, p=0.04), and high serum creatinine (HR 4.12–S.D.1.7-10.3, p=0.002) could predict mortality after steroid non-response at the time of randomisation. None of the other parameters including Lille score could predict mortality after steroid non-response. Patients tolerated G-CSF without any major side effects. Conclusions About a quarter of SAH patients did not respond to corticosteroid therapy and had a high mortality. Administration of G-CSF was safe and helped reduce disease severity and mortality in such select group of patients. PPLE-36 Iron-overload triggers ADAM-17 mediated increase in sCD163, TNF-α and promotes inflammation in severe alcoholic hepatitis Jaswinder Singh Maras1, Sukanta Das1, Sachin Sharma1, Jitendra Kumar1, Manish Chandra Choudhary1, Sukriti Sukriti1, Shvetank Sharma1, Guresh Kumar1, Chagan Bihari2, NirupamaTrehanpati1, Rakhi Maiwall3, Shiv Kumar Sarin1,3 Correspondence-S K [email protected] Department of Molecular and Cellular Medicine1,3, Department of Pathology2, Department of Hepatology3, Institute of Liver and Biliary Sciences, New Delhi 110 070, India Background Iron accumulation in hepatocytes and macrophages correlates with inflammation and mortality in severe alcoholic hepatitis (SAH). Molecular mechanisms linking iron-overload and hepatic/macrophage inflammation is unclear. We investigated the role of iron-overload in the induction of oxidative stress, inflammation and organ injury in SAH.

Methods Liver biopsy, peripheral blood mononuclear cell (PBMC) transcriptomics was performed in SAH with hepatic iron-overload (Gr. A:SAH-IO, Scheuer-grade ≥1+: n=5) and no iron-load (Gr. B: SAHNIO, n=9) in discovery cohort. Differentially regulated genes and pathways were confirmed using ELISA, immunohistochemistry [IHC] and Western blot in validation cohort (n=86) and correlated with outcomes. Gene expression of purified CD163+macrophages was compared to healthy monocyte derived macrophages (MDM) and Tohoku Hospital Pediatrics-1 (THP1) macrophages treated with iron/Fenton-reagent in presence/absence of deferiprone. Results Liver and PBMC transcriptome analysis segregated Gr. A from B based on 310 genes (261-up regulated, 49-down regulated) in biopsy and 454 (87-up regulated, 367-down regulated) in PBMCs. Genes linked to iron-loading, oxidative stress, inflammation together with CD163 and ADAM-17 were significantly upregulated (p<0.05) in Gr. A. Increased CD163, ADAM17 and CD68 expression in Gr. A was confirmed by IHC (p<0.01). Serum TNF-α, iron, ferritin and sCD163 levels were higher (p<0.01) and haemoglobin hepatoglobin (He-Hp) complex was lower (p<0.05) in non-survivors. Levels of sCD163 and TNF-α correlated with poor outcome (HR >3, C-index=0.70, p<0.01). CD163+vemacrophages of SAH non-survivors and MDM/THP1macrophages under iron/Fenton stress showed markedly increased expression of iron-processing, metalloprotease activation, oxidative-stress and inflammation genes (p<0.01) which got neutralized by iron-chelation (p<0.05). Importantly iron-chelation decreased ADAM17 expression (p<0.01) thereby preventing TNF-alpha maturation, CD163 shedding and inflammation. Conclusions Liver and macrophage iron accumulation triggers inflammation and oxidative-stress via ADAM17 induction and lipid peroxidation. These events were neutralized by iron-chelation, which can be used as a therapeutic option in SAH with iron-overload. Grant support: The work was funded by the CEFIPRA/IFCPAR (Indo-French center for promotion of advance research) grant no: 4903-3C. PPLE-37 Organ failures associated with acute kidney injury in critically ill cirrhotics have a major influence on disease progression and outcomes- A prospective ICU based study Rakhi Maiwall1, Priyanka Jain2, Guresh Kumar2, Shivendra Singh Chandel1, Ankit Bharadwaj2, S K Sarin1 Correspondence- Shiv Kumar [email protected] 1 Departments of Hepatology1, and Biostatistics2, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Background and Aim Acute kidney injury (AKI) is a known detrimental complication in patients with cirrhosis. Currently, there are no studies evaluating the impact of extra-renal organ failures (E-OF) on the course of AKI and outcome in critically ill cirrhotics. We addressed this question in a large prospective cohort of cirrhotics admitted to liver intensive-care. Methods Patients were prospectively followed until death, recovery or liver transplant for prevalence, development and progression of AKI and it’s association with extra-renal organ failures (E-OF). Binary logistic regression models using multivariate repeated measures using Generalized Estimating Equations (GEE) were used to identify significant variables associated with AKI progression at day 7. Results A total of 291 patients with cirrhosis, aged 48.±11years, 87% males, mean MELD 30.1±8.4; SOFA score 11.6±4.5, 145 (49.8%) were alive at 1-month. AKI at admission was present in 168 (58%), (Stage I:II:III in 11%: 33%: 56% respectively); 231 patients (79%) had at least one E-OF. At day 7, 49% had AKI progression with peak AKIN stage III:II:I in 66%: 25%: 9% respectively. Presence of any E-OF was strongly associated with progression of AKI (p=0.002, OR 3.99, 95%CI 1.6-9.8). This risk further increased with increase in the number of E-OFs (p< 0.001, OR 1.8, 95% CI 1.4-2.4). Further, AKI at admission alone was

Indian J Gastroenterol

not associated with mortality, but predicted mortality together with any EOF (p=0.02, OR 1.9, 95%CI 1.12-3.4). On multivariate analysis using GEE model, number of extrarenal organ failures (OR 1.67, 95% CI 1.322.14), increasing serum bilirubin (OR 1.05, 95% CI 1.02-1.08), declining urine output (OR 0.98, 95% CI 0.97-0.99) and increase in the components of SIRS (OR 2.5, 95% CI 1.2-4.8) predicted AKI progression at day 7. Conclusion Extrarenal organ failures are commonly associated with AKI in critically ill cirrhotics which determine progression of AKI as well as mortality. Presence of AKI alone is not associated with worse outcome in critically ill cirrhotics. PPLE-38 Flare of autoimmune hepatitis as a cause of acute-on-chronic liver failure and its response to steroid therapy Lovkesh Anand1, Ashok Choudhary1, Chhagan Bihari1, Barjesh C Sharma1, Manoj Kumar1, Rakhi Maiwall1, Guresh Kumar1, Soek Siam Tan2, Samir R Shah3, Saeed Hamid4, Amna S Butt4, Syed M Jafri4, Deepak N Amarapurkar5, Yogesh K Chawla6, Sunil Taneja6, Mamun A Mahtab7, Hasmik Ghazinyan8, Zhongping Duan9, Yu Chen9, Akash Shukla10, Jinhua Hu11, Zaigham Abbas12, Sombat Treeprasertsuk13, Laurentius A Lesmana14, Jose D Sollano15, Gian Carpio15, Manoj K Sahu16, Shiv K Sarin1, APASL ACLF working party Correspondence - Shiv Kumar [email protected] 1 Institute of Liver and Biliary Sciences, New Delhi, India; 2Hepatology, Selayang Hospital, Kepong, Malaysia; 3Hepatology, Global Hospital, Mumbai, India; 4Medicine, Aga Khan University, Karachi, Pakistan; 5 Gastroenterology, Bombay Hospital, Mumbai, India; 6PGIMER, Chandigarh, India; 7Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh; 8Nork Clinical Hospital, Yerevan, Armenia; 9 Hepatology, Youan Hospital, Capital Medical University, Beijing, China; 10Kem Hospital, Mumbai, India; 11302 Hospital, Beijing, China; 12 Ziauddin University, Karachi, Pakistan; 13Chulalongkorn University, Bangkok, Thailand; 14 Medistra Hospital, Jakarta, Indonesia; 15 University of Santos Tomas, Manila, Philippines; 16IMS and SUM Hospital, Odissa, India Background Autoimmune hepatitis (AIH) is considered less common or is underdiagnosed in the Asian-Pacific Region. Due to this, flare as a cause of acute-on-chronic liver failure (ACLF) is often missed and treatment is delayed. We aimed at defining clinical, histopathological spectrum and role of steroid therapy in AIH-ACLF. Methods Patients with AIH-ACLF, prospectively recruited and followed between 2012-2017, were analyzed from the APASL ACLF Research Consortium (AARC) data base. Diagnosis of AIH was confirmed using International Autoimmune Hepatitis Group (IAIHG) score or simplified AIH score with histopathology in 90%; diagnosis of ACLF based on APASL definition. Results Of 2825 ACLF patients, 82 (2.9%) fulfilled criteria of AIH (age 42.09±18.12 yr.,70% females). Etiology of flare could be ascribed in 8 (9.7%) to drugs and in 6 (7.3%) to virus. At baseline, mean bilirubin was 18.6±8.2 mg/dL, CTP score 11.75±1.39 and MELD score 27.65±6.49. Mean IgG was 21.61±7.32 g/dL, 49% were seronegative, 43.9% seropositive had ANA (1:80) and 19.5% ASMA positive. Median HAI was 10 [IQR:7-12]; 43.5% had underlying cirrhosis; 56% had significant parenchymal necrosis (bridging and confluent necrosis) and 90% moderate to severe interface activity. Twenty-eight (34%) patients received steroid therapy, with their baseline bilirubin and severity score comparable to those not receiving steroids. Patients receiving steroid had significantly shorter duration of ICU stay (median 1.5 vs. 4 day; p<0.001) and improved 90 day survival (75% vs. 48.1%; p=0.02). Six (21.4%) patients developed infection on steroid therapy; incidence not different from those not on steroids. Factors associated with steroid response were age (p=0.05), bilirubin (p=0.02), INR (p=0.06), MELD score (p=0.05) and presence of hepatic encephalopathy (p=0.04) at baseline. On multivariate

analysis, only MELD score (<27) predicted steroid response (AUROC=0.86; 83.3% sensitivity, 78.9% specificity). Conclusions AIH is an uncommon cause of ACLF in Asia Pacific region and therefore, requires high degree of suspicion, a low threshold for transjugular liver biopsy as nearly half the patients are seronegative. Early stratification (MELD <27) to steroid therapy or liver transplantation (MELD >27) would reduce ICU stay and help improve outcomes. PPLE-39 Expression of TLR-2, 4 and 5 and pro-inflammatory (IL-6, CXCL-11 and CXCR-3) and anti-inflammatory cytokines (IL-10) among patients with IBS and controls in relation to the gut microbiota Ujjala Ghoshal, Ratnakar Shukla, Prabhat Ranjan, Uday C Ghoshal Correspondence- Ujjala [email protected] Departments of Microbiology and Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Background Evidence showing low-grade inflammation and altered hostmicrobial interaction suggests that innate immune response may play an important role in the pathogenesis of irritable bowel syndrome (IBS), hitherto an enigmatic disorder. Since, Toll like receptors (TLRs) are important component of innate immune system leading to release of cytokines and chemokines in response to invading pathogens or altered microbial flora, it may cause intestinal inflammation. Therefore, we aimed to study the expression of TLRs (2, 4 and 5), cytokines (IL-6 and IL-10) and chemokines (CXCL-11 and CXCR-3) in colonic biopsies and its correlation with fecal microbiota among patients with IBS. Methods Quantitative real-time PCR was used to determine mRNA level of TLRs, cytokines and chemokines in 47 patients with IBS (Rome III criteria) and 25 controls. The expression of TLR-4 and TLR-5 was further confirmed using immunohistochemistry. Results Of 47 patients with IBS (comparable in age and gender with controls), 20 had constipation (IBS-C), 20 diarrhea (IBS-D) and 7 unclassified (IBS-U) sub-types. The expression of TLR-4 and TLR-5 was upregulated in IBS patients than controls (p=0.013 and p<0.001, respectively). Protein level of TLR-4 and TLR-5 was 4.2 and 6.6-fold higher in IBS-D than controls. The mRNA level of IL-6 (p=0.003), CXCL-11 (p<0.001) and CXCR-3 (p<0.001) was higher in IBS patients than controls. The expression of IL-6 (p=0.002), CXCL-11 (p<0.001) and CXCR3 (p<0.001) was higher, while IL-10 (p=0.012) was lower in IBS-D patients than controls. Conclusion Up-regulations of TLRs (4 and 5), pro-inflammatory cytokine (IL-6) and chemokines (CXCL-11 and CXCR-3) and downregulation of anti-inflammatory cytokine (IL-10) were found in patients with IBS-D. Our study suggests that dysregulated immune system in response to altered microbial flora may trigger the intestinal inflammation in a sub-group of IBS patients. PPLE-40 Comparative metagenomics of gut microbiota of rural and urban healthy Indian communities in low altitude and high altitude areas Bhabatosh Das, Tarini Shankar Ghosh, Saurabh Kedia, Ritika Rampal, Shruti Saxena, Satyabrata Bag, Ridhima Mitra, Mayanka Dayal, Ojasvi Mehta, A Surendranath, Simon P L Travis, Prabhanshu Tripathi, G Balakrish Nair, Vineet Ahuja Correspondence- Vineet [email protected] Molecular Genetics Laboratory, Centre for Human Microbial Ecology, Translational Health Science and Technology Institute, NCR Biotech Science Cluster, Faridabad 121 001, India, Department of Gastroenterology and Human Nutrition, All India Institute of Medical S c i e n c e s , N e w D e l h i 11 0 0 2 9 , I n d i a , a n d Tr a n s l a t i o n a l Gastroenterology Unit, Oxford University Hospitals, Oxford UK

Indian J Gastroenterol

Introduction and Methods Few studies have looked at the effect of environment on gut microbiota diversity in similar ethnic communities. The diversity and basic functional attributes of gut microbiome of healthy Indians living in different regions is yet to be understood. This study looked at the gut microbial diversity in three communities: rural and urban individuals residing in low altitude areas in Ballabhgarh (in the National Capital Region of Delhi) and rural high altitude areas of Leh, Ladakh in North India. We adopted metagenomic approaches to explore bacterial species and genomic repertoires in the fecal microbiota of 84 healthy adult individuals. Results Our findings revealed that the gut of Indian population is dominated by Firmicutes followed by bacteroidetes, actinobateria and proteobacteria. Although, 54 core bacterial genera were detected across the three populations, the gut bacterial community compositions displayed distinct signatures and observed to be influenced by the geographical location and dietary intake of the individuals. The gut microbiomes of Leh residents were observed to be significantly more homogenous, having a high representation of bacteroidetes and minimal abundance of proteobacteria. In contrast, Ballabhgarh residents harbored significantly high number of firmicutes and proteobacteria. Although all three groups had healthy individuals, yet rural community from low altitude areas had a unique microbiome characterized not only by a higher diversity, but also more homogeneity. In addition to identify associations of certain genera to specific dietary intake patterns, the whole genome sequences of subset of samples predicted a high abundance of several xenobiotic degradation pathways in the gut microbiomes of individuals in the Ballabhgarh regions. Conclusion Firmicutes and prevotella copri dominate the gut microbiome of healthy Indians. Amongst healthy Indians, rural population harbored unique microbiota with the highest degree of diversity and homogeneity reflecting a healthier microbiome compared to urban healthy population. STOMACH STH-01 Comparison of yield of rapid urease test for H pylori infection between gastric body and antrum in patients with peptic ulcer disease S A Rajeev, Amit Kumar Dutta, C E Eapen, Uday George Zachariah, Ashish Goel, Sudipta Dhar Chowdhury, Reuben Thomas Kurien, Deepu David, Mahasampath Gowri Correspondence- S A [email protected] Christian Medical College, Vellore 632 004, India Introduction Data comparing the yield of rapid urease test (RUT) for detecting H pylori infection between gastric body and antrum is limited from India. We aimed to assess and compare the yield of RUT at these two sites among our patients with peptic ulcer disease. Methods We conducted a prospective study on patients with dyspepsia who had peptic ulcer disease diagnosed on endoscopy. Patients with recent antibiotic or PPI use, acute gastrointestinal bleeding and gastric malignancy were excluded. During endoscopy, tissue sample for RUT was taken from the gastric body and antrum and placed on the test kit for upto 24 hours. A colour change by 24 hours was considered positive test. The frequency of positive RUT from antrum and body were estimated and compared using Chi-square test. Informed consent was obtained, and the study was approved by institute review board. Results Sixty-two patients were included in the study. Their mean age was 46.26+/-14.88 years and 50 were males (80.65%). Median duration of symptoms was 6 months (range 1-120). Gastric ulcers were found in 24 (38.71%), duodenal ulcers in 36 (58.06%) and both in 2 (3.23%). Overall, RUT was positive for H pylori infection in 48 (77.42%) subjects. A positive test in gastric antrum was noted in 41 (66.13%) and in gastric body in 44 (70.97%). Positive RUT at both sites were noted in 37, positive test only in body in 7, positive test only in antrum in 4 and negative

test at both sites in 14. The yield of RUT from body and antrum was not different significantly (p=0.56). RUT from antrum alone would have missed 7 (14.6%) cases of H pylori infection. Conclusion The yield of RUT for detecting H pylori was similar between gastric body and antrum. Taking tissue samples from both antrum and body may improve the overall yield. STH-02 Effect of diabetes mellitus Type 2 on gastric emptying in patients with dyspepsia and correlation of control, duration and complications of diabetes mellitus with gastroparesis Raajeev Vijay Hingorani Correspondence- Palaniappan Singaram- [email protected] M I O T International Hospital, Chennai 600 125, India Introduction There are very few Indian studies for correlation of gastric emptying time with type 2 diabetes mellitus alongwith its correlation with control of diabetes, duration of diabetes, age, gender, mode of treatment, admission and more so, correlation with complications related to diabetes. Hence this study was undertaken. Methods Study Setting: MIOT Hospital, Chennai. Study Design Observational, comparative study. Subjects Amongst dyspeptic patients (both OPD AND IPD), after applying inclusion and exclusion criteria, 43 subjects with type 2 diabetes mellitus and 43 without, were selected for test and control group respectively. Methods After ruling out all other causes of dyspepsia, gastric emptying scintigraphic study was performed. Gastric empyting time (t-half) was correlated with presence of type 2 diabetes mellitus, also emptying time in diabetics was compared with HbA1c, duration of diabetes mellitus, diabetic microvascular complications, age, gender, inpatient vs. outpatient, mode of treatment. Type of Statistical Analysis Using SPSS statistical package, Student's unpaired t-test, to test the significance of difference between quantitative variables and Yate's and Fisher's chi-square tests for qualitative variables were used. Sensitivity, specificity, correlation coefficient and ROC analysis were also calculated. Results Test group had higher incidence of gastroparesis (60.5%) vs. control group (7%)-(p<0.001). Emptying T-half (median) Test group=101.5 min vs. control=51.3 min. (p=0.004). Presence of diabetic neuropathy, nephropathy, retinopathy correlated with gastroparesis (p=0.034 for neuropathy, p=0.001 for nephropathy, p=0.005 for retinopathy, p=0.001 for all 3 complications together. HbA1c >8% (AUROC=0.805) and duration of diabetes >10 years (AUROC=0.728) best predicted gastroparesis. Female gender (p=0.0105) and inpatient admission for symptoms (p=0.0108) correlated with diabetic gastroparesis, whereas insulin therapy correlated with gastroparesis (but p=0.054). Age did not correlate (p=0.396) with gastroparesis. Conclusion Type 2 diabetics had a higher prevalence of gastroparesis, esp. at HbA1c >8%, and/or >10 years of diabetes. Presence of diabetic microvascular complications (nephropathy/neuropathy/retinopathy) independently as well as when taken together, had statistically significant correlation with diabetic gastroparesis. Other variables which correlated with higher incidence of diabetic gastroparesis, with statistical significance proven, were: female gender, and inpatient admission for symptoms related to gastroparesis. Also gastroparesis was more in patients on insulin therapy. However, age did not have a correlation with diabetic gastroparesis in this study. STH-03 Correlation of endoscopic findings and rapid urease test in diagnosis of Helicobacter pylori Pratibha Setty

Indian J Gastroenterol

Correspondence- Pratibha Setty- [email protected] Kamineni Hospital, L B Nagar, Hyderabad 500 069, India Aim To evaluate the efficacy of endoscopic findings of H. pylori infection in comparison to rapid urease test (RUT). Methods All patients who undergo endoscopy for various diagnosis and have endoscopic findings suggestive of H pylori infection were included in the study and underwent a RUT and the results were analyzed. Results A total of hundred cases were analyzed, 76 cases turned positive and 24 were negative. The commonest endoscopic diagnosis in these patients was antral gastritis seen in 32/76 (42%) and 9/24 (37%) patients. Pangastritis was seen in 25/76 (32%) and 8/24 (33%) patients, ulcers was seen in 10/76 (14%) and 5/24 (21%) patients and other diagnosis was present in 10/76 (14%) and 2/24 (8%) patients respectively. Conclusion An endoscopic suspicion of H pylori gastritis was accurate in 76% patients. Among these patients antral gastritis and pangastritis was the most common diagnoses. Ulcers were seen in a small percentage of patients in both groups. STH-04 miRNA expressions profiling in Helicobacter pylori infected gastrointestinal diseases Avinash Bardia, Sandeep Kumar Vishwakarma, Nagarapu Raju, Lakki Reddy Chandrakala, B V S Sastry, Safwaan Habeeb, Aleem Ahmed Khan, Mohammed Aejaz Habeeb Correspondence- Mohammed Aejaz Habeeb [email protected] Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India

Correspondence- Mohammed Aejaz Habeeb- [email protected] Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India Introduction H. pylori infection is considered the leading cause of gastric mucosal inflammation. The bacterium induces histologically detectable damage to the gastric mucosa through a complex combination of virulence factors and results in inflammatory responses induced in the host’s mucosa. As reported gastric inflammation and epithelial damage are believed to be important in the etiopathogenesis of various gastrointestinal (GI) diseases, but their association with various genotypes of H. pylori are little investigated. Aims The aim of the present study was to investigate the gastric histopathology in patients infected with H. pylori with various GI disorders and assess its relationship with bacterial genotypes. Methods A total of 80 H. pylori infected subjects who had undergone upper GI endoscopy were included in the study. Biopsy sample were collected and used for culture of H. pylori followed by DNA isolation and genotyping. One part of biopsies was immersed in 10% buffered formalin. Slides from each specimen were stained by modified Giemsa, haematoxylin & eosin and alcian blue PAS stains respectively. Results Present study demonstrated that histomorphological changes associated with H. pylori infection largely depends upon the genotypic trait of the gastric pathogen though it may require the involvement of host related and environmental factors. It was observed that the severity of gastritis correlated with the presence of more virulent genotypes. Conclusion Therefore these results strongly demonstrate that distinct H. pylori genotypes seem to be associated to the outcome of the infection and may have important clinical and epidemiological implications. STH-06

Introduction H. pylori induced gastroduodenal disease depends on the inflammatory response of the host and specific virulence factors that cause damage to gastric epithelial cells. Among the mediators induced in response to the infection, miRNA has the potential impact on the outcome of the bacteria-host interaction. This has led to the identification of miRNA associated with inflammatory response initiated by the H. pylori infection. Therefore, the present study was designed with an objective to characterize the miRNA profile with various gastrointestinal diseases. Methods A total of 80 H. pylori infected subjects with various gastrointestinal diseases were included. Biopsy sample were collected before and after treatment. Biopsy was used for miRNA extraction using GITC method followed by cDNA constraction. miR-21, miR-155, miR-146, miR-181 and miR-7 expression levels were quantified by using real time-quantitative PCR based on SYBR-Green. Results We have demonstrated that even after eradication of H. pylori with a triple antibiotic treatment for a 7-day period, the levels of miR-21 did not change but there is down regulation in miR-155, miR146, miR-181. In contrast, the levels of tumor-suppressor miRNA, including miR-7 increased after eradication. These results suggest that after infection and eradication of H. pylori, some underlying processes may continue that promote tissue damage and lead to gastric malignancy. Conclusion Our study suggest that miRNA may be modulating pathways associated with differential out comes in response to infection with H. pylori. This will opens up the possibility of more efficacious and global treatments for illnesses with common origins. STH-05 Histopathology and distinct genotypes of Helicobacter pylori in gastrointestinal disease Avinash Bardia, Sandeep Kumar Vishwakarma, Nagarapu Raju, Lakki Reddy Chandrakala, B V S Sastry, Safwaan Habeeb, Aleem Ahmed Khan, Mohammed Aejaz Habeeb

Evaluation of dyspeptic symptoms in patients with and without Helicobacter pylori infection on proton pump inhibitors Suresh Ragavendra, T Rajkumar Solomon, A Aravind, R Balamurali, K Muthukumar, G Ramkumar, Vaishnavi Priyaa, G Kavitha, S B Mallipatill, P Umalakshmi, Sachin Dhande Kashinath, Ravi Anand, Sravan Thumati Correspondence- Ragavendra [email protected] Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College and Hospital, Chennai 600 018, India Introduction A relationship between Helicobacter pylori infection and dyspeptic symptoms in patients on proton pump inhibitors (PPI’S) has not yet been clearly demonstrated. Therefore, to evaluate any possible difference in symptoms and endoscopic findings between dyspeptic patients already on PPI’s with and without H. pylori infection Methods A series of 100 consecutive patients on PPI’s affected by upper abdominal disturbances completed a symptoms questionnaire before undergoing upper gastrointestinal endoscopy with a rapid urease test (RUT) to detect H. pylori infection. The symptoms assessed were belching, bloating, odynophagia, dysphagia, postprandial fullness, heartburn, early satiety, nausea, vomiting, regurgitation, epigastric pain - fasting, postprandial, nocturnal, and pain in right hypocondrium. The endoscopic findings were also documented. Results A total of 55 H. pylori-positive and 45 H. pylori-negative patients were compared. Among the symptoms evaluated, belching and bloating were present in more than 50% of patients of both groups. RUT positivity for H. pylori infection were more common in males than in females. Heartburn, Epigastric pain–postprandial, Postprandial fullness were more often seen in the H. pylori positive group (statistically more significant). Deformed pylorus were more often seen in the H. pylori positive group than in the negative group (p<0.003). Conclusion In patients already on PPI’s, patients with persistent epigastric pain, postprandial fullness and heartburn more often have H. pylori

Indian J Gastroenterol

infection. Endoscopic finding of deformed pylorus was associated with H. pylori infection. SMALL INTESTINE SI-01 Duodenal neuroendocrine tumors- Our experience in tertiary care Venkatesh Pabbisetti, M Umadevi, Shravan Kumar Correspondence - M Umadevi - [email protected] Gandhi Medical College, Walker Town, MIGH Colony, Padmarao Nagar, Secunderabad 500 003, India Introduction Duodenal neuroendocrine tumors (NET) are rare neoplasms that originate from enterochromaffin cells of gastroenteropancreatic neuroendocrine system. duodenal nets account for 2.6% of NET. Mostly discovered incidentally during upper gastrointestinal endoscopy (UGIE) as solitary lesions confined to mucosa and submucosa, approximately 40% to 60% have metastasis to liver and lymphnodes at time of diagnosis. Methods We are reporting 2 cases of duodenal net. A 35-year-old male presented with heartburn and epigastric pain not relieving with PPIs, recurrent oral aphthous ulceration of 4 months duration. UGIE showed 3 nodular subcentimeter lesions in anterior wall of D1. Fifty-year-old male patient presented with melena, exertional SOB of 2 months duration. UGIE showed multiple small polyps with ulceration in D1. Results Biopsy of both patients showed lesion arising from lamina propria and muscularis propria with cells showing stippled chromatin and eosinophilic cytoplasm, features suggesting NET. Both patients immunehistochemistry showed synaptophysin+ and chromogranin+. KI67 of 1% [G1 well differentiated] in first patient, 3% [G2 moderately differentiated] in second patient. CECT chest and abdomen showed no lymphnode involvement/distant metastasis in both. PET-CT in first patient showed no evidence of somatostatin receptor positive abnormality. Both patients are treated endoscopically and followed up. Conclusion Duodenal NETS are rare NET, with majority are non-functional, 10% are gastrinomas, <4% are with typical carcinoid syndrome. Most are incidentally discovered in UGIE. Measurement of serum gastrin and chromogranin-A and screening for MEN-syndrome is mandatory in all patients. Well differentiated G1 tumor <20 mm confined to submucosa are treated by ESD/EMR. Transduodenal surgery may be needed for tumor invading muscularis propria. Tu m o r l a rg e r t h a n 2 0 m m , s p o r a d i c g a s t r i n o m a s a n d periampullary NET need to undergo radical surgery. Metastatic disease need cytoreductive surgery and cisplatin, etoposide chemotherapy. Peptide receptor nuclide therapy useful in somatostatin receptor positive cases and progressive disease. SI-02 A computed tomographic study of abdominal cocoon: Report of 22 cases Ujjawal Gorsi, Pankaj Gupta, Harshal S Mandavdhare, Harjeet Singh, Vishal Sharma Correspondence -Vishal Sharma - [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction The diagnosis of abdominal cocoon (AC) is made either on radiological evidence of membrane around small bowel loops or surgical findings. We report radiological findings from a cohort of patients with AC. Methods This is a retrospective analysis of findings on computed tomography (CT) in patients with AC.

Results Of 30 patients with suspected AC, images of 5 patients couldn’t be retrieved while 3 were found not to have AC after consensus between four observers. Of 22 patients included, mean age was 37.31 years (range 16-70) and 17 (77.27%) were males. Underlying etiology was tuberculosis in 19, malignancy in 2. The mean duration of symptoms was 5.79 months range (15 days-60 months) and the clinical presentation in decreasing order was abdominal pain 22 (100%), loss of weight 20 (90.90%), loss of appetite 18 (81.81%), subacute intestinal obstruction 14 (63.63%), lump abdomen 12 (54.54%) and fever 11 (50%). The basis of diagnosis of cocoon was on CT in 17 (77.27%), CT with surgery in 4 (18.18%) and on CT and MRI in 1. On CT type 1, 2 and 3 cocoon were found in 7, 7 and 8 respectively. Peritoneal enhancement could be seen in 14 (63.63%) and nodules in 2 (9.09%) while omental thickening seen in 9 (40.90%), nodularity in 5 (22.72%) and omental mass in 1 patient. Visceral scalloping of liver and spleen seen in 2 (9.09%). Cauliflower sign was seen in 14 (63.63%), concertina appearance in 5 (22.72%) and bottle gourd sign could be seen in 6 (27.27%). Post treatment weight gain was seen in 14 (63.63%), resolution of ascites in 12 (54.54%). Four underwent surgery (18.18%) and 3 (13.63%) had mortality (2 due to liver failure and 1 from malignancy). Conclusion Radiological findings are helpful in the diagnosis of abdominal cocoon. SI-03 Epithelial barrier gene (PTPN2) polymorphisms in patients with Crohn’s disease Kaushik Chatterjee, A Rekha *, Ashish Goel, A J Joseph, Sudipto Dhar Chowdhury, Reuben Thomas Kurien, Deepu David, Prasanna Samuel**, Amit Kumar Dutta Correspondence - Amit Kumar [email protected] Department of Gastroenterology and Hepatology, Christian Medical College and Hospital, Vellore 632 004, India, *Department of Wellcome Biochemistry, Christian Medical College and Hospital, Vellore 632 004, India, and **Department of Biostatistics, Christian Medical College and Hospital, Vellore 632 004, India Background Crohn’s disease is being increasingly diagnosed in the Indian subcontinent. PTPN 2 gene plays a key role in epithelial barrier function, autophagy pathway, innate and adaptive immunity and thought to be associated with Crohn’s disease. Two apparently common polymorphisms in the PTPN2 gene rs 2542151, rs 7234029 are found in up to 18% of sporadic patients with Crohn’s disease in western countries. We examined whether such polymorphisms are also found in Indian patients with Crohn’s disease. Methods An on-going cross sectional study where venous blood was collected from 32 patients (mean age 34.7 yrs, range: 20-53 years, male: female 16:16) with Crohn’s disease and 26 control patients of non-ulcer dyspepsia as per ROME IV criteria (mean age 41.6 yrs, range: 17-62 years, male: female 19:7); DNA was extracted and amplified using specific set of primers. The amplified fragments were digested with restriction enzymes (Bsp1286Irs2542151 and Hpy188I-rs7234029) and the restriction pattern was documented after electrophoresis. Results Twelve patients had ileocolonic disease, 13 ileal disease, 7 colonic disease. Minor allele frequency for PTPN2, rs7234029 (wild type AA) for Crohn’s disease patients was 23.4% (4 homozygous, 7 heterozygous) and 15.4% for controls (8 heterozygous). P value was not significant (0.35). Minor allele frequency for PTPN2, rs2542151 (wild type TT) for Crohn’s disease patients was 15.6% (10 heterozygous) and 21.2 % for controls (4 homozygous, 3 heterozygous). p value was again not significant (0.47). Conclusion The minor allele frequency of PTPN2 polymorphisms rs7234029 and rs2542151 described above was not significantly different between patients with Crohn’s disease and controls.

Indian J Gastroenterol

SI-04 Bottle gourd sign: A new radiologic sign of abdominal cocoon on computed tomography Vishal Sharma, Harshal S Mandavdhare, Ujjawal Gorsi, Harjeet Singh Correspondence- Vishal [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Radiological findings on computed tomography are helpful in diagnosis of abdominal ccoon and may include cauliflower sign, concertina pattern and presence of membrane around small bowel loops. Methods We describe a new radiological sign peculiar to patients with abdominal cocon having intestinal obstruction. The "Bottle Gourd sign" which represents a dilated duodenum with cut-off usually at the duodenojejunal flexure. This possibly is due to the fact that cocoon formation is unlikely to involve the duodenum as it is a retroperitoneal structure. Results Of the 12 patients with CT done during episodes of intestinal obstruction the Bottle Gourd sign was seen in 6 of them while none of the patients with CT done in absence of IO had this feature. Although cauliflower and concertina signs were seen in a larger number of patients but they were not specific to presence of IO Conclusion We describe a new radiological sign in abdominal ccoon which is noted in CT done during episodes of IO. SI-05 Primary duodenal tuberculosis with gastric outlet obstruction: Report of two cases managed with medical therapy alone Alok Chandra, K Ravikanth Correspondence- Alok [email protected] Department of Gastroenterology, Base Hospital, Delhi Cantt, New Delhi 110 010, India Introduction Gastrointestinal tuberculosis primarily involving the duodenum is rare. Most cases reported have been diagnosed on surgery for gastric outlet obstruction (GOO). Herein, we present two cases of duodenal tuberculosis in young patients presenting with GOO. They were successfully diagnosed with endoscopy and biopsy and responded well to medical management. Case Report: Case 1 A 23-year-old male presented with epigastric pain, early satiety, post prandial vomiting and weight loss of two months duration. CT scan of the abdomen showed circumferential mural thickening in duodenum causing luminal narrowing. Gastroscopy revealed large gastric residue and narrowing in distal duodenum with nodularity and pseudopolyps. Biopsy showed chronic inflammatory infiltrateand well formed epitheloid granulomas with caseation. Case 2 A 35-year-old lady presented with post prandial abdominal discomfort, low grade fever, vomiting and significant weight loss of three months duration. CT scan of the abdomen showed luminal narrowing in distal duodenum and circumferential thickening of cecum and ascending colon. Gastroscopy showed narrowing in distal duodenum with nodular mucosa. Colonoscopy showed ulcers in cecum and ascending colon with deformed cecum and ileocecal valve. Endoscopic biopsies showed chronic inflammation and epithelioid granulomas with caseation in lamina propria. They were started on antituberculosis therapy (ATT) as per standard guidelines. They had significant resolution of symptoms of GOO and weight gain. Repeat endoscopy showed near complete resolution with nonobstructive fibrotic stricture in distal duodenum. Case 2 also required endoscopic balloon dilatation of the stricture.

Conclusion The unusual location, lack of specific signs and symptoms, varied non-specific radiological and endoscopy findings and poor yield of mucosal biopsy makes diagnosis a challenge. High index of clinical suspicion and obtaining deeper biopsies helps in diagnosis. Duodenal tuberculosis can be successfully treated with ATT and endoscopic stricture dilatation and surgery should be reserved for emergencies. SI-06 Eosinophilic gastroenteritis - An association with allergy and functional dyspepsia: Single centre prospective Study Gaurav Garg1, Vinod Kumar Dixit1, Sunit Kumar Shukla1, Shivam Sachan2, Sudhir Kumar Singh2 Correspondence- Gaurav Garg- [email protected] Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Aim Classical eosinophilic gastroenteritis (EGiD) is a rare disease, but may be misdiagnosed in clinical practice. Patients with mucosal form of disease often present with nonspecific gastrointestinal (GI) tract symptoms and may or may not have macroscopic endoscopic findings. Allergy and functional GI disorders have been associated with eosinophilia in duodenal mucosa. Method Patients presented in Gastro. OPD with symptoms of fundtional dyspepsia were included in study. Eosinophilic gastroenteritis was defined based on the following criteria: (1) eosinophilic infiltration in the GI tract and (2) exclusion of other causes of general eosinophilia (e.g. parasitic infestations, connective tissue disease, Crohn’s disease, lymphoma and other intestinal tumors, celiac disease, vasculitic syndromes, Menetrier’s disease). Results Total 360 no. of patient presented in Gastro. OPD with symptoms of dyspepsia included in this study. The overall mean age was 28.14±8.32 years with range of 18-44 years. We report eosinophilic GI that was diagnosed in 5 patients (3 male: 2 female: mean age 24.6 years). The median duration of symptoms prior to diagnosis was 8 weeks (range 4 weeks to 20 weeks). Epigastric pain or discomfort was the most common symptom presented in all patients (5/5: 100%), followed by anorexia, nausea, and vomiting (60%, 60%, and 40%, respectively). One (20%) patient had diarrhea. Two patients (40%) had a history of allergy, while three (60%) had peripheral eosinophilia. Conclusions A high degree of suspicion and biopsy at upper endoscopy is necessary for diagnosis of this rare disease in patients presented as symptoms of allergy and functional dyspepsia. SI-07 Six months of therapy for abdominal tuberculosis: A real world experience Harshal S Mandavdhare, Vishal Sharma, Harjeet Singh, Ravi Sharma, Surinder Rana, Rajesh Gupta Correspondence- Vishal Sharma- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Six months of anti-tubercular therapy (ATT) is recommended for abdominal tuberculosis on basis on randomized trials. However, trial setting may not simulate the real world setting. We report our experience of 6 months of ATT in abdominal tuberculosis. Methods The present report is based on the retrospective analysis of patients with abdominal tuberculosis seen at a large tertiary care hospital in North India. Patients were diagnosed to have confirmed (presence of acid fast bacilli on smear/culture and /or caseation necrosis or evidence of tuberculosis elsewhere in body) or probable tuberculosis (clinical and radiological evidence with granulomas or chronic inflammation or high

Indian J Gastroenterol

adenosine deaminase values in ascitic fluid with exclusion of alternate diagnosis) who improved on ATT on follow up were included. Subjective (weight gain, sense of well-being) and objective response (resolution of ascitic or ulcer healing on colonoscopy) to treatment were sought. Results Of 101 patients, 93 had complete records and were included. The mean age was 35.90±14.06 years. Fifty-three (56.98%) patients were males. Forty-two patients (45.16%) had intestinal involvement, 24 (25.08%) had peritoneal, 22 (23.65%) had combined involvement and 05 patients (5.37%) had isolated lymph-nodal tuberculosis. Six patients received prolonged ATT (>6 months). Six patients developed ATTinduced hepatitis. Of 64 patients with intestinal involvement, 45 had stricturing disease (68.18%) of whom 7 (15.5%) required surgery due to refractory symptoms. Overall there was one death and eight patients (including one with massive gastrointestinal bleeding) needed surgery. Conclusion Six months of ATT is associated with objective clinical response in most patients with abdominal tuberculosis. However, surgical treatment may be needed in a subset of patients with abdominal tuberculosis. SI-08 Unusual lower gastrointestinal bleed: Jejunal gastrointestinal stromal tumors Paul Joyes, P Anbalagan, P Padmanabhan Correspondence- Paul Joyes- [email protected] Meenakshi Medical College, Enathur, Karrapettai Post, Kanchipuram 631 552, India Introduction Gastrointestinal stromal tumors (GIST) are rare tumors (2%) and can be a cause of gastrointestinal (GI) bleeding. GISTs are diagnosed rarely and they should be kept as differential diagnosis of GI bleed. They are commonly located in stomach (60%) and small intestines (30%). GIST normally grows extraluminally and it can cause intermittent bleeding only when it ulcerates or erodes into the mucosa. Case History We present an elderly female presenting with melena, fever, lower abdominal pain, mass in the umbilical and hypogastric region of 2 weeks duration. On evaluation patient was severely anemic with stool guaic test positive. The esophagogastroduodenoscopy was normal. Colonoscopy showed normal mucosa till ileum with black stool residue in the lumen which suggested small intestinal source of bleeding. A contrast enhanced CT abdomen was done which showed a mass lesion in the jejunum. Patient underwent laparotomy with small bowel resection and anastomosis. The histopathological evaluation showed GI stromal tumor and confirmed with immunohistochemistry CD117 and CD34. Discussion GISTs are the most common mesenchymal tumors of stomch and small intestines. They have unique histologic, immunophenotypic and molecular genetic features that sets them apart from leiomyoma and schwanomas. surgical resection with curative intent is the treatment of choice with localized GIST. Complete resection should be performed as chance of recurrence is high. Approximately 10% GIST show malignant potential. Conclusion A case of GIST presented for its rarity. SI-09 Association of gut motility with small intestinal bacterial overgrowth in adults and children with celiac disease

patients continue to experience GI symptoms after gluten-free diet. In these cases, small intestinal bacterial overgrowth (SIBO) may be one of cause of not improving. SIBO may occur in these patients due to altered gut motility. Incidence of SIBO and altered motility may be different in adult celiac patients and children with celiac disease due to different time interval of disease. Therefore, this study was planned to find out incidence of SIBO and measure gut motility in celiac patients (children and adults). Methods One hundred and twenty adults and 95 children with confirmed celiac disease were enrolled. Non-invasive glucose hydrogen breath test was done to diagnose SIBO. Rise ≥10 ppm in hydrogen concentration over baseline value within two hours was considered to be suggestive of SIBO. Non-invasive lactulose hydrogen breath test was done to measure gut motility (OCTT). Time taken for rise ≥10 ppm in hydrogen concentration in 2 consecutive readings over baseline value was considered as OCTT. Results Out of 120 adult patients with celiac disease 65 were males while 55 females with age range 18-60 years (Mean±SD, 44.8±11.6 years). In children, 68 were males while 27 females with age range 3-15 years (Mean±SD, 8.2±2.7 years). Hydrogen breath test was suggestive of SIBO in 22/120 (18.4%) adult celiac patients while 8/95 (8.4%) in celiac children. The difference was significant (p<0.01) between both groups. OCTT was also found to be significantly (p<0.0001) delayed in adult (176±5.2 minutes) celiac patients as compared to celiac children (84.8 ±.4.5 minutes). Conclusion This study indicates that incidence of SIBO is higher in adult celiac patients as compared to celiac children. his may be due delayed gut motility in these patients and also due to long standing (undiagnosed and untreated) celiac disease in adults. SI-10 Spectrum clinical and subclinical endocrinopathies in patients with treatment naïve celiac disease Vipin Gupta, Alka Singh, Asif Iqbal, Ashish Agrawal, Snigdha Soni, P K Chaturvedi, Akshi Garg, Rajesh Khadgawat, Vineet Ahuja, Govind K Makharia Correspondence- Govind Makharia- [email protected] All India Institute of Medical Sciences, New Delhi 110 029, India Introduction Celiac disease (CeD) is associated with many autoimmune diseases including autoimmune thyroid disease and type I diabetes. What happens to other endocrine organs in CeD is not well-described. We evaluated treatment naïve patents with CeD for endocrine organ function(s). Methods Seventy-four treatment naïve patients with CeD underwent clinical, biochemical evaluation and assessment for functions of endocrine organs including, thyroid, pancreas, parathyroid, pituitary and adrenal glands. Biochemical assessment of endocrine organ functions was done using relevant tests e.g. Chemiluminescence assay. Clinical endocrinopathy was defined if patient had both relevant clinical symptoms/history of treatment of endocrinopathy and abnormal biochemical/hormonal assessment and subclinical endocrinopathy if they had abnormal biochemical/ hormonal assessment, but no symptoms. Results Following was spectrum of clinical and subclinical enteropathies (Table) Endocrinopathy

Satyavati Rana, Aastha Malik, Rajni Kumari, Sadhna Lal, B R Thapa, K K Prasad, S K Sinha, R K Kochhar Correspondence- Satyavati Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Hypothyroidism (n=74)

Background Celiac disease is gluten sensitivity enteropathy with symptoms like diarrhea and nutritional deficiencies. In some cases, celiac

Hypogonadism

Type 1 diabetes (n=74)

Clinical: 7 (9.5%) Subclinical: 3 (4.1) Clinical: 10 (13.5%) Subclinical: 4 (5.4%) Clinical: 6 (11.1%)

Patients with CeD 10 (13.5%) 14 (18.9%) 12

Indian J Gastroenterol (Age >15 years to ≤40 Subclinical: 6 (11.1%) years) (n=54) Primary growth hormone Clinical: 8 (88.9%) deficiency in age Subclinical: Not <18 years (male) and evaluated <17 years (females) (n=9) Primary Clinical:1 (1.4%) hypoparathyroidism (n=74) Primary Clinical:1 (1.4%) hyperparathyroidism (n=74) Total no. of Clinical: 33 (44.6%) endocrinopathies Subclinical: 13 (17.6%) in all patients Patients with at least 1 endocrinopathy (clinical/subclinical) Patients with one endocrinopathy (clinical/subclinical) Patients with two or more endocrinopathies (clinical/subclinical)

8/9

1 (1.4%)

Result Of 101 known HLA results, 79 were positive HLA-DQ2/DQ8 and 22 were HLA-DQ2/DQ8 negative samples by standard test, all 79 reported positive and 22 reported negative by rapid test. There was an excellent concordance rate between testing by standard method and rapid method. Amongst unknown samples, 186 of 209 of CeD, and 2 of 10 healthy controls were either/or HLA-DQ2/DQ8 positive by the rapid test. Conclusion Rapid single PCR reaction HLA gene test method showed an exellent concordance with standard test. Rapid testing could be a cost reducing and an effective tool for CeD gene screening. SI-12

1(1.4%)

A single center experience on 110 patients with celiac disease in adults: A retrospective review 46

31(41.9%)

Uday C Ghoshal, Prabhakar Kumar Thakur, V A Saraswat Correspondence- Uday Chand [email protected] Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India

18 (24.3%) 13 (17.6%)

Conclusions 41.9% of patients with CeD had atleast one endocrinopathy either clinical or subclinical. High prevalence warrants early screening of endocrinopathies in patients with CeD. Whether high prevalence of endocrinopathies are the manifestation of CeD or associated autoimmune endocrine organ diseases, needs exploration. Furthermore, the response to gluten-free diet in them is worth exploring. SI-11 Validation of a novel single-drop rapid HLA-DQ2/-DQ8 method to identify people susceptible to celiac disease Anil K Verma1, Alka Singh2, Simona Gatti1,3, Elena Lionetti1,3, Tiziana Galeazzi1, Vineet Ahuja2, Carlo Catassi1,3, Govind K Makharia2 Correspondence- Govind [email protected] 1 Celiac Disease Research Laboratory, Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy, 2Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India 3Department of Pediatrics, Università Politecnica delle Marche, Ancona, Italy

Background Celiac disease (CD) is an important cause of chronic diarrhea in children; studies on its clinical presentations in adults are a few. This study was undertaken to evaluate the clinical presentations and outcomes of celiac disease in adult patients. Methods Case records of 110 consecutive adult (≥15 years) CD patients were analyzed retrospectively. The diagnosis of CD was made as per modified ESPGHAN criteria. Data were collected regarding modes of presentation, clinical manifestations, endoscopy, duodenal histology, adherence to gluten-free diet (GFD) and outcome. Results The mean age of these patients at diagnosis was 25 (range 15-60) years. The median duration of symptoms before diagnosis was 4 years (range: 6 months to 20 years). Chronic diarrhea was the commonest mode of presentation (59.1%). Other common mode of presentations were short stature (16.4%), refractory anemia (11.8%), delayed menarche (5.5%) and chronic liver disease (5.5%). Endoscopy showed decreased duodenal folds in 75.5%, scalloped folds in 60% and normal folds in 20% patients. Subtotal villous atrophy was seen in 67.3% patients. One hundred and eight (98.2%) showed clinical improvement though only 81% patients strictly adhered to GFD initially; however, with repeated counselling, adherence to GFD improved. Conclusions Diarrhea, short stature and anemia are the commonest presentation of adult CD patients. Though strict adherence to GFD was not as good initially, most patients had clinical improvement after adherence with repeated counselling. SI-13

Introduction Major histocompatibility complex (HLA) HLA-DQ2 and/or DQ8 is considered essential risk-factor for celiac disease (CeD). About 90% to 95% of patients with CeD have HLA DQ2/DQ8 haplotype and HLA DQ2/DQ8 typing is considered as an additional diagnostic test. Conventional PCR-based HLA typing method is expensive and complex, requires well-trained person to perform test and it takes hours to provide result. We assessed efficacy of a new-fangled sequence-specific, primer based rapid single PCR reaction HLA method for detection of HLADQ2/-DQ8. Rapid test takes about one and half hours to complete the test. Methodology For detecting the sensitivity of rapid test in comparison to the gold standard test, we required subjects with a positive HLADQ2/DQ8 haplotype where HLA haplotype has been determined by the standard SSO-PCR testing (Gold standard) as well as DQ2/DQ8 negative samples. We performed rapid HLA test using a BioDiagene Celiac Gene Screen kit, that foresees a rapid DNA extraction (1 min), a DNA amplification and a detection using a fluorescence reader. In addition to 101 patients with known HLA for assessment of sensitivity, we also determined HLA-DQ2/DQ8 status in additional 219 samples (CeD n=209 and healthy controls n=10) using rapid HLA haplotype detection test.

Spectrum of endocrine organ autoimmunity in patients with treatment naïve celiac disease Vipin Gupta, Alka Singh, Asif Iqbal, Ashish Agrawal, Snigdha Soni, P K Chaturvedi, Akshi Garg, Rajesh Khadgawat, Vineet Ahuja, Govind K Makharia Correspondence- Govind [email protected] All India Institute of Medical Sciences, New Delhi 110 029, India Introduction Celiac disease is an immune mediated enteropathy with strong association with autoimmune endocrinopathies e.g. diabetes mellitus (pancreas) and thyroid. Though the prevalence of endocrine autoimmunity with or without endocrinopathy (clinical/sunclinical) is not known. Methods Prospective patients of treatment naïve celiac disease (diagnosed as per ESPGHAN criteria) were recruited in the study. All the clinical and physical parameters were noted. Biochemical assessment of endocrine organ functions were done using relevant tests e.g. Chemiluminescence assay. Antinuclear antibodies (ANA) was measured as a marker of

Indian J Gastroenterol

generalised autoimmunity using immunoflorescence. Glutamic acid decarboxylase (anti-GAD) and anti-thyroid peroxidase autoantibody (antiTPO) autoantibodies were measured using Chemiluminescence assay. Results Seventy-four patients were recruited in the study after screening for inclusion and exclusion criteria. Following was the spectrum of autoimmunity (Table 1). Table 1 Prevalence of autoimmunity in patients with treatment naïve celiac disease (CeD): Antibody

Patients with celiac disease (n=74) ANA 14 (20%) Anti TPO antibody 20 (27%) Anti GAD antibody 10 (13.5%) Total no. patients with at least one antibody 35 (47.3%) positivity Patients with 1 antibody positivity 26 (35.1%) Patients with two or more antibodies 9(12.2%) positivity

Results Forty-six genes were upregulated and 540 were downregulated in the intestinal mucosa of FDRs in comparison to CeD and controls. Pathways analysis revealed three transcription factors known to be involved in maintenance of intestinal architecture namely YY1 (yin yang 1), KLF5 (KruppelLike Factor 5) and NF-?b were upregulated in intestinal mucosa of FDR. About 70 percent of upregulated gene subset in the FDRs were constituted by pseudogenes. Antigen processing and cross presentation pathways were downregulated in the intestinal mucosa of FDR. Conclusions Our analysis suggests that the intestinal mucosa of FDRs consist of a unique phenotype that is distinct from CeD patients and controls. The transcriptomic landscape of FDRs promotes maintenance of crypt-villous axis, as well as modulate immune responses. These differences clearly demonstrate that intestinal mucosa in FDRs is distinct from that of patients with CeD and that compensatory mechanisms may protect them from developing enteropathy. LARGE INTESTINE LI-01 Video assisted patient education improves compliance with follow up and depression scores in inflammatory bowel diseases

Conclusion This study showed that Thirty-five patients (47.3%) had autoimmunity with 9 of them showed positivity for multiple autoantibodies. Interestingly, anti-GAD antibody positivity had strong association with anti-TPO positivity with 80% of anti-GAD positive patients also had antiTPO positivity. Not all patients with autoimmunity have endocrinopathy but are at risk of it. SI-14 First degree relatives of patients with celiac disease harbor an intestinal transcriptomic signature that might protect them from enterocyte damage Pragyan Acharya1#, Rintu Kutum2,5#, Rajesh Pandey2,4#, Asha Mishra3, Vineet Ahuja3, Mitali Mukerji2,5, Govind K Makharia3 Correspondence- Pragyan [email protected] 1 Department of Biochemistry, All India Institute of Medical Sciences, New Delhi 110 029, India, 2Genomics and Molecular Medicine and CSIR-TRISUTRA, Ayurgenomics Unit, Council for Scientific and Industrial Research-Institute of Genomics and Integrative Biology, New Delhi, India, 3Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi110 029, India, 4Current affiliation:Mammalian Genetics Unit, MRC Harwell Institute, Harwell Science and Innovation Campus, Oxfordshire OX11 0RD, United Kingdom, 5Academy of Scientific and Innovative Research, CSIRIGIB, Delhi, India, #These authors have contributed equally to this work. Introduction Celiac disease (CeD) is an autoimmune enteropathy which affects approximately 0.7% of the global population. While 7.5% of firstdegree relatives (FDRs) of patients with CeD develop enteropathy, many however do not. Therefore, intestinal mucosa of FDRs might have protective compensatory mechanisms against immunological injury. We explored the protective mechanisms that may be active in intestinal mucosa of FDRs. Methods Intestinal mucosal biopsies (4-5 pieces) from treatment naïve patients with CeD (n=12), FDRs (n=12) (anti-tissue transglutaminase negative) and controls (anti-tTGAb negative) were obtained from each individual and subjected to microarray analysis using HT-12-v4 human expression bead chips (Illumina). Differential gene expression analysis was carried out and resulting gene lists were analyzed using ToppFun.

Nagesh Kamat1, C Ganesh Pai1, P S V N Sharma2, M Surulivel Rajan3, Asha Kamath4 Correspondence - Nagesh Kamat - [email protected] 1 Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, Manipal 576 104, India, 2Department of Psychiatry, Kasturba Medical College, Manipal University, Manipal 576 104, India, 3Department of Pharmacotherapy, UNTS College of Pharmacy, University of North Texas Health Science Center, Fort Worth, Texas 76107, USA, 4Department of Community Medicine, Kasturba Medical College, Manipal University, Manipal 576 104, India Background Patients with inflammatory bowel diseases (IBD) have to deal with a poor quality of life (QOL) and psychomorbidity resulting from an incurable illness. We aimed to study the effect of patient education on QOL, compliance, anxiety and depression in IBD. Methods Patients were prospectively enrolled over two years beginning 2014 and divided into an interventional and usual care group. Both the groups received the standard of care, but the former in addition received an 8 minute video assisted patient e d u c a t i on a l se ss i o n by t h e tr ea ti ng ga st ro en t e r o l o g i s t . Compliance to drugs defined as drug intake of >80% of the prescribed dose, and adherence to scheduled follow up visits were also compared. Self-administered questionnaires namely Short IBD questionnaire (SIBDQ), Beck Anxiety and Depression Inventory (BAI, BDI-II), Hospital Anxiety and Depression Scale (HADS) were used to assess QOL, anxiety and depression respectively at baseline, 6 months and 1 year. Results Of the 91 patients included, 7 (7.7%) were lost to follow up. Eighty-four patients [79.2%; male=66 (78.57%)] completed the follow up. Significantly more patients were compliant to follow up visits in the intervention and usual care groups respectively at 6 months (88.4% vs. 65.8% respectively; p<0.01) and 1 year (72.1% vs. 46.3% respectively; p<0.01). The median (IQR) scores for HADS-Depression over 1 year were significantly better in the interventional group than usual care [1 (1-4) vs. 4 (1-7) respectively; p<0.049]. The differences in SIBDQ, BDIII, BAI, HADS-Anxiety and compliance to drug therapy between the groups did not reach statistical significance. Conclusion Video assisted patient education improves compliance to follow up visits and depression scores in IBD. Further modifications in the educational video content and delivery might improve compliance to drug therapy, QOL and anxiety scores.

Indian J Gastroenterol

LI-02 Tacrolimus as rescue therapy for steroid dependent/steroid refractory ulcerative colitis: Experience from tertiary referral centre Sukrit Sud*, Sanjeev Sachdeva*, Anil Agarwal^, A S Puri* Correspondence - Sukrit Sud - [email protected] Department of Gastroenterology* and GI Surgery^, G B Pant Institute of Postgraduate Medical Education and Research, New Delhi 110 002, India

Conclusion Extent of disease at index ASC does not predict colectomy at admission or long-term colectomy. LI-04 Do Truelove and Witts’ criteria for diagnosing acute severe colitis apply to developing countries: A prospective study Saransh Jain1, Saurabh Kedia1, Sawan Bopanna1, Dawesh P Yadav1, Sandeep Goyal1, Peush Sahni2, Sujoy Pal2, Nihar Ranjan Dash2, Govind Makharia1, Simon P L Travis3, Vineet Ahuja1 Correspondence to- Vineet [email protected] 1 Departments of Gastroenterology, 2 Gastrointestinal Surgery 3 Translational Gastroenterology Unit, Oxford University Hospitals, Oxford UK, and All India Institute of Medical Sciences, New Delhi 110 029, India

Introduction Approximately 20% to 40% patients of severe ulcerative colitis (UC) are either nonresponsive to steroids (SRUC) or become steroid dependent (SDUC). Tacrolimus is an oral and relatively cheap drug with minimal adverse events. Methods Forty-five UC patients diagnosed as SDUC/SRUC were started on Tacrolimus 0.05-0.1 mg/kg. Clinical Mayo score (CMS) and UCEIS were recorded prior to starting Tacrolimus and after 8 weeks. 5-ASA and immunomodulators were continued if the patients were already on these drugs. Clinical response at 8 weeks was defined as CMS decrease by 3 points. Clinical remission was defined as CMS ≤2 with UCEIS <3. Results The mean age of 45 patients (25 males) was 34.8±13.8 years. Extent of disease was E3 in 31 patients. Seven failed treatment within 8 weeks and 4 were subjected to surgery and 3 patients were switched to Infliximab. Three patients either discontinued Tacrolimus or were lost on follow up. Thirty-five patients continued Tacrolimus for 8 weeks. Mean CMS and UCEIS prior to starting Tacrolimus were 6±1.2 and 4.7±1.1 respectively. At 8 weeks median CMS and UCEIS were 2.5±1.8 and 2.7 ±1.4 respectively. Twenty-five (71%) patients responded while 23 of the 35 (65%) had CMS ≤2 and 16 out of 35 (45.7%) had CMS ≤2 and UCEIS <3 suggesting that they had achieved clinical remission. Ten patients showed partial/no response at 8 weeks. There was a significant fall in both CMS and UCEIS at 8 weeks of Tacrolimus therapy (paired t-test p<0.001) in both SDUC and SRUC subgroups. Conclusion Our results show that Tacrolimus was effective in inducing a clinical response in 71% of patients with SDUC and SRUC. In view of its low cost and safety profile it may be considered as first line therapy for SDUC/SRUC.

Introduction Truelove and Witts’ criteria have been used to define acute severe colitis since the 1950s. However, the hemoglobin (a central criterion of the definition) is lower in developing countries than in the West. We aimed to determine the applicability of Truelove and Witts’ criteria in India. Methods Consecutive patients with acute severe colitis satisfying Truelove and Witts’ criteria hospitalized at a single centre from April 2015 to December 2016 were included; all received intravenous corticosteroids and 16 came to colectomy. The admission hemoglobin was subsequently excluded from the parameters of the definition to determine what impact this had on the criteria for admission. Results Out of 61 patients of acute severe colitis diagnosed according to the original Truelove and Witts’ criteria, 12 (20%) patients had one additional criterion, 32 (54%) had two additional criteria and 15 (25%) had three or more additional criteria on admission. On excluding hemoglobin as an additional criterion in Truelove and Witts’ all patients were still classified as acute severe colitis. Conclusions Truelove and Witts’ criteria can be used to define acute severe colitis in developing countries despite lower mean hemoglobin in the native population.

LI-03

LI-05

Extent of ulcerative colitis does not predict outcome after Acute severe colitis: A retrospective study

Role of Iohexol permeability estimated in urine ex-vivo by computed tomography as a marker of gut mucosal permeability and inflammation in ulcerative colitis

Saransh Jain1, Saurabh Kedia1, Sawan Bopanna1, Dawesh Prakash Yadav1, Sandeep Goyal1, Peush Sahni2, Nihar Ranjan Dash2, Sujoy Pal2, Govind Makharia1, Vineet Ahuja1 Correspondence – Vineet [email protected] 1 Departments of Gastroenterology, and 2Gastrointestinal Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India Background Extent of ulcerative colitis (UC) has been found to be a predictor of acute severe colitis (ASC) but it is unclear whether extent of disease at index episode of ASC is predictor of long-term outcome. Methods Hospitalized patients satisfying Truelove and Witts’ criteria under follow up at a single centre from January 2003–December 2016 were included. Extent of disease at index ASC was classified according to Montreal classification as left-sided or extensive colitis. Extent was used to predict the long-term risk of colectomy or steroid dependence following an index episode of ASC. Results Of 2076 patients with ulcerative colitis, 241 (12%) had an index episode of ASC. Thirty-four (14%) patients underwent colectomy at index admission and 53 (26%) over a median follow up of 48 (1-172) months. Left sided colitis and extensive colitis did not differ in the rate of colectomy at index admission (12% vs. 15%, p=0.4) and colectomy in follow up (31% vs. 23%, p=0.17). Readmission due to ASC was also similar between the 2 groups (28% vs. 32%, p=0.6).

Arun Veerabhadraiah, Anindita Sinha, Kaushal Prasad, Ajay Gulati, Chetana Vaishnavi, Bipad Bhanjan, Vishal Sharma, Surinder Singh Rana, Usha Dutta Correspondence- Usha Dutta- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Increased intestinal permeability is an early and possibly the primary defect in pathogenesis of ulcerative colitis (UC) patients. Patients with UC require repeated assessment of disease activity by colonoscopy. Colonoscopy is cumbersome, invasive and has low patient acceptability. Iohexol, non-iodinated contrast agent has enhanced absorption through inflamed mucosa and excreted through kidney without much metabolism. Methods The study was conducted in two phases, in vitro phase to assess the validity and feasibility of iohexol estimation by CT scan to detect urine iohexol concentration, followed by assessment in patients with UC. All patients underwent colonoscopy with severity assessment by UCDAI score with biopsy. Supernatant of stool samples were stored at -800C for estimation of fecal calprotectin by ELISA. Iohexol permeability was done with 100 mL Iohexol followed by 200 mL of water after overnight

Indian J Gastroenterol

fasting. Urine was collected over 12 hour periods next 24 hours. Computed tomography (CT) was performed on ex-vivo urine to determine Hounsfield units (HU) as an indicator of iohexol permeability. Results In-vitro study showed that on serial dilution of iohexol from 0% to 32%, there was a linear and positive correlation of HU with iohexol concentration. Iohexol permeability was studied in patients with UC (n=50) and HU values of urine compared with UCDAI score, fecal calprotectin, endoscopic severity, extent of disease and histopathological severity. High iohexol values (>100) were present only in those with UCDAI scores ≥6 (p=0.003); raised fecal calprotectin (p=0.008); and presence of ulcers on biopsy (p=0.041). However, iohexol total HU value did not show a statistically significant relationship with endoscopic severity, extent of disease and histopathological severity. Conclusion Urine iohexol concentration estimation is a safe, easy, non-invasive and effective method for detection of intestinal permeability. The level of urine iohexol also correlated with inflammation in ulcerative colitis in form of UCDAI score and fecal calprotectin. LI-06 Malignancies in inflammatory bowel disease – A single centre experience Maya Peethambaran, Prakash Zacharias, Aby Somu, Shibi Mathews, John Mathews, M Prashanth, Pushpa Mahadevan, Mathew Philip Correspondence- Maya Peethambaran- [email protected] PVS Institute of Digestive Diseases, PVS Memorial Hospital, Kochi 682 017, India Introduction Patients with inflammatory bowel disease (IBD) are at increased risk for gastrointestinal as well as extraintestinal malignancy. This study aims to analyse the clinical profile of patients with IBD who developed malignancy. Methods Retrospective analysis of data from IBD registry from January 2000 to June 2017. Results There were 2562 patients who were diagnosed to have IBD in the 17 year period : Crohn’s disease (CD)=1404 (55%), ulcerative colitis (UC)=1131 (44%), IBD–U=27 (1%). Malignancy was diagnosed in 41 patients–UC (n=23) and CD (n=18); M:F=1.4:1 (24:17). The overall prevalence of malignancy which included intestinal and extraintestinal malignancies among IBD patients was 1.6% (ulcerative colitis=2%, Crohn’s disease=1.2%). The median age of diagnosis of IBD was 35 y (range=3 to 74 y). Median age of diagnosis of malignancy was 43 y (range=18 to 74 y). The mean duration of illness to the malignancy was 7 y (range=1 m to 26 y). Most common malignancy in UC was colorectal malignancy (87%) (n=20/23) which included one patient with adenocarcinoma at ileoanal pouch anastomotic site after proctocolectomy and one case of rectal lymphoma. Most common site of colonic involvement was rectosigmoid (13/20). Other malignancies in UC were cholangiocarcinoma (n=2/23) (8.6%) and extraintestinal malignancy (ovarian malignancy-1/23) (4%) . Extent of inflammation in UC: pancolitis-20/23 (87%), left sided colitis-2/23 (8.6%), proctitis (1/23) (4.4%). Malignancies in CD: gastrointestinal malignancies (n=13/18; 72%) (colorectal malignancy (n=10/13) including one patient with burkitts lymphoma of rectosigmoid and 2 cases with anal canal carcinoma) and small bowel adenocarcinoma (n=3/13). Five patients (n=5/18) had extraintestinal malignancy (squamous cell carcinoma oral cavity=2, follicular lymphoma=1, ovarian cancer=1, clear cell carcinoma kidney=1). Conclusion Colorectal malignancies were more common in UC with pancolitis. Small bowel adenocarcinoma and extraintestinal malignancies were seen in CD.

LI-07 Alopecia totalis in a patient with ulcerative colitis: A rare manifestation Kumar Shwetanshu Narayan, Gaurav Kumar Gupta, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Ulcerative colitis (UC) is a chronic idiopathic inflammatory disease of the gastrointestinal (GI) tract. Patients present with a wide range of extraintestinal manifestations (EIM), most commonly involving the skin, eyes, mouth, joints, and liver. There are only a few case reports of alopecia areata being associated with ulcerative colitis. Here we discuss a case of 22-year-old male presenting with GI symptoms and alopecia totalis. Patient was diagnosed as ulcerative colitis and treated with oral steroids following which his GI symptoms improved but alopecia persisted. Such association has not been reported earlier in literature. LI-08 Over-expression of COX-2 mRNA in North Indian colorectal cancer patients Ram Rattan Negi, Satyavati Rana, Vikas Gupta, Rajesh Gupta, D K Dhawan Correspondence- Satyavati Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, Panjab University, Chandigarh 160 014, India Introduction Colorectal carcinoma is the most common neoplasm of the gastrointestinal tract. COX-2 may play an important role in colorectal cancer development. In view of the fact, the present study was planned to investigate the levels of COX-2 in colorectal adenocarcinoma and to evaluate the correlation with the clinicopathological parameters to assess the usefulness of mRNA expression marker for the diagnosis of CRC. Methods For this study, tumor tissue was taken from general surgery OT of PGIMER, Chandigarh from twenty-seven patients of colorectal cancer treated by surgery. Adjacent colonic mucosa specimens were also collected from all patients as normal control tissue. To determine the expression level of COX-2, real-time PCR was performed on twenty-seven pairs of colorectal adenocarcinoma and adjacent normal colonic tissues. Results Out of 27 CRC patients, 18 (66.7%) were males and 9 females. Mean age of patients was 51.1±14.8 years. Seventy percent of the cases were of early stage (I-II) and 30% in advanced (III-IV) tumor stage. The quantitative relative expression of COX-2 mRNA was observed to be significantly higher (p<0.05) in CRC tissues as compared with that in adjacent normal colon tissues. Also, female CRC patients showed significantly higher (p<0.009) expression of COX-2 mRNA than male CRC patients. Conclusion This is the first study which has reported a significant correlation between COX-2 mRNA expression with gender of CRC. Our data shows that there was over expression of COX-2 mRNA in colorectal carcinoma in contrast to normal mucosa. This reflects possible role of COX-2 in the tumorigenesis of CRC. Further, COX-2 inhibitors can be effective in treatment of colorectal cancer along with other drugs. LI-09 Clinical profile in patients with lower gastrointestinal bleed - A prospective study Sanjay Agrawal, Vinod Kumar Dixit, Sunit Kumar Shukla, Dawesh Kumar Yadav, Gaurav Garg, Raju Kumar Correspondence- Sanjay Agrawal- [email protected] Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Indian J Gastroenterol

Objectives Lower gastrointestinal bleed (LGIB) one of the common clinical presentation leading to admission in Gastroenterology Department. Hematochezia is usual clinical presentation. Colonoscopy is usually 1st diagnostic procedure followed by other investigations. This study was designed to evaluate various etiologies of lower gastrointestinal (GI) bleed. Methods A total of 110 cases presented with lower GI bleed (hematochezia, bloody diarrhea) in Gastroenterology OPD, Institute of Medical Sciences, Banaras Hindu University, Varanasi were included in this study. All patients underwent colonoscopy examination to evaluate etiology and treatment was given accordingly. Results Out of 110 patient majority were males which constituted 68.18% (75/110) and female 31.82% (35/110). Common clinical presentation were hematochezia (54.54%,) and bloody diarrhea (45.5%). On colonoscopy varied etiologies were as- Int hemorrhoid (45/110), features suggestive of inflammatory bowel disease (30/110), rectal polyp (14%), solitary rectal ulcer (8%), radiation proctitis (4%). Colonic malignancy seen in 4 patients. Conclusion Etiology of lower GI bleed varies according to age group of patients. Rectal polyp were most common in paediatric patients, hemorrhoids and inflammatory bowel disease and SRUS in middle age group while radiation proctitis and malignancy were common older age. LI-10 Primary epiploic appendagitis - Uncommon cause of abdominal pain: Case series Sandeep Kumbar, George Joseph, Lijesh Kumar, Aby Somu, M Prashanth, P Maya, Shibi Mathew, John Mathews, Prakash Zacharias, Mathew Philip Correspondence- Sandeep Kumbar- [email protected] PVS Institute of Digestive Diseases and PVS Memorial Hospital, Kaloor, Kochi 682 017, India Introduction Epiploic appendagitis (EA) is an inflammatory response of an appendage to infarction or spontaneous venous thrombosis. It may mimic acute abdominal conditions like diverticulitis, appendicitis, mesenteric infarction, ureteric colic. Our aim is to describe common clinical features of patients who were diagnosed with EA by CT and post surgery in last 3 years. Method Retrospective descriptive review of records of all the patients diagnosed with EA by CT and post surgery from 2013 to 2017. Clinical data obtained by record review. Results Twenty-eight patients diagnosed as EA were included in the analysis. There were 21 males and 6 females with mean age of 48 years (range 7-60). All presented with abdominal pain. Localization of pain was left lower quadrant 12 (43%), right lower quadrant 10 (36%), right upper quadrant 2 (7%) and lumbar pain 4 (14%). Based on BMI value 10 (36%) were overweight, 8 (28%) were obese and 10 (36%) were in normal range. History of strenuous physical activity prior to onset of symptoms was noted in 7 (25%). Neutrophilic leukocytosis was found in 6 patients (21%) and raised CRP in 12 (43%). Only 2 were diagnosed on ultrasound. Classical CT findings of paracolonic oval hypo dense fat tissue with thickened peritoneal ring and periappendageal fat stranding were present in 22 patients (79%) and remaining 6 (21%) had atypical features. In CT scan the sites of involvement were sigmoid colon 13 (47%), descending colon 8 (28%) and cecum/ascending colon 7 (25%).Twenty- seven patients underwent conservative treatment with only one being operated. Conclusion Epiploic appendagitis can mimic other intra-abdominal acute conditions. Though it is self limiting disease, awareness is low. CT scan provides definitive diagnosis of EA, thus avoiding unnecessary surgical intervention. Strenuous physical activity and obesity are the main risk factors.

LI-11 Clinical, endoscopic and histopathological features for differentiation of Crohn’s disease and intestinal tuberculosis N O A Sasi Kiran, Manasa Manne, L R S Girinath Correspondence- Manasa Manne- [email protected] Andhra Medical College, Visakhapatnam 530 002, India Introduction Differentiating Crohn's disease from intestinal tuberculosis often challenges clinicians, the aim of the present study is to analyze the clinical endoscopic and histological features for finding out the predictor features for differentiation between CD and intestinal tuberculosis. Methods This is a prospective observational study conducted on total of 55 patients with the diagnosis of ITB (35 patients) and CD(20 patients). Results Clinical manifestations like chronic diarrhea, blood in stools and perianal disease favour the diagnosis of CD whereas abdominal pain, abdominal mass, constitutional symptoms favor the diagnosis of ITB. Extraintestinal manifestations favor Crohn’s disease whereas lung involvement favor intestinal tuberculosis. The involvement of rectum, sigmoid colon, descending colon, ascending colon and jejunum was significantly more common in patients with CD than in patients with intestinal tuberculosis. Ileocecal valve involvement favors intestinal tuberculosis rather than crohns disease. Endoscopically skip lesions, aphthous ulcers, deep ulcers and cobblestone appearance of the mucosa significantly favoured Crohn’s disease where as nodularity and stricture formation favored intestinal tuberculosis. Histologically confluent, caseating well formed granulomas strongly favors intestinal tuberculosis whereas microgranulomas, focal active colitis with architectural abnormalities favor Crohn’s disease. In the multivariate analysis constitutional symptoms (OR 8.6, CI 2.1-31.6), involvement of IC valve (OR 9.8 CI 2.2-43.9), caseous granulomas (OR 5.9, CI 1.7-20.6) favored ITB whereas blood in stools (OR 0.1 CI 0.04-0.4), jejunal involvement (OR 0.07 CI 0.01-0.3) with microgranulomas (OR 18.9, CI 3.5-102.8) favored CD. Conclusion Constitutional symptoms, involvement of IC valve, caseous granulomas blood in stools, jejunal involvement with microgranulomas were the most important features in differentiating CD from intestinal tuberculosis. LI-12 Colonoscopic fecal microbiota transplantation for patients with ulcerative colitis with failure of 5-amino salicylates and dependence on corticosteroids and/or thiopurine intolerance: 30-month follow up of first study in India Avnish Kumar Seth, Priti Jain Correspondence- Avnish Seth- [email protected] Fortis Memorial Research Institute, Gurugram 122 002, India Background To study the long-term efficacy of fecal microbiota transplantation (FMT) in select patients with ulcerative colitis (UC). Methods Ten consecutive patients with UC and Mayo score of more than 3 with corticosteroid (CS) dependence and/or intolerance to Thiopurines and no evidence of Cytomegalovirus (CMV) were subjected to FMT. Colonoscopic FMT was done at 0, 2 and 4 weeks and then every 6 months or on relapse. Results Median age was 37 (range 24 to 49) years and duration of UC 5.9 (range 2 to 13) years. Peak Mayo score was 10.9 (range 10 to 12). Extent of disease was E3 in 3, E2 in 6 and E1 in 1. All patients were on 5-ASA, 8/10 on azathioprine and 6/10 on CS. Clinical, colonoscopic and histological remission was achieved in 6/10 (60%) patients. CS was tapered at 2 months and azathioprine at 4 months post FMT. Among responders the median Mayo score at peak of illness, start of FMT, and at 1, 2, 4 and 6 months follow up was 10.8, 5.8, 3.1, 1.3, 0.3 and 0 respectively. Responders were less likely to have terminal ileal ulcers (0/6 vs. 2/4,

Indian J Gastroenterol

p=0.031) and shorter stool donation to FMT interval (271 vs. 379 minutes, p=0.019). There was a trend towards less response with spousal donor (2/6 vs. 4/4, p= 0.076). At average follow up of 21.8 (range 15 to 30) months, relapse was seen in 4/6 patients at average of 13 (range 11 to 15) months and 3/4 had received antibiotics for enteric/UTI/tuberculosis. Remission could be achieved with rescue FMT in 1, rescue FMT+ CS in 2 and rescue FMT+CS+Aza in 1 patient. Conclusion FMT may be useful in maintaining CS and azathioprine free remission in UC. Antibiotic use is common cause of relapse after FMT in India. LI-13 Prevalence and characteristics of colorectal polypsdetected during colonoscopy done in patients attending our Hospital from June 2016-June 2017 Umalakshmi Premnath, T Rajkumar Solomon, A Aravind, K Caroline Selvi, R Balamurali, G Ramkumar, Muthukumar, Kavitha, Vaishnavi Priyaa, A Anand, S B Malipatil, Raghavendra, Ravi Anand, Sachin Dande, Sravan Correspondence- T Rajkumar Solomon- [email protected] Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College, Chennai 600 102, India Aim 1. To study the polyp detection rate in patients who underwent colonoscopy for various lower gastrointestinal (GI) complaints. 2.To study the different types of polyps. Method A retrospective cohort study was conducted using colonoscopy reporting database of individuals presenting with lower GI symptoms from June 2016 and June 2017. Results Two hundred and fifty-three colonoscopies were performed and colonic polyps were discovered in 53 cases, the detection rate was 20.0%. Mean age of presentation was 49 years (standard deviation was 47+/-7) 62.2%. Ninety-five percent confidence interval is 45.1 to 48.9. Males represented 62% (confidence interval of 49% to 75%) of which 24.5% were hyperplastic polyps and 75.5% adenomatous. Multiple polyps were found in only 5 patients, all of which were above 55 years of age. Tubular architecture was the most common making 39.6%, followed by tubule villous making 26.4 and then the villous pattern making 9.4%. Low grade dysplasia was however noted in just 5 among these, of which 2 had multiple locations of polyps. Bleeding per rectum was the most common symptom, mean of 36% and a confidence interval of (24-49%), followed by constipation. Bleeding per rectum was commonly found for the polyps on the left side of the colon. Rectosigmoid polyps was the most common site (representing 30%), followed by descending colon making 20%, followed by cecum making 19%, transverse colon 17% and then the ascending colon making 13%. Most of the polyps measured 5mm-1cm. Conclusion As there is paucity of data on polyps in general population in south India this study was done. No associations were found between polyp size andsymptoms, site and architecture. A positive correlation between size of polyp and age of the patients was found. As screening protocol was not used for asymptomatic people and for younger individual a larger cohort needs to be studied. LI-14 Study on follow up of ulcerative colitis patients on sulfasalazine at our hospital–Retrospective-cohort study S B Malipatil, T Rajkumar Solomon, A Aravind, K Caroline Selvi, R Balamurali, G Ramkumar, Muthukumaran, S Kavitha, Vaishnavi Priya, A Anand, Ravianand, Umalakshmi, Sachin Dhande, Sravan Correspondence- T Rajkumar Solomon- [email protected] Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College, Chennai 500 102, India

Introduction Ulcerative colitis (UC) is a chronic inflammatory disease of the colon of unclear etiology. Clinical remission by definition based on stool frequency, rectalbleeding, endoscopic mucosal appearance and PGA sub score. Sulfasalazineis used in treatment of UC to achieve clinical response. Aim To study the clinical remission in ulcerative colitis (UC) patients on sulfasalazine at our hospital. Methods Retrospective data of 70 patients with UC on sulfasalazine diagnosed by clinical, endoscopic and histopathologic evaluation from year 2014-2017 at our hospital were included in the study and patients with other comorbidity, non-compliance to treatment, on azathioprine or biologicals were excluded. The primary end-point was clinical response and secondary end-point was endoscopic mucosal appearance assessed by Mayo severity score. Results Retrospective data of 70 patients with UC on sulfasalzine diagnosed at our hospital from year 2014-2017 were collected. Seventy patients (Male=43, female=27) age group 24-56 years with mean age 40 years and average symptom duration of 6 months prior to our hospital visit were assessed during follow up at our hospital and classified into mild UC (n=23) moderate UC (n=31) severe UC (n=16) using Truelove and Witts classification. Mild UC patients showed improvement in mayo score from 6 to 2 with 1 point improvement in mucosal appearance (n=10) on endoscopy. Among moderate UC patients 26 showed improvement in Mayo score from 9 to 3 with 1 point improvement in mucosal appearance (n=7) 2 was not responsive to sulfasalazine, started on shortterm steroids but subsequently was dependent on steroids, 3 lost follow up. Among severe UC patients 9 showed improvement in mayo score from 11 to 6 with 1 point improvement in mucosal appearance (n=1) 2 were not responsive to sulfasalazine, started on short-term steroids but subsequently were dependent on steroids, 1 lost follow up, 3 were refractory to conventional treatment and 1 required emergency colectomy for toxic megacolon. Conclusions In our study, ulcerative colitis patients on sulfasalazine achieved 82.85% clinical response with 31.03% endoscopic mucosal healing, thus sulfasalazine remains first line and well tolerated effective treatment for ulcerative colitis in the era of biologicals and other immunosuppressants. LI-15 Evaluation of atherosclerosis by carotid intima media thickness in patients with ulcerative colitis - Significant? Harit Goverdhan Kothari, Sudhir Jagdishprasad Gupta, Nitin Rangrao Gaikwad, Amol Rajendra Samarth, Tushar Hiralal Sankalecha Correspondence- Harit Goverdhan Kothari - [email protected] Department of Gastroenterology, Government Medical College and Superspeciality Hospital, Nagpur 440 009, India Introduction Ulcerative colitis (UC), is characterized by chronic relapsing–remitting infammation of the gastrointestinal tract. Chronic infammatory process may predispose to atherosclerosis. Effect of chronic infammation on development of atherosclerosis has already been demonstrated in various studies which showed that Carotid intima media thickness (CIMT) can be used in early diagnosis of atherosclerosis, risk classification and evaluation of response to treatment. Objective To assess Carotid intima media thickness (CIMT) and its relation to atherosclerosis in patients of ulcerative colitis. Methods This study was carried out in Department of Gastroenterology, Government Medical College and Superspeciality Hospital, Nagpur as an observational study. We included 80 patients with proven ulcerative colitis with minimum 6 months duration who were in remission. Age and sex matched healthy controls were taken. Patients with known risk factors for atherosclerosis were excluded from study. Routine blood investigations along with CRP, ESR and Fasting lipid profile were done. CIMT was measured using B-mode Doppler imaging study.

Indian J Gastroenterol

Results Out of total 83 patients of UC, 47 males and 36 females were there. Average age was found to be 36.95 and 37.19 years. Average duration of disease was 2.59 years. Nine patients had proctitis (E1) with average CIMT (right and left) of 0.50 mm and 0.489 mm. Thirty-eight patients had left sided colitis (E2) with average CIMT of 0.585 mm and 0.55 mm respectively. Thirty-six patients had extensive colitis (E3) with average CIMT of 0.551 mm and 0.536 mm respectively. Two patients had complication in form of deep venous thrombosis of lower limb, 1 each from E2 and E3 group. CIMT was not found statistically significant in UC patients (p>0.05). Conclusion Increased Carotid Intima Media Thickness (CIMT) does not necessarily predict subclinical atherosclerosis in ulcerative colitis specially who are in remission. LI-16 Clinical and histopathological profile of colonic polyps in a tertiary care centre in northern India Saveena Jindal, Neena Sood, Varun Mehta, Arshdeep Singh Correspondence- Varun Mehta- [email protected] Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India Introduction Colorectal polyps are common among individuals older than 50 years and some polyp types have a malignant potential. There is dearth of data on clinic-pathological profile of colonic polyps in India. Methods This prospective observational study was conducted at Dayanand Medical College and Hospital, Ludhiana, India from January 2017 to June 2017. Adults=18 years and diagnosed with=1 polyp during a colonoscopy examination were evaluated. Clinical features, colonoscopic description and histologic findings of all patients with polyps were noted. Results Thirty-four individuals (mean age 52.82±15.86 years, 64.7% males) underwent colonoscopic examination. Indication for colonoscopy was hematochezia in 12 (35.29%), altered bowel habits in 14 (41.17%), lower abdominal pain in 4 (11.77%) and evaluation for anemia in 4 (11.77%) patients. A total of 44 polyps [5 (14.70%) patients had=2 polyps] were identified, excised and measured, and underwent histopathological examination. Adenomas accounted for 31 (72.09%) of all polyps and tubular type was the most frequent one (83. 87%). Twenty-four (54.54%) patients had pedunculated polyps. The majority of polyps [39 (88.64%)] were small (<1 cm), and 5 (11.36%) were larger than 1 cm. There was no gender difference with regard to patient age or polyp size. Adenomas were more frequent among men compared to women (p=0.0001). Two patients (ages 67 and 72) had adenomatous polyps with high grade dysplasia. Polyps in both the patients were large (>1 cm), multiple (=2), sessile and had either tubulo-villous or villous histology. Conclusion Adenomas in recto-sigmoid region account for the majority of the colonic polyps. LI-17 Ulcerative colitis associated toxic megacolon: Experience from tertiary referral center in India A S Puri, Vallurupalli Krishna Priya, S Sachdeva, Anil Aggarwal Correspondence- A S [email protected] Department of Gastroenterology, G B Pant Institute of Post Graduate Medical Education and Research, New Delhi 110 002, India Background Toxic megacolon (TMC) is an uncommon complication of severe ulcerative colitis occurring in 5% patients. More than 50% of patients require colectomy as a definitive therapy. Toxic megacolon is associated with high mortality rate (30%) especially in those with perforation. Biologicals are now SOC for moderately severe ulcerative colitis

but experience with TMC is anecdotal. Ours is first study from South Asia which evaluated outcome of TMC in severe UC. Methods Prospective study. Study Period: March 2013 to March 2017. Diagnosis of TMC : Based on transverse colon diameter ≥ 6 cm along with Clinical Mayo Score ≥ 6. Exclusion Criteria: TMC associated with diseases other than ulcerative colitis. Results Over stipulated study period 15 patients diagnosed to have toxic megacolon. Fourteen (3.2%) out of 430 cases with ulcerative colitis diagnosed to have TMC. Mean age was 32.9 years. In 7 (50%) out of 14 patients, TMC documented in 1st episode. Mean Clinical Mayo Score at admission was -7.5. Colonic perforation occurred in 6 (42%) out of 14 patients. Surgical intervention (subtotal colectomy) was required in 9/14 (64%) patients. Postoperative mortality was 5/9 (55%). Successful medical therapy was given in 3 (21%) patients (Infliximab in 2). Conclusion Toxic megacolon occurred in 3% of patients with ulcerative colitis. More than 50% patients develop toxic megacolon during 1st episode of UC. Surgery is mainstay of treatment. Considerable postoperative mortality (55%) is due to late referral. Biologic therapy needs further investigation. LI-18 Isolated colonic Crohn’s is less aggressive compared to ileal/ ileocolonic Crohn’s disease Umang Arora, Saurabh Kedia, Sawan Bopanna, Saransh Jain, Dawesh P Yadav, Sandeep Goyal, Peush Sahni1, Sujoy Pal1, Nihar Ranjan Dash1, Govind Makharia, Vineet Ahuja Correspondence- Vineet [email protected] Departments of Gastroenterology and 1GI Surgery, All India Institute of Medical Sciences, New Delhi 110 029, India Background The literature on disease characteristics of colonic Crohn’s disease (CD) is sparse, especially from Asia, where the burden of inflammatory bowel disease (IBD) is on the rise. The present study aims to describe the disease characteristics of colonic CD, and compare it with that of ileal/ileocolonic disease. Methods This retrospective study included adult patients of CD (diagnosed by standard criteria, follow up duration >6 months) on follow up at All India Institute of Medical Sciences, New Delhi, India from August 2004–January 2016. The disease location was classified by Montreal classification. The data was recorded on demographic characteristics, smoking status, disease phenotype, disease course, treatment received, hospitalization and surgeries. Results Of 388 patients with CD, 123 had colonic (mean age (at onset): 30.4+13.2 years, 59.3% males) and 265 had ileal/ ileocolonic disease (mean age(at onset): 32.9+13.8 years, 61.5% males). The frequency of smoking and oral tobacco use was similar between colonic and ileal/ileocolonic CD. The frequency of inflammatory behavior (61.8% vs. 46.4%, p=0.003), perianal disease (23.6% vs. 4.5%, p<0.001) and extraintestinal manifestation (42.3% vs. 30.2%, p=0.019) was more common in colonic than ileal/ileocolonic CD. The disease course pattern was similar between the two groups. Similar proportion of patients in both the groups were treated with 5-aminosalicylates, azathioprine, and methotrexate. Steroid use was higher in patients with colonic CD (84.3% vs. 74.2%, p=0.036). There was no difference in the frequency of hospitalization between the two groups (30.1% vs. 27.1%, p=0.45). The overall requirement for surgery was significantly lower in colonic CD (17.1% vs. 26.1%, p=0.032) and patients with colonic disease were at lower risk of undergoing first surgery in the first 10 years of follow up [Hazard Ratio: 0.556 (95% CI: 0.313-0.985), p=0.045]. Conclusion Colonic CD was associated with less aggressive disease behavior and lower requirement of surgery as compared to ileal/ileocolonic CD.

Indian J Gastroenterol

LI-19 Infliximab and anti-infliximab monitoring in inflammatory bowel disease patients – A preliminary report Devendra C Desai1, Suruchi P Parkar2, Alpa J Dherai2,3, Bhamini G Keny3, Tester F Ashavaid2,3 Correspondence- Dr. Devendra [email protected] 1 Division of Gastroenterology, 2Research Laboratories, and 3Department of Biochemistry, P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India Introduction Measurement of infliximab (IFX) level and antibody to infliximab (ATI) has been advocated to optimize therapy in inflammatory bowel disease (IBD) and to assess secondary loss of response. Monitoring of anti-TNF drug levels is not routine in India. Methods Pre-dose (trough level) blood sample was collected for IFX and ATI estimation by ELISA method from 13 IBD patients on maintenance IFX. Management was optimized based on IFX level and presence or absence of ATI. IFX level in the range 3-7 mcg/mL in maintenance phase and absence of ATI was considered optimal [1]. Result Therapeutic level was obtained in 3/13 (23%) while 10 (77%) patients had sub-therapeutic level of which 4 had presence ATI. The ATI levels ranged from 5.1 to>100 ng/mL while their IFX level was <0.5 ug/mL. The IFX in 3 patients with therapeutic level was 4.3, 6 and 7 ug/mL each while patients with sub-therapeutic IFX and absence of ATI (n=6) had <0.5 ug/mL in 4 patients and 0.5, 0.7 and 1.63 ug/mL in the remaining three. Those with therapeutic IFX level improved clinically and were continued on the same drug schedule. Management was altered in remaining 10 patients, all with active disease. Modifications such as switch to once-a-month dosing (3), dose increased to 10 mg/Kg (1), switched to another biologic agent (3), and advised increase in dose or change to another agent (1 each; no follow up available) and one patient underwent surgery. Conclusion A third of patients in this study had therapeutic infliximab level on maintenance dose; the rest had sub-therapeutic level and their management had to be modified. Antibody to infliximab was present in about a third of patients. Management was changed in 2/3 of patients. Acknowledgement We thank Dr Philip Abraham, Consultant Gastroenterologist, for reviewing the manuscript. 1. Vande Casteele N, Ferrante M, Van Assche G, et al. Gastroenterology. 2015;148:1320-9 LI-20 Can we use commercially available kit to measure infliximab level for Indian biosimilar drug? Devendra C Desai1, Bhamini G Keny2, Alpa J Dherai2,3, Suruchi P Parkar3, Dhanshri Shetty2, T F Ashavaid2,3 Correspondence- Devendra [email protected] 1 Department of Gastroenterology, 2 Department of Biochemistry, 3 Research Laboratories, P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India Introduction Infliximab (IFX) biosimilar agents are increasingly used in inflammatory bowel disease. For optimizing the therapy, infliximab trough level and antibody to infliximab (ATI) estimation are advocated. The commercially available immunoassays for estimation of IFX need to be validated for biosimilar used in our setting. Aim To assess the efficacy of the commercially available RIDASCREEN ELISA IFX (infliximab) kit to estimate infliximab biosimilar, Infimab. Method In this pilot study, the ELISA method was evaluated for accuracy, precision and recovery. The above parameters were assessed in biological matrices (bovine serum albumin and serum from healthy volunteers not on any medication and patients on infimab therapy). The serum samples

of inflammatory bowel disease patients (n=14) receiving either formulation were also included in the study. Result The biosimilar spiked in the biological matrix was linear throughout the concentration range specified for both maintenance phase and induction phase (0.5–12 ug/mL and 2-48 ug/mL respectively). The spiked samples at 5 ug/mL and 25 ug/mL concentrations repeated in different batches of analysis showed a % CV of 14 and 8.3 respectively. The spiked biosimilar in all three matrices performed at three concentrations gave a mean recovery of 104% for bovine serum albumin, 84% for drug free healthy volunteer sample and 98% for patient on IFX therapy. The IFX level in patients on various formulations showed a positive correlation with the drug level. Conclusion The ELISA Kit showed satisfactory performance for estimation of the biosimilar suggesting that the method can be used to estimate IFX level in patients receiving Infimab. LI-21 The epidemiology of lower gastrointestinal bleed in Odisha Manoj Kumar Sahu, Jimmy Narayan, Kanishka Uthansingh, Ayaskanta Singh,Manas Behera, Debasmita Behera Correspondence- Manoj Kumar [email protected] IMS and SUM Hospital, Bhubaneswar 751 003, India Introduction Acute overt lower gastrointestinal bleeding (LGIB) accounts for approximately 20% of all cases of gastrointestinal (GI) bleeding, usually leads to hospital admission with invasive diagnostic evaluations, and consumes significant medical resources. Although most patients with acute LGIB stop bleeding spontaneously and have favorable outcomes, morbidity and mortality are increased in older patients and those with comorbid medical conditions. There is dearth of data on the epidemiology of LGIB in our country. Method One hundred and twenty-six consecutive patients with lower GI bleed were prospectively included in this study within a period between January 2016 to January 2017. Hemodynamic status was initially assessed with intravascular volume resuscitation as needed. Colonoscopy was performed within 24 hours of presentation. Result Of the 126 patients with LGIB, 76% are male, the age group varies from 4 -75 years, with 64% between 30-50 years. The etiology of bleed was internal hemorrhoids, rectal polyps, ulcerative colitis, reco-sigmoid cancers, rectal ulcers, radiation proctitis and ileal ulcers in 25%, 19%, 17%, 15%, 8%, 6%, 4% respectively, in 0.9% of patients colonoscopy was normal. Thirty-eight percent of patients required endotherapy, 1% radiological intervention for control of bleeding. Most of the patients are managed in the ward, eight of them required ICU care. Three patients died, and the death was attributable to associated co-morbidity. Conclusion Patients presenting with acute lower GI bleed should undergo a focused evaluation simultaneous with hemodynamic resuscitation. Early colonoscopy within 24 hours will establish the diagnosis and simultaneously provide endotherapy for control of bleeding. Due importance should be given to associated co-morbidity, as they are the major determinant of mortality. LI-22 National survey of inflammatory bowel disease awareness and management by physicians Rupa Banerjee, Partha Pal, Ganesh Girish, M Kavitha, D Nageshwar Reddy Correspondence- Rupa [email protected] Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Indian J Gastroenterol

Introduction Inflammatory bowel disease (IBD) is on the rise in the Asia Pacific including India. There is very limited data on the awareness and clinical approach to diagnosis and management of IBD by Indian physicians. Methods We conducted a questionnaire based survey of practicing physicians attending the conference of Association of physicians of India. The questionnaire was designed to understand the awareness about IBD including diagnosis, prognosis and management. An Iintitutional review board approval was taken and data was anonymized. Only fully completed questionnaires were included in the analysis. Results Complete response obtained from 813 physicians. Four hundred and fourteen (52.7%) saw about 1-4/month, 152 about 5-9/m and 214>10/month. Majority (59.7%) of patients were 30-40 years and from an urban background. 39.8% referred their IBD patients to a specialist. 36.5% diagnosed IBD based on symptoms alone. 56.5% believed UC was a curable short-term illness. 26.1% perceived that UC was either infectious, stress related or associated with smoking. 58.3% physicians used mesalamine and corticosteroid combination as first line treatment for UC. 55.1% used antibiotics for symptomatic UC. 74.6% used corticosteroids to maintain remission in UC. 81% used mesalamine to maintain remission in CD. >51% physicians had used biologics for treatment. Conclusion IBD is commonly managed by physicians in India. However, there is a lack of awareness regarding IBD among them regarding nature of disease, prognosis and management. A significant majority prescribed corticosteroids for maintenance of remission in UC and mesalamines for maintenance of remission in CD. A large proportion of physicians believed that IBD was a curable disease. As IBD increases in India Increasing physician awareness and education is necessary for optimal management. MOTILITY DISORDERS MD-01 Endoscope guided pneumatic dilatation of achalasia cardia-A tertiary care experience B Mohammed Noufal, K Prem Kumar, Kani Sheikh, Ratnakar Kini, T Pugazhendhi Correspondence- B Mohammed Noufal- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Pneumatic dilation (PD) is considered to be the first line nonsurgical therapy for achalasia. The principle of the procedure is to weaken the lower esophageal sphincter by tearing its muscle fibers by generating radial force which is done endoscopically without fluoroscopic control using a low-compliance balloon such as Rigiflex dilator. It has the advantage of determining mucosal injury during the dilation process, so that a repeat endoscopy is not needed to assess the mucosal tearing. Aim To study the series of cases of achalasia cardia, managed by pneumatic dilatation and observe their outcomes and complications, presenting in our centre during the period of July 2015 to 2017 Methods Twenty-seven cases of achalasia cardia which presented to our centre during July 2015 to 2017 were managed by endoscope guided pneumatic dilatation and their outcomes were observed. Results Twenty-five of 27 patients with achalasia presented with dysphagia for solids or liquids. Twenty patients had regurgitation and vomiting. Weight loss of more than 5 kg was observed in 10 patients. History of nocturnal cough was present in 7 patients. Thirty-five dilatations were performed in 27 patients. All patients had relief of dysphagia and regurgitation within 24 hours. Barium swallow within a week of dilatation showed a decrease in the maximum diameter of the esophagus from 42.4+11.4 mm to 30.5+10.5 mm and increase in the diameter of the narrowed lower segment from 2.45+1.5 mm to 11.4+2.2 mm. None of the patients showed a hold up of barium after dilatation. Twenty patients

complained of retrosternal pain during procedure but none persisted for 24 hours. No perforations were encountered during the study. There was no procedural mortality. Conclusion Endoscope-guided PD is an efficient and safe nonsurgical therapy with results comparable to other treatment modalities. MD-02 Anorectal manometric abnormalities in functional constipation and IBS-C Omesh Goyal, Monika Bansal, Ajit Sood Correspondence- Omesh Goyal- [email protected] Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana 141 001, India Background Functional constipation (FC) and constipation predominant irritable bowel syndrome (IBS-C) are a part of functional bowel disorders, and have a significant personal, healthcare, and social impact. Data on the anorectal manometric abnormalities in these patients in Indian population is scarce. We aimed to study the anorectal manometric abnormalities in patients with functional constipation and constipation predominant IBS. Presenting to a tertiary care institute in northern India. Methods A total of 114 consecutive patients with history of chronic constipation who underwent ano-rectal manometry from January 2013 to December 2016 in our institute were enrolled. Standard laboratory tests and colonoscopy were normal. Twenty-six healthy volunteers served as controls (HC). Results Mean age of patients was 46.7 years, 75.4% were males. The median duration of constipation was 60 months. Sixty-two patients fulfilled ROME IV criteria for functional constipation (FC) and 52 had irritable bowel syndrome-constipation predominant (IBS-C). A comparison of the anorectal motor and sensory manometry parameters among patients with FC, IBS-C and healthy controls was performed. The resting anal pressure and the squeeze pressure were similar in all three groups. Dyssynergic pattern of defecation was seen in significantly more patients in the FC group (43.5%; p<0.001) and IBS-C group (21.5%; p<0.001) compared to controls (7.8%). The first sensation threshold, desire to defecate and maximum tolerable volume were significantly higher among FC patients compared to controls. Recto-anal inhibitory response was present in all patients except 4.9% patients in FC group. Abnormal balloon expulsion test was seen in 7.8% of controls, 19.2% of IBS-C and 51.5% of FC patients. Conclusions Dyssynergic pattern of defecation is seen in significantly more patients with FC and IBS-C compared to controls. Patients with FC have marked elevation of all sensory thresholds, while IBS-C patients have elevated threshold for first urge but decreased maximum tolerable volume. MD-03 Association of altered gut motility with SERT gene polymorphism in T2DM patients Satyavati Rana, Rajesh Kumar Morya, Aastha Malik, Gaurav Sharma, Surinder Rana, Sanjay Kumar Bhadada Correspondence- Satyavati Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Type 2 diabetes is multifarious disease. Both environmental and genetic aspects play role in pathogenesis and complications of diabetes. Common gastrointestinal symptoms like constipation and diarrhea can occur due to alteration in gastrointestinal motility in T2DM patients. Aim To study association of altered gut motility with serotonin transporter gene polymorphism in type 2 diabetic patients.

Indian J Gastroenterol

Methods One hundred and thirty-five T2DM patients attending Diabetes Clinic at PGIMER, Chandigarh were enrolled. They had diabetes for ≥5 years. One hundred and thirty-five age and sex matched healthy controls (who were not relatives of patients but gave consent for study were also enrolled). Non-invasive lactulose hydrogen breath test was used for measurement of gut motility i.e. orocecal transit time (OCTT). 5 mL blood was taken from subjects. Plasma was used for measurement of serotonin levels by ELISA and buffy coat was used for isolation of DNA using phenol chloroform method. Serotonin transporter (SERT) gene polymorphism was performed by PCR. Results Out of 135 patients, 62/135 (45.9 %) were males while 61/135 (45.2%) males out of 135 controls. Mean±SEM of age in patients was 52.1±0.63 years and 51.7±0.59 years in controls. Frequency of S allele and SS genotype was significantly higher (p<0.05) in patients than controls and was associated with increased risk of disease. OCTT was significantly delayed in patients as compared to controls. Delay was more significant (p<0.05) in individuals with LL genotype as compared to SS genotype. Levels of serotonin were highest in SS genotype. Diarrhea was present in 13.9% diabetic patients. OCTT was also rapid in patients with diarrhea than patients with constipation or who had no problem. Serotonin levels were higher in patients with diarrhea. Conclusion This study shows that there is association of SS genotype with rapid gut motility through increase in serotonin levels in diabetic patients. Individuals with SS genotype may be more prone of developing diarrhea. MD-04 Frequency, factors associated with malnutrition among patients with achalasia and effect of pneumatic dilation Prabhakar Kumar Thakur, Uday C Ghoshal, Asha Misra, Abhai Verma, Vivek A Saraswat Correspondence- Uday Chand [email protected] Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India

LIVER L-001 Efficacy and safety of direct acting antiviral therapy for chronic hepatitis C in thalassemic children Shivadatta Padhi, Gaurav Kumar Gupta, Sudhir Maharshi, Manoj Kumar, Sandeep Nijhawan, Kapil Garg Correspondence: Sandeep Nijhawan - [email protected] Department of Medial Gastroenterology and Thalassemia Unit, Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Introduction Prevalence of chronic hepatitis C in thalassemic children is 19% to 68% in various studies. There is no study on efficacy and safety of directly acting antiviral therapy (DAA) for chronic hepatitis C in pediatric population. We assessed the efficacy and safety of DAA for chronic hepatitis C thalassemic pediatric patients. Methods Prospective study was conducted in Department of Gastroenterology, S M S Medical College, Jaipur between Sepetember 2015 to January 2017. All chronic hepatitis C pediatric patients with age above 5 years were included in this study. DAA for patient of genotype 2, 3 was adult dosage of sofosbuvir 400 mg+daclatasvir 80 mg for 12 weeks, for genotype 1, 4, 5, 6 it was sofosbuvir 400 mg+ledipasvir 90 mg according to EASL guideline 2015. Observations Fourteen thalassemic patients (age 9.7±1.9 years, 12 males) were studied. All patients were of genotype 3 and received DAA (sofosbuvir 400 mg+daclatasvir 80 mg) for 12 weeks. The mean serum bilirubin was 2.6±2.6 mg/dL and mean viral load was 2.5±2.7 X 103 IU/ ML. None of the patients showed evidence of cirrhosis. All patients achieved end of treatment response (ETR) and sustained virological response at 12 weeks (SVR 12). None of the patients develop any adverse effects of DAA. Conclusion DAA at adult dosage is safe and effective for treatment of chronic hepatitis C (genotype 3) pediatric thalassemic population. L-002

Background Patients with achalasia are often undernourished due to dysphagia and inadequate intake. Since only a few reports evaluated nutrition in achalasia, we studied, (i) frequency of malnutrition among achalasia patients, and (ii) effect of pneumatic dilatation (PD) on nutritional parameters. Methods Seventy adult (≥18 years) achalasia patients (on high resolution manometry) and 70 healthy controls were evaluated by dietary recall, anthropometry, serum protein, albumin, iron and calcium levels. Patients were followed up for 6 months after PD to evaluate symptom and nutritional improvement. Results Patients with achalasia had lower intake of calorie (1803.1 [9502400] vs. 2085 [1850-3100] Kcal/day, p=0.001), protein (40.9 [22-70] vs. 53.6 [40.5-80.5] g/day, p=0.00), calcium (362.7 [123-1020] vs. 480.7 [260-1110] mg/day, p=0.001) and iron (8.6 [3-15] vs. 9.6 [5.8-16.9] mg/day, p=0.001) than controls. Serum protein (7.2 [5.5-9.8] vs. 7.7 [5.8-9.7)] g/dL, p=0.03) and albumin (3.9 [2.8-5] vs. 4.1 [3.8-5.2] g/dL, p=0.009) were low in patients while no difference was observed in hemoglobin, iron and calcium between the two groups. Patients had lower body mass index (BMI) (19.7 [12.8-30] vs. 22.8 [18-30.5], p=0.04), midarm circumference (MAMC) (21 [14.1-34] vs. 24.2 cm [18.1-32.3], p=0.001), biceps (BSFT) (3.2 [0.6-12] vs. 5.6 [2.1-14.3] mm, p=0.001) and triceps skin fold thickness (TSFT) (6.1 [0.4-20.5] vs. 7.8 [2.4-31] mm, p=0.001). Though calorie (1803 [950-2400] vs. 2085 [1850-3100] Kcal/day, p=0.001), protein intake (40.9 [22-70] vs. 53.6 [40.5-80.5] gm/ day, p=0.001), BMI (19.6 [12.8-30] vs. 22.2 [15.9-30], p=0.001) and MAMC (21 [14.1-32] vs. 24.2 [15-32] cm, p=0.03) increased after PD, skin fold thickness remained comparable. Conclusions Malnutrition is common in achlasia and PD is associated with improvement in nutritional status.

Acute-on-chronic liver failure: A tertiary care center experience Bhanwar Singh Dhandhu, Atul Janrao Gawande, Shashank Wanjari, Vasudha Goel, Vinay Rathore, Gaurav Gupta, Sandeep Nijhawan Correspondence - Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Introduction Acute-on-chronic liver failure (ACLF) is an acute event associated with high mortality. There are chances of regional differences for epidemiology of ACLF. The present study is planned to assess etiologies, course, and outcome in ACLF patients in north western region of India. Methods Two hundred and eight (182 males and 26 females) patient of ACLF fulfilling modified APASL Consensus criteria 2009 admitted to the Gastroenterology Department of S M S Medical College and Hospital, Jaipur between January 2015 and January 2017 were included and prospectively evaluated for 1 month, or till death. We evaluate etiology of underlying chronic disease and acute event for decompensation in ACLF. Result Most common chronic etiology of chronic liver disease (CLD) was alcohol (72.1%). Viral, cryptogenic, autoimmune, nonalcoholic steatohepatitis, Wilson’s disease as cause of CLD was present in 32 (15.4%), 12 (5.8%), 9 (4.3%), 3 (1.4%), 2 (1%) respectively. Alcohol, sepsis, bleeding, reactivation of hepatitis B, hepatitis E, drugs, antitubercular drugs, and autoimmune hepatitis, as cause of acute event was present in 100 (41.8%), 34 (16.3%), 19 (9.1%), 17 (8.2 %), 15 (7.2%), 11 (5.3%), 8 (3.8%), 2 (1%), 2 (1%) of patients respectively. In 8 (3.8%) patients the precipitating event was not known. One month mortality in

Indian J Gastroenterol

this study was 37.5%. Higher model for end-stage liver disease (MELD) score and high Child-Turcotte-Pugh (CTP) score was significantly associated with mortality (p<0.001). There was no significant difference regarding acute precipitating events between survivors and nonsurvivors. Conclusion Alcohol was most common cause for chronic etiology as well as acute precipitating event. Neither etiology of CLD nor cause of precipitation of acute decompensation was significantly associated with increased mortality. L-003 Prevalence of deep vein thrombosis in patients with advanced liver cirrhosis: Rare entity in a tertiary care centre Vijyant Tak, Gaurav Gupta, Sandeep Nijhawan, Vasudha Goyal Correspondence – Sandeep Nijhawan - [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Introduction Venous thromboembolism (VTE) has traditionally been considered rare in Asia. There is scarce Indian data on time trends of deep vein thrombosis in chronic liver disease in India. Objectives Aim of this study were to know the prevalence of DVT among cirrhotic patients and to compare clinical pictures between cirrhotic patients with and without DVT. Methods This is a case control study performed on the basis of medical record data of patients with liver cirrhosis compensated or decompensated of any etiology admitted between January 2016 and July 2017 in S M S Hospital and Medical College, Jaipur. DVT in CLD was established by duplex Doppler ultrasonography of the lower extremities. Patients with splanchnic thrombosis and portal vein were excluded from this study. Patient with DVT were treated with LMWH and warfarin. Observation A total of 365 patients with liver cirrhosis were included in this study; 296 (81.2%) among them were men. Patient’s mean age was 58.5±10.5 years, ranging from 20 to 65 years. Alcohol liver disease accounted for 93.2% of patients with liver cirrhosis. DVT was found in 6 (1.64%) patients. There was no significant laboratory difference between cirrhotic patients with and without DVT (serum albumin, platelet count, aminotransferases, c-glutamyl transpeptidase, alkaline phosphatase, total bilirubin levels, and prothrombin time). Conclusions The prevalence of DVT in patients with liver cirrhosis was 1.6%, and deep vein thrombosis is a rare condition in cirrhotic patients with coagulopathy in Indian patient and warrants further studies on the mechanisms and prevention. L-004 Acute viral hepatitis related acute-on-chronic liver failure in hepatic Wilson’s disease – A single centre experience Piyush Gupta, Ashish Goel, Uday Zachariah, Chundamannil E Eapen Correspondence - Piyush Gupta- [email protected] Department of Hepatology, Christian Medical College and Hospital, Vellore 632 004, India Introduction There is limited data on acute-on-chronic liver failure (ACLF) in patients with Wilson’s disease (WD) with acute etiological insult being acute viral hepatitis. We aimed to study the same. Methods Case records of 184 Hepatic WD patients, diagnosed (in Hepatology Department) from June 2006 to July 2017 were studied. Seven patients had index presentation with acute viral hepatitis (hepatitis-A and hepatitis-E) related sudden decompensation of liver disease. Case records of these patients were retrospectively analyzed. Results Seven patients with underlying hepatic WD presenting as ACLF were identified. They had defined acute etiological insult being hepatitisA (3 patients) and hepatitis-E (in 4 patients) virus related hepatitis. ACLF was the index presentation in all these patients who presented at the age of

15 (7-21) years (4 males). None of the patients were on any prior medication for WD. A typical prodrome associated with acute viral hepatitis was noted in 5 patients. All patients had presented with jaundice (bilirubin >5 mg/dL), coagulopathy (INR >1.5), and ascites (4 patients developed ascites within 1 month, 3 patients within 3 months of jaundice). Two patients had hepatic encephalopathy and one patient had sub-clinical hepatopulmonary syndrome. None had family history or neurological manifestation of WD. The median hospital stay was 10 (5-35) days. Four patients had AST-to-ALT ratio >2.2 whereas only 1 patient had ALP-to-bilirubin ratio <4. There was single in-hospital mortality. Four patients showed improving MELD/PELD scores during follow up (duration of follow up 1133, 342, 61, 22 days respectively). None of the patient underwent liver transplantation. Conclusion Wilson’s disease presenting as syndrome of ACLF needs to be considered for new and early interventional strategies. Acute viral hepatitis related ACLF with underlying Wilson’s disease may be associated with a better prognosis than fulminant hepatic Wilson’s disease and thus needs to be differentiated from same. L-005 The association of Helicobacter pylori infection in non-alcoholic fatty liver disease patients Raju Kumar, V K Dixit, S K Shukla, Shivam Sachan, Sanjay Agarwal Correspondence- Raju Kumar - [email protected] Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction Helicobacter pylori (H. pylori) can cause a wide array of gastric disorders, including chronic gastritis, peptic ulcer, and gastric cancer. The worldwide prevalence of non-alcoholic fatty liver disease (NAFLD) in the general population is estimated to be 20% to 30% in Western countries and 5% to 18% in Asia and is increasing over time. Recently, accumulating evidence has implicated H. pylori infection in extra gastrointestinal diseases such as cardiovascular diseases, neurological disorders, and metabolic diseases. Due to high prevalence, unclear etiology and difficult treatment of NAFLD, confirming the pathogenicity of H. pylori infection in NAFLD will undoubtedly provide insights for novel treatment strategies for NAFLD. Treatment for H. pylori infection is easy and relatively inexpensive. Methods This is a cross sectional study in which 120 patients of age 20-50 yrs with various dyspeptic symptoms undergoing upper GI endoscopy in the Institute of Medical Sciences, Banaras Hindu University from November 2016 to April 2017 were enrolled. The patients underwent rapid urease test (RUT) for diagnosis of H.pylori infection and they were advised for ultrasonography to see for fatty liver .The patients were divided into NAFLD and non-NAFLD group accordingy. For significant differences between two groups Chi-square test was applied. Results Twenty-seven patients were having NAFLD out of which RUT was positive in 11.In the non-NAFLD group of 93 patients RUT was positive in 20. H. pylori infection was found in 25.8% of patients overall. The prevalence of H. pylori infection was significantly higher in NAFLD group (40.7%) than in those without (21.5%) with a significant p value of 0.044).

NAFLD (n=27) Non-NAFLD (n=93)

RUT positive 11 (40.7%) 20 (21.5%)

RUT negative 16 (59.3%) 73 (78.4%)

Conclusion The association of H. pylori infection with NAFLD suggests that H. pylori infection may represent another contributing factor for NAFLD. Eradicating H. pylori infection may have therapeutic prospects in NAFLD treatment.

Indian J Gastroenterol

L-006 Factors associated with the survival of acute liver failure patients Siddharth Dharamsi, Anil C Mathew, L Venkatakrishnan, Noel George, Alan Jose Correspondence- Siddharth Dharamsi - [email protected] PSG Institute of Medical Sciences and Research, Coimbatore 641 004, India Background Acute liver failure (ALF) is characterized by severe and sudden liver cell dysfunction leading to coagulopathy and hepatic encephalopathy in previously healthy persons with no known underlying liver disease. The aim of the current study is to provide an overview of the factors associated with the survival of acute liver failure patients and to suggest an optimum cutoff value for chemically significant parameters. Methods The patients suffering from ALF who visited the hospital between January 2016 and May 2017, were reviewed in this study. The factors studied were age, sex, pregnancy, total serum bilirubin, aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum albumin, urea, serum creatinine, and recent hepatitis E virus infection. We then conducted a complete house to house survey to find the actual survival of those patients. Results It was found that, those who had blood urea <50 mg/dL and those who had ALT <470 IU/L were found to have better survival. In other words, a higher urea value and a higher ALT value were predictors of higher risk of mortality. In receiver operator characteristic (ROC) curve analysis, the optimum cutoff value of urea was found to be 42 mg/dL and ALT was found to be 174 IU/L. Conclusion The identification of new and easily available prognostic markers in ALF such as blood urea and ALT may be used along with the existing criterias to rapidly assess the patients in need of early liver transplantation. L-007 Spectrum, clinical profile of spontaneous bacterial peritonitis and factors affecting outcome in these patients in terms of mortality B M Raghu, Aby Somu, Maya Peethambaran, Prashanth Menon, Shibi Mathew, John Mathews, Prakash Zacharias, G N Ramesh, Mathew Philip Correspondence- Mathew Philip- [email protected] PVS Memorial Hospital, Kaloor, Cochin 682 017, India Introduction Spontaneous bacterial infection of ascitic fluid is the most common infection in patients with cirrhosis of liver. In-hospital mortality of patients with SBP is high. The spectrum, clinical profile and various clinical parameters affect the prognosis of these individuals. This study looks in to these prognostic parameters in these patients. Methodology Study design - Prospective observational cohort study. Time frame - One year (November 2014- November 2015). All patients admitted in P V S Memorial Hospital, Kaloor, Kochi diagnosed to have SBP in cirrhosis of liver. Data collected was based on clinical history, physical examination, laboratory parameters and the course in the hospital until improvement, discharge or death. Results About 250 patients were enrolled in the study. Study population had a mean age of 56 years. Males predominated (83.2%). The survival rate in our study population was 86.4%. Multidrug resistant organism (19.2%), suboptimal ascitic fluid improvement, high child score and higher MELD score were independent predictors of mortality. SIRS (22.8%), higher creatinine level (mean of 1.48), higher INR (2.23 vs. 1.5) and lower sodium levels (122 vs. 129) was associated with higher mortality. Conclusion Gram negative organisms were the predominant group of organisms causing spontaneous ascitic fluid infections out of which

Escherichia Coli was the most common organism. Infection with multidrug resistant organisms and suboptimal response to initial antibiotic treatment indicated poor prognosis. Features of SIRS and renal dysfunction at admissions were the two parameters which showed highest association with mortality. Higher Child-Pugh-Turcott score, hyponatremia, higher bilirubin level were independent predictors of mortality. L-008 Assessment of malnutrition in cirrhotic patients and impact of malnutrition on short-term mortality and development of complications Rajendra Gunjal, D Krishnadas, S Shanid, Varun Tadkalkar, Gaurav Kapoor, B Biji, S Neehar Correspondence- Rajendra Gunjal- [email protected] Department of Medical Gastroenterology, Govt Medical College, Trivandrum 695 011, India Introduction Malnutrition and sarcopenia have a negative impact on prognosis of cirrhosis. We aim to assess the nutritional status of cirrhotic patients and whether malnutrition predicted short-term mortality and complications. Methods A prospective study evaluating the nutritional status of cirrhotic patients by subjective global assessment (SGA), triceps skinfold thickness (TSF), handgrip strength (HG) and mid arm muscle circumference (MAMC). Malnutrition by TSF, HG and MAMC was defined as 2 standard deviations below that of age and sex matched population. Patients were followed up to verify the incidence of major complications and death. Results Among 122 cirrhotics, 90% were male and 10% were female. All patients completed one month and 60 patients 3 months of follow up. The commonest etiology was alcohol (61%). 39% were in Child status A, 45% Child B and 16% Child C. Overall prevalence of malnutrition were 64.8% by SGA, 45.1% by TSF, and 32.8% by HG. Across all Child-Pugh classes, SGA was significantly better than HG, TSF and MAMC in assessing malnutrition (p<.001). Both HG and SGA predicted major complications developing in 75.5% of malnourished patients versus 53.1% of normally nourished ones (p=0.017) and 71% vs. 39.5% (p=0.001) respectively. One month mortality was 6.5% while 3 month mortality was 25%. SGA and TSF, but not HG, predicted significant mortality among malnourished patients compared to normally nourished patients with 20.3% vs. 2.3% (p-0.02) and 23.6% vs. 6% (p-0.02) deaths respectively. MAMC did not predict malnutrition or major complications or mortality. For assessing malnutrition, HG had a sensitivity 48%, specificity 95.3%, positive predictive value 95%, negative predictive value 50% and kappa value 0.360 when compared with SGA. Conclusions SGA is superior to HG and TSF in assessing malnutrition. Malnutrition by SGA and HG predicted a significant incidence of major complications while SGA and TSF predicted significant incidence of mortality in malnourished cirrhotic patients. L-009 A study of etiological and clinical profile of acute viral hepatitis at a tertiary care hospital Swapnil B Kankare, Aby Somu, P Maya, M Prashanth, Shibi Mathew, John Mathews, Prakash Zacharias, Mathew Philip Correspondence- Swapnil Kankare- [email protected] PVS Institute of Digestive Diseases, PVS Memorial Hospital, Kaloor, Kochi 682 017, India Introduction This study was undertaken to gain the understanding of etiological spectrum, symptomatology, clinical features, pattern and trend of investigations, severity and complications during the course of acute viral hepatitis in a tertiary care hospital in Kerala. Methods This prospective, descriptive observational study included consecutive OPD/IPD patients above age of 18 years having acute viral

Indian J Gastroenterol

hepatitis (AVH). Patients with chronic liver disease, clinical or radiological evidence of biliary obstruction/drug induced liver injury (DILI)/autoimmune hepatitis were excluded. Appropriate statistical tests were used for analysis and a p value of <0.05 was considered significant. Results AVH was more common (47.1%) in younger age group (20-40 yrs) with male (4.23:1) preponderance. Acute hepatitis B was most common (55.8%) etiology and among it 40-60 year age group was most commonly (49.1%) affected. Jaundice (87.7%) was the most common presenting symptom followed by nausea/vomiting, fever and anorexia. History of recent travel was the most common risk factors for hepatitis A/E. For hepatitis B, recent dental extraction was most common risk factor. Icterus and splenomegaly were most common clinical findings. Hepatitis B showed slower reduction rate for bilirubin with mild increase (not significant) at 1 week as compared to other etiologies. Majority patients with hepatitis B had HBV DNA of >106 copies/mL at baseline. HBV DNA levels and baseline bilirubin, SGOT, SGPT and INR had a weak negative correlation. Statistically significant positive correlation between HBV DNA and SGOT, SGPT at 2 weeks was seen. Mean duration for HBsAg loss was 3.54+1.08 months. Conclusion Acute hepatitis B was the commonest etiology in this hospital based study with slower biochemical recovery as compared with other etiologies. L-010 Assessment of depression and anxiety in patients with chronic liver disease A Anand, Caroline Selvi, T Rajkumar Solomon, A Aravind, G Ramkumar, R Balamurali, K Muthukumaran, Vaishnavi Priya, S Kavitha, Ravi Anand, S B Malipatil, Ragvendra, Umalakshmi, Sachin, Shravan Correspondence- A Anand- [email protected] Department of Medical Gastroenterology; Government Royapettah Hospital and Department of Digestive Health and Diseases, Chennai 600 010, India Introduction To determine the frequency of depression and frequency of anxiety in patients with chronic liver disease. Method Adult outpatients with chronic hepatitis C (CH-C), chronic hepatitis B (CH-B), alcohol-related liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) were included in the study. Hamilton depression rating scale (HDRS) and Hamilton anxiety rating scale (HARS) were used to assess depression and anxiety respectively in these patients. Results The study included 42 male and 38 female patients. Depression was present in 67.5% and anxiety in 22.5% of the patients. A higher HDRS was noted in the patients older than 50 years. A higher HARS score was present in the men (p=0.013), unmarried patients (p=0.007) and those with nonalcoholic liver disease (p=0.008). Patients with ascites and gastrointestinal (GI) bleeding had a significantly higher frequency of depression and anxiety than those without ascites and GI bleeding (p=0.016). Conclusions Chronic liver disease is associated with depression and anxiety which may impact on quality of life, worsening of clinical outcome, reduced compliance and mortality rates. L-011 Nailfold capillary changes in patients with acute-on-chronic liver failure- A preliminary report Anand Sharma1, A S Harshini2, Sukesh Chandran Nair3, Ruchika Goel2, Debasis Danda2, Uday George Zachariah1, Ashish Goel1, C E Eapen1 Correspondence- Anand Sharma- [email protected] 1 Department of Hepatology, Christian Medical College, Vellore 632 004. India, 2Department of Rheumatology, Christian Medical College, Vellore 632 004, India, and 3Department of Transfusion Medicine, Christian Medical College, Vellore 632 004, India

Background Microcirculatory changes are known to underlie the pathophysiology of acute- on-chronic liver failure (ACLF). Nailfold capillaries constitute an accessible site for the study of microcirculation. We attempted to study the same and correlate with the clinical course, 28 day mortality and vWF antigen levels at admission. Methods An on-going observational study done on admitted patients with ACLF who underwent vWF antigen level testing and nailfold videocapillaroscopy on admission and received standard of care and the clinical course, baseline plasma vWF antigen levels and 28 day mortality was recorded. Results Fourteen patients with ACLF [male 13, Age 47±12 years; MELD score 32±7; SOFA score 9±3; etiology of chronic liver disease (CLD) alcohol (7) viral (4) : etiology of acute hit: infection (4) HBV flare (2), alcohol (2)] were enrolled. Grade of ACLF at baseline was grade 2 (6) and 3 (6) and grade 1 (2)]. Baseline mean vWF antigen level was 444±90 IU/dL. Within one month 11 patients (79%) succumbed to their illness. Between the dead and alive patients the baseline SOFA (9±3 vs. 8±2; p 0.88), MELD (33±7 vs. 30±7; p 0.57) and vWF levels (461±66 vs. 384±156; p 0.20) were similar. Four patients (29%) developed new onset in hospital organ failure. Nailfold capillary examination was satisfactory in 10 patients. Mean nailfold capillary density was 8±2 per mm and did not show a correlation with MELD (Pearson’s correlation coefficient=0.35), SOFA (Pearson’s correlation coefficient=0.36) and vWF antigen levels (Pearson’s correlation coefficient=0.18). The morphology was abnormal in 1 patient. Conclusion In the preliminary study, significant nailfold capillary changes were not present in ACLF patients. Mean nailfold capillary density did not correlate with baseline MELD score, vWF antigen levels and SOFA score. More patients are being recruited into this study. L-012 Correlation of magnetic resonance liver fat fraction with bioimpedance and anthropometric measurements in patients with non-alcoholic fatty liver disease Guruprasad Basavaraj Padsalgi, M Chooracken, R J Mukkada, A P Chettupuzha, V F Jose, C P Shelley, P G Mathew, P Shobha, A Koshy Correspondence- Dr. Guruprasad [email protected] VPS Lakeshore Hospital, Kochi 682 040, India Introduction and Aim of the Study To find out the best anthropometric measurement and/or bioimpedance parameter that can effectively be associated with MR liver fat fraction. Methods The study was conducted in the Departments of Gastroenterology and Family Medicine at Lakeshore Hospital and Research Centre, Kochi. Study population Patients presenting to Gastroenterology and Family Medicine Outpatient who were detected to have fatty liver on USG abdomen. Inclusion criteria Patients with fatty liver on USG, age-(18-65) years, Type 2 diabetes mellitus, hyperlipidaemia and BMI>22.9 kg/m2. Exclusion Criteria Significant alcohol consumption, positive (HBV and HCV), Wilson’s or autoimmune liver disease, H/o indigenous treatment in recent past (6 months), pregnancy and lactation, cirrhosis of liver, serum creatinine >2 mg/dL, patient on long-term steroids or has stopped steroids for <6 months, history of malignancy in last 1 year and CCF (EF <40%). Study design This was a cross sectional study where included patients underwent MRI fat fraction and subcutaneous fat measurement, anthropometric measurements (BMI, waist measurement, skin fold thickness (SFT)) and bioimpedance. The MR liver fat fraction and subcutaneous fat was correlated with anthropometric measurements and bioimpedance using Pearson’s correlation coefficient. Results Thirty patients were included in the study. Mean age-48 yrs, M:F22:08, diabetics:15/30, dyslipidaemic:25/30, hypertensive:5/30. The MR

Indian J Gastroenterol

liver fat fraction did not correlate with anthropometric measurements (p value>0.05) and BMI (p value>0.05) in our study. MR abdominal subcutaneous fat correlated with waist circumference (p value-0.000), SFT biceps (p value-0.000), SFT triceps (p value-0.020) and SFT subscapular (p value-0.004) and all were statistically significant. MR abdominal subcutaneous fat showed a positive correlation with BMI (p value-0.000). Waist circumference was the only independent variable that could predict MR abdominal subcutaneous fat in multivariate analysis. Conclusions 1. Liver fat does not correlate with anthropometric and bioimpedance fat measurements. 2. Liver fat has to be measured directly by MRI. L-013 Comparison of clinical characteristics in overweight and lean patients with non-alcoholic fatty liver disease with advanced fibrosis Varun R Tadkalkar, Aniruddha Pratap Singh, Rathan Cyriac Joseph, Manoj Yadav, Neehar Shanavas, G Ponnikrishan, S Srijaya, Krishnadas Devadas Correspondence- Varun Tadkalkar- [email protected] Department of Gastroenterology, Medical College, Thiruvananthapuram 695 011, India Background and Objective Overweight and obesity are major risk factors for the development of non-alcoholic fatty liver disease (NAFLD). However, a minority of NAFLD patients have a body mass index (BMI) <23 kg/m2 (lean NAFLD). We sought to investigate whether significant differences exist between lean NAFLD and more common forms of NAFLD associated with overweight/obesity. Methods The diagnosis of NAFLD was made on the basis of characteristics ultrasonography features, features of metabolic syndrome, and histologic confirmation whenever possible. Patients with NAFLD who underwent transient elastography (TE) by FibroScan (Echosens, France) and detected to have advanced fibrosis by TE score >9 (F3, F4 fibrosis) were enrolled. Lean NAFLD was defined as having a BMI <23 kg/m2. by Asia Pacific criteria. Factors like presence of DM, HTN, dyslipidemia, hypothyroidism and LFT, hemoglobin and platelet levels, BP, lipid profile were compared between lean NAFLD and obese NAFLD patients. Results A total of 331 consecutive patients with NAFLD underwent TE. Two hundred and eight patients had either no fibrosis or F1, F2 fibrosis. They were excluded. 122 patients had advanced fibrosis (TE >9 kpa suggestive of F3/F4 fibrosis). Twenty-three patients (18.8%) were lean NAFLD. TE score was not found to be significantly different between obese NAFLD and lean NAFLD. Compared to NAFLD patients with overweight/obesity, patients with lean NAFLD had a mean age of 37.9+21 vs. 48.8+9.8 (p<0.001), lower levels of LDL cholesterol (99.7+29.6 vs. 123+27.3, p<0.001) and a higher prevalence of the hypothyroidism (p=0.009). On logistic regression, hypothyroidism was found to be independent risk factor for lean NAFLD. Conclusion In summary, lean NAFLD patients are younger as compared to obese NAFLD. Hypothyroidism is a risk factor for lean NAFLD. L-014 Correlation of risk factors to hepatic steatosis in patients with chronic hepatitis B Jeesemon Jose, M Chooracken, R J Mukkada, A P Chettupuzha, V F Jose, P G Mathew, A Koshy Correspondence- Jeesemon Jose- [email protected] VPS Lakeshore Hospital, Nettor. Kochi 682 040, India Introduction Hepatic steatosis is a common problem in patients with chronic hepatitis B. The aim of this study was to assess the correlation of risk factors to hepatic steatosis in chronic hepatitis B patients.

Methods Twenty-two chronic hepatitis B patients, between 18 to 60 years of age were selected. Clinical, anthropometric, laboratory data were collected including skinfold thickness, bioimpedance, liver function tests, lipid profile, fasting blood glucose and insulin levels, and PNPLA3 variant. All patients underwent MRI liver fat estimation by fat fraction ratio. Liver fat in biopsy was estimated as per NAFLD activity score. Results Out of 22 chronic hepatitis B patients, 13 were overweight (BMI >25) and 9 had normal BMI (BMI <24.9). Hepatic steatosis was assessed by magnetic resonance imaging (MRI) in 20/22 (90%) patients and by liver biopsy in 10/22 (45%) patients. The prevalence of steatosis in chronic hepatitis B patients was 59%. BMI (r=0.6, p=0.005), insulin resistance (r=0.62, p=0.009), and subscapular skinfold thickness (r=0.54, p=0.024) were positively correlated to liver fat assessed by MRI on univariate analysis. On multivariate analysis insulin resistance was independently correlated to liver fat assessed by MRI in patients with chronic hepatitis B. Genetic analysis was done in 11 chronic hepatitis B patients and 3/11 (27%) patients had PNPLA3, I148M variation. Conclusion Body mass index (BMI), insulin resistance and subscapular skinfold thickness correlated to hepatic steatosis quantified by MRI in chronic hepatitis B patients. On multivariate analysis insulin resistance was independently correlated to liver fat assessed by MRI in patients with chronic hepatitis B. L-015 Gold nanoparticles-tagged drug for targeted therapy in resistant hepatocellular carcinoma cells Sandeep Kumar Vishwakarma, Avinash Bardia, L Chandrakala, B V S Sastry, N Raju, Phanni Bhushan Meka, Md. Aejaz Habeeb, Aleem Ahmed Khan Correspondence- Aleem Ahmed Khan- [email protected] Department of Gastroenterology and Hepatology, Centre for Liver Research and Diagnostics, HLS, Hyderabad 500 058, India Introduction Hepatocellular carcinoma (HCC) is one of the most common cause of death in adults worldwide. The major delimiting factor for the treatment is drug resistance which does not allow the sufficient amount of drugs in cancer cells. It results in increased level of drugs in other parts of the body that further leads to harmful side-effects on healthy cells. Considering the increasing rate of HCC patients with drug resistance, it is highly desirable to develop alternative strategies to overcome resistance mechanisms without eliciting the toxicological response in healthy cells. Herein, we developed a novel biologically safer gold nanoparticles (GNPs) tagged drug conjugate for efficient killing of HCC cells at lower dose and can overcome on drug resistance mechanisms without inducing the toxicity in healthy cells. Methods Ultra-small GNPs were synthesized by facile reduction process and tagged with ant-cancer drugs to generate a drug-nanoconjugate. Biological safety of drug-nanoconjugate was tested in human hepatocytes and in Wister rats. Therapeutic efficacy of drug-nanoconjugate was evaluated on 3D-biomimeic drug resistant HCC model system. The reversal of drug resistance mechanisms was identified by analysing key regulatory molecules specifically drug transporters. Results The facile reduction process generated highly stable colloidal suspension of ultra-small size GNPs in aqueous solution. Eighty percent drug loading was achieved on GNPs which does not produce cytotoxicity in human hepatocytes and also does not elicit bio/immunological responses in rats. The dose dependent therapeutic response of drugnanoconjugate was observed in 3D-biomimeic drug resistant model. Very minute concentration of the drug-nanoconjugate showed better therapeutic response to overcome resistant mechanisms in resistant cells without eliciting toxicological response. Conclusion The present study provides bench to bedside approach for safer applicability of GNPs tagged drugs to overcome drug resistance in

Indian J Gastroenterol

HCC to improve the clinical outcomes of cancer patients without inducing severe side-effects. L-016 Combining hepato-renal ratio and shear wave elastography: The way forward in non-alcoholic fatty liver disease? Aby Somu, Sandeep Kumbar, Sudharshan, Neha Rhode, Swapnil Kaknkare, Maya Peethambaran, M Prashanth, Shibi Mathew, John Mathews, Prakash Zacharias, Mathew Philip Correspondence- Aby Somu- [email protected] PVS Memorial Hospital, Kochi 682 017, India Background The current gold standard for evaluation of non-alcoholic fatty liver disease (NAFLD) is liver biopsy, which is invasive. The hepato-renal ratio (HRR) by ultrasound is a noninvasive simple method that could be used to diagnose significant hepatic steatosis. HRR may be combined with shear wave elastography (SWE) for evaluation of patients with significant steatosis. Aim To study the usefulness of combining HRR and SWE in evaluating patients with NAFLD. Methods The study was conducted in the Department of Medical Gastroenterology, P V S Memorial Hospital, Kochi. Consecutive adult patients with the diagnosis of fatty liver on qualitative ultrasound were selected. The same operator performed all ultrasound examinations. Patients were divided into two groups, HRR<1.49 (<5% steatosis) and HRR >1.49 (>5% steatosis). Liver stiffness measurements (LSM) were recorded using SWE and further stratified according to the METAVIR stage. Results Total number of patients were 96. 67 patients were males, 29 were females. Thirty-four patients had diabetes and 16 patients were obese and 44 patients were overweight. Twenty-two patients had features of metabolic syndrome. Thirty-five patients had HRR <1.49, were as 61 patients had HRR >1.49. All patients in the first group with HRR <1.49 and didn’t have significant liver stiffness (<7.1kPA). In the second group with HRR >1.49, 12 patients had F2 METAVIR stage, 5 had F3 and 11 patients had F4 stage, rest of the patients were F0-F1. Fibrosis was seen only in the second group of patients with HRR >1.49, which was significant statistically (p value 0.001) Conclusion (1) Only those patients with significant steatosis as per HRR had fibrosis; (2) The combination of HRR and SWE may help in ideal utilisation of resources. Limitations (1) No biopsy correlation; (2) Small sample size. L-017 Humanized biomimetic 3D-liver system as better model for six CYP probe-based drug testing Sandeep Kumar Vishwakarma, Avinash Bardia, L Chandrakala, B V S Sastry, N Raju, Phanni Bhushan Meka, Md. Aejaz Habeeb, Aleem Ahmed Khan Correspondence- Aleem Ahmed Khan- [email protected] Department of Gastroenterology and Hepatology, Centre for Liver Research and Diagnostics, HLS, Hyderabad 500 058, India Introduction Differences between human and animals in liver metabolism pathways now necessitate the use of appropriate humanized in vitro models based on suitable panel of molecular probes for pharmacological drug testing. Cytochrome P450 (CYP) are highly expressed in liver cells and their involvement in drug metabolism pathways has been well appreciated in drug testing. However, 2D-culture systems lacks natural architecture for cells arrangement, expansion and survival. Hence there is need to establish 3D-biomemetic culture systems for identifying the response of cells against the drugs in natural microenvironment. Herein, we developed a biomimetic

3D-humanized whole liver system as an alternative of human and animal models based on six CYP probe (CYP1A2, CYP2C19, CYP2C9, CYP2D6 and CYP3A4) for next generation drug testing. Methods The 3D-humanized liver was developed by repopulating the human hepatic progenitor cells into decellularized xenogenic liver scaffolds through major hepatic artery. Five major isoforms of CYP enzymes were estimated against six selected drugs (Phenacetin, Diclofenac, mephenytonin, Dexamethorphan, Nifedipine and testosterone) targeting these six CYP probes in 3D-humanized model system and compared with the 2D culture system for drug metabolism by HPLC analysis. The metabolic activity was determined by substrate depletion assay. Results Depletion of all five substrates indicated higher degree of maturation and involvement of six CYP probes in 3D-humanized biomimetic model system as compared to 2D system. CYP3A4 showed the highest activity and depletion for Phenacetin was more in 3D (>95%) as compared to 2D culture (<90%) after. Similarly, the depletion of other five substates was also higher in 3D culture as compared to 2D. Conclusion 3D-biomemetic culture systems provides better model for evaluation drug metabolism using substrate depletion approach based on six CYP probes which is similar to the adult metabolism. This approach will be helpful for determining the actual dose separately for neonates and adults. L-018 Clinical profile and outcomes in acute-on-chronic liver failure patients in hospital setting in a tertiary centre Kerala Netaji Garad, Aby Somu, P Maya, M Prashanth, Shibi Mathew, John Mathews, Prakash Zacharias, Mathew Philip Correspondence- Netaji Garad- [email protected] PVS Institute of Digestive Diseases, PVS Memorial Hospital, Kochi 682 017, India Introduction Acute-on-chronic liver failure (ACLF) is frequently being recognized in clinical practice, so there is growing interest to understand the various aspects like the nature of acute insult, etiologies of underlying chronic liver diseases, pathophysiology and prognostic outcome. Methods All consecutive cases of ACLF attending to hospital and satisfying APASL definition were included. Their clinical and laboratory parameters were recorded using predesigned questionnaire. Organ failure was assessed by EASL-CLIF consortium. Study design: Prospective observational study Time Frame of study: January 2015 to June 2016 Results A total 100 patients were enrolled for the study, most of the patients were between 40-60 years age group (61%) and males outnumbered females by 4.8 times. The presenting features were ascites (100%), jaundice (100%), pedal edema (73%), encephalopathy (49%) and GI bleed (10%). The most frequent acute insult leading to ACLF was active alcoholism in 51% of patients followed by hepatotropic viral infections in about 26% of patients (HBV infection (acute and reactivation)1-7%, HE-5%, HAV-2% and HCV-2%). Mortality at 28 days was 55%. As per EASL-CLIF consortium, 28 days mortality was in no ACLF (10%), ACLF-1 (45%), ACLF-2 (77.8%) and ACLF-3 (95.7%). Organ failures (OF)–liver (67%), renal (32%), coagulation (39%), cerebral (15%), circulatory (30%) and respiratory failure (13%) were seen. Sepsis (29%), renalfailure (32%) and pneumonia (13%) were significantly higher in ACLF group. APACHE II score had highest sensitivity (92.7%) however equal specificitivity (77.77%) as compared to CTP, MELD, MELD-Na and CLIF-SOFA score compared to the survivors. Conclusions Alcoholic hepatitis was the most common acute precipitating insult for ACLF. The common presenting features were jaundice, ascites and encephalopathy. Presence of multiorgan failure, sepsis and pneumonia were poor indicators of survival in patients with ACLF. APACHE II scoring was found to have high sensitivity in predicting severity in patients with ACLF.

Indian J Gastroenterol

L-019 Neutrophil lymphocyte ratio as the novel biomarker predicting the outcome in decompensated cirrhosis, experience from a tertiary care centre in South India Gaurav Kapur, Sandeep Narayanan, Rajendera Gunjal, Anirudhha Pratap Singh, M Neehar, Shanavas, Biji Benny, Arun Iyer, A Shanid, Sandesh Kumar, D Krishnadas Correspondence- Gaurav Kapur- [email protected] Government Medical College and Hospital, Trivandrum 695 011, India Introduction Decompensated cirrhosis is a condition associated with poor outcomes including high mortality. It has been shown that ongoing inflammatory activity in such patients is one of the contributors to these outcomes. Neutrophil lymphocyte ratio (NLR) is one such marker which reflects the inflammatory activity in the body. We aimed to evaluate the prognostic role of NLR in decompensated cirrhotics in this study. Methods In this observational study patients with decompensated cirrhosis admitted in Medical Gastroenterology Department, M C H, Trivandrum from May 2016 to November 2016 were included. The data at time of admission was collected and outcome at 90 days in the form of mortality/ re admission were recorded. Predictors of outcome such as CTP, MELD, NLR were studied for their prognostic value. Univariate and Multivariate regression analysis was used for analyses. Results Amongst 89 patients included mean age was 54.4 years with male predominance 75 (84.3%). Alcohol was the major etiology accounting for 44 (49.4%) cases. Twenty-nine (32.6%) patients expired during this period after being discharged from hospital. Whereas 34 (38.2%) patients needed readmission. MELD, CHILD stage, presence of SBP and NLR were found to be significant factors in univariate analysis for mortality. Whereas NLR and MELD score were significant in multivariate analysis. For readmission presence of hepatic encephalopathy, SBP, alcoholic hepatitis and high NLR came to be significant on univariate analysis. On multivariate analysis however NLR was the most significant factor. ROC curve with sensitivity of 82.8% was generated with a cut off value of 3.22 of NLR. These results are consistent with study by Zhang et al. Conclusion NLR seems to be useful tool in predicting both mortality as well as complications leading to re admissions. However, since specificity in ROC curve is low it has to be considered along with other prognostic markers and not as an independent marker. L-020 A study on the effect of fatty liver on the prognosis and severity of drug induced liver injury Sandeep Narayanan, Gaurav Kapur, Rathan Cyriac, Rajendra Gunjal, Nihar Shnavas, Biji Benny, Shahna S Fathima, A Shanid, K Sandesh, D Krishnadas Correspondence- Sandeep Narayanan- [email protected] Government Medical College, Trivandrum 695 011, India Introduction The factors predicting outcome in drug induced liver injury (DILI) has not been well understood. Of late several studies has linked DILI severity with underlying NASH as both the disorders has been thought to be due to mitochondrial dysfunction. Aims and Objectives Objective of the study was to determine whether fatty liver is an independent predictive factor for severity of drug induces liver injury. Methods All cases with suspected DILI with Roussel Uclaf Causality Assessment Method (RUCAM) more than 6 were enrolled. Patients with viral marker positivity and decompensated cirrhosis were excluded. Liver echogenicity was extracted either from an ultrasound done in the 1year period of presentation. Severe DILI was defined by INR>1.5 or ascites/ hepatic encephalopathy in noncirrhotics

Results A total of 76 patients were included in the study, out of which 28 had severe DILI. There was 7 cases of fatal DILI, out of which 3 had underlying cirrhosis. Females formed 59.2% of the cohort. The most common cause of DILI was ATT (27.6%), followed by CAMS (15.8%), chemotherapeutic drugs (13.2%) and antiepileptics (13.2%). Fatty liver was seen in 39.5% of the patients which is high compared to the population prevalence of around 30% based on previous studies. Only 14.3% of severe DILI patients had fatty liver compared to 56.3% of non severe DILI patients. Conclusion ATT is still the most common cause of DILI in our population. Our study showed that fatty liver proportion in DILI patients is higher than in normal population signifying that fatty liver could be a risk factor for DILI. We also found that fatty liver did not predispose to severe DILI and did not predict mortality. Limitations: Acute hepatitis can cause alteration in liver echogenicity. We have used ultrasound within 1 year of presentation if available instead of fresh ultrasound to offset this. L-021 Peptic ulcer disease in liver cirrhosis: A retrospective endoscopic and clinical study Gaurav Garg1, Vinod Kumar Dixit1, Sunit Kumar Shukla1, Shivam Sachan1, Sudhir Kumar Singh1 Correspondence- Gaurav Garg- [email protected] Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Aim It has been showed that peptic ulcer is more frequent in patients with liver cirrhosis, is associated with the severity of cirrhosis, and occurs without upper abdominal pain in up to 70% of patients. The aim of this study was to retrospectively assess the characteristics of peptic ulcer in a large series of patients with liver cirrhosis. And chronic hepatitis. Method In this retrospective study the consecutive records of 380 endoscopies, performed in patients with liver cirrhosis and during a period of 1 year, were reviewed to evaluate the frequency and clinical characteristics of peptic ulcer at Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi. Result A total of 36 peptic ulcer disease cases were detected. The ulcer prevalence was 9.4% (36/380), and 72.2% (26/36) of the patients were asymptomatic. Gastric and duodenal ulcer both were presented in 22.2% (8/36) of patients, while 77.8% (28/36) patients had only duodenal ulcer. The positive rate of H. pylori was not different between cirrhotic patients with duodenal ulcer and those without duodenal lesions (9/16 vs. 18/34). Patients with asymptomatic ulcer had a more decompensated cirrhosis. Conclusion This retrospective study confirms the high frequency of peptic ulcer in patients with liver cirrhosis. It also confirms that the peptic ulcer in these patients is very often asymptomatic and much more in patients severe liver disease. The presence of H. pylori per se does not play an important role in the increased prevalence of duodenal ulcer in cirrhotic patients. These findings suggest portal hypertension-induced impairment of the gastric mucosal defenses to be an important factor in the pathogenesis of gastric ulcer in patients with liver cirrhosis. L-022 Role of adenosine deaminase in diagnosis of peritoneal tuberculosis patients with cirrhosis Amol Sonyabapu Dahale, Amarender Singh Puri, Sanjeev Sachdeva, Anil Agarwal, Ajay Kumar Correspondence- Amarender Singh Puri- [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India

Indian J Gastroenterol

Introduction Peritoneal tuberculosis (PTB) is difficult to diagnose in chronic liver disease (CLD) patients. Studies on role of adenosine deaminase (ADA) in PTB with CLD are scarce and contradicting. We prospectively studied role of ADA in PTB patients with CLD. Methods We enrolled patients with suspected PTB with underlying CLD as cases. Those confirmed histopathologicaly as tuberculosis taken as cases. Patients with CLD with ascites taken as controls. Epidemiological data noted and both group underwent ascitic fluid analysis-cytology, SAAG, ADA. All parameters were compared with proper statistical methods. Results Total 30 cases (PTB with chronic liver disease) and 91 controls (CLD with ascites) included. Of all underwent ascitic fluid analysis. Of 30 cases 7 underwent ultrasound guided peritoneal biopsy while 23 underwent laparoscopic biopsy. Mean age of cases was 35±10.8 yrs while that of controls were 45.2±14 yrs. Male were predominant in both groups-80% and 78% in cases and controls respectively. Hematological parameters and biochemical parameters comparable in both groups except platelet count and serum total protein which were lower in controls. Ascitic fluid analysis revealed higher leukocyte count with lymphocyte p r e d o m i n a n c e ( 6 9 1 ± 6 2 1 v s . 1 3 7 ± 2 0 0 c e l l s / μ L ) . To t a l protein was higher with significant p value in cases (3.4±1.5 vs. 1.5±0.9 gm/dL). ADA values were significantly higher in cases than in controls (64+21 vs. 19+11 U/L). At cut-of value of 38 U/L ADA shows sensitivity and specificity of 93.33% and 91.20% respectively. Conclusion ADA is highly sensitive and specific for diagnosis of PTB in CLD patients. L-023 Post transplant lymphoproliferative disorder in deceased donor liver transplant A R Venkateswaran, Malarvizhi Murugesan, Hardik Rughwani Correspondence- A R Venkateswaran- [email protected] MCI, Chennai Introduction The term post transplant lymphoproliferative disorder (PTLD) is commonly used to describe a wide spectrum of lymphoproliferative disorders after solid organ and hematopoietic cell transplantation that ranges from infectious mononucleosis to highly invasive malignant lymphoma. PTLD is an uncontrolled proliferation of B cells or T cells after liver transplant typically in response to primary EBV infection, can be polyclonal or monoclonal. Pediatric patients are a particular risk. The majority of patients with PTLD present with extra nodal masses, primarily involving the GI tract, lungs, skin, CNS or hepatic allograft. Management includes reduction in immunosuppression and chemotherapy. Case We report a case of PTLD in a 19-year-old male, who presented 7 months post deceased donor liver transplant (DDLT), done for Wilsons disease, with cervical and mediastinal lymphadenopathy, found to be diffuse B cell lymphoma on immunohistochemistry with EBV (NA) IgG positive, presently under treatment at our centre with reduction of Tacrolimus dose and chemotherapy in form of R-CHOP. Conclusion Epidemiological studies in solid organ transplant recipients have shown that primary EBV infection from an EBV positive donor organ is the most important risk factor for development of PTLD. So it is essential to identify patients at risk by performing EBV serology before transplantation. After transplantation, such patients should be monitored for the acquisition of EBV infection. As the PTLD in our patient has developed 7 months post-transplant, the infection would have acquired from the donor liver. So we infer that the post transplant viral prophylaxis with Ganciclovir should be extended to 6 months compared to present 3 months regimen.

L-024 Causative factors responsible for renal dysfunction in cirrhosis and the impact Rishabh Jain, Ajit Kumar, Y Raghavendra, B Sukanya, Nayana Joshi, Vineet Chaudary, N Ravichandra, R Gaurav Correspondence- Rishabh Jain- [email protected] Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Introduction Cirrhotic patients with renal dysfunctions have high mortality rates. This study investigated the prevalence, cause and clinical outcome in patients with cirrhosis and renal dysfunction. Methods This was a prospective observational study of consecutive patients admitted with cirrhosis at a tertiary centre. Renal dysfunction was classified according to revised recommendations by International Club of Ascites, causes and outcome were analyzed. Results Total 356 patients were admitted during the study period from 1st January 2016 to 31st December 2016. Renal dysfunction was present in 112 (31.4%) patients. Presentation with abdominal distension, altered sensorium, diuretic use and oliguria at admission, presence of infective foci, ascites, diuretic use and hepatic encephalopathy were associated with higher renal dysfunction. Urinary tract infections (UTI) were most common infection in renal dysfunction (29.5%) as well as without renal dysfunction (11.1%). Renal dysfunction with infection (49.1%) was most common cause followed by hypovolemia (28.7%), hepatorenal syndrome (HRS) (18.7%) and parenchymal renal diseases (3.5%). Acute kidney injury (AKI) stage II (41.1%) at presentation was most common, followed by stage I (39.3%) and III (19.1%). The mean days of hospital stay (9.07±3.54) and mean ICU days stay (4.75±3.4) were significantly higher in patients with cirrhosis with renal dysfunction. The in-hospital mortality was 13.48%, which was significantly higher in patients with cirrhosis with renal dysfunction (29.5%) than as compared to patients without renal dysfunction (6.1%) [p<0.001]. Conclusion Renal failure has a high prevalence in cirrhotics and is associated with high mortality and morbidity. Infections are most common cause of renal failure. L-025 Hepatic progenitors cell transplantation in liver cirrhosis: 2 Year follow up Avinash Bardia, Sandeep K Vishwakarma, Nagarapu Raju, Lakki Reddy Chandrakala, B V S Sastry, Safwaan Habeeb, J Venkateswarlu, Aleem Ahmed Khan, Mohammed Habeeb Correspondence- Mohammed Aejaz Habeeb- [email protected] Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India Introduction Liver cirrhosis is a major public health concern owing to high morbidity and mortality. Liver transplantation is the only option for the management of patients with advanced liver cirrhosis due to the unavailability of adequate treatment modalities. Hepatic stem/progenitor cells (HSPCs) transplantation in liver cirrhosis patients has emerged as one of the most promising supportive modality which provides an alternative option to bridge the liver transplantation. However, the long-term safety and therapeutic efficacy of transplanted HSPCs has not been evaluated so far in clinical settings. The present study has aimed to prove the long-term safety and efficacy of human HPCs transplantation in patients with end-stage liver cirrhosis after two years follow up post transplantation. Methods From a total of 25 subjects enrolled in our previous study (Khan et al. 2010), 10 liver cirrhosis patients of class I to class III were followed up for two years after human HPCs transplantation. Blood sample was

Indian J Gastroenterol

collected from each subject after 9, 12, 18, and 24 month posttransplantation to investigate changes in biochemical parameters and MELD score. Computed tomography (CT) scans were also performed during follow up to identify the sign of tumor development or any other related complications. Results Post transplantation follow up of patients in all three classes showed improvements in their serum biochemical parameters and MELD score. None of the subject developed disease related complications and side effects even after two years. Hepatic angiogram revealed absence of thrombosis in hepatic arteries after successive time intervals during follow up. Conclusion Our study has demonstrated the safety and clinical efficacy of human HPCs transplantation strategy for long-term management of liver cirrhosis without causing severe side-effects and procedure related complications.

Objective To study clinical and etiological profile of liver abscesses. Methods This retrospective study was conducted over a period of one year, from January 2016 to December 2016, at the Department of Gastroenterology in S M S Medical College, Jaipur, Rajasthan. Patients of all age groups and both genders who had diagnosis of liver abscess were included in the study. A definitive diagnosis of liver abscess was based on compatible clinical features, ultrasound, CT abdomen and aspiration of pus. Results Clinical features, ultrasound findings, laboratory studies and outcome of therapy were evaluated retrospectively. Treatment options were antibiotics alone or in combination with needle aspiration, catheter drainage L-028 Significance of ascitic fluid C reactive protein level in differentiation of Po

L-026 Glucose metabolism disorders in liver cirrhosis - Correlation with CTP scoring Prashasti Gupta, Aparna Agrawal, Jayashree Bhattacharjee Correspondence- Aparna Agrawal- [email protected] Lady Hardinge Medical College, C-604, Shaheed Bhagat Singh Road, Diz Area, Connaught Place, New Delhi, Delhi 110 001, India Introduction Liver cirrhosis is commonly associated with glucose metabolism disorders (GMD)-pre-diabetes and diabetes. Our aim was to determine the proportion of cirrhosis patients having GMD and correlate the presence of prediabetes and diabetes with the severity of cirrhosis. Methods It was a cross-sectional, observational study conducted in L H M C and Associated Hospitals, Delhi between November 2015 to April 2017. One hundred consenting in-patients of liver cirrhosis (diagnosed clinically, biochemically and radiologically) were included. Patients with pancreatic disease, gallbladder disease, hepatocellular carcinoma, nondiabetic endocrinopathies and those on corticosteroids within 48 hours of admission were excluded. History, examination and investigations were done to calculate the CTP score, and find out the underlying etiology of cirrhosis. SPSS version 21.0 was used for statistical analysis - numbers and % for categorical variables, mean+SD for continuous variables, unpaired t-test (quantitative variables), chi-square test (qualitative variables) and multivariate logistic regression were used. p<0.05 was considered significant. Results Thirty-nine percent of patients had GMD (13/100-prediabetes and 26/100-diabetes). Six, 21 and 73 patients were categorized respectively as CTP Grade A, B and C. The proportion of patients with prediabetes did not increase with increasing CTP scores (0/6 Grade A, 5/21 Grade B and 8/73 Grade C, p=0.189). The frequency of patients with diabetes did increase with worsening CTP scores, 17%, 24% and 27% respectively for Grade A, B and C), however, the increase was not significant statistically (p=0.82, x2=1.926, df=2). The presence of GMD, pre-DM or DM was not found to be significantly associated with any particular etiology of cirrhosis (p>0.1 for each etiology). Conclusions GMD-both pre DM and DM are quite common in patients of cirrhosis. However it does not correlate with the severity or etiology of cirrhosis. L-027 Clinical spectrum of liver abscess at a tertiary care hospital in Rajasthan Mukesh Jain, Kumar Shwetanshu Narayan, Gaurav Kumar Gupta, Hemandra Bhardwaj, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India

Deepak Sharma Correspondence- Deepak Sharma- [email protected] DM, Jaipur CRP is an acute phase protein synthesized by liver. Its level rises in response to inflammation and lower in liver dysfunction. Aim of study was to assess discriminant value of ascitic fluid CRP level in differentiating P. HTN and non P.HTN ascites, influence of spontaneous bacterial peritonitis on ascitic fluid CRP level and to differentiate malignant from non malignant ascites. Methods Prospective study involving 146 patients of ascites, admitted to S M S Hospital, Jaipur, from January 2016 to December 2016. Patients were divided into two groups: Group 1, ascites due to P.HTN (highgradient) and Group 2, ascites without P.HTN (low gradient). Group 1a (high-gradient without SBP) and group 1 b (high-gradient with SBP). Group 2a (benign low gradient) and Group 2b (malignant low gradient). Results Out of total 146 patients, 119-group 1 and 27-group 2. Group 1a (n=106) and group 1b (n=13). Group 2a-19 patients and Group 2b-8 patients. On ascitic fluid analysis, AF CRP was significantly lower in group 1a compared to group 2. (0.8±0.5 vs. 4.3±1.4, .p=<0.001s). On ROC analysis a cut off of less than or equal to 2.35 mg/mL (AUC=0.834) had sensitivity of 88.7.0 % and specificity of 80 %. Mean AF CRP in gr 1b was significantly higher than gr 1a (2.3±1.0 vs. 0.8±0.5, p=<0.001s). On comparing, benign ascites (gr1a+gr 2a) with malignant ascites (gr 2b), mean CRP level was significantly higher in patients with malignant ascites (5.0±1.5 vs. 1.3±1.3, p=<0.001). Conclusions Ascitic fluid CRP levels can be an useful marker in differentiating P.HTN from non P. HTN related ascites as well as benign from malignant ascites. L-029 Dose, duration and type of alcohol consumption in alcoholic liver disease Atul Gawande, Sudhir Maharshi, Shashank Wanjari, Gaurav Gupta, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Introduction Alcoholic liver disease (ALD) and its complications are one of the major causes of morbidity and mortality. Predisposing factors for ALD includes amount, type, duration of alcohol consumption, patient’s genetic predisposition, race, sex and other comorbid conditions. There is paucity of data in literature in Indian population studying effects of dose, duration and type of alcohol consumption on ALD. Aim was to study the dose, duration and type of alcohol consumption in ALD and effect of these parameters on severity and outcome. Methods Prospective study was conducted at Department of Gastroenterology, S M S Medical College, Jaipur between December 2015

Indian J Gastroenterol

to December 2016. All patients with alcoholic liver disease were enrolled. Data relating to dose, duration, type, pattern of alcohol intake along with biochemical, ultrasonographic and clinical parameters were analyzed. Results One hundred and ten patients (age 43.5±9.9, all male) were studied. Mean alcohol consumption was 130.4±105.4 gm/day. Sixty-three (57.3%) patients consumed <120 gm, 25 (22.7%) between 120-239 gm, while 22 (20%) patients consumed ≥240 gm of alcohol per day. Mean duration of alcohol consumption was 15.89±6.57 years. Sixty (54.55%) patients consumed country made liquor, 26 (23.64%) whisky, 23 (20.91%) mixed or variable type while 3 (2.73%) patients consumed wine. Occurrence of hepatic encephalopathy (HE) significantly associated with dose (p<0.001) and type (p<0.001) of alcohol. MELD Na score significantly correlated (r=0.48, p<0.001) with dose of alcohol. Conclusion Mean alcohol consumption is 130 gm/day for a mean duration of 16 years in patient with ALD in north western region of India. Country made liquor is most common type of alcohol consumed. MELD Na score significantly correlated and occurrence of HE significantly associated with dose of alcohol. L-030 Extrahepatic manifestation in patients with chronic hepatitis C infection Sanjay Agrawal, Vinod Kumar Dixit, Sunit Kumar Shukla, Gaurav Garg, Raju Kumar Correspondence- Sanjay Agrawal- [email protected] Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Objective Hepatitis C virus (HCV) infection affects 150–170 million people worldwide. Extrahepatic manifestation can occur during chronic hep C liver disease which can increase morbidity and mortality. In this study we evaluate the extrahepatic manifestation in patients with chronic hepatitis C infection and there correlation with severity of liver disease. Methods Forty patients with chronic hepatitis C presenting to GI OPD were analyzed. They were divided into two groups: with or without liver cirrhosis. Those with liver cirrhosis were further subdivided according to the Child-Turcotte-Pugh scoring system. Patients were examined for extrahepatic manifestation and thyroid and blood sugar was done apart from routine investigations. Patients with abnormal TSH were subjected to the measurements of FT3, FT4, TPO-Ab. Results Out of 40 patients, males were 60% (24/40) and female 40% (16/ 40). Thyroid dysfunction was seen in 25% of patients. Frank hypothyroidism seen mainly in patients with advanced liver disease (CTP-C). Five patients were diabetic of which 1 patient was obese. Arthralgia was seen in 20% of which 2 patients had large joint arthritis. Vitiligo was seen in 1 patient. Conclusion Beyond the liver, HCV chronic infection leads to a multifaceted systemic disease. Clinicians should know such extrahepatic manifestations which improve the quality of life. Thyroid dysfunction (autoimmune thyroiditis) were seen commonly in this study, mainly in cirrhotic patients. L-031 Serum miRNA expression profile reveals a novel prognostic panel for HCV patients Raju Nagarapu, Sandeep Kumar Vishwakarma, Rahamathulla Syed, Shaik Iqbal Ahmed, Avinash Bardia, Chandrakala Lakkireddy, B V S Sastry, Safwaan Habeeb, Mohammed Aejaz Habeeb, Vishnupriya Satti, Aleem Ahmed Khan Correspondence- Aleem Ahmed Khan- [email protected] Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India

Introduction Micro RNAs (miRNAs) are emerging diagnostic and therapeutic targets in hepatitis C virus (HCV) pathogenesis. However in Indian context, the clinical correlation of miRNAs expression with available parameters is not available during HCV pathogenesis or treatment. In the present study, we have targeted five HCV disease relevant miRNAs (miR-21, miR-122, miR-146a, miR-155 and miR-181a) to identify their vital kinetics during HCV infection and treatment response for the combination anti-viral therapy using Pegylated interferon-α2a (PEG-IFN α2a) and ribavirin (RBV) in genotype 1 and/or genotype 3 patients. Methods The expression of selected circulatory miRNAs was quantified in 60 healthy controls and 72 HCV patients with viral load ≥1,00,000 copies/ml (≥1 Lakh copies/mL), before and during the treatment and further compared with the serum biochemical changes and hematological parameters. Results Significantly reduced expression of miR-122, 146a and 155 was observed post-treatment (3-12 months) in both the genotypes, however, miR-181a showed highly up regulated expression during treatment. The biochemical parameters showed respective response with the treatment duration and well correlated with the miRNAs expression. Conclusion We observed miR-122 as one of the most significant responder with the treatment in both the genotypes and possibly will be a direct measure for HCV pathogenesis and treatment response. L-032 A clinical study on nonalcoholic steatohepatitis and hypothyroidism A K Koushik, P Ganesh Correspondence- P Ganesh- [email protected] Sri Ramachandra University, Chennai Introduction A possible association between nonalcoholic steatohepatitis (NASH) and hypothyroidism has been suggested. Possible explanations for this association are the recognized links between hypothyroidism and various elements of the metabolic syndrome which is often present in NASH. The aim of this study was to characterize the relationship between hypothyroidism and NASH. Thyroid hormones are totally involved in the regulation of body weight, lipid metabolism, and insulin resistance; hence we anticipated that thyroid hormones may have a role in the pathogenesis of NASH. Methods We evaluated 70 patients with NASH and investigated the connection between hypothyroidism. Descriptive statistics were computed for all factors. Mean and standard deviations were calculated for continuous variables and frequencies and percentages for categorical variables. Results Hypothyroidism was more frequent among patients with NASH (27%) but statistically not significant, mean TSH is 3.04. The prevalence of NASH and abnormal liver enzyme levels increased steadily with increasing grades of hypothyroidism. Most of the patient are overweight, mean being 27.34 which is statistically significant. Increased female predominance was noted [54% females and 46% males]. Thirty-three percent patients had systemic hypertension and 50% patient had type 2 DM among them 60% had uncontrolled diabetes. Dyslipidemia is seen in most of the patients. High Total cholestrol was observed in 60% of the patients and the mean being 230. 62.8 % patients had hypertriglyceridemia. Conclusion Prevalence of hypothyroidism was demonstrated in patients with NASH but not statistically significant. Results of current study are conflicting about the association between thyroid abnormalities and NASH. Results of some of the reviewed studies propose hypothyroidism as a risk factor for NASH and some studies have failed to show an association between hypothyroidism and NASH.

Indian J Gastroenterol

L-033 The relationship between severity of chronic liver disease and pulmonary function tests S Babu Kumar, Yogesh Garg, Alexander Paul, Sandeep Jindal Correspondence- Yogesh Garg- [email protected] Chettinad Hospital and Research Institute, Kelambakkam, Kanchipuram Dist., Chennai 603 103, India Introduction Liver cirrhosis with portal hypertension leads to many deleterious effects on multiple organ systems, including the pulmonary system. Various pulmonary vascular complications are portopulmonary hypertension and hepatopulmonary syndrome. These pulmonary manifestations are in general less recognized by attending clinicians and are usually not given due importance in routine management of patients with cirrhosis of liver. Aim This study aimed to investigate the frequency of hypoxemia and impairment of pulmonary function tests in patients with chronic liver disease and to examine the relationships of these impairments with liver cirrhosis as per Child-Pugh Score. Methods Forty-five patients with chronic liver disease without intrinsic cardiopulmonary disease were enrolled in this study. All were subjected to complete clinical examination, Routine laboratory investigations, radiological investigations including abdominal ultrasound, chest X-ray, ultrasonography abdomen, pulse oximetry, arterial blood gas analysis, pulmonary function tests and diffusion studies, upper GI endoscopy, ECG and 2D Echo was done in selected patients. Results Hypoxia was found in significant number of patients. Among the PFT parameters, FEV1/FVC and FEF25–75% values were found to be lower in patients with ascites than those without. The presence of hypoxemia is increased in patients with advanced liver disease and its severity is positively correlated with the severity of liver disease assessed by the Child-Pugh Score. Pulse oximetry and pulmonary function tests are simple tools for initial screening of pulmonary complications in chronic liver disease. Conclusion Liver cirrhosis is associated with unique pulmonary complications. The early identification of pulmonary dysfunctions in cirrhotic patients is crucial as it affects the prognosis. L-034 Noninvasive indices for prediction of esophageal varices in compensated cirrhosis Rathan Cyriac Joseph, Aniruddha Singh, Varun Tadkalkar, B K Bincy, V Neeraj, Jose Mathew, K S Prasanth, S Srijaya, Krishnadas Devadas Correspondence- Rathan Cyriac- [email protected] Department of Medical Gastroenterology, Govt. Medical College Thiruvananthapuram 695 005, India Introduction With the increasing use of transient elastography, patients with compensated advanced chronic liver disease (CACLD) are on a rise, which inturn leads to the overburden of endoscopy units. Hence, simple, noninvasive, accurate tests are needed to identify patients really at risk of having esophageal varices prior to endoscopy. This study focuses on the currently available non-invasive indices like liver stiffness (LS), liver stiffness-spleen diameter-to-platelet ratio risk score (LSPS), aspartate aminotransferase-to-platelet ratio (APRI), FIB-4 index, and platelet-tospleen ratio (PSR) for prediction of varices among patients with compensated cirrhosis. Methods A sample of 100 patients with compensated cirrhosis who had undergone endoscopy, transient elastography and ultrasonography were enrolled. Exclusion criteria were: LS lower than 10 kPa or Child-Pugh score greater than 6. ‘Varices needing treatment’ (VNT) were defined as medium-large varices or small varices with red colour signs. All

laboratory data were obtained on the same day itself as transient elastography. The non-invasive indices for varices prediction were also assessed at enrollment according to published formulae. Diagnostic applicability was assessed by the area under the receiver–operator curve (AUC). Results Prevalence of all-size varices was 30%. Prevalence of ‘varices needing treatment’ was 13%. LSPS-based model had the best discriminative ability in predicting all-size varices (AUC-0.86) followed by platelet-spleen ratio (AUC-0.80). For prediction of ‘varices needing treatment’, again LSPS had the best discriminative ability (AUC, 0.87) followed by platelet-spleen ratio (AUC, 0.81). Conclusion LSPS was superior to the other non-invasive indices in identifying patients with compensated cirrhosis who are most likely to have varices including ‘varices needing treatment’(VNT). L-035 Vitamin D: Recent armour in non-alcoholic fatty liver disease Tarun Varshney, Honey Gupta, M R Ajmal, Mustakim Ahmed Mazumdar Correspondence- Tarun Varshney- [email protected] J N Medical College, AMU, Aligarh 202 001, India Introduction Non-alcoholic fatty liver disease (NAFLD) is one of the most common cause of chronic liver disease in the world. Its etiology and pathogenesis is poorly understood till today. Vitamin D a lipophillic vitamin which linked to alterations in glucose metabolism, metabolic syndrome, T2DM. Vitamin D is capable to reduce FFA mediated insulin resistance both in peripheral tissues and hepatocytes, thus alterations in vitamin D levels can lead to NAFLD. In this study we aimed to investigate the role of vitamin d status in NAFLD. Methods We included 128 consecutive subjects to examine the presence of NAFLD. Of these subjects 48 did not have NAFLD and 80 had NAFLD. NAFLD was diagnosed by upper abdomen ultrasonography, metabolic syndrome was identified according to the NCEP/ATPIII modified criteria. Insulin-resistance was evaluated by means of HOMA-IR. fatty-liver-index, a recently identified correlate of NAFLD, was also estimated. Serum 25(OH) vitamin D was measured by colorimetric method. Results Patients with NAFLD (n=80, 62.5%) had reduced serum 25(OH) vitamin D levels compared to subjects without NAFLD (15.8±5.2 vs. 25.5±6.7 ng/mL, p<0.001, OR 0.95, IC 95% 0.92-0.98). The relationship between NAFLD and reduced 25(OH) vitamin D levels was independent from age, sex, triglycerides, high density lipoproteins (HDL) and glycemia (p<0.005) and fatty liver index inversely correlated with low 25(OH) vitamin D regardless sex, age and HOMA-IR (p<0.007). Conclusions Low 25(OH) vitamin D levels are associated with the presence of NAFLD independently from metabolic syndrome, diabetes and insulin-resistance profile. L-036 Fibroscan monitoring for liver complications of methotrexate use in psoriasis patients Rabindranath Eswaran1, Ashwini R Mahesh2, K Premkumar1, U R Dhanalakshmi2, Ratnakar Kini1, Kani Shaik Mohammad1 Correspondence- Rabindranath Eswaran- [email protected] 1 Institute of Medical Gastroenterology, Madras Medical College, 2 Department of Dermatology, Rajiv Gandhi Government General Hospital, Madras Medical College, Chennai 600 003, India Introduction The aim of our study was to evaluate the degree of liver fibrosis by transient elastography (FibroScan) in psoriasis patients treated with chronic long-term methotrexate. FibroScan is a rapid, non-invasive and reproducible method developed for measuring liver stiffness. Longterm methotrexate is known to cause hepatic fibrosis in psoriasis patients.

Indian J Gastroenterol

Methods During October 2016 to March 2017, we conducted a prospective analytical study in psoriasis patients receiving longterm methotrexate treatment in Rajiv Gandhi Government General Hospital, Chennai. Fibroscan measurement for transient elastography (TE), was graded as normal (F0/F1, TE 0–7), mild fibrosis (F1/F2, TE 7.1–9), moderate fibrosis (F2/F3, TE 9.1–12) or severe fibrosis/cirrhosis (F4, TE >12). Results In total 46 psoriasis patients taking methotrexate had fibroscans performed; 1 was excluded due to inadequate imaging (due to obesity) 71.1% (n=32) were female and the mean age was 51 years. The mean weekly dose of methotrexate was 13.1 mg, the mean cumulative dose was 1.85 g and the mean duration of therapy was 30.6 months. Overall 73.33% of patients had normal fibroscans (F0/F1); 15.56% had mild fibrosis (F1/F2), 11.1% had moderate fibrosis (F2/F3) and no one had severe fibrosis/cirrhosis (F4). Patients with diabetes, obesity, significant alcohol use and use of other hepatotoxic agents had significant fibrosis. No significant correlation was observed in fibroscan values with cumulative dose and the duration of drug intake. Also liver enzymes abnormality did not correlate with fibroscan measurements. Conclusion Psoriasis patients who developed fibrosis on long-term methotrexate often had other risk factors for fatty liver disease. Fibrosis was less common and not accurately identified with liver enzyme abnormalities. FibroScan could be recommended and liver biopsy could be performed only with patients with high values and/or with chronic liver enzyme abnormalities. L-037 Liver dysfunction in patients with celiac disease and effect of glutenfree diet on them Asif Iqbal, Prasenjit Das, Alka Singh, Vipin Gupta, Ashish Agrawal, Vineet Ahuja, Govind K Makharia Correspondence- Govind Makharia- [email protected] All India Institute of Medical Sciences, New Delhi 110 029, India Introduction With its wide spectrum of manifestations, celiac disease (CeD) is known to affect liver in many forms including asymptomatic increase in transaminases, autoimmune liver diseases, cirrhosis of liver and vascular disorders. We, in a prospective study, evaluated consecutive patients with CeD for liver dysfunction and the response to gluten-free diet (GFD) in them. Methods One hundred and forty-six adult treatment naïve patients with CeD were screened prospectively for liver dysfunction using liver function tests, ultrasound, fibroscan, and colour doppler. They were evaluated extensively for etiology of the liver disease. Liver dysfunction was defined if the patients had any or more of the following: increase in transaminases more than one and half times the normal value, altered echotexture of liver on ultrasound or presence of cirrhosis. Result Liver dysfunction was found in 24 (16.4%) patients. Mean age of these patients was 27.8±1.5 years (16, 66.6% males). Serum ALT or AST were elevated in 18 (12.3%) patients and 6 (4.1%) had cirrhosis. The etiology of liver dysfunction was found in 5 (hepatic venous outflow tract obstruction in 2, alcohol, drug-induced and chronic hepatitis B in one each) and in 19 the liver dysfunction remained cryptogenic. Eighteen patients underwent liver biopsy as part of diagnostic work up, which showed features suggestive of autoimmune hepatitis in 3, and rest 15 (with persistently elevated transaminases) the features were nonspecific such as mild chronic inflammation, occasional spotty necrosis, mild ballooning, steatosis and focal lipofuscin deposition. ALT/AST normalized in 11 (73.3%) of them with gluten-free diet over a mean follow up of 16±1.3 weeks. Conclusion Overall liver dysfunction was found in 16.4% of patients. Elevated transaminases, in majority (73.3%), normalized with GFD.

L-038 Predictive factors that determine response to transarterial chemoembolization in patients with hepatocellular carcinoma Mahmoud Zaki Abdelsamea elsayed Elkadeem Correspondence- Mahmoud [email protected]

Elkadeem-

Hepatocellular carcioma is one of the leading causes of cancer deaths worldwide. Transarterial chemoembolization (TACE) is a standard therapy for intermediate stage of liver cancer. It is associated with higher survival than supportive care. However, It may have a risk of mortality and morbidity. Many factors other than radiological response determine TACE outcomes. The aim is to analyze the outcomes after TACE comparing with different radiological responses. Sixty-two patients who underwent transarterial chemoembolizaton were subjected to clinical examination, laboratory investigations, triphasic abdominal CT with contrast, and evaluation of ChildPugh score, model for end-stage liver disease, and barcelona clinic liver cancer staging before and one month after therapy. Tumor response according to modified response evaluation criteria in solid tumors was calculated by one radiologist. Patients were followed up for six months or till death. Statistical analysis including regression and survival analysis were performed. As regard to modified response criteria in solid tumors: 25 patients showed complete response, 15 patients showed partial response, 2 patients showed stable disease, and 20 patients showed progressive disease. As regard decompensation after TACE (which was considered as increase Child-Pugh score one or more than the score before TACE), 36 patients had decompensation, and 26 patients did not. As regard 6 month survival, 11 (17.7%) of 62 patients died within 6 months follow up after TACE. The cumulative proportion of surviving was 82%. Significant difference was detected in patients with different radiological responses as regard tumor criteria and technique of TACE;). Size of lesions (two dimensions), serum bilirubin, AST level, INR, model for end-stage liver disease (MELD), and low platelet count were detected to be associated with decompensation after TACE. And negatively affecting 6 month survival. In conclusion many factors other than radiological response can determine the outcome after transaterial chemoembolization. L-039 Treatment outcome after discontinuation of nucleot(s)ide analogues in hepatitis B virus patients harboring diagnostic escape variants: Relapse rate Balkumar Reddy Panyala1, Rathindra Mohan Mukherjee1, Mitnala Sasikala1, Gelli Veena Shravanthi1, Sirisha Priyadarsini1, Avanthi Nagavalli 1 , Padaki Nagaraja Rao 2 , Mithun Sharma 2 , Duvvuru Nageshwar Reddy2 Correspondence- Balkumar Reddy Panyala- [email protected] 1 Asian Healthcare Foundation, 6-3-661, Somajiguda, Hyderabad 500 082, India, and 2 Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background Diagnosis escape variants (DEVs) of hepatitis B virus which escape detection by commercial real time PCR assay emerge due to alteration of genomic sequences in the precore/core region of the virus. Using strategic inner primer mismatched to wild type sequences, we devised an indigenous nested PCR assay that is able to detect such variants in HBV infected subjects. The aim of the present work was to study the treatment response of patients harboring DEVs follow up for 1 year. Methods HBsAg positive patients (n=100) who were eligible for treatment and attended the Asian Institute of Gastroenterology (AIG),

Indian J Gastroenterol

Hyderabad, India during the period 2009 to 2013 were included. The study was approved by the Research Advisory Board of AIG. Entecavir (n=80) or Telbivudine (n=20) was used for treatment of patients for 48 weeks and followed up for a period of 96 weeks after stopping the therapy as per the APASL 2008 guidelines. Blood was collected from the patients after taking informed consent. Serological and biochemical analysis were done using standard protocols. Roche COBAS TaqMan48 was used to estimate the viral load and an In-house PCR assay was performed to detect wild type and DEVs of HBV. Software IBM-SPSS-v20 was used to perform statistical analysis. Results The in-house PCR assay detected about 12% patients harbored DEVs along with wild type at baseline. Patients with DEVs at baseline showed 92% relapse rate after stopping the therapy compared to patients with only wild type virus accounting to 14%. Six patients who were negative for DEVs at baseline appeared positive for the same at 48 weeks of treatment Conclusion Anti-viral therapy might generate inter conversion of wild to variant types of the virus and vice versa. High rate of relapse in DEV positive patients indicate the necessity of attention and better clinical management of these patients. L-040 Results of Sofosbuvir plus Ribavirin in patients with decompensated cirrhosis T M U Naveen, Ashish Kumar, Praveen Sharma, Vikas Singla, Naresh Bansal, Anil Arora Correspondence-T M U Naveen- [email protected] Institute of Liver, Gastroenterology, & Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi 110 060, India Background Data is scarce about efficacy of Sofosbuvir (SOF) plus ribavarin (RBV) in Indian patients with decompensated cirrhosis. We evaluated the efficacy of SOF plus RBV in decompensated cirrhosis, and compared the outcome with compensated cirrhosis and noncirrhotics. Methods Consecutive decompensated cirrhotic patients of chronic HCV with detectable HCV RNA were treated with 24-week course of SOF (400 mg) plus RBV. SVR, CTP and MELD scores were assessed at 36 weeks (i.e. 12 weeks after completion of therapy). Non-cirrhotic chronic hepatitis C patients and patients with compensated cirrhosis treated with SOF plus RBV during the same period were used as controls. Results A total of 47 patients [median age 50 (29-82) years, 64% males] with decompensated cirrhosis were included as ‘cases’; while, 28 patients with compensated cirrhosis and 28 patients with chronic hepatitis were included as ‘controls’. The median CTP and MELD scores of cases were 8 (7-12) and 13 (6-25) respectively. Among cases 39 (83%) could complete the therapy, while 1 (2%) was intolerant and 7 (15%) died before completion of therapy. ETR was achieved in 37/ 39 (95%) cases. Of these, another 3 died before SVR, and 7 failed to achieve SVR, thus 27/34 (79%) could achieve SVR. Thus according to intention-to-treat analysis, only 27/47 (57%) cases could achieve SVR. In comparison, 24/28 (86%) compensated cirrhotic and 27/28 (96%) of chronic hepatitis achieved SVR. There was a significant improvement in mean CTP score in cases who achieved SVR (p<0.01) compared to those who did not achieve SVR/ETR. On multivariate analysis the only independent factor influencing successful outcome patients was a serum albumin>3.5 g/dL. Conclusions A 24-week course of Sofosbuvir plus Ribavirin in decompensated HCV cirrhosis could lead to SVR in only 57% of patients. The failure of therapy in 43% patients was either due to non-response, intolerance, or death. A serum albumin of >3.5 g/dL is associated with success of antiviral therapy. Thus an early initiation of antiviral therapy is recommended before decompensation sets in and precludes successful outcome.

L-041 Slow infusion of furosemide and albumin with or without terlipressin SIFA(T) improves deranged systemic hemodynamics and survival in patients with severe acute-on-chronic liver failure Prabhat Narain Sharma, Gaurav Pande, Samir Mohindra, Sudeep Kumar, V P Krishna, Vivek Anand Saraswat Correspondence- Vivek [email protected] Departments of Gastroenterology, and Cardiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Aims Acute-on-chronic liver failure (ACLF) is characterized by abrupt onset of severe liver dysfunction with extrahepatic organ failure(s) but with potential for reversal once the acute insult resolves. Although deranged systemic hemodynamics underpins extrahepatic organ failure, changes in hemodynamics after recovery or complete mobilization of ascites have not been reported. We studied hemodynamics in ACLF before and after complete mobilization of ascites with slow infusion of furosemide and albumin with/without terlipressin [SIFA (T)] and its impact on determining the clinical outcomes. Methods Twenty-five consecutive patients with ACLF fulfilling the EASL-CLIF criteria and with large ascites admitted between October 2016 and March 2017 were enrolled. Patients with active GI bleed, severe comorbidities, malignancy, BCS, <18 yrs, pregnancy were excluded. Besides the standard workup for ACLF, systemic hemodynamic parameters were determined by clinical and echocardiographic examination including cardiac index, systemic vascular resistance index and stroke work. All patients were treated with a response guided protocol with SIFA(T) for mobilization of ascites. Changes in clinical, biochemical, organ failure, hemodynamic parameters measured after resolution of ascites were compared with baseline data. Results Eleven (44%) patients had ACLF grade 3, while six (24%) had ACLF grade 2. Five (20%) patients died during the hospitalization. Systemic hemodynamics could be reassessed after complete mobilization of ascites in 20 patients using SIFA(T) regimen given for a mean period of 15.1±4.6 days. At discharge there was significant improvement in all the parameters assessed (p<.0001 for cardiac index, systemic vascular resistance index) as well as CTP and MELD scores (p<.0001 for both). Conclusions Complete mobilization of ascitic and third space fluid in severe ACLF could be successfully achieved in 80% patients with SIFA(T) with minimal adverse events. This was associated with significant improvement in liver function, improvement in organ failure(s), in systemic hemodynamics, and in improved survival. We suggest that improving systemic hemodynamics in ACLF with SIFA(T) therapy may reverse extra-hepatic organ failure and improve survival. L-042 Outcome of a 5-day hepatitis screening camp in Continental Hospitals, Financial District, Hyderabad in the state of Telangana M Asha Subbalakshmi, Abdul Wadood Ahmed Correspondence- Asha Subbalakshmiu [email protected] Continental Hospitals, Financial District, Hyderabad 500 032, India Aim Outcome of a 5-day hepatitis screening camp in Continental Hospitals, Financial District, Hyderabad in the state of Telangana Methods Hepatitis Screening On the occasion of World Hepatits day, A hepatitis screening camp was organized by the Department of Gastroenterology and Hepatology for a period of 5 days from 24th July 2015 to 28th July 2017. All the pateints were screened for hepatitis B (HBsAg) and hepatitis C (anti-HCV). Results A total of 62 patients mainly hailing from the Financial district in the City of Hyderabad were screened, of which 38 (61.3%) were males

Indian J Gastroenterol

and 24 (38.7%) were females. Male:Female ratio 1.5: 1. The ages of the patients ranged from 16-68 years. Mean age 28 years. Of all the patients screened 2 (3.2%) patients were found to be reactive for HBsAg (positive) of whom male female ratio was 1:1 who are on follow up. P value was calculated for prevalence to establish statistical significance. None of the patients were found to be positive for HCV. Conclusions 1. The prevalence of hepatitis B in the population screened at Continental Hospitals conducted by Department of Gastroenterology and Hepatology, was 3.2%. L-043 Can liver stiffness measurement by fibroscan predict the presence and size of esophageal varices in south Indian patients with liver cirrhosis Sravan Thumati, Rajkumar Solomon, A Aravind, K Caroline Selvi, R Balamurali, G Ramkumar, K Muthukumar an , S Ka vitha, Vaishnavipriyaa, A Anand, Umalakshmi Premnath, Dhande Sachin Kasinath, Ravi Anand, S B Malipatil, S Ragvendra Correspondence- T Rajkumar Solomon- [email protected] Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai 600 010, India Background and Aim Liver stiffness measured by transient elastgraphy correlates with hepatic vein pressure gradient. Aim is to predict esophageal varices presence by fibroscan and possible grading by degree of liver stiffness in patients with cirrhosis. Methods This cross-sectional study included sixty patients with cirrhosis of any etiology. Inclusion criteria were age >18 years, BMI <35, no history of upper GI bleeding, hepatocellular carcinoma, ascites. ALL patients underwent complete clinical evaluation, laboratory investigations, abdominal ultrasonography, liver stiffness measurement (LSM) using Fibroscan and upper gastrointestinal endoscopy. Also, non-invasive tests like platlet count, spleen diameter, platelet count/spleen diameter ratio (PSR). They were divided into (Group I=no varices, Group II=small varices (Grade 1 and 2), Group III=large varices (Grade 3 and 4). The diagnostic performance of each parameter was assessed using receiver operating characteristic (ROC) curves. Results Sex distribution is 80% were male patients 20% were female patients. Mean fibroscan values in Group I vs. II and III were 24.21Kpa vs. 56.56Kpa, P value is less than 0.0001, cutoff 26 Kpa (sensitivity 97.83% and specificity 78.57%) while its value in Group II vs. III were 50.46 vs. 68.01, p value 0.0002, cutoff 60.4 Kpa (sensitivity 87.5 and specificity 73.3%). Platelet count, splenic size, platelet count/splenic size in Group I vs. II and III were 96,714 vs. 54,700, 12.3 cm vs. 13.3 cm, 723.4.6 vs. 478, p value 0.003, 0.0036, 0.005, cutoff 85,000, 12.3 cms 775, sensitivity and specificity (80.43% and 64.29%, 73.9% and 71.43%, 84% and 74%) respectively. On multivariate analysis fibroscan (OR 1.113; p=0.005) and platelet count/splenic size (OR 0.995; p=0.012) were positive predictors of esophageal varices presence. Conclusion 1) Fibroscan is a good non-invasive method for predicting esophageal varices. L-044 Validation of a staging system for stage 1 acute kidney injury in chronic liver disease patients: A single centre experience Chitta Ranjan Khatua, Debakanta Mishra, Subhendu Panigrahi, Preetam Nath, Prasant Kumar Parida, Sambit Kumar Behera, Suryakanta Parida, Kaibalya Ranjan Dash, Shivaram Prasad Singh Correspondence- Chitta Ranjan Khatua- [email protected] S C B Medical College, Cuttack 753 007, India

Introduction Acute kidney injury (AKI) occurs commonly in patients with chronic liver disease (CLD) and negatively impacts survival. As per International Club of Ascites, AKI is classified into 3 stages and recently stage 1 has been divided into subgroups stage 1A and stage 1B with different outcomes. We performed a prospective study to validate association between subgrouping and outcome. Methods This study was conducted in decompensated cirrhosis (DC) patients hospitalized in Gastroenterology Department, S C B Medical College, from October 2016 to August 2017. Demographic, clinical and laboratory parameters were compared between AKI 1A and AKI 1B patients. Duration of hospitalization and outcome was compared. Results One hundred and ninety-one subjects were enrolled of which 84 (44%) had AKI; 51 (27%) had stage1, 20 (10%) had stage2 and 13 (7%) had stage3 AKI. Twenty-five (49%) had early (AKI 1A) and 26 (51%) late stage1 AKI (AKI 1B). ALD was predominant cause of CLD in both groups. Patients with AKI 1B had higher CTP (11.44±1.86 vs. 9.88±2.94, p=0.015) and MELD (22.24±6.23 vs. 17.54±5.20, p=0.001) and lower mean arterial pressure (86.22±12.22 vs. 89.69±8.91, p=0.158 than AKI 1A. Patients with AKI 1B received significantly more Terlipressin in comparison to AKI 1A (27% vs. 4%, p= 0.004), indicating more hepatorenal syndrome (HRS) development in AKI 1B patients. Further, AKI 1B patients had lower 90 days survival (44% vs. 70%, p=0.028). Conclusions In our institution, over 40% DC patients had AKI. Alcohol was predominant cause of underlying CLD in both AKI 1A and 1B. Patients with AKI 1B more often progressed to higher AKI stages i.e. AKI 2 or AKI 3 with a lower 90 days survival. Result suggests need for early intervention at AKI 1A stage which is not in vogue. L-045 Progression of liver fibrosis in HCV genotype 3a is associated with modulation in let-7 miRNA family Manish Chandra Choudhary1, Sadaf Bashir Dar1, Ekta Gupta2, Syed Naqui Kazim3, Gayatri Ramakrishna1, Shiv Kumar Sarin4 Correspondence- Shiv Sarin- [email protected] 1 Molecular and Cellular Medicine Department, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India, 2 Department of Virology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India, 3CIRBSc, Jamia Millia Islamia, 4Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Chronic HCV infection is major cause of liver fibrosis and end stage liver disease. There is limited data on systematic miRNA based biomarker study on hepatic fibrogenesis in HCV genotype 3a. We profiled circulating miRNAs in plasma of HCV G3a infected patients with different stages of hepatic fibrosis. Forty-seven subjects with histologically proven chronic hepatitis C were categorized based on stage of hepatic fibrosis: F0-1 (n=32), F3-4 (n=15) and compared with healthy controls (n=28). Differentially expressed miRNAs in plasma of 4 subjects each of healthy controls, F0-1 and F3-4 were studied and subsequent validation by stemloop RT-PCR. miRNA target gene prediction was done by multiMiR analysis. Of the total 185 miR.NAs screened in the panel, 31 miRNAs were commonly identified in all the groups. Three miRNAs were significantly down regulated (p<0.01, fold change<-3) when F0-1 were compared to F3-4. ΔCt for most significantly downregulated miRs in F0,1 vs. F3,4 were: let-7a (-0.1671±0.6263 vs. -1.465±0.8206, p<0.0001), let-7c (-3.345±0.8334 vs. -4.384±0.8114, p=0.0012) and let-7f (-2.515±1.105 vs. -3.970±0.9538, p=0.0006). The AUROC for all the validated miRNAs in fibrosis vs healthy subjects were AUROC>0.9, p<0.01, while in F0,1vs F3,4 AUROC>0.8, p<0.01). ΔCt cut-off of let-7a at -1 was most discriminatory miRNA between HCV and healthy subjects with 92% sensitivity and 73% specificity. All the validated miRs correlated negatively with the stage of fibrosis (r2> -0.8; p <0.0001). In-silico analysis revealed extracellular matrix interaction pathway as the most

Indian J Gastroenterol

enriched pathways, p=1.94E-16. Our findings indicate significance of let7 family miRs in HCV mediated liver fibrosis progression. L-046 An update on the prevalence of hepatitis viruses in South India: 5 years hospital-based study Shaik Iqbal Ahmed, Raju Nagarapu, Sandeep Kumar Vishwakarma, Syed Rahamathulla, Avinash Bardia, Chandrakala Lakkireddy, Safwaan Habeeb, Aleem Ahmed Khan, Mohammed Aejaz Habeeb Correspondence- Aejaz Habeeb Mohammed- [email protected] Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Hyderabad, 500 058, India Background Several infectious diseases are transmitted by consumption of contaminated food or water, and blood transfusion, especially viral infections. The most common blood-transmitted viruses are hepatitis B virus (HBV) and hepatitis C virus (HCV). Approximately 240 million people are still chronically infected with HBVand 170 million with HCV worldwide. These viruses cause an acute, chronic, cirrhosis, and hepatocellular carcinoma. The prevalence of these viruses varies by nationality and geography. The purpose of this study was to establish the current prevalence of hepatitis (A, B, C and E) viruses among Outpatient ward of Gastroenterology in Owaisi Hospital and Research Centre at Hyderabad, South India. Methods Serological markers of HAV, HBV, HCV, and HEV were studied in 1246 (843 males and 403 females), using commercially available ELISA (Enzyme linked immuno sorbent assay) kits and molecular analysis was done by RT-qPCR over a period of 5 years from 2013 to 2017 in Owaisi Hospital and Research Centre at Hyderabad, South India. Results and Discussion The prevalence was significantly higher in males than in females. Hepatitis A virus IgM (Immunoglobulin M) positivity higher in children’s with the age group ≤20, hepatitis B surface antigen (HBsAg) and anti-HCV positivity tend to increase with increase in age, and hepatitis E virus IgM high positives in the age group ≥41. Conclusions This study highlights the prevalence rates of HAV, HBV, HCV, and HEV among different groups. The prevalence varies from one group to another, HAV and HBV infection is common in ≤20 and 21-40 groups respectively. HCV, HEV in ≥41 age group. L-047 Child-Pugh vs MELD vs renal resistance index score for assessment of prognosis in liver cirrhosis M Indrakeela Girish, K Sravan Kumar, L R S Girinadh Correspondence- K Sravan Kumar- [email protected] Department of Gastroenterology, Andhra Medical College, Vishakapatnam 530 002, India Introduction Liver related mortality is the tenth leading cause of death in India. Compensated and decompensated cirrhotic patients have 5 and 10 fold increase risk of death with median survival of 9–12 and 2 yrs. Child–Pugh and MELD scores have been widely used for the assessment of prognosis in liver cirrhosis. The resistive index (RI) can be used to assess vascular resistance by Doppler ultrasonography. Cirrhotic patients with elevated intra renal RIs tend to develop HRS, leading to poor prognosis. The study is designed whether intra renal resistive index can be used as a prognostic parameter in cirrhotic patients and comparing this with the existing prognostic scores. Methods Prospective single center study. Cirrhotic patients >18 yrs were included. Hepatorenal syndrome, gastrointestinal bleed, diabetes, hypertension, decreased kidney size on ultrasound abdomen, malignant disease were excluded. Statistical analysis was performed using SPSS software.

To discriminate the predictive value of the parameters, a receiver operating characteristic (ROC) curve was established by standard procedures. Results Out of 92 patients 56 alive, 26 died, 10 lost follow up. Male/Female–62/20. Mean Age-41.13+/-9.24. On comparing the baseline characteristics of both the dead and alive group, intrarenal resistive index is the only parameter that is statistically different. In ROC analysis CTP score has an AUROC of 0.749, MELD score has 0.836 and RRI has 0.858. When compared with both CTP and MELD score, renal resistive index performed better. Kaplan-Meir survival analysis showed a significant difference in survival between the groups with intrarenal resistive index (RI) ≤0.71 and RI >0.71. Conclusion When compared with MELD score and CTP score, intra renal resistive index is better in predicting short-term survival among cirrhotic patients. L-048 Etiological and clinical profile of space occupying lesions of liver in cirrhosis Virothu Srinivasa Rao, R Kiran, L R S Girinadh Correspondence- Kiran Repana- [email protected] Department of Gastroenterology, Andhra Medical College, Visakhapatnam 530 002, India Background and Aim Identifying etiology of space occupying lesion (SOL) of cirrhotic liver is important for proper management of the case. To access the most common clinical presentation in various types of SOLs in cirrhotic liver. Method This observational study was done in adult cirrhotic patients (n=69) with SOLs in their liver, which are detected either incidentally or during surveillance in King George Hospital from February 2015 to December 2016. Staging and treatment of HCC was done according to the Barcelona Clinic Liver Cancer (BCLC) classification. Carcinoembryonic antigens, CA19-9 are positive and alphafetoprotein is negative in cholangiocarcinoma. Results The average age of presentation is 50.08±10.8 years. Male:female ratio is 3:1. HCC was the most common etiology of SOL which constituted 38 (65%) cases. HCC has its highest incidence in 51-60 years group. Male: female ratio is 3.2:1. The most common symptom being abdominal distention or right upper quadrant pain seen in 27 (52%) of cases. Most of the lesions above the size of 2 cm were because of HCC. HBV cirrhosis had the highest number of HCC cases (37%) followed by alcohol (31%), HCV (23%). Among the HCC cases 63% were in CTP B, 29% were in CTP A and 8% in CTP C. Conclusion HCC was the most common space occupying lesion in the cirrhotic liver. Benign lesions made up 34% of space occupying lesions and were more frequent in lesions with less than 2 cm size. HBV was the most common etiology for HCC in our geographical area. L-049 The role of HNF4a, TGF-ß1 in the pathogenesis of liver fibrosis caused by hepatitis B and C Raju Nagarapu, Shaik Iqbal Ahmed, Sandeep Kumar Vishwakarma, Syed Rahamathulla, Avinash Bardia, Chandrakala Lakkireddy, Safwaan Habeeb, Mohammed Aejaz Habeeb, Vishnupriya Satti, Aleem Ahmed Khan Correspondence- Aleem Ahmed Khan- [email protected] Centre for Liver Research and Diagnostics, HLS, Deccan College of Medical Sciences, Hyderabad 500 058, India Background Hepatitis B and hepatitis C are major human pathogens can causes chronic liver disease, leading to progressive hepatic

Indian J Gastroenterol

fibrosis and ultimately cirrhosis and hepatocellular carcinoma (HCC). Hepatic fibrosis is a critical step in liver cirrhosis caused by both the viruses. It is already known that immune cells, including Kupffer cells, mediate liver fibrosis. Hepatocyte nuclear factor-4α (HNF4α), is the most abundant transcription factor in the liver, regulates the VLDL secretory pathway and transforming growth factor β1 (TGF-β1) plays a key role in its pathogenesis, However, the effects of HNF4α, TGF-β1 on HBV and HCV life cycle are unclear. In this study, our aim was to investigate effects of HNF4α and TGF-β1 on HBV and HCV infected patients with fatty liver. Methodology Blood samples were collected from 25 healthy controls, 25 uninfected fatty liver patients, 25 HBV infected with fatty liver and 25 HCV infected with fatty liver patients. Viral load for HBV and HCV was quantified by using RT-qPCR. Viral replication, biochemical and pathological parameters were compared to find their association with disease pathogenicity. Results and Discussion In this study, we observed the effect of viral infections on liver fibrosis by measuring HNF4α and TGF-β1 by RTqPCR. We found that both the markers at infected condition expressed the highest levels. Furthermore the hepatic expression of TGF-β1 was positively correlated to transaminases and stage of liver fibrosis and it negatively correlated with serum albumin and prothrombin concentration. Conclusion Conclusively, these results indicated that one or more viral proteins trigger the production of HNF4α and TGF-β1 for liver fibrosis. The TGF-β1 may be implicated in the progression of liver fibrosis associated viral infections. Therefore, the application of TGF-β1 antagonist may be a useful in the future as anti-fibrotic therapy to ameliorate the disease progress. L-050 NUTRIC score guided aggressive nutrition therapy significantly decreases 28 day mortality in critically ill patients with chronic liver disease Harshita Tripathi1, Jaya Benjamin1, Puja Bhatia1, Varsha Shasthry1, Rakhi Maiwall2, Lalita G Mitra3, Naveen Yadav3, Prashant Aggarwal3, Vandana Saluja3, Y K Joshi1, Shiv K Sarin2 Correspondence- Jaya [email protected] 1 Clinical Nutrition, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India, 2Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India, 3Critical Care, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background Malnutrition is universal and increases risk of mortality in critically ill patients with chronic liver disease. Nutrition Risk in Critically ill (NUTRIC) score is a validated tool to identify patients at nutrition risk that may benefit the most from aggressive nutrition therapy. Aim To assess the effect of aggressive nutrition therapy on 28 day survival in critically ill cirrhotics stratified by NUTRIC score. Methods A prospective nutritional intervention study in critically ill adult Liver ICU was designed to collect baseline and follow up data during ICU stay. The NUTRIC score [0-4=low NUTRIC score (LNS), 5-9=high NUTRIC score (HNS)], clinical, hemodynamic, biochemical, nutritional parameters, use of mechanical ventilation (MV), length of ICU stay (LOS), and development of new onset infection (NOI) were recorded. Daily nutritional adequacy was calculated as energy received ÷ energy required × 100. Logistic regression analysis was done to assess the association between NUTRIC score and 28 day mortality. Results One hundred and fifty patients [(M-83%, age-51±12.1, BMI-24 ±4.7kg/m2; cirrhosis (74.2%), acute on chronic liver failure (25.8%), median LOS 6 (2-24 days)] were studied. At baseline 116 (77%) had HNS and 34 (23%) LNS. Patients with HNS had significantly higher mortality (69.8% vs. 44.1%; p=0.007; OR (95% CI) unadjusted 3.

Fourteen (1.42, 6.96; p=0.005); adjusted for age, shock, diagnosis, renal failure, co-morbidity, FiO2=3.53 (1.11, 11.2; p=0.032), total days on MV [5 (2-24) vs. 3 (2-24); p=0.02], incidence of NOI [41.4% vs 11.7%; p=0.002; OR (95% CI:7 (2, 24.5)] compared to LNS. Nutritional adequacy was aimed in all patients and achieving it, significantly decreased the predicted mortality, though only in patients with HNS. Conclusion The NUTRIC score in critically ill cirrhotics is a valuable tool in recognizing nutrition risk and predicting mortality. Aggressive nutrition therapy, especially in patients with High NUTRIC Score can significantly reduce mortality risk in this cohort. L-051 Pattern and profile of infections in hospitalized patients with cirrhosis and its role in short-term mortality Sunu Sara Kurien, Thazhath Mavali Ramachandran Correspondence- Thazath Mavali Ramachandran- [email protected] Department of Gastroenterology, Government Medical College, Kozhikode 673 008, India Introduction Infections are one of the most common causes of admission in cirrhotic patients. This study aimed to assess the clinical profile and short-term mortality caused by infections in hospitalized patients with cirrhosis. Methods This is a prospective study where hospitalized cirrhotics were studied for presence or absence of infections. They were analyzed for site and type of infection; community-acquired (CA), health care-associated (HCA) or hospital acquired (HA). Both in hospital mortality and mortality at 3 months were studied. Results Of the 90 patients included in the study, 51 had infection (56.6%) whereas 39 (43.4%) did not. Both groups were comparable in terms of age, sex and etiology of disease. CHILD C status (p0.038) and MELD score (p=0.01) were seen to be associated with infection. In those with infection, the most common was SBP (70.5%) followed by cellulitis (19.65) and urinary tract infection (17.6%), with 8 having more than 1 type of infection. There were 26 cases which were health care associated infections (50.9%), 16 which were hospital acquired (31.3%) and 9 community acquired cases. Cultures were positive in 17 (33.3%) with gram negative infections being more common than gram positive (52.9% vs. 47.1%). Those with infection had a significantly greater duration of hospital stay compared to those without (10.6+/-6.7d vs 6+/-3.1d: p=0.00). In hospital mortality was greater in those with infection though not statistically significant (7vs1 p=0.065). Three month mortality was significantly higher in those with infection (24 vs. 4 p=0.00). Conclusion Infections are an important determinant of mortality in cirrhotics. Most infections in cirrhotics are either hospital acquired or health care associated. Hence cirrhotic patients should be monitored closely for infections. L-052 Profile of esophageal varices due to portal hypertension in children: A retrospective study of etiology at a tertiary care hospital of north India M H Usmani, V K Dixit, S K Shukla, Gaurav Garg Correspondence - M H Usmani - [email protected] Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Objective Studies about etiologies of portal hypertension in children are scarce. We therefore assessed the reasons for portal hypertension in children attending a tertiary care centre of north India.

Indian J Gastroenterol

Methods A retrospective review was done in 64 consecutive patients (<18 years) of upper GI bleed coming in the Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, from January 2016 to May 2017. Portal hypertension was diagnosed on endoscopy. The diagnosis of extrahepatic portal venous obstruction (EHPVO) and Budd-Chiari syndrome (BCS) were made on the basis of doppler ultrasound. The etiology of cirrhosis was diagnosed on the basis of clinical, laboratory tests, USG or CT scan, and liver biopsy (when indicated). Cirrhosis of unknown etiology was considered cryptogenic. Results A total of 64 children with portal hypertension, aged between1 year to 18 years, comprising of 36 males (56.25 %) and 28 females (43.75 %), were included. Causes of PHT included EHPVO in 62%, cirrhosis in 34% and BCS in 4%. The most common causes of liver cirrhosis were Wilson disease (n=22; 34.3%), and cryptogenic cirrhosis (n=19; 29.6%). Other causes were autoimmune hepatitis (n=11; 17.1%), HBV related cirrhosis (n=9; 12.4 %), NAFLD (n=3; 4.7%) and choledochal cyst (n=1; 1.5%). Conclusions Overall most common etiology for portal hypertension in children came out to be EHPVO followed by cirrhosis. The most common etiology for cirrhosis was Wilsons disease. Treating physicians need to be well informed about the possible etiologies for better patient management. L-053 Rare case of Crigler-Najjar syndrome Type 2 with pregnancy A Keeerthi, P Shravan Kumar, M Umadevi Correspondence- A Keeerthi- [email protected] DRNTRUHS, Hyderabad 520 007, India Background Crigler-Najjar syndrome is associated with indirect hyperbilirubinemia due to a deficiency of enzyme Uridine Di Phospho Glucoronosyl Transferase (UDPGT). We presented here a case of a pregnant female who was diagnosed to have type 2 Crigler-Najjar syndrome. Unconjugated bilirubin can cross the placental barrier causing neurological damage in the newborn. Patient was carefully monitored during pregnancy and treatment with phenobarbitone in low doses was adjusted such that the serum bilirubin levels were below 10 mg/dL. Crigler-Najjar syndrome being rare needs to be diagnosed early in pregnancy to avoid adverse fetal outcomes. Case Report A 22- year-old female with history of jaundice since childhood. She came to us in her first trimester of pregnancy with jaundice. Patient had unconjugated hyperbilirubinemia with normal liver enzymes. Tests for viral hepatitis, autoimmune liver disease and Wilson’s disease were negative. Hemolytic work is negative. The UDT1A1 gene was studied for the TATA sequence. The result was negative; Gilbert’s syndrome was ruled out. Total bilirubin at 12 wk of gestation was 8.76 mg/dL with indirect bilirubin being 7.20 mg/dL and albumin of 4 g/dL. Her liver enzymes were normal. A dose of 30 mg/d of phenobarbitone was started for the patient. Her serum bilirubin and albumin levels were measured at weekly intervals for the first month and then monthly. We diagnosed the patient to be a case of Crigler-Najjar type 2 based on: (1) history of hyperbilirubinemia since childhood; and (2) response to phenobarbitone. Through out her pregnancy, bilirubin levels were maintained below 10. She had normal vaginal delivry. Bilirubin levels in neonate are normal. Conclusion Crigler-Najjar disease type II seems to pose no unique maternal risk during pregnancy. The fetus seems to be resistant to elevated maternal unconjugated bilirubin, but the neonate may required therapy for hyperbilirubinemia.

L-054 Hand grip strength in Child C cirrhosis patients and it’s association with mortality and complications Veerendra Rajendra Koujalagi, Thazhath Mavali Ramachandran Correspondence- Ramachandran Thazhath [email protected] Government Medical College Calicut, Kozhikode 673 017, India Introduction Sarcopenia is common in patients with liver disease. Measurement of hand grip strength using hand grip dynamometer helps to assess sarcopenia objectively. This study aimed to look in to the hand grip strength and its association with prognosis and mortality in patients with Child C cirrhosis. Methods This is an ongoing prospective observational study. Hand grip strength of Child C cirrhosis patients was measured using a hand grip dynamometer and were followed up for a period of 6 months to asses mortality and complications. Results A total of 58 Child C patients were studied. Twenty-six of the 58 patients survived and 32 did not survive. The mean hand grip strength among survivors was 27.6 (SD 5.5K) Kg were as among non-survivors it was 14.7 Kg (SD 5). There was a significant association between hand grip strength and survival (p value <0.001). The patients with complications like upper GI bleed, AKI, Infection and SBP had mean hand grip strength lower than those without complications but it was not significant. Conclusions Sarcopenia is an important predictor of mortality in patients with child c cirrhosis. Hand grip dynamometer is an easy bedside tool to assess the sarcopenia of these patients and is strongly associated with mortality. L-055 Cardiac dysfunction in portal hypertension: A single centre experience Sambit Kumar Behera, Sunil Mishra, Chitta Ranjan Khatua, Debakanta Mishra, Suryakanta Parida, Kaibalya Ranjan Dash, Subhendu Panigrahi, Uttam Kumar Patnaik, Shivaram Prasad Singh Correspondence- Sambit Kumar Behera- [email protected] SCB Medical College, Cuttack, Odisha 753 007, India Introduction In cirrhosis of liver, diastolic dysfunction of heart is well documented. However, the relative contribution of portal hypertension and hepatic dysfunction is unknown. We examined the patients of portal hypertension with or without liver insufficiency to understand the contribution of portal hypertension and cirrhosis in causing cardiac changes. Methods A cross sectional observational study was undertaken where consecutive patients with portal hypertension due to various etiologies were enrolled after excluding any known cardiac illness. Cardiac assessment was performed non-invasively using electrocardiogram (ECG), transthoracic echocardiography (ECHO). Results were interpreted using SPSS software. P value less than 0.05 was considered to be significant. Results Among the 37 patients of portal hypertension 7 patients had extrahepatic portal vein obstruction (EHPVO) 1 patient had BuddChiari syndrome and 29 patients had cirrhosis of liver due to various etiologies. All the patients of EHPVO and Budd-Chiari syndrome had normal cardiac function. In patients of cirrhosis of liver there was presence of diastolic dysfunction in 6 patients (16.2%). QT prolongation was seen in ECG of 3 patients with cirrhosis (8.1%). There was no significant correlation found between diastolic dysfunction and ascites (p=0.16). Cardiac dysfunction was equally prevalent among patients of cirrhosis due to alcohol and other etiologies (p value=0.92). Conclusion Patients with portal hypertension due to extrahepatic causes have normal cardiac function while one sixth of patients with cirrhosis of liver have cardiac abnormalities including diastolic dysfunction and QT

Indian J Gastroenterol

prolongation. Our study has limitations of inadequate sample size. Further studies with large number of patients are needed to assess the spectrum and severity of cardiac abnormalities in these patients. L-056 CYP2C9 and VKORC1 mutations predicts bleeding complications in patients of Budd-Chiari syndrome on warfarin Vinit Kahalekar, Urmila Thatte, Nithya J Gogtay, Abhinav Jain, Shobna Bhatia, Akash Shukla Correspondence- Akash [email protected] Seth G S Medical College and K E M Hospital, Mumbai 400 012, India Introduction Testing for mutations (CYP2C9*1, 2, 3 and VKORC1) are mandated for all patients on warfarin. We conducted this study to assess genetic determinants for dosing warfarin and their association with occurrence of bleeding episodes in Budd-Chiari syndrome (BCS) on warfarin. Methods Eighty patients of BCS on warfarin for at least 3 months were evaluated for presence of warfarin mutations [of CYP2C9 enzyme (i.e. CYP2C9*1, CYP2C9*2, CYP2C9*3) and VKORC1:AA,AG and GG] by Restriction Fragment Length Polymorphism. All patients were aimed at maintaining an INR of 2-3. The genotypes were then compared to dose of warfarin and incidence of complications due to warfarin using ANOVA and Chi-square test. Results Thirty-seven (46.2%) patients were found to have mutations in at least one of the genes. Twenty-two (27.5%) patients had mutations of CYP2C9, 22 (27.5%) of VKORC1 and 7 (9%) had mutations of both. Twenty-one out of 80 (26.3%) patients had hemorrhagic complications (six major bleeding episodes) due to warfarin at a median follow up 5 months (range: 0.5-150). The incidence of hemorrhagic complications was higher in patients with mutations [14/37 vs. 7/43, p=0.04; OR 3.13 (95% CI 1.098-8.922)]. Mean warfarin dose was similar in patients without (4.93±2.4 mg/dL) and with any mutation (4.05±2.1mg/dL, p =0.089). The frequency of bleeding complications and dose of warfarin didn’t correlate with baseline Rotterdam score (p=0.44 and 0.97 respectively). Conclusions The bleeding complications of warfarin are three times more likely in patients with mutation(s) of CYP2C9 and VKORC1. L-057 Clinical profile of patients with autoimmune hepatitis: Single tertiary referral center experience Bimal Kumar Sahu, Ashok Dalal, Ajay Kumar, Siddharth Srivastava, Sanjeev Sachdeva, A S Puri Correspondence- Siddharth [email protected] G B Pant Hospital, New Delhi 110 002, India Background and Aims Autoimmune hepatitis is considered to be rare in Asia-Pacific region. This study was planned to evaluate the clinical, biochemical profile of patients with autoimmune hepatitis, in a single nontransplant tertiary referral center . Methods Retrospectively maintained data of patients treated as AIH was analyzed and patients who qualified as AIH by histopathology on liver biopsy were enrolled. Results Twenty patients qualified (14 males; 6-females; median age 22.5 yrs, range 4–65 yrs) were included in study. Seventeen patients qualified as Type I AIH, 3 as type II AIH and 4 were autoimmune markers negative. Modes of presentation was acute hepatitis (n=5), chronic hepatitis (n=2), acute on chronic liver failure (n=1), cirrhosis (n=9), while 3 were clinically asymptomatic. All patients underwent pretreatment liver biopsy. The median AST and ALT at presentation was 78 IU/mL (range=4-

1411) and 75 IU/mL (range=14-1831) respectively. The median MELD was 14 (range=6-24). Conclusion In our study for the spectrum of AIH at a tertiary care center we found that most of the patients had Type I AIH. The most common presentation of AIH in our study was de-compensation of chronic liver disease. L-058 Efficacy and safety of carvedilol in patients of acute-on-chronic liver failure with small or no esophageal varices – A placebo control open label randomized trial (NCT02583698) Sumeet Kainth, Manoj Kumar, Ashok Kumar Choudhury, Ankur Jindal, Lovkesh Anand, Guresh Kumar, Priyanka Jain, S K Sarin Correspondence- Sumeet [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims Acute-on-chronic liver failure (ACLF) is a clinical syndrome with high mortality. Rapid rise in portal pressure (PP) probably underlies complications, like HRS and variceal bleed. Role of PP reduction, safety and efficacy of beta-blockers has not been studied in ACLF. We investigated the efficacy of carvedilol in ACLF patients to prevent growth of varices and PHT related complications. Methods ACLF patients with no/small esophageal varices and HVPG >12 mmHg were randomized to carvedilol (Gr.A, n=66, 43.29±10.1 yr, M:93.9%) or placebo (Gr.B, n=70, 44.7±10.5 yr, M:91.4%) and followed till death or 90 days to assess outcomes at day 28 and 90. Results Two hundred and eighty consecutive ACLF patients were screened; 136 fulfilling selection criteria were randomized. Baseline clinical parameters {alcoholic hepatitis 69% and 70%, mean MELD 24.62+ 4.12 and 25.06+3.3) [p=0.49] and hemodynamics were comparable {mean HVPG 19.7+5.2 and 18.6+4.9 respectively [p=0.18]}. Median maximum tolerated dose of carvedilol was 12.5 mg (3.13–25). The incidence of bleed at 90 days was comparable [n=8 (12.1%) vs. n=4 (5.7%), p-0.18], with no difference in baseline HVPG in bleeders and nonbleeders [n=12 (19.7+4.2 mmHg) and n=124 (19.1+5.1 mmHg) [p0.69]. HVPG at 90 day done in 63/100 (63%) survivors, with 32 (50.7%) showing >20% reductions; {Gr.A=18, GrB=14} with lower variceal growth in those with HVPG reduction by >20% [3/32, 9.4% vs. 14/ 31, 45.2%, p=0.01]. HVPG reduction with carvedilol [18/34 (52.9%) in Gr. A-34/63 (53.9%)] or spontaneous [14/29 (48.3%) in Gr.B-29/ 63(46.1%)] was comparable. The PVRI increased with carvedilol [28/ 34 (82.4%) vs. 16/29 (55.2%), p=<0.01] from 112.1+38.5 to 134.4+ 44.2. Carvedilol reduced the incidence of AKI [9 (13.6%) vs. 25 (35.7%), p=0.03] and sepsis [10 (15.2%) vs. 33 (47.1%), p=0.01] at day 28 with reduced mortality [7 (10.6%) vs. 17 (24.3%), p=0.03] though not at day 90 [16 (24.2%) vs. 20 (28.6%), p=0.69]. Conclusion Carvedilol reduces incidence of sepsis and AKI with improved survival at 28 days. Addition of carvedilol did not delay growth of varices or increased HVPG reduction, but it improved pulmonary hemodynamics and reduced complications due to rapid rise in PP with survival benefit at day 28. L-059 Early addition of prokinetics reverses gut paralysis and improves survival in critically ill cirrhotics- An open label placebo controlled RCT (Feed Intolerance and Treatment-FIT protocol). NCT02528760 V Rajan, Rakhi Maiwall, Ashok Choudhary, Kapil Jamwal, Jaya Benjamin, Guresh Kumar, Y K Joshi, Shiv K Sarin Correspondence-V Rajan- [email protected] Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India

Indian J Gastroenterol

Background and Aims Gut-paralysis causing feed intolerance (FI) is common in critically ill cirrhotics (CIC). Prokinetics, such as Metoclopramide (Met) and Erythromycin (Ery) are first line treatment for FI. We evaluated the incidence, role of prokinetics and predictors of 28 day mortality in CIC who developed FI. Methods Consecutive CIC patients, admitted in ICU, who developed new onset FI were randomized to either IV Met (Gr. A, n=24), IV Ery (Gr. B, n=25) or placebo (Gr. C, n=23). FI, defined as presence of 3 of 5 variables-absence of bowel sounds, vomiting, diarrhea, bowel distension and gastric residual volume ≥500 mL. Primary end-point was resolution (atleast 3/5 variables resolved) of FI at 24 hours. Results In this study, 72 patients were randomized to 3 groups. Resolution of FI was significantly better at 24 hr (p=0.026) in Gr A and B compared to C with a trend to better resolution in Gr B than A (24% vs. 8.7%, p=0.16). Partial response (2/5 variables resolved) at 24 hr was better in Gr A, B than C (p<0.001) and in Gr B than A (p=0.018). Time to restart enteral nutrition was shorter (Gr A, B, C=2.61±0.72, 2.20±0.91, 3.47 ±1.29 days) with Gr B>A (p=0.03). The 7 day survival was better in Gr A, B compared to C (p=0.07) with significantly higher 28-day all cause mortality in Gr. C (p=0.007). On univariate analysis, resolution of FI at 72 hr (OR:3.45:95% CI-1.19-9.99, p=0.02), presence and persistence of organ failures at 72 hours (OR:2.59;95% CI-0.91-7.38, p=0.07) and new sepsis after development of FI (OR: 0.18;95% CI-0.02-1.53, p=0.08) were predictors of 7 and 28-day survival, though on multivariate analysis only resolution of FI at 72 hours was significant (OR:3.45:95% CI-1.199.99, p=0.02). Conclusions Early detection and addition of prokinetics helps in resolution of FI in CIC. Gut paralysis manifesting as FI should be regarded as an independent organ failure requiring early treatment. L-060 Diagnostic and prognostic role of procalcitonin in infected cirrhotic patients Dadasaheb Maindad, B V Tantry, Suresh Shenoy, Sandeep Gopal, Anurag Shetty Correspondence- Dadasaheb Maindad- [email protected] Kasturba Mediacl College, Mangalore 575 001, India Early diagnosis and treatment is a major predictor of outcome in infected cirrhosis patients. Each hour delay in starting antibiotic therapy significantly increases mortality and morbidity. As the immune altered status of cirrhotic patients, WBC is not a reliable marker of infection. Early infection diagnosing methods are important for management of suspected infected cirrhosis patients. Methodology Study type Prospective, single centre, observational. This study was performed in KMC, Mangalore, from September 2015 to July 2016. The study was included 201 infection episodes (174 culture positive and 27 culture negative). All patients underwent detail clinical examination, relevant laboratory investigations, bacterial culture and sensitivity. Procalcitonin was tested in 186 patients who consented to test (160 culture positive and 26 culture negative). Statistical analysis was done. Results

Patients Expired (n=31) n=136 Recovered/partially recovered (n=105)

Procalcitonin Mean± tested SD (ng/mL) 30 3.97±2.01 P<0.007 99 2.52±2.24

152

2.9±2.07

P<0.0001

Episodes Single infection n=201 (n=165) Multiple infections 34 (n=36) Culture positive 160 infection (n=174) Culture negative 26 infection (n=27)

4.66±1.96 3.04±2.28 P<0.0169 1.92±1.58

Table 1 Shows procalcitonin level in 186 infection episodes in 136 patients. Procalcitonin was elevated in all patients. In expired patients (n=31) mean procalcitonin level was significantly higher than recovered patients (3.97±2.01 ng/mL vs. 2.52±2.24 ng/mL) (p< 0.0007). Episodes with multiple infections had significantly higher mean procalcitonin (4.66 ±1.96 ng/mL) level than single infection episodes (2.9±2.07 ng/mL) (p<0.0001). Higher mean procalcitonin level was seen with culture positive episodes (n=160) (p< 0.0169). Highest mean procalcitonin level was seen with multiple culture positive infections (4.66±1.96 ng/mL) Conclusion for prompt diagnosis of bacterial infections procalcitonin is good modality which helps in starting of empirical antibiotics. L-061 Albumin is required to decrease the incidence of paracentesis induced circulatory dysfunction in patients with acute-on-chronic liver failure patients with <5 litres of ascitic tap: A randomized controlled trial (NCT02467348) Vinod Arora, Rakhi Maiwall, Sherin Thomas, Barjesh C Sharma, Manoj Kumar, Priyanka Jain, Guresh Kumar, Shiv K Sarin Correspondence-Vinod Arora- [email protected] Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Background Paracentesis induced circulatory dysfunction (PICD), defined as ↑ in plasma renin activity (PRA) (>50% from the baseline or >4 ng/mL/hour) on day 6 post LVP (>5l) and associated with increased incidence of encephalopathy, hyponatremia and mortality. There is lack of data on the incidence, diagnosis and management of PICD in acute-onchronic liver failure patients (ACLF). We hypothesized an increased predisposition to PICD after modest volume paracentesis (MVP) in ACLF patients and aimed to determine the need for albumin infusion with a lesser volume of paracentesis. Patients Fify-nine consecutive patients of ACLF, undergoing paracentesis of <5 L were randomized to receive albumin (8 g/L of ascitic fluid, Gr A, n=30) or no albumin (Gr. B, n=29). Heart rate, systolic BP, diastolic BP were monitored for 6 days. PRA were analyzed at baseline, day 3 and 6. Hyponatremia (Na < 130 meq/L or >5 meq decrease, AKI (ICA-AKI criteria) and HE ≥grade 2. Results Baseline characteristics were comparable in two groups, including mean volume of tap (4.21±.15 vs. 4.26±.24 L, p=.35), baseline PRA (19.59±7.4 vs. 22.52±9.1 ng/mL, p=.18), HVPG (19.1±4.6 vs. 19.3±5.7 mmHg, p=.18) and SVR 1357.5±511.6 vs. 1375.5±419.3 dyn-sec/cm5/ m2, p=.83). PICD was seen more frequently in Gr A than B (62% vs. 26%; p=0.002). Higher incidence of HE (24% vs. 6.7%, p=.06), hyponatremia (62% vs. 30%, p=.05), AKI (36% vs. 11%, p=.001) and ↓ in DBP (4.37±6.3% vs. 9.61±8.4%, p=.009) was seen in Gr B. Increase in PRA at day 3 correlated significantly (p<.001, r2=0.8) with day 7. Predictors of PICD on day 6 on univariate analysis were: Baseline HVPG (1.19,1.02-1.39, p=.02), PRA at day 3 (1.08, 1.02-1.15, p=.007) and non-albumin infusion (6.11,1.97-18.89, p=.002). On multivariate analysis, only non-albumin infusion (11.66, 2.43-55.83, p=.002) was significant. Patients who developed PICD had higher mortality (80% vs. 20%, p=.001). Gr B had a higher mortality (73% vs. 26%, p=0.03). Conclusions Even <5L of ascitic tap results in PICD in 62% ACLF patients with high incidence of associated complications

Indian J Gastroenterol

and mortality. Albumin infusion decreases PICD and mortality in ACLF patients undergoing MVP. L-062 Socioeconomic impact of hepatitis B viral infection in patients with chronic hepatitis B in Odisha Suryakanta Parida, Sambit Kumar Behera, Kaibalya Ranjan Dash, Debakanta Mishra, Subhendu Panigrahi, Chitta Ranjan Khatua, Shivaram Prasad Singh Correspondence- Suryakanta Parida- [email protected] Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India Introduction Hepatitis B virus infection is a major public health problem in India. There is scarce data on the socioeconomic impact of hepatitis B viral infection in patients with chronic hepatitis B. The present study was developed to assess the socioeconomic impact of hepatitis B on patients with hepatitis B liver diseases, and their families. Methods The study was conducted in the Department of Gastroenterology, S C B Medical College, Cuttack from February 2016 to July 2017. The demographic and socioeconomic data were collected from outpatients and hospitalized patients, with chronic hepatitis B (CHB) and their attendants using a self designed non validated questionnaire and analyzed. Results The study subjects included 86 consecutive CHB patients. Most were married (75 %), literate (66 %), and either businessmen (56 %) or employed (36 %) belonging to middle socioeconomic class. Thirty percent had hepatitis B before age 40 years. In 50%, HBV was detected during hospitalization. Average expenditure on hepatitis B was INR 3600/month. For treatment expenses, 35 % of patients borrowed money from friends/relatives, 26 % used saving deposits, 4 % sold personal belongings, and 7 % sold immovable property. In 26 % of cases, their children were deprived of education due to treatment cost. Besides, 30% of CHB patients could not afford treatment and required assistance of Odisha State Treatment Fund (OSTF). Conclusion Majority of patients with CHB and their families had severe financial problems. In a third of patients, they required assistance from state treatment fund for treatment. Besides in a fourth of them, their children are deprived of education due to treatment costs. L-063 Clinical profile of hepatocellular carcinoma in a tertiary care centre in coastal eastern India Kedarnath Panda1, Prakash Chandra Dalai1, Bijay Misra1, Brundaban Nahak2, Manoranjan Mohapatra3, Adya Kinker Panda3 Correspondence-Bijay Misra- [email protected] 1 Department of Gastroenterology, Institute of Gastro and Kidney Care, Bhubaneswar, Odisha 751 015, India, 2Department of Gastrosurgery, Institute of Gastro and Kidney Care, Bhubaneswar, Odisha 751 015, India, and 3Department of Radiology, Institute of Gastro and Kidney Care, Bhubaneswar, Odisha 751 015, India Background Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. Aim of the study is to access the clinical profile HCC attending the liver clinic of our centre. Method Consecutive patients of HCC were enrolled in the study between 2015-17. Result Out of 37 patients majority were male with M: F 5:1 and average age of 63.21±10.97 years. On etiological evaluation only 32.43% had HBV infection, rest 67.56% were cryptogenic. Underlying cirrhosis was found in (30/37) 81.08% of cases. Out of rest 7 cases 2 case had HBVand HCC without cirrhosis. About half of cryptogenic HCC had diabetes

mellitus. Most common presentation were anorexia (89.64%), pain abdomen (72.92%), jaundice (48.64%), mass abdomen (37.83%), fever of unknown origin in 21.62% of cases. Of all HCC 75% had multifocal lesion in the triphasic CT scan and all had portal vein thrombosis. Majority patients belongs to BCLC C and D. Serum AFP was elevated in about three fourth of cases. Patients were managed with supportive management due to advanced disease. Conclusion Most of the patients had advanced inoperable HCC. Two third of the patients cryptogenic and one third had HBV infection in etiology. Regular follow up of NASH related cirrhosis patients are required to diagnose HCC at early stage so that definite treatment can be offered to them. L-064 A comparative study of mortality profile in alcoholic liver disease and non-alcoholic fatty liver disease Murali Krishnan, Thazhath Mavali Ramachandran Correspondence- Thazhath Mavali [email protected] Government Medical College, Kozhikode 673 008, India Introduction Alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD) are leading causes of liver related morbidity and mortality. The worldwide mortality from ALD and NAFLD is increasing. There is dearth of data regarding comparison of ALD and NAFLD patients for initial presentation and natural history on follow up. In this background we decided to study the mortality profile of two groups of cirrhotic patients -alcoholic liver disease (ALD) and non-alcoholic fatty liver disease (NAFLD). Methods This study was a retrospective observational analysis. Data was collected from case records of patients expired in Medical Gastroenterology Department, Government Medical College Hospital, Kozhikode from January 2013 to December 2016 (3 Years). Clinical variables including age of the patient, duration of the illness, reason for admission, duration of hospital stay, complications during the hospital stay, model for end-stage liver disease (MELD) score, CHILD status were compared. Results One hundred and six patients expired due to ALD (n=67, 63%) and NAFLD (n=39, 36%) during this study period. One hundred and four patients were CHILD C, 2 were CHILD B. Mean age of the ALD group (51.9±9.08) was significantly (p<0.001) lower compared to NAFLD group (62.05±9.17). Reason for admission like gastrointestinal bleed, spontaneous bacterial peritonitis, soft tissue infections, hepatic encephalopathy, urinary tract infections, respiratory tract infections were equally distributed in both groups except for acute-on-chronic liver failure (ACLF) [ALD n=16 (23 %)], NAFLD [n=1 (2.6%)] which was significantly (p<0.001) higher in ALD group. Complications leading to death like aspiration pneumonia, GI bleed, soft tissue infection, UTI, sepsis were equally distributed among both groups except for acute kidney injury (AKI) which was significantly (p=0.011) higher in ALD Group [n=50 (74%)] compared to NAFLD [n=19 (48%)]. Conclusion Reasons for terminal admission was comparable in ALD and NAFLD group except for ACLF, which was significantly higher in ALD Group. Complications leading to death were also similar in both groups except for AKI which was significantly higher among ALD Group. L-065 Comparison of continuous infusion versus intermittent boluses of terlipressin for control of acute variceal bleeding in patients with cirrhosis S K Jha, Manish Kumar Mishra Correspondence- Sanjeev [email protected] Indira Gandhi Institute of Medical Sciences, Patna 800 014, India

Indian J Gastroenterol

Introduction Terlipressin is a widely used vasoactive agent for management of acute variceal bleed. It acts by decreasing portal venous pressure and has been used traditionally as intermittent intravenous boluses. Recent studies have shown that between two intermittent boluses portal venous pressure rebounds. At equivalent dosing schedule continuous infusion of terlipressin causes lesser but sustained reduction in portal venous pressure. In this study we have compared the efficacy of continuous infusion with intermittent boluses of Terlipressin in management of acute variceal bleeding. Method Study is a prospective RCT conducted at Department of Gastroenterology, I G I M S, Patna. Total 71 patients with history of recent gastrointestinal bleeding enrolled in study. Five patients excluded for not fulfilling inclusion criteria. Out of 66 patients 34 were treated with intermittent boluses of terlipressin while 32 patients received continuous infusion. Duration of treatment was 5 days. Patients underwent endoscopic treatment if required and followed upto 6 weeks to look for early rebleed/mortality. Result Baseline characteristics (age, median MELD and CTP scores) of both group are similar. Out of 34 patients in intermittent bolus group 17 patients had treatment failure (rebleed/death) while out of 32 patients in continuous infusion group 8 had treatment failure (50% vs. 25%, p value 0.037). Conclusion Continuous infusion of terlipressin has lower treatment failure rate than intermittent boluses (50% vs. 25%). The percentage difference is statistically significant with p value 0.037. Larger sample size study should be done to look for differences between two treatment strategies. L-066 Urinary NGAL-A novel diagnostic biomarker of for early diagnoses hepatorenal syndrome in acute kidney injury in cirrhosis Suhas Udgirkar, Sanjay Chandanani, Ravi Thange, Vinay Zanwar, Ravi Surude, Samit Jain, Qais Contractor, Pravin Rathi Correspondence- Suhas [email protected] Department of Gastroenterology, T N M C and B Y L Nair Hospital, Mumbai 400 008, India Background Acute kidney injury (AKI) is prone to increase mortality in patients with cirrhosis by four-fold. Due to higher volume of distribution and low muscle volume patient may have falsely low values in cirrhosis. This study aimed to determine an usefulness of a new marker, uNGAL (urinary neutrophil gelatinase associated lipocalcin) for early diagnosing hepatorenal syndrome (HRS) in cirrhosis patients and prediction of transplant free mortality at 30 days. Methods We prospectively enrolled patients with cirrhosis at single institute from western India. Patients were investigated for uNGAL by CMIA (Chemiluminescence Microparticle Immunoassay) method upon hospital admission (within 24 hrs or after development of AKI). FeNa (fractional excretion of sodium) calculated from urine and serum creatinine and urinary sodium values. Patients with urinary tract infection and anuria were excluded. Patients were followed at 30 days. Results We enrolled 45 patients of cirrhosis. Four (9%) patients had normal kidney function, 5 (11.37%) stable chronic kidney disease, 14 (29.50%) prerenal azotemia, 16 (36.37%) HRS and 6 (13.64%) had intrinsic acute kidney injury (iAKI). Patients with HRS had uNGAL levels of (mean 432.45+/-134 ng/mL) intermediate between prerenal azotemia (mean 256+/-80 ng/mL) and iAKI (1389-/-344 ng/mL). FeNa values don’t differentiate between prerenal and HRS group (less than 1%). Patients with SBP (6) had higher mean uNGAL values (1234 ng/ mL) than patients with hepatic encephalopathy (11) (552 ng/mL). Values of uNGAL in other infections did not differ from SBP. Twelve (27%) patients died at 30 days. Conclusions uNGAL level and FeNa can serve as early marker in differentiating HRS and pre renal AKI and intrinsic AKI than serum creatinine. Patients with higher uNGAL levels had higher transplant free mortality at

30 days. Thus uNGAL can help in identification of early diagnosis of type of AKI and can obviate the need for 48 hour algorithm for diagnosis of HRS. L-067 Experience of Sofosbuvir based combination therapy for chronic hepatitis C genotype 3 patients from real life western Indian population Sonny Bherwani, Kaushal Vyas, Sushil Narang, Nilesh Pandav Correspondence- Sonny [email protected] V S Hospital, Ahmedabad 380 007, India Introduction Hepatitis C is caused by single stranded RNA virus with seven genotypes. Genotype 3 (G3) is implicated in 30.1% infection globally. We aimed to study sustained viral response (SVR) and end treatment response (ETR) on treatment naïve Western Indian chronic hepatitis C (CHC) genotype 3 patients. Methods A prospective observation al study was done to analyze treatment response by HCV RNA levels in 80 CHC G3 patients at V S Hospital, Ahmedabad. Patients were divided into Group A CHC G3, Group B (CHC G3 compensated cirrhosis) and treated with Sofosbuvir 400 mg (SOF) and Daclatasvir 60 mg (DCV), Group C (CHC G3 decompensated cirrhosis) treated with SOF+DCV± weight based Ribavirin (RBV). Cirrhosis and portal hypertension were diagnosed by clinical, biochemical, endoscopic, radiological and elastography criteria. ETR was studied in Group A at 12 week and Group B/C at 24 week and SVR in Group A/B/C after 12 weeks of therapy. The baseline level of HCV RNA were obtained in all the groups at the time of admission. Statistical analysis was done by SPSS 20.0 version. Results Out of 22 patients in Group C one patient left therapy and one died during course of treatment. In group C 11 patients with Hb >8.5g/dL were given RBV therapy. The result of study is shown in Table: Group A 36

Group B 24

Group C 20

SOF+DCV (12 week)

SOF+DCV (24 week)

Mean age (years) Sex

46.7 (25-62)

46.9 (28-68)

SOF+DCV ±RBV (24 week) 46.9 (36-65)

M=24 F=12 Mean viral load 68736.055 (IU/mL) (12500-7501000) SVR 100%

M=13 F=11 260766.66 (10200-795600) 100%

M=11 F=9 4117743.6 (25610-2125000) 95%

ETR

100%

100%

95%

Patients number Therapy

Conclusion SOF+DCV dual therapy is safe and effective to obtain nearly 100% SVR/ETR in CHC G3 patients. In patients with decompensated cirrhosis exclusion of Ribavirin therapy didn’t effect the ETR/SVR. L-068 Impact of sustained virological response on indirect serum biomarkers of fibrosis in chronic hepatitis C patients Anup Sreedharan Nair, Thazhath Mavali Ramachandran Correspondence- Thazhath Mavali [email protected] Department of Gastroenterology, Government Medical College, Calicut 673 008, India

Indian J Gastroenterol

Introduction Novel direct antiviral agents (DAA) targeting hepatitis C virus (HCV) have revolutionized the treatment of chronic hepatitis C infection (CHC). Rates of sustained virological response (SVR) to treatment have drastically improved since introduction of DAA. We evaluated the changes in the indirect serum biomarkers of fibrosis scores, FIB -4 and APRI, after DAA treatment of CHC. Methods In an ongoing clinical prospective study, till date 30 patients were completed the study. All those patients with chronic hepatitis or compensated cirrhosis of liver received Sofosbuvir 400 mg and Daclatasvir 60 mg for 12 weeks and those with decompensated cirrhosis of liver had it for 24 weeks. SVR at 12 weeks after completion of treatment assessed. FIB-4 and APRI scores were calculated prior to the treatment and after achieving SVR. The data were compiled and analyzed using statistical software SPSS v22.1. Results Thirty patients (22M: 8F) with a mean age of 47±8 years were included, of which 13 (43.3%) had cirrhosis of liver. Of the 13 cirrhotic patients 9, 3, and 1 were in CTP A, B and C stage respectively. Among the total patients 23 (76.7%), 5 (16.7%), 2 (6.7%) were genotype 3, 1 and 4 respectively. Median viral load was: 499801 IU/mL (range:2.4x10 3-7.1x 108). Overall ETR and SVR were 100% in patients across the genotype. Median FIB-4 and APRI values significantly decreased from 2.32 (IQR 1.31-4.34) and 1.39 (IQR 0.50 -1.9) to 1.70 (IQR 0.99 -3.04, p<0.001) and 0.55 (IQR 0.34 -1.04, p<0.001), respectively. Conclusion Chronic hepatitis C patients, who were treated with DAA and had SVR, showed significant regression of FIB -4 and APRI scores of liver fibrosis. Whether this indicates a regression of fibrosis or merely resolution of chronic liver inflammation needs long-term follow up and further evaluation. L-069 Efficacy of enhanced liver fibrosis score and transient elastography for assessment of severity of fibrosis in chronic hepatitis C Manish Kumar, A S Puri, Ajay Kumar, Sanjeev Sachdeva, Siddharth Srivastava, Ashok Dalal, Amol Dahale, Pooja Sakhuja, Alok Mantri Correspondence- Amarender Singh [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background Chronic hepatitis C (CHC) patients with Genotype 3 infection having advanced fibrosis or cirrhosis need a longer duration of therapy and sustained virological response rate is lower with currently available directly acting antiviral therapy. Enhanced liver fibrosis (ELF) score and transient electrography (TE) are noninvasive methods for ruling out cirrhosis, have not been compared in Indian CHC patients. Aim To compare ELF and TE for ruling out advanced fibrosis or cirrhosis in CHC patients. Methods Consecutive CHC patients who attended OPD at GIPMER from September 2016 to May 2017 were included in the study. Patients with decompensated cirrhosis, BMI ≥30 kg/m2 or additional etiology for liver disease were excluded. The liver biopsy was used as a gold standard; The METAVIR scoring system was used for grading fibrosis in liver biopsy. The TE by using fibroscan 430 mini and ELF were done on the same day in fasting state. Results Total of 30 patients were included, mean age was 34.7 years. The All TE, ELF score calculation and liver biopsy was done in all patients. Median ELF score and TE score for patients were 9.28 and 9.04 kPa respectively. The area under the receiver operator characteristic curve (AUROC) of ELF was 0.620, with the sensitivity of 33% and specificity of 67% for severe fibrosis and AUROC for TE, was 0.903, with sensitivity and specificity 33% and 100% respectively using liver biopsy as gold standard for diagnosing advanced fibrosis or cirrhosis. Conclusions TE, as compared to ELF, is a better noninvasive method for diagnosing advanced fibrosis or cirrhosis is in CHC patients.

L-070 Increasing severity of liver disease does not increase the risk of ‘Restless Leg Syndrome’ in patients with cirrhosis H J Vijay,1 Amit Goel,1 Vimal Paliwal,2 Rakesh Aggarwal1 Correspondence- Rakesh [email protected] Departments of Gastroenterology1 and Neurology,2 Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Introduction Restless leg syndrome (RLS) is commonly associated with systemic illnesses. We recently reported that prevalence of RLS is higher in patients with cirrhosis than in healthy controls. The present study was aimed at studying whether the occurrence of RLS is related to the severity of liver disease. Methods Adult (>18 years) patients with cirrhosis but no recent hospitalization, clinical deterioration, encephalopathy or gastrointestinal bleeding were enrolled. Cirrhosis was diagnosed using a combination of standard clinical, laboratory, imaging and endoscopic criteria, and its severity was graded as Child-Turcott-Pugh (CTP) class A, B and C. The patients were also categorized as having compensated or decompensated cirrhosis (the latter if they had ever had one of the following three: ascites, hepatic encephalopathy, or a combination of serum bilirubin level >2.5 times the upper limit of normal plus prothrombin time INR >1.5). A gastroenterologist interviewed each patient using the international RLS diagnostic criteria; all those who fulfilled two or more of the five criteria were reevaluated by a neurologist, and RLS was diagnosed if all five criteria were present. Results Of the 200 patients (males 133; mean [SD] age: 48.5 [12.1] years; cause: alcohol 20, HBV 52, HCV 74, cryptogenic 52, autoimmune 1, primary biliary cirrhosis 1), 74 had compensated and 126 had decompensated disease. RLS was diagnosed in 18 (9%) patients. Its prevalence was similar in decompensated and compensated cirrhosis (13/126 vs. 5/74; p=0.45), and in patients in Child-Pugh class A, B and C (7/79, 9/110 and 2/11, respectively). Presence of RLS also had no association with gender (males: 10/133, females: 8/67), and the cause of liver disease (ethanol 2/20, HBV 2/52, HCV 8/74, cryptogenic 6/52). Conclusion RLS was identified in 9% of patients with cirrhosis, but its presence was not associated with severity or cause of liver disease. L-071 Study of APRI and FIB-4 to assess severity of liver fibrosis in chronic hepatitis Ruchit B Patel, T Vadivukkarasi, P Ganesh Correspondence- Ganesh [email protected] Sri Ramachandra Hospital and Research Centre, Chennai 600 116, India Aims and Objectives To diagnose liver fibrosis using non-invasive biomarkers (APRI and FIB-4 scoring system). To validate non invasive biomarkers as primary tool to detect fibrosis by comparing it with liver elastography. Inclusion criteria Patients presenting to our Liver Clinic with chronic liver disease of any etiology–alcohol, viral, NAFLD, autoimmune or cryptogenic. Patients with elevated transaminases for more than 6 months without radiological evidence for liver cirrhosis. Exclusion criteria Age <18 and >75 years. Pregnancy, acute hepatitis – viral, alcohol, drugs, ischemic, ACLF – acute on chronic liver failure, decompensated chronic liver disease, hepatic SOLs- solid and cystic lesions. Method This is prospective ongoing study carried out at Sri Ramachandra Medical College and Research Institute, Chennai. One hundred and fifty-seven patients fulfilled the inclusion criteria. Routine investigations like complete blood count, LFT, PT-INR were done. APRI was calculated using the formula - AST/upper limit of normal)/platelet count (109 /l) x100.

Indian J Gastroenterol

FIB-4 was calculated using age [years] × AST [IU/L]/platelet count [expressed as platelets × 109 /L] × (√ALT) [IU/L]. Liver elastography was done using Toshiba APLIO 500 ultrasound. ARFI was generated Baseline investigation like complete blood counts using Sysmax cell counter, liver function tests using dimension siemon analyser, PT/INR using Sysmax C- 1500. Results One hundred and fifty-seven patients were consecutively included in the study, from which 115 were men (59.76%). The mean age of the patients was 46.06 years. HCV was present in 41, HBV was present in 33 patients, alcohol abuse in 9 patients, NASH in 38 patients and cryptogenic in 36 patients with APRI cutoff of 1 was used in order to predict fibrosis the sensitivity was 48% FIB-4 with a cut-off of 1.25 was 72%. Conclusion APRI and FIB-4 are good non-invasive biomarkers to detect advanced fibrosis but liver elastography remains the best available noninvasive tool to diagnosis liver low grade and advanced fibrosis. L-072 More than one-third patients with hepatitis B virus infection in India present late with advanced liver disease: An audit of 1737 patients from a tertiary care center Shivam Khare, Anil Arora, Praveen Sharma, Ashish Kumar Correspondence- Shivam [email protected] Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi 110 008, India Background and Aims There is no published data from India looking into the spectrum of hepatitis B virus (HBV) infection at presentation. We aimed to study the spectrum of patients with HBV infection presenting to a tertiary care center in India. Methods This was an observational study enrolling HBsAg+ patients, aged ≥12 years presenting to Sir Ganga Ram Hospital, Delhi both retrospectively and prospectively from 2006 to 2016. We categorized these patients into various stages of liver disease. Results A total of 1737 patients [median age 40 (13-95) years, 80% males] were included. The risk factors for infection were history of blood transfusion (9%), needle stick injury (4%), past surgery (24%) and unknown (63%). Of these, 1131 (65%) were noncirrhotic [inactive carrier (30%), chronic hepatitis (55%), and acute hepatitis/reactivation (15%)]. The chronic hepatitis patients were HbeAg+in 36% and HbeAg negative in 64%. Remaining 606/1737 (35%) patients presented with advanced liver disease (cirrhosis and/or HCC). These had following distribution: decompensated cirrhosis (255/606, 42%); compensated cirrhosis (200/ 606, 33%); acute-on-chronic liver failure (81/606, 13%); and HCC (70/ 606,12%). Among patients with advanced liver disease 64% were HBeAg negative. Conclusion Our study shows that, alarmingly, up to 35% patients with HBV infection present late when they already have developed cirrhosis and/or HCC. These patients have lost the opportunity when they could have received antivirals to prevent progression. We recommend wider screening of general population to identify patients who can be treated with antiviral for prevention of disease progression to cirrhosis/HCC. L-073 Clinical profile of hepatitis C patients on direct acting antivirals in a tertiary care centre in Western India Sanjay Jagdish Chandnani, Suhas Udgirkar, Ravi Thanage, Samit Jain, Ravindra Surude, Sunil Pawar, Vinay Zanwar, Qais Contractor, Pravin Rathi Correspondence- Sanjay Chandnani- [email protected] Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India

Background Hepatitis C causes of cirrhosis and HCC. Direct acting antiviral agents are associated with higher success rates in treatment outcomes in last few years. Data regarding SVR rates, side effect profile is insufficient in western India. Aims To study the treatment outcomes and adverse effect profile in hepatitis C patients. Methods Ninety-two patients with detectable RNA were seen during last one and half year period. Genotypic analysis proved genotype 3 (71%) was most common followed by genotype 1 (23%), genotype 4 (3.3%), genotype 5 and 6 each (2%). Patients were provided Sofosbuvir combination regimens according to current guidelines depending on their status. Chronic hepatitis was present in 38 patients (42%) while rest were having chronic liver disease. Past history of blood transfusion or surgery was present in 67 (73%) cases. Past history of decompensation in form of upper gastrointestinal bleed, ascites or encephalopathy was seen in 22 (24%) cases. Results In this prospective study SVR rates were high reaching 100% for Genotype 1, 4, 6, 98.4% for genotype 3. SVR was not achieved in a patient with Genotype 3 chronic hepatitis C. Lethargy, easy fatiguability was noted in 34 cases. Nine patients on ribavirin were required to stop or reduce the dose in view of falling hemoglobin. Diarrhea was noted in 14 patients of which 3 (4%) developed AKI, decompensation and led to death. Fixed drug eruption was seen in 1 patient. Myocardial infarction was noted in 1 patient with Chronic liver disease. Conclusion Mortality was seen in 4% cases. Patients need to be monitored closely for adverse effects and risks of decompensation. Patients had successful outcomes of 100% SVR rates among survivors of all genotypes except Genotype 3 with 98.4%. L-074 Genetic variation of CD14 gene promoter region influences the expression of lipopolysaccharide receptor complex in alcoholics Neelanjana Roy1, Hem Kumar1, Hem Kumar Pandey2, Yatan Pal Singh Balhara3, Anoop Saraya1, Shalimar1, Baibaswata Nayak1 Correspondence- Baibaswata [email protected] 1 Department of Gastrenterology and HNU, AIIMS, New Delhi, 2 Department of Blood Transfusion Medicine, AIIMS, New Delhi, 3 Department of Psychiatry, National Drug Dependence Treatment Centre (NDDTC), AIIMS, New Delhi Introduction Alcoholic liver disease (ALD) is directly related to high alcohol consumption for prolong period but disease severity observed in some individual and some may not develop disease. This susceptibility is dependent upon individual genetic makeup of either alcohol metabolizing enzyme genes or genes mediating inflammation. The lipopolysaccharide (LPS) receptor complex consists of CD14, TLR4 receptor and an associated protein MD-2. The genetic variation affecting expression of any protein of this complex may alter inflammatory response leading to ALD. Objective To study effect of CD14 gene promoter (-159) region polymorphisms (rs2569190: C>T) on lipopolysaccharide receptor complex in alcoholic individuals. Methods We have included individuals (n=30) each with ALD, alcoholic controls without ALD and with alcohol drinking habit (ALCon >80 gm/ day for >10 years) and healthy control with no alcohol habit (HLC). The CD14 rs2569190 SNP genotyping of above individuals (n=90) was carried out RFLP and sequence confirmation. The sCD14 and MD-2 level in serum was measured by commercial ELISA. Results The individuals of each group were genotyped to CC, CT and TT genotype for CD14 SNP rs2569190 and serum levels of CD14 and MD2 were measured in each group for these three genotypes. Significant increased serum level of CD14 was observed in TT genotype of ALD patients (186.11 ng/mL±102.12 ng/mL) and ALCon subjects (181.89 ng/mL±

Indian J Gastroenterol

110.80 ng/mL) as compare to HLC individual (139.26 ng/mL±29.97 ng/ mL) (p-value=0.019). The serum level of MD2 was less in ALD patients with TT genotype (1713.19 pg/mL± 618.75 pg/mL) as compare to HLC subjects (3250.27 pg/mL±304.24 pg/mL) (p-value<0.0001). Conclusion Increased transcription and CD14 expression in TT genotype variants may enhance inflammatory response in alcoholic individuals modulating LPS receptor complex. L-075 Virological responses and liver functions in patients with HCV related cirrhosis after treatment with directly acting antivirals, a real life experience from a tertiary care center in India Swapnil Ramesh Dhampalwar, Sunil Taneja, Ajay Duseja, Mini P Singh, Radha K Dhiman, R K Ratho, Yogesh K Chawla Correspondence- Yogesh Kumar [email protected] Department of Hepatology and Department of Virology, Postgraduate Institute of Medical Education amd Research, Chandigarh 160 012, India Introduction Chronic hepatitis C virus (HCV) infection causes progressive fibrosis leading to cirrhosis and hepatic decompensation. directly acting antivirals (DAAs) have radically changed HCV management. Aim of the study was to assess virological and clinical outcomes in cirrhotic patients in real life settings. Methods The study included 123 patients of HCV related cirrhosis presenting to Liver Clinic at PGIMER, Chandigarh from June 2015 to January 2017. Study population had two groups. A retrospective group treated with Sofosbuvir and Ribavirin, with or without PegIFN. A prospective group treated with Sofosbuvir and NS5A inhibitors, with or without Ribavirin. Ledipasvir was used for Genotypes 1 and 4 and Daclatasvir in the remaining genotypes. Results Mean age of patients was 51.23±9.5 years with male predominance (62.6%). Genotype 3 was most common 88 patients (71.5%), followed by genotype 1, 25 (20.3%) and genotype 4, 10 (8.1%). Sixtysix patients had compensated and 57 had decompensated cirrhosis. Child A cirrhosis constituted the majority 69 out of 123 (56.1%), followed by Child B 44 (35.8%), and Child C 10 (8.1%). Overall SVR 12 rate was 91.1%, 95.5% in compensated and 86% in decompensated cirrhosis. SVR 12 rate in genotype 3, 1, and 4 infections were 90.9%, 96%, and 80% respectively. In decompensated cirrhosis, improvement in mean CTP and MELD scores post therapy was statistically significant. In patients with baseline MELD ≥15, delisting rate from liver transplantation waiting list was 61.5%. Decrease in occurrence of decompensating events like ascites and upper GI bleed was significant. Fatigue was the most common adverse event seen in 36 (29.3%) patients. Twelve patients (9.8%) required decrease in dosage of RBV. Conclusion Treatment with DAAs showed high SVR rates, good tolerance and safety in real-life settings. DAA therapy improved liver functions, decreased occurrence of decompensating events, and delisted patients on liver transplantation waiting list. L-076 Young cirrhosis- pre and post transplant scenario in liver transplant center Government Stanley Medical College Hospital case study R Gopalakrishnan, A R Venkareswaran, M S Revathy. S Chitra, R Murali, J Malarvizhi, M Manimaran Correspondence- A Rajeswaran [email protected] Government Stanley Medical College, Chennai 600 001, India Introduction In INDIA with majority of people living below poverty line with lack of awareness of organ donation and organ transplant. In this study we have included young cirrhosis patients under evaluation in pretransplant follow up and post transplant follow up.

Aim of Study To evaluate young cirrhotics–For etiology of cirrhosis, treatment, pretransplant work up follow up post liver transplant. Methods/Study Design Prospective study period August 2015 to July 2017. All young cirrhotic patients aged 12-40 yrs attending Medical Gastroenterology Liver Transplant OPD were included. Total 63 Male 49/Female 14 63 young cirrhosis patients admitted through Casualty and Liver Transplant Clinic, ICU for treatment of complications on pretransplant workup 13 livertransplant done 7 on follow up 5 etiology diagnosis alcohol 30 Wilson disease 11 hemochromatosis-1 progressive familial intrahepatic cholestasis- 2 vascular BCS 9 autoimmune 3 viral hepatitis 5 hepatocellular carcinoma-1 others-post kasai secondary biliary cirrhosis-1 post transplant complications mortality 1 acute cellular rejection–plasma exchange done-1 died postranplant lymphoproliferative disease on chemo-1. Results Sixty-three young cirrhosis patients admitted through casualty and liver transplant clinic. Fifty-two (84.12%) MGE ward/11 (17.4%) ICU for treatment of complications. Nineteen (30.18%) with MELD Na <15 not considered 14 (22.22%) with alcohol absteinence period of <6 months asper UNOS policy. Nine (17.30%) patients died due to various complications like HE, HRS. Conclusions Government Stanley Medical College, Chennai is the only centre approved for LTx. in Government Medical Colleges. This study enumerates the etiology, pretansplant work up, outcome after liver transplant which 38.46% survival in a Government set up after DDLT. 13 (25%) patients were worked up for liver transplant out of which 7 (13.46%) patients died while awaiting liver transplant due to organ shortage and disease severity (11.53%) patients underwent DDLT and under immunosuppression and regular follow up for the past 2 years. One patient died after 13 months due to poor compliance and severity of disease. L-077 To assess the correlation between transient elastography and development of esophageogastric varices in patient with compensated advance chronic liver disease Sanjeev Kumar Jha, Kuldeep Saharawat Correspondence- Sanjeev Kumar [email protected] Indira Gandhi Institute of Medical Sciences, Sheikhpura, Patna 800 014, India Introduction Gold standard method to define clinically significant portal hypertension (CSPH) is HVPG measurement (>10 mm of Hg), an invasive procedure. Transient elastography (TE), a noninvasive method, allows early identification of CSPH by liver stiffness measurement (LSM). TE also helps to identify group of patients at risk of having endoscopic signs of portal hypertension and can identify group of patients with compensated advanced chronic liver disease (cACLD) who can avoid screening endoscopy. In this study, we assessed the correlation between TE and development of esophageogastric varices in patient with compensated advance chronic liver disease. Methods It was a single center prospective study done in Gastroenterology Department, IGIMS, Patna. Total 41 patients with compensated CLD, with LSM value >10 kpa were included. Endoscopy was done within one month of TE. Results Forty-one patients with compensated CLD were included in the study. The etiology of CLD were HBV (53.6%), NAFLD (17.07%), cryptogenic (9.7%), Alcohol (9.7%) and others (9.7%). Twenty patients (48.78%) had esophageal varices on endoscopy, with median LSM 18.25 kpa (10.8–48.0). Twenty-one patients (51.21%) had no esophageal varix on endoscopy with median LSM 13.20 kpa (10.10–35.30). AUROC of LSM for prediction of esophageal varices was 0.819 (95% confidence interval 0.683–0.955). Taking LSM cut-off value of 17.6 kpa, the sensitivity, specificity, PPV and NPVof having esophageal varix were respectively 65 %, 90.5%, 86.6% and 73%.

Indian J Gastroenterol

Conclusion Our study highlights the good diagnostic accuracy of LSM, a non-invasive tool for prediction of esophageal varix. Further studies are needed to validate the role of LSM to monitor evolution of portal hypertension in cirrhosis. L-078 A study of predictors of short-term mortality in patients with severe alcoholic hepatitis Ravi Daswani, Ashish Kumar, A Shrihari, Praveen Sharma, Vikas Singla, Naresh Bansal, Anil Arora Correspondence- Ravi [email protected] Institute of Liver, Gastroenterology, and Pancreatico-Biliary Sciences, Sir Ganga Ram Hospital, New Delhi 110 060, India Background Severe alcoholic hepatitis (SAH) has very high mortality. There is limited data from India on predictors of mortality and comparison of various severity indices in patients of SAH. We analyzed patients with SAH admitted to our Institute and compared various parameters and severity indices in predicting 28-day and 90-day mortality. Methods In this prospective study, we analyzed patients with SAH (defined as modified discriminant function [mDF] and 32) admitted from September 2015 to February 2017 at our Institute. All patients were administered standard treatment according to various established guidelines for SAH and their 28-day and 90-day mortality were determined. Various biochemical and severity indices including were compared between survivors and patients who died. Results A total of 183 patients (98% males, median age 41 years [range 20-70 years]) were included in our study. The median (range) values of severity scores at baseline were as follows: DF 70 (32-320); GAHS 9 (612); ABIC 7.6 (4.7-12.0); MELD 26 (15-40); MELD-Na 30 (14-40); and CTP 11 (7-14). Only 21 (12%) could be offered steroid therapy, due to contraindications in the remaining. 56 (31 %) and 80 (44%) patients had died by 28th day and 90th day respectively. On multivariate analysis presence of ascites, hepatic encephalopathy, high bilirubin, low albumin, high creatinine, high INR, and low potassium independently predicted 90-day mortality. All the scores performed significantly in predicting 90day mortality with no statistically significant difference between them. MELD score had maximum area under the curve 0.76 for 90-day mortality. A combination of Child class and presence of acute kidney injury (creatinine and ge;1.35) was good in predicting 90-day mortality. Conclusion SAH in India has 31% 28-day mortality and 44% 90-day mortality. All the prognostic models could accurately predict the shortterm prognosis. Presence of Child C and high creatinine (and ge; 1.35 mg/ dL) accurately predicts mortality. L-079 Bioelectrical impedance analysis is in close agreement with computed tomography for the assessment of muscle mass, total body fat and visceral fat in obese cirrhotics Puja Bhatia1, Jaya Benjamin1, Harshita Tripathi1, Varsha Shasthry1, Puneet Puri2 , Y K Joshi1, Shiv K Sarin3 Correspondence- Jaya [email protected] 1 Department of Clinical Nutrition, Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India, 2 Department of Gasteroenterology, Hepatology, Nutrition, Richmond University, Virginia, VA, United States, and 3Department of Hepatology, Institute of Liver and Biliary Sciences, D 1, Vasant Kunj, New Delhi 110 070, India Introduction Computed tomography (CT), the gold standard is an expensive method not suitable for continued monitoring, whereas bioelectrical impedance analysis (BIA) is inexpensive, safe and simple for assessing

the effect of weight loss therapy in obese cirrhotics, however its reliability has not been assessed and compared with CT scan. Aim To study the agreement between CT and BIA for measuring body fat, visceral fat, and muscle mass in obese cirrhotics. Methods BC of 120 obese (BMI >25 Kg/m2) compensated (CTP ≤8) cirrhotics attending the Liver Nutrition Clinic for weight loss was assessed by BIA-Multi-frequency analyser (Tanita MC-180) giving the fat mass (FM-Kg), fat % (F %), muscle mass (MMKg), and visceral fat rating (VFR). MM/height m2 gave total skeletal muscle index (TSMI-Kg/m2). CT data within 3 months of enrolment was retrieved from the hospital database. Single slice CT images at L3 vertebra were analyzed using Slice-Omaticsoftware to give cross-sectional areas of five muscles normalized for height-expressed as skeletal muscle index (SMI-Kg/ m2), area of subcutaneous (SAT) and visceral adipose tissue (VAT; cm2), SAT plus VAT as total adipose tissue (TAT). Agreement was assessed using Pearson’s correlation and intra class correlation coefficient (ICC) after conversion to Z scores. Result CT images available in 75 obese cirrhotics [M:73%, aged 32-65 yrs, mean BMI 34.1±5.2 kg/m2, obesity grade (Asian criteria):class I (15%):II (45%):III (40%); Child A:58% and rest all B; etiology: NASH (80%), alcohol (15%) and viral (5%) were used for analysis. Excellent correlations were seen between CT and BIA [r, ICC (95% CI)] for SMA and MM [0.73, 0.84 (95%)]; SMI and TSMI [0.56, 0.70 (95%)]; TAT and FM [0.54, 0.71 (95%)], TAT and F% [0.40, 0.57 (95%)]; TAT and visceral fat [0.40, 0.67 (95%)] p=<0.001 for all. Conclusion Body composition assessed by BIA is in close agreement with CT, the gold standard and provides a valid measure of muscularityand adiposity. BIA may be a convenient and practical approach for monitoring in obese cirrhotics. L-080 Prevalence and risk factors of hepatitis B virus infection among a tribal population in Odisha: A pilot study Bijaylaxmi Baliarsingh, Kanishka Uthansingh, Jimmy Narayan, Manas Kumar Behera, Manoj Kumar Sahu, Ayaskanta Singh Correspondence- Ayaskanta [email protected] IMS and SUM Hospital, Bhubaneswar 751 003, India Background and Aims Hepatitis B infection is one of the world's major infectious diseases with about 350 million chronic carriers. There is a large tribal population in Odisha and there is no data on the prevalence and risk factors of this important disease. This cross-sectional study investigated the prevalence and risk factors of hepatitis B virus (HBV) infection among a tribal population attending a tertiary care centre in Odisha for HBV vaccination from January 2017 to June 2017. Methods A group of subjects attending the Gastroenterology Department of IMS and SUM hospital for free HBV vaccination and screening programme from a tribal area of Kandhamal district of Odisha were evaluated. Results Of the 125 patients screened for HBV; 6 (4.8%) were positive for HBsAg. Male: female ratio was almost 1:1. Most of the male subjects were farmers (27. 4%) or labourers (64%) while most of the females were housewives (50%). Among those six patients who were positive for HBV infection, around 30% had exposure to community barbers, 16 % had undergone dental procedures and tattooing respectively and 50% had undergone nose piercing or ear piercing, 16% had frequent injections. None of the positive patients had any history of blood transfusion or surgical procedure. When compared with those subjects who were negative for HBsAg; dental procedures and tattooing were the statistically significant risk factors (p<0.005). Conclusion Prevalence of HBV infection among a small sample of tribal population is around 5%. Undergoing dental procedures and tattooing were identified to be the statistically significant risk factors. A community

Indian J Gastroenterol

based study is required to identify the exact burdern of hepatitis B among the tribal population of Odisha. L-081 Sofusbuvir and Ribavirin therapy with or without pegylated interferon-a in the management of treatment-naive non-cirrhotic genotype 3 chronic hepatitis C patients

0.6 kPa vs. 5.55+1.21 kPa) (p<0.05). Patients treated with Peg-IFNα had a more rapid fall in LSM (36% vs. 21.05%) improvement 12 weeks after the completion of therapy (p<0.05). Conclusions Our study also evaluated the impact of successful therapy on liver stiffness measurement (LSM). The Peg-IFNα/SOF/RBV arm had a more significant improvement in LSM as compared to SOF/RBV (36% vs. 21.05%, p<0.05). L-083

Atul Jha, P Puri, A Sood, M Manrai, R Jain Correspondence- Atul [email protected] Army Hospital (Research and Referral), New Delhi 110 010, India Aim To compare the efficacy of SOF and RBV therapy with Peg-IFNα, SOF and RBV therapy in the treatment naïve non-cirrhotic GT 3 CHC infection. Methods An open label randomized control trial evaluated 103 noncirrhotic treatment naive patients with Sofosbuvir and ribavirin with or without pegylated interferon alfa. A sustained virological response at 12 weeks post therapy was evaluated. Results Rapid virological response was determined at 04 weeks from start of therapy. 93.6% of the non-Peg IFNα arm had undetectable RNA whereas 96.4% of patients in the Peg IFNα had undetectable RNA (p=0.026). All the patients in both the groups had undetectable RNA at the end of therapy. SVR was determined at 12 weeks after the end of therapy. In the non-Peg IFNα arm 93.3 % had undetectable RNA whereas 98.1% of patients in the Peg IFNα arm had undetectable RNA (p=0.024). Although it was not a primary end-point the study showed that amongst patients treated with Peg IFNα, there is a 50% possibility of achieving SVR despite not achieving RVR but in patients on non-Peg IFNα regime, the possibility of achieving SVR after failing RVR is negative. Conclusions The addition of Peg-IFNα significantly improved the response rates (98.1% vs. 93.3%, p=0.024) as measured by sustained virological response (SVR) at 12 weeks post therapy. With a 93.3% SVR rate Peg IFn based therapy may still have a role in the pure DAA era when patients fail standard medical therapy. L-082 The impact of pegylated interferon on liver stiffness in management of treatment naive non-cirrhotic patients Genotype 3 chronic HCV infection Atul Jha, P Puri, A K Sood, M Manrai, R Jain Correspondence- Atul [email protected] Army Hospital (Research and Referral), New Delhi 110 010, India Aim To study the impact of sofosbuvir and ribavirin with or without pegylated interferon alfa on liver stiffness in the management of treatment naive non-cirrhotic patients Genotype 3 chronic HCV infection. Methods An open label randomized control trial evaluated 103 noncirrhotic treatment naive patients with Sofosbuvir and ribavirin with or without pegylated interferon alfa. The change in liver stiffness of the two arms were analyzed in patients who had achieved a sustained virological response at 12 weeks. Results One hundred and three non-cirrhotics, treatment naïve patients of CHC GT 3 were randomized into Non Peg-IFNα arm (n=48) and PegIFNα arm (n=55). They received SOF/RBV for 24 weeks or PegIFNα2b, SOF/RBV for 12 weeks. The average LSM Peg IFNα arm was 7.03+0.71 kPa and for non-Peg IFNα arm was 7.25 kPa+ 0.58 (p=0.95). At ETR, the average LSM was significantly lower in the Peg IFNα arm (5.66+1.22 kPa vs. 7.01+0.7 kPa) (p<0.05). The average LSM at SVR was also significantly lower in the Peg IFNα arm (4.6+

Comparison of patients with infection related ACLF (i-ACLF) with acute hepatic insult related ACLF (h-ACLF) amongst patients of alcoholic cirrhosis Amritangsu Borkakoty1, Manu Mehta1, Ajay Duseja1, Sunil Taneja1, Vikas Gautam2, Radha Krishna Dhiman1, Yogesh Kumar Chawla1 Cprrespondence- Ajay [email protected] 1 Departments of Hepatology, and 2Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Acute-on-chronic liver failure (ACLF) is distinct clinical entity associated with high mortality and potential for recovery. Controversy exists regarding including sepsis as an acute precipitant; clinical significance and impact of different acute insults on mortality is largely unknown. Aim To compare the patients of infection related ACLF(i-ACLF) with patients with ACLF related to hepatic insults (h-ACLF) in a homogenous group of alcohol related cirrhosis. Methods Consecutive patients with alcoholic cirrhosis with acute decompensation were prospectively recruited and followed up for 6 months. Patients were categorized as ACLF based on the either of the definitions given by APASL, EASL-AASLD and NACSELD. Various parameters including hospital stay, prognostic scores and morality were compared between patients with i-ACLF and h-ACLF. Results A total 127 patients of ACLF with alcohol as chronic etiology, (mean age 45.66±9.69 yrs) were included. Hepatic insults were acute precipitants in 77 [60.6%, 67 (76.13%) had alcoholic hepatitis, mean MDF 92±46.5] followed by infections in 36 (28.3%), both in 11(8.7%) and unknown in 3 (2.4%) patients. Patients with i-ACLF had significantly higher past history of decompensation (88.89% vs. 37.66%) and hospital stay (mean 19.44±15.29 vs.12.05±9.34 days). Liver failure (day1, 3, 5) was more common in h-ACLF patients, whereas i-ACLF patients had higher frequency of extrahepatic organ failures (circulation day1 and respiration day 5). Grades of ACLF, severity scores and in-hospital, 1, 3 and 6 month mortality were similar across all patient groups. Independent predictors of mortality were HE at presentation (OR 4.7) and development of second infection (OR 5.3). LPS levels were significantly higher in patients with i-ACLF and those developing second infection. Grade of ACLF, no. of organ failure, SOFA and CLIF-C-OF score positively correlated with TNF-α levels (p<0.05 for all). Conclusion ACLF precipitated by hepatic insults (h-ACLF) is clinically distinct from ACLF precipitated by infections (i-ACLF) with higher prior decompensation, hospital stay and extrahepatic organ failure in i-ACLF; prognosis remains same in both the groups. L-084 Randomized control trial of Rifaximin and norfloxacin in primary and secondary prophylaxis of spontaneous bacterial peritonitis in cirrhotic patients Dibyalochan Praharaj, Sunil Taneja, Ajay Duseja, Y K Chawla, Radha K Dhiman Correspondence- Radha K [email protected] Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Indian J Gastroenterol

Background Spontaneous bacterial peritonitis (SBP) is a life threatening infection in patients with cirrhosis. Patients with advanced cirrhosis with or with out prior history of SBP have a high risk of developing SBP for which they need either primary or secondary prophylaxis respectively. Norfloxacin has been used for SBP prophylaxis since decades which has led to increase in incidence of SBP on prophylaxis and SBP related to gram positive organisms. Thus alternative oral antibiotic must be used to prevent this life threatening complication in cirrhotic patients. Rifaximin is an oral antibiotic effective against both gram positive and gram negative organisms and is used to prevent and treat hepatic encephalopathy in cirrhotic patients. Aim To compare rifaximin and norfloxacin in both primary and secondary prophylaxis of SBP in cirrhotic patients with ascites. Methods One hundred and seventeen patients with decompensated cirrhotic patients with ascites were enrolled into study. Fifty-nine patients had past history of SBP and were randomly assigned to receive norfloxacin (400 mg OD) or rifaximin (550 mg BD) as secondary SBP prophylaxis. Rest 58 patients with advanced cirrhosis as defined by CTP score of 9 or more, hyperbillirubinemia, hyponatremia but with no history of SBP and were randomly assigned to receive norfloxacin or rifaximin at same dosage. All the patients were followed up for 6 months and were evaluated for presence of SBP at end of 3 months and 6 months or when symptomatic. Results Thirteen of 33 (39%) patients receiving norfloxacin for secondary prophylaxis and 6 of 30 (20%) patients receiving norfloxacin for primary prophylaxis developed SBP compared to 2 of 26 (7%) patients receiving rifaximin for secondary prophylaxis and 4/28 (14%) patients receiving rifaximin for primary prophylaxis. Patients receiving norfloxacin had higher rate of development of SBP compared to rifaximin in both primary (20% vs. 14%; p=0.731) and secondary (39% vs. 7%; p=0.007) arm. Conclusion Rifaximin was more effective than norfloxacin in secondary prophylaxis of SBP. L-085 Vitro score: A novel predictor of decompensation and esophageal varices in cirrhosis of liver Gaurav Trimbak Ratnaparkhi, B Sukanya, J Nayana, Y Raghvendra, J Rishabh, C Vineet, N S Ravichandra, A Sumaswi, C Bhushan, Ajit kumar Correspondence- Gaurav [email protected] Department of Medical Gastroenterology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Background The role of VITRO score (plasma von Willebrand factor (vWF)/ Thrombocyte ratio) in cirrhotic patients is not well established. The aim of this study was to investigate the association of VITRO score with decompensation and presence of esophageal varices (EVs) in patients with cirrhosis of liver (COL). Methods Patients of cirrhosis of liver were included in this study. Endoscopic assessment of the severity of EVs was done. Child-Pugh (CTP) score was used to define decompensation. Plasma vWF estimation and VITRO score calculation was done. VITRO score was then correlated with CTP class and severity of EVs. Results Total 78 patients of COL were included. Mean+SD VITRO score in cases who had EVs (3.89+2.79) was significantly higher than in cases without EVs (1.25+0.39) (p-0.0026). At cutoff value of 1.69, VITRO score has shown excellent AUC (0.94), sensitivity (87.57%), specificity (90.11%) and likelihood ratio (LR) of 9.5 for prediction of EVs (p value <0.0001). Similarly VITRO score was significantly higher in decompensated (3.82+2.77) cirrhotics as compared to compensated cirrhotics (1.13+0.28), hence it is useful in prediction of decompensation. (The two-tailed p value equals 0.0049). Also at cutoff value of 1.69, VITRO score has shown excellent AUC (0.97), sensitivity (86.97%), specificity (100%) and LR (8.5) for prediction of decompensation of liver disease (p value <0.0001).

Conclusion The VITRO score represents a highly sensitive, specific, and accurate non-invasive predictor for the presence of decompensation and EVs in liver cirrhosis of any etiology. L-086 Sero- prevalence of hepatitis B infection and impact of health education on vaccination in Odisha Manoj Kumar Sahu, Ayaskanta Singh, Kanishka Uthansingh, Manas Behera, Jimmy Narayan, Debasmita Behera Correspondence- Manoj Kumar [email protected] IMS and SUM Hospital, Bhubaneswar 751 003, India Introduction More than 240 million people have been infected worldwide with hepatitis B Virus. India has approximately HBV carrier rate of 3.0% with a high prevalence in the tribal population. Chronic hepatitis B (CHB) infection is associated with an increased risk of cirrhosis, hepatic decompensation and hepatocellular carcinoma. The burden of chronic HBV infection is increasingly being recognized, with cirrhosis and liver cancer attributable to HBV continuing to increase. Method Free screening, awareness through health education and vaccination against hepatitis B was carried out on all working days at the hospital, 23 different schools and 78 different places in the community from 2013 to 2017. Those who are willing for screening, health education and vaccination were included in the study. The sero-prevalence of hepatitis B infection and the compliance on completion of three doses of vaccination were measured. Result From January 2013 to July 2017, 46,664 people were screened for hepatitis B infection; among them 47% were male and 53% females, 40% of them are in the age group of 20-30 years, 30% between 30-50 years and 20% below 20 years. Who are negative of the infection, provided with 10 minutes of health education on hepatitis B infection and the first dose of vaccine was administered. Three percent are positive of hepatitis B infection; and they are further evaluated for treatment. The compliance on completion of three doses of hepatitis B vaccination was found to be 86%. Conclusion Hepatitis B infection is a Global health problem. Creating awareness on prevention and vaccination are the most important ways of achieving WHO target of eliminating viral hepatitis by 2030. L-087 Microbial profile and antibiotic sensitivity in decompensated cirrhotic patients with community acquired infections in Odisha Manoj Kumar Sahu, Jimmy Narayan, Kanishka Uthansingh, Ayaskanta Singh, Manas Behera, Debasmita Behera Correspondence- Manoj Kumar [email protected] IMS and SUM Hospital, Bhubaneswar 751 003, India Introduction Bacterial infections continue to be a leading cause of mortality in decompensated chronic liver disease. A systematic approach to study the bacteriology, and medication utilization is needed to improve outcome. Methods Thirty consecutive hospitalized decompensated cirrhotic patients with community acquired bacterial infections were included in the study (December 2016 to June 2017). Blood, urine, ascetic fluid cultures were sent immediately, empiric antibiotic modified within 24 hours after receipt of sensitivity report. Result Of the 30 patients, 64% were male and 40% were between 40-55 years. The mean baseline MELD Score was 18.04. The most common site of infection was UTI (62%), followed by SBP, pneumonia and cellulites. The isolated strains were mostly klebsilla spp, followed by E coli, staphlococcus aureus and acinetobacter spp. The sensitivity was 80% to Clarithromycin, Linazolid, Tecoplanin, and Piperacillin - Tazobactum. The survival rate was 93%.

Indian J Gastroenterol

Conclusion In community acquired infections with decompensated cirrosis, higher and costly antibiotics should not be started from the beginning, instead should send cultures and empiric antibiotics tailored as per the sensitivity report. L-088 Epidemiology and outcomes of patients with acute-on-chronic liver failure in Coastal Odisha Manoj Kumar Sahu, Ayaskanta Singh, Kanishka Uthansingh, Manas Behera, Jimmy Narayan, Debasmita Behera Correspondence- Manoj Kumar [email protected] IMS and SUM Hospital, Bhubaneswar 751 003, India Introduction Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of chronic liver disease associated with organ failures and high short-term mortality. The study on epidemiology and outcomes of ACLF will provide better insight and understanding on effective management of this condition. Methodology Forty-four consecutive patients of ACLF are prospectively included in the study within a period from April 2016 to May 2017. Their epidemiology and outcomes are documented and assessed. Result Of the 44 patients, 51% are more than 50 years of age, 49% in the age group between 30-50 years. Seventy-six percent are male with ACLF. The mean CTP score, MELD score, MELD Na and SOFA score was 10.96, 25.73, 31.95 and 8.44 respectively. The etiology of acute insult was alcohol in 52 % of cases followed by hepatitis B infection 21 %, hepatitis E infection 14%, hepatitis A infection 10% and drugs in 3% of patients. Majority of the patients (72%) are successfully treated and 28% of patients are died during hospitalization. Sixty-four percent of them required ICU care with a mean stay of 14.6 days. The main cause of death was sepsis and multi organ failure. Conclusion ACLF carries high short-term mortality, but understanding the epidemiology and outcomes provides a better insight on effective management of this condition.

Introduction Serum alpha fetoprotein (AFP) is the biomarker for hepatocellular carcinoma (HCC). About 70% of HCC patients have AFP secreting tumor. This study was performed to evaluate the role of serial AFP monitoring in AFP secreting HCC patients treated by loco-regional therapy. Methods In this retrospective study, case records of AFP secreting HCC patients treated with locoregional therapy between 2005 and 2014 were examined. Patients with complete clinical, demographical, biochemical, imaging profile and follow-up details were included. HCC patients with AFP ≥20 ng/mL were labelled AFP secreting. Serial AFP evaluation and tumor response evaluation with contrast enhanced MRI at 1, 3 and 6 month post treatment was done. Changes in AFP levels were correlated with treatment response. Based on the mRECIST criteria, patients with complete response (CR), partial response (PR) were responders and with progressive disease (PD) were non-responders. Comparisons of demographic profile, laboratory investigations, performance status, mass characteristics and survival were made between the two groups. Results AFP secreting HCC patients (n=107) who underwent locoregional therapy were studied. Of these, 42 were responders, 65 non-responders. Patients with PD had significantly larger HCC size (4 cm vs. 5.5 cm, p=0.02). After completing treatment, mean reduction in AFP from baseline in complete response patients was 97 % and of these, 22 (88%) patients developed normal AFP level (<20 ng/mL). PD patients depicted an 87% increase in AFP level while in PR patients, the AFP had almost similar or marginal increase (1.1%). On survival comparison, PD patients had significantly lower overall survival compared to the responders. On multivariate analysis, MELD score was significantly associated with survival (HR 1.18, CI 1.01-1.37, p= 0.028). Conclusion Serial AFP monitoring is useful in predicting response to loco-regional therapy in AFP producing HCC patients. MELD score is associated with poor survival in these patients. L-091 Prevalence of sarcopenia and its clinical relevance in assessment of nutritional status in patients with cirrhosis

L-089 Study of clinical profile of patients with reactivation of chronic hepatitis B post immunosuppression Prerna Pallavi, A K Sood, Manish Manrai, Rahul Jain Correspondence- Prerna [email protected] Army Hospital (R&R), Army Hospital (R&R), Army Hospital (R&R), Army Hospital (R&R), Delhi 110 010, India Aims To study the clinical profile of patients with reactivation of chronic hepatitis B post chemotherapy. Background Patients who were previously HBsAg negative were found to be HBsAg positive after receiving chemotherapy. These patients should be tested for occult hepatitis B infection prior to starting chemotherapy. Conclusion Patients with occult hepatitis B infection tend to reactivate after receiving chemotherapy and hence should be tested prior to starting chemotherapy. L-090 Role of alpha fetoprotein (AFP) as a therapeutic marker in AFP producing hepatocellular carcinoma Shekhar Singh Jadaun1, Neeti Nadda1, Mona Pathak2, Shashi Bala Paul3, Shivanand R Gamanagatti3, Ekta Dhamija3, R Vidyasagar3, Shalimar1, Saurabh Kedia1, Baibaswata Nayak1, Subrat Kumar Acharya1 Correspondence- Shekhar Singh [email protected] All India Institute of Medical Sciences, New Delhi 110029

Rohan Mahajan, Amit Mathur, Shankar Lal, Rajat Bhargava, Ramesh Roop Rai Correspondence- amit [email protected] Department of Gastroenterology, National Institute of Medical Sciences, Jaipur 302 019, India Introduction and Aims Sarcopenia is one of the most common complication in patients with cirrhosis. The aim of the study is to assess the prevalence of sarcopenia in patients with cirrhosis; to investigate the correlation between sarcopenia and the severity of liver disease and whether the inclusion of sarcopenia for assessment of nutritional status along with the anthropometric tools could improve the prediction of clinical outcome in patient with cirrhosis. Methods Forty patients were included in this one-year prospective study. Skeletal muscle index at L3 vertebra (L3 SMI) was measured by MRI, sarcopenia was defined using previously published gender and BMI specific cut offs. Nutritional status of patients was assessed using anthropometric tools like mid-arm circumference, body mass index, hand-grip strength and subjective global assessment. Results Baseline characteristics were mean age (42.5 years), males (80%), alcoholics (45%), HBV (25%), Child-Pugh C (32.5%) and MELD >15 (60%). Sarcopenia was present in 33 (82.5%) patients. L3 SMI was significantly lower in patients with SGA grade C as compared to SGA score A (22 vs. 14; p<0.0001), patients with MAC <5th percentile (19.6 vs. 26.7 mm, p<0.001), lower BMI (17.1 vs. 23.2 kg/m2, p<0.0001) and weaker HG strength (19.2 vs. 36.3 kg, p<0.001). There is a poor correlation between L3 SMI, MELD and CP scores (Corr. Coefficient: -0.404; p< 0.14).

Indian J Gastroenterol

Conclusion Sarcopenia is common in advanced cirrhosis. Sarcopenia is positively correlated with the other anthropometric tools and should be included for the evaluation of nutritional status in cirrhotic patients though it does not correlate with the severity of liver dysfunction. L-092 To study cardiac abnormalities in specific reference to corrected QT interval in cirrhotic patients Ankit Makadia, K R Thankappan, M G Srinivas, M Harsha, M Sreeharsha, D Venkateswara Raju Correspondence- Ankit [email protected] Narayana Medical College Hospital, Chinthareddipalem, Nellore 524 002, India Introduction Cirrhotic cardiomyopathy is a relatively illcharacterized condition, which is often under-diagnosed due to absence of defined diagnostic criteria. ECG showing corrected QT Interval prolongation is the most suitable available option for diagnosis of this condition. Aim To study cardiac abnormalities in specific reference to corrected QT interval in cirrhotic patients. Methodology Patients (n=102) with confirmed cirrhosis, 18 years or older, presented in Narayana Hospital, Nellore between September 2015 to August 2017, were enrolled in this cross-sectional study after taking consent. ECG was done using calibrated ECG machine, and the QT Interval was measured. Corrected QT was calculated using Bazett’s formula and a QTc of more than 0.44 seconds was considered as being prolonged. Results The mean age of the patients was 51.45±11 years. The corrected QT interval varied from 334 ms to 568 ms. The mean QTc Interval was 431.38 ms±48.21. QTc was prolonged in 37 out of 102 patients (36.2%). Frequency of QTc prolongation was 3.9% in Child-Pugh Grade A, 25.6% in Child-Pugh Grade B, and 31.2% in Child-Pugh Grade C. Association of Child-Pugh scoring with QTc prolongation was determined and found to be statistically significant (p<0.05). Conclusion QTc interval was prolonged in 36.2% of cirrhotic patients in our study. There was a significant increase in frequency with worsening of Child-Pugh Grade, thereby indicating an association between QTc prolongation and the severity of cirrhosis. L-093 Serum ferritin–An independent prognostic marker in predicting early mortality in liver disease M Sreeharsha, K R Thankappan, M G Srinivas, M Harsha, Ankit Makadia, Naveen Kumar Correspondence- Sree harsha [email protected] Narayana Medical College Hospital, Chinthareddipalem, Nellore 524 003, India Introduction Various prognostic models were devised to predict the future events in patients with cirrhosis, thereby help in listing the patients for transplantation. The model for end-stage liver disease (MELD) is usually preferred for organ allocation priorities whereas Child-Turcotte-Pugh (CTP) score is preferred in daily practice. This study was carried out to know the efficacy of serum ferritin in predicting future events in patients with advanced liver disease. Aim To study whether serum ferritin can independently predict the 15 days mortality in patients with advanced liver disease. Methodology This study was conducted at tertiary referral center, Department of Medical Gastroenterology, Narayana Medical

College, Nellore. The evaluation period was from September 2015 to August 2017. Adult patients in age group 12 years and above with chronic liver disease were enrolled. Routine investigations and serum ferritin levels were recorded. Mortality was assessed at 15th day of evaluation. Prognostic models along with serum ferritin were analyzed. Results A total of 94 consecutive patients were enrolled. Among the 94 patients 81 were diagnosed to have decompensated cirrhosis and remaining 13 patients were in compensated phase of cirrhosis. All the patients involved in the study had jaundice at the time of presentation, 86% of patients had ascites and 68 % of patients had encephalopathy. Fifty-one percent of the patients evaluated had experienced upper gastrointestinal bleed. Serum creatinine and serum sodium were found to be useful in predicting mortality. CTP score, MELD and serum ferritin were found to be useful prognostic models in predicting outcome, but serum ferritin was superior to other two models. Addition of serum ferritin to MELD was found to increase the accuracy and precision. Conclusion Serum ferritin levels were highly elevated in patients with early mortality. Serum ferritin as an independent prognostic appears to be convincing. L-094 Association of HLA-G 3’ UTR polymorphisms with hepatocellular carcinoma in Indian populations Neeti Nadda, Nelanjana Roy, Renu Yadav, Shashi Paul, Shalimar, Anoop Saraya, Baibaswata Nayak Correspondence- Baibaswata [email protected] Departments of Gastroenterology and Radiodiagnosis, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background Human leukocyte antigen-G (HLA-G) is a potent immunetolerant molecule found to be associated with cancer due to its tumordriven immune escape mechanisms. Most of the polymorphic sites present at 3’ untranslated region (UTR) influence it mRNA stability and processing. HLA-G polymorphism is associated with several malignancies but not known for hepatocellular carcinoma (HCC) patients of Indian populations. Objectives To study association of HLA-G 3’ UTR polymorphism with hepatocellular carcinoma in Indian populations Methods The HLA-G 3’ UTR flanking exon 8 region (nt8790-9144) were PCR amplified from genomic DNA of healthy control (n=57) and HCC (n=50) patients. The genotyping of SNP: rs371194629 (Ins/Del), rs1710 (G/C) and rs1063320 (+3142:G/C) were carried out sanger sequencing and chromatograph reading. Genotype, Allele frequencies, HardyWeinberg equilibrium (HWE) testing and test of association (OR, Chisquare and p value) were carried out by bioinformatics software statcal and online software. Result and Discussion The INDEL polymorphism in HCC patients (n=50) had shown 14bp INS, INS/DEL and Del genotype in 24%, 50% and 26 % cases. The minor allele (Ins) frequency is 0.49 and 0.35 for HCC and controls. The minor allele (G) frequency is 0.47 for rs1710 (G/C) and rs1063320 (+3142:G/C) in HCC patient. Test of deviation from HWE is not found significant in HCC cases for rs371194629 (Ins/Del). Assuming insertion (Ins) risk allele and del as reference, we have have found association of rs371194629 (Ins/Del) with HCC (χ2-7.646, 0.022), OR (odds ratio) Ins/Del vs. Del/Del: 3.49 (CI: 1.49-8.63, p-0.006), OR Ins/ Del+Ins/Ins vs. Del/Del: 2.95 (CI-1.3-6.68, p-0.009). Association with HCC was found for rs1063320, OR-3.16, CI-1-9.99), p=0.04 for GC vs. GG assuming CC as risk and GG as reference. No significant association was found for SNP rs1710 SNP. More significant association may found by increasing more sample number for this study.

Indian J Gastroenterol

BILIARY TRACT BT-01 Brushcytology in cholangiocarcinoma-Not so insensitive D Srujan Kumar, P Shravan Kumar, M Uma Devi Correspondence - Shravan Kumar Porika - [email protected] Department of Gastroenterology, Gandhi Hospital, Secunderabad 500 003, India Introduction Cholangiocarcinoma, a disease of late presentation of symptoms has only a single curative treatment option–surgery, whose results are more favorable with early stage disease. Biliary brush cytology provides the only definitive diagnosis used for establishing therapeutic strategies. Methoos The study included 42 patients diagnosed to have cholangiocarcinoma based on clinical, biochemical and cross sectional imaging features over last one year. Of them 39 patients (16 male, 23 female with mean age 51.2 years) underwent successful endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) cannulation. Cholangiograms revealed strictures at terminal CBD in 11 cases (28.2%), mid CBD in 7 cases (17.9%) and hilar/CHD in 20 cases (51.28%). One case had normal CBD with absent flow in right hepatic system. At presentation 25 patients (64.1%) had jaundice, 21 patients (53.8%) had pain abdomen, 16 patients (41%) had fever and 3 patients (7.6%) had gallstones. Brush cytology was done in all 39 cases using wire guided sheathed cytology brush. Results Brush cytology was done in all cases and repeat brush cytology was done in 5 cases. First brush cytology was positive in 17 cases (43.5%). Among the patients with repeat cytology 4 were positive making overall sensitivity to 21 out of 39 cases (53.84%). Conclusion Tissue diagnosis is required for extrahepatic cholangiocarcinoma before embarking on either palliative or curative treatments. Brush cytology during ERCP is a simple procedure with low sensitivity in most studies. However the present study has shown a promising sensitivity of 53.84% whose positivity rate can be increased by a simple repeat cytology. BT-02 Profile of obstructive jaundice in tertiary referral hospital V Gopalakrishna, P Shravankumar, M Umadevi Correspondence – V Gopalakrishna - [email protected] Department of Gastroenterology, Gandhi Medical College Hospital, Hyderabad 500 003, India Background/Aim Obstructive jaundice is one of common refferal to gastroenterology. In this study, we aimed at identifying clinical and etiological profile of obstructive jaundice in patients referred for endoscopic retrograde cholangiopancreatography (ERCP). Methods Three hundred and seven patients with obstructive jaundice over a period of 4 years from 2013-2016 were studied retrospectively. Demographic, clinical, biochemical and ultrasonography, CT and MRCP were recorded. ERCP findings were analyzed and biopsy details were noted. Results Of the 323 patients 128 males (40%); median age 42 years; range 17-67 years and females 195 (60%); median age 38 range 19-64 years. The clinical profile of patients include jaundice 323 (100%), abdominal pain 170 (55%), vomiting 130 (42%), anorexia 90 (29%), loss of weight 80 (26%), pruritus 50 (15%), pale stools 58 (18%). The spectrum of diseases diagnosed include choledocholithiasis 139 (43%), periampullary carcinoma 47 (15%), benign biliary stricture 44 (14%), hilarcholangio carcinoma 31 (10%), distal cholangiocarcinoma 20 (6), carcinoma head of pancreas 16 (5%), post op bile leak 15 (5%), choledochal cyst 4 (1%),

carcinoma gallbladder 3 (0.9%), hydatid cyst 2 (0.6%), portal biliopathy 2 (0.6%), PSC 2 (0.6%). Age wise analysis 15-40 yrs 144 (45%); 41-55 yrs 126 (39%) and above 55 yrs 53 (16%) and most common etiology in different groups choledocholithiasis 92 (29%) in 15-40 yrs age group, choledocholithiasis 38 (12%) and benign biliary stricture 36 (11%) in 41-55 yrs age group, periampullary carcinoma 32 (10%). Gender wise analysis 128 males (40%) 195 females (60%). Common etiology in males choledocholithiasis 53 (17%), periampullary carcinoma 38 (12%), hilarcholangiocarcinoma 20 (6%). In females choledocholithiasis 86 (27%), benign biliary stricture 28 (9%). Conclusion Choledocholithiasis found to be the commonest cause of obstructive jaundice followed by periampullary carcinoma and benign biliary stricture in this study. BT-03 Endotherapy in choledochal cyst - A single tertiary care center experience in South India Allwin James, Prem Kumar Karunakaran, Kani Sheikh Mohammad, Rathnakar Kini, T Pugazhendhi Correspondence - Allwin [email protected] Madras Medical College, Madras Medical College, Chennai 600 003, India Introduction Choledochal cyst is a type congenital anomaly in which there is dilatation of the intra or extrahepatic biliary tree. Choledochal cysts are classified into five types based on location or shape of the cysts. Here we present an observational study of endotherapy in patients with choledochal cyst at our institute. Methodology The study was conducted from January 2015 to June 2017 at Madras Medical College. All patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) and had finding of choledochal cyst on cholangiogram were included in the study. Patients were assessed on their demographic data, clinical findings, presentation, and complications. Results Twenty-five (2.5%) patients with findings of choledochal cyst on cholangiogram in 990 ERCP’s performed during study period were included. Average age of study population was 43.2±18.5 years and M:F ratio was 1: 4 with female preponderance. Eleven (44%) patients presented with obstructive jaundice, 9 (36%) with recurruent biliary pain, 2 (8%) with recurrent acute pancreatitis and 3 (12 %) were asymptomatic. Five (10%) patients had cholangitis at presentation. Type 1C was the most common type seen in 16 (64%) patients followed by type 1B in 4 (16%) patients. One had Type 1A with anomalous pancreaticobiliary malunion. Two (8%) had type 3. Successful common bile duct (CBD) cannulation was achieved in 21 (84 %) patients following a biliary sphincterotomy in 24 (96%) cases. Choledocholithiasis and hepatolithiasis was found in 13 ( 5 2 % ) a n d 2 ( 8 % ) p a t i e n t s r e s p e c t i v e l y. Tw o ( 8 % ) h a d choledochoduodenal fistula and 3 (10%) had periampullary diverticulum. Successful stone retrieval was done in 10 (40%) patients. All patients were referred for surgery for further management. Conclusion Type 1C was the most common type of choledochal cyst with obstructive jaundice due to large CBD stones as the most common presentation in this study. BT-04 Case series of patients with HIV/AIDS cholangiopathy Rabindranath Eswaran, Thirumoorthi, K Premkumar, Ratnakar Kini, Kani Shaik Mohammad Correspondence- Rabindranath Eswaran- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003

Indian J Gastroenterol

Introduction AIDS cholangiopathy is a condition characterized by abnormalities of the bile ducts in patients with advanced AIDS. If untreated the disease is rapidly fatal. With HAART the disease mortality is decreased. We aimed to describe the varied presentation of AIDS cholangiopathy at different stages and to describe the clinical profile, diagnostic investigations and cholangiography findings of four cases. Methods Four cases of HIV cholangiopathy from June 2014 to March 2017 were assessed with a battery of laboratory tests including HIV by ELISA, CD4 counts, LFT, chest X-ray, ultrasound abdomen, CECT abdomen, MRCP and ERCP. Results All four cases showed MRCP picture of AIDS cholangiopathy. Three patients CD4 counts were less than 100/cumm (60–96/cumm) and one patient had 190/cumm, which is atypical for AIDS cholangiopathy to occur. Two patients presented as the initial presentation of HIV disease, presented with abdominal pain and fever. One vertically acquired case in adolescence was a HAART defaulter for two months presented with mild jaundice, epigastric pain, pale stools and pruritus. One case diagnosed in a terminally ill elderly female, spouse being HIV positive, also had coinfection with disseminated tuberculosis and was started on ATT prior to HAART, but succumbed to illness. Other three cases responded well to HAART. Two patients had normal bilirubin and two had mildly raised bilirubin. All cases had mildly raised transaminases and high serum alkaline phosphatase levels. All cases had cholangiography picture of combined papillary stenosis and sclerosing cholangitis. Three cases underwent sphincterotomy and had significant pain relief. Conclusion AIDS cholangiopathy should be considered in varied case presentations as a differential diagnosis, appropriately investigated and timely treated with HAART. BT-05 Etiological spectrum in patients with obstructive jaundice subjected to ERCP Dande Tejaswini, Thangavelu Pugazhendhi, K. Premkumar, Kini Ratnakar, M Kani Sheikh Correspondence- tejaswini dande- [email protected] Madras Medical College, Chennai 600 003, India Background and Aims Obstructive jaundice occurs from a blockade in the intra or extrahepatic biliary tree. Therapeutic ERCP is done to relieve this obstruction. The aim of this study is to analyze the etiological spectrum of obstructive jaundice in the patients undergoing ERCP in our institution. Methodology We did a retrospective analysis from July 2015 to July 2017 at the Madras Medical College. All the patients who underwent ERCP for obstructive jaundice were included in the study. Results A total of 1200 ERCPs were performed during the study period. Six hundred and fifty (54.17%) patients with obstructive jaundice underwent ERCP. Two hundred and forty-one (36.63%) patients were <50 yrs, and 409 (63.37%) were ≥50 yrs. There were 341 (52.46%) male and 309 (47.54%) female patients. Three hundred and seventy (56.92%) patients presented with a benign disease; 171 (32.70%) <50 yrs and 199 (53.78%) ≥50 yrs. Two hundred and eighty (43.08%) presented with a malignant cause, including malignant external compression; 70 (25%) <50 yrs, 210 (75%) ≥50 yrs age. The etiological spectrum was as follows-choledocholithiasis 298 (45.84%), cholangiocarcinoma 83 (12.77%), ca gallbladder with infiltration 26 (7.23%), cholangitic abscess 3 (0.46%), strictures 64 (9.84%), lymph node compression 9 (1.38%), ca colon with liver mets 10 (1.54%), choledochal cyst 9 (1.38), ampullary growth 64 (9.84%), duodenal growth 21 (3.23%), pancreatic pseudocyst compressing on CBD 10 (1.54%), PSC 3 (0.46%), stomach malignancy compressing on CBD 2 (0.31%). Successful ERCP was done in 89% patients. Eleven percent underwent other surgical/radiological interventions for relief from obstructive jaundice. Conclusion Choledocholithiasis was the most common cause of obstructive jaundice in the pts subjected to ERCP in our institution.

BT-06 Cholangiocarcinoma in Kerala: A clinical profile and risk factor analysis Priya Nair, B R Harshavardhan, V Suprabha, Rama P Venu Correspondence- Priya Nair- [email protected] Department of Gastroenterology, Amrita Institute of medical sciences, Kochi 682 041, India Introduction The incidence of cholangiocarcinoma (CCA) in India is on the rise especially in Kerala. However, the clinical profile and outcome of these patients has never been reported. The aim of this study was to identify region specific epidemiological trends and natural history of CCA in Kerala. Methods This was a hospital based epidemiology study in Amrita Institute of Medical Sciences, Kochi. Incident cases of CCA as per standard guidelines from January 2014 to August 2016 were studied. Patient demographics and all relevant clinical and laboratory data, imaging studies and treatment, were recorded in a predesigned performa. Statistical analysis was done using SPSS 20.0. Results A total of 137 patients (mean age 62.92±12.5 years, M:F=1.2) were studied of which 109 patients had pCCA, 16 patients had dCCA and 12 patients had iCCA. A vast majority of patients were from coastal areas and rubber plantation regions. Known risk factors were conspicuously absent in our patients. Fifty-five patients (50.5%) of pCCA had Bismuth Type IV disease. Left hepatic ducts were more commonly involved (46, 44.2% vs. 31, 29.8%). Most intrahepatic CCA (iCCA) (7/12) patients had stage IV disease at presentation. 36/137 patients (27.7%) underwent surgery of which only 17/137 (12.4%) had curative resection. Patients who underwent treatment with a curative intent were younger with less advanced disease and therefore, had a significant 3 month, 6 month and 1 year survival advantage (p <0.05). The overall 1 year mortality was 66.1% (91/137). The 30-day post-op mortality was 4.3%. Conclusions CCA patients in Kerala exihibit some unique characteristics including a conspicuous absence of known risk factors, relative concentration of cases in coastal areas, advanced stage at presentation precluding treatment modalities with a curative intent. Among patients deemed resectable (27.7%), curative resection was possible only in a minority. Thus, at best, surgery offers better palliation in selected patients. BT-07 Predictive factors of positive and negative findings of choledocholithiasis Nitin Jagtap, Vaibhav Ajmere, Sundeep Lakhtakia, Mohan Ramchandani, Manu Tandan, Rajesh Gupta, Rakesh Kalapala, G V Rao, D N Reddy Correspondence- Nitin Jagtap- [email protected] Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Aim Substantial number of patients with suspected choledocholithiasis have no stones on EUS, even in the patients with high probability of choledocholithiasis. We aimed to evaluate clinical and noninvasive predictive factors of choledocholithiasis with special attention to high risk group of ASGE criteria. Method A retrospective analysis of patients undergoing EUS and/or ERCP for suspected choledocholithiasis was performed. After biochemical testing and ultrasound, all patients were stratified according to ASGE criteria into high, intermediate and low likelihood of choledocholithiasis. Univariate and multivariate analysis was performed for predictors of positive findings of choledocholithiasis in overall and high risk patients. Results Out of total 1028 patients, 274 (26.65%) had choledocholithiasis. Overall univariate analysis showed that male sex, presence of

Indian J Gastroenterol

pancreatitis, cholangitis, cholecystitis and elevated bilirubin, ALT, AST, ALP with dilated CBD were significantly associated with choledocholithiasis (p<0.05). On multivariate analysis, cholangitis (p 0.001, OR 13.442; 95% CI 5.73–31.33), cholecystitis (p 0.008, OR 1.72 95; % CI 1.15–2.56), raised ALT (p 0.002, OR 2.10; 95% CI 1.306–3.362) and dilated CBD (p 0.001, OR 5.279; 95% CI 3.675– 7.584) increased likelihood of choledocholithiasis. However, pancreatitis (p 0.001, OR 0.439; 95 % CI 0.297–0.650) decreased likelihood of choledocholithiasis. In high risk group, out of total 236 patients, 140 (59.32%) had choledocholithiasis. On univariate analysis age >55 years, presence of pancreatitis, cholangitis and cholecystitis, raised bilirubin and ALT were significantly associated with choledocholithiasis. On multivariate analysis, age >55 years (p 0.002, OR 4.34; 95% 1.73–10.92), cholangitis (p 0.03, OR 2.68; 95% CI 1.103–6.514) increased likelihood of choledocholithiasis while pancreatitis (p 0.001, OR 0.116; 95% CI 0.47–0.288) decreased. Conclusion In patients with suspected choledocholithiasis with acute pancreatitis should undergo confirmatory test such as EUS before ERCP, even in high probability group. BT-08 Choledocholithiasis in patients with acute calculus cholecystitis Nitin Jagtap, Vaibhav Ajmere, Mohan Ramchandani, Sundeep Lakhtakia, Rajesh Gupta, Manu Tandan, G V Rao, D N Reddy Correspondence- Nitin Jagtap- [email protected] Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

duct or Hartmann's pouch of the gallbladder. It is classified into four types based on the presence and extent of a cholecystobiliary fistula or biliobiliary fistula. Here we present our experience with Mirizzi syndrome at our institute. Methodology The study was conducted from January 2015 to June 2017 at Madras Medical College. All patients who underwent ERCP and had finding of Mirrizzi’s syndrome on cholangiogram were included in the study. Patients were assessed on their demographic data, clinical findings, presentation, and complications. Results During the study period, 990 ERCPs were done in our institute. Of which 802 (81%) cases were biliary cases for various indication. Stone disease was noted in 543 (67.7%) patients. Of which 10 (1.8%) patients had Mirrizzi’s syndrome. Seven were males and 3 were females. Mean age was 45±2.6 years. All patients had obstructive jaundice as presentation. And two had features of cholangitis. Four (40%) had type 1, 2 (20%) had type 2, 2 (20%) had type 3, 1 (10%) had type and 1 (10%) had type 5 respectively. Cannulation was successful in 9 of 10 patients. Cholangiogram concurrently confirmed findings in all patients as with radiological imaging (MRCP). Stone was successfully removed in 7 of 9 patients who were successfully cannulated. Two patients had associated periampulllary diverticulum. All patients were refered to surgery for further management with cholecystectomy. None had mortality. Conclusion Mirrizzi syndrome is an uncommon complication seen in bile duct stone disease. It is common in males with type 1 being most common type in our study. All patients should be managed by surgery after ERCP. BT-10 A rare presentation of primary sclerosing cholangitis – Case report

Aim The bilirubin level may rise to 4 mg/dL in the absence of complications in patients with acute calculus cholecystitis along with elevation in liver enzymes. In the presence of abnormal liver function test, further evaluation for choledocholithiasis can be costly and increases morbidity. We aimed to evaluate predictive factors for choledocholithiasis in patients with patients with acute calculus cholecystitis. Methods We retrospectively analyzed clinical and laboratory data patients admitted with acute calculus cholecystitis in whom choledocholithiasis was suspected. Patients with concomitant acute pancreatitis and cholangitis were excluded. Choledocholithiasis was confirmed by using EUS and/ERCP. Univariate analysis and multivariate analysis was performed for predictive factors of choledocholithiasis. Results A total of 200 patients with ACC were analyzed, out of which 52 (26%) had choledocholithiasis. On Univariate analysis, age >55 years, dilated CBD on USG, bilirubin and ALP were significantly associated with choledocholithiasis. On logistic regression analysis, only dilated CBD on USG (p 0.001, OR 6.532; 95% CI 2.895–14.742) and ALP (p 0.001, OR 1.01; 95% CI 1.004–1.012) were predictive of choledocholithiasis. Combining ALP and dilated CBD on USG have (AUC=0.833) at ALP >150 IU/mL with sensitivity of 77.78% and specificity of 89.29%. Conclusion Over one fourth patients had concomitant choledocholithiasis in patients with acute calculus cholecystitis. Raised ALP >150 IU/mL in presence of dilated CBD on ultrasound is highly specific for choledocholithiasis in patients with acute cholecystitis. BT-09 Mirizzi syndrome – Experience in a tertiary care centre in South India Allwin James, Kani Sheik Mohammad, Prem Kumar Karunakaran, Ratnakar Kini Correspondence- Allwin James- [email protected] Madras Medical College, Chennai 600 010, India Introduction Mirizzi syndrome refers to common hepatic duct obstruction caused by an extrinsic compression from an impacted stone in the cystic

A Shafique. Y Jaipaul, R Ramasubramanian Corespondence- R Ramasubramanian- [email protected] Department of MGE, Tirunelveli Medical College, High Ground, Palayamkottai, Tirunelveli, Tamil Nadu 627 011, India, Department of MGE, Thoothukudi Medical College, 3rd Mile, Kamaraj Nagar, Thoothukudi, Tamil Nadu 628 008, Department of MGE, Thoothukudi Medical College, 3rd Mile, Kamaraj Nagar, Thoothukudi, Tamil Nadu 628 008, India Introduction Sclerosing cholangitis encompasses a spectrum of cholestatic conditions that are characterized by patchy inflammation, fibrosis, and destruction of the intrahepatic and extrahepatic bile ducts. Primary sclerosing cholangitis (PSC), is an idiopathic disorder that usually occurs in association with inflammatory bowel disease (IBD) but may develop independently. Here we are presenting a case of primary sclerosing cholangitis without association with IBD. Case History 35-years female presented with h/o abdominal pain, jaundice, pruritus and clay coloured stools of 1 month duration. Her LFT revealed features of cholestasis with raised alkaline phosphatase level. There was no A:G reversal and no features of decompensation like ascites or UGI bleed. UGI scopy and USG abdomen found to be normal. Colonoscopy with random biopsy of mucosa found to be negative for IBD. MRI abdomen reveals hepatomegaly. Viral markers and markers of intrahepatic cholestasis like ANA, AMA, anti-LKM-1 and ASMA were negative. Hence ERCP was performed to find out the etiology of cholestasis. Cholangiogram showed alternate dilatation and beading of CBD indicating features of sclerosing cholangitis. Sphincterotomy done to facilitate free flow of bile. Hence to confirm the diagnosis, liver biopsy was done which showed ballooning degeneration of hepatocytes, intracytoplasmic bile stasis along with distortion of normal cord pattern indicating features of primary sclerosing cholangitis stage 1 and fibrosis grade 1. Patient was put on ursodeoxycholic acid for 3 months and patient showed remarkable improvement of her symptoms. Conclusion Primary sclerosing cholangitis is rare cause of cholestatic jaundice which can cause biliary cirrhosis and hepatic failure if not

Indian J Gastroenterol

detected early. In our patient, the diagnosis could only be confirmed after ERCP and liver biopsy. Careful monitoring and regular follow up of these patients are essential to prevent complications. BT-11 Brush cytology and forceps biopsy in the diagnosis of malignancy in patients of biliary strictures S C Santhosh Kumar, K R Palaniswamy, A T Mohan, U Dhus, P Piramanayagam, S Parameswaran, U Srinivas, M Hariharan, M S Revathy, V P Seshadri, M Preethi Correspondence – S C Santhosh Kumar - [email protected] Department of Medical Gastroenterology, Apollo Hospitals, Chennai 600 006, India Introduction Biliary strictures can be of both benign and malignant etiology. Pancreatic cancer is the most common cause of malignant biliary strictures, other causes being cholangioca, ampullary tumors, GB cancer. Pathologic evidence of malignancy in biliary strictures is useful in the therapeutic planning and prognosis. ERCP (biliary brushings-cytology, biopsy) EUS-FNA, IDUS (intra-ductal ultrasonography) are some of the methods to obtain tissue diagnosis. Here we propose to study the diagnostic accuracy of biliary brush cytology and forceps biopsy in biliary strictures suspicious of malignancy. Methods All patients above 18 years of age with strictures on imaging MRCP/CECT were included in this prospective cross sectional study conducted in the Department of Gastroenterology, Apollo Hospitals, Chennai. They underwent ERCP with biliary brushing cytology and forceps biopsy. The results were noted. The results were compared with the gold (reference) standard-surgical specimen, FNAC from metastatic lesions of liver or ascitic fluid cytology or clinical follow up. Results With a study period of 2 years, till now we have evaluated 43 patients (Proximal-16, mid-11, distal-16). The interim results showed that brush cytology was positive in 26/43 (60.4%) patients and forceps biopsy was positive in 23/43(53.3%). BT-12 Biliary Ascariasis: Experience at tertiary care centre Ankush Pawar, Ashok Dalal, Ajay Kumar, S Srivastava, S Sachdeva, A S Puri Correspondence- Siddharth Srivastava- [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background Ascaris lumbricoides is the most common helminthic infection in the world. Biliary ascariasis is an important cause of biliary diseases in developing countries. We aimed to study the demographic profile, clinical features and ERCP findings in patients with biliary ascariasis. Methods We retrospectively analyzed patients who underwent ERCP over last four years (January 2013 to June 2017) for biliary ascariasis. Data was collected from ERCP registry. Diagnosis was based on ultrasound, MRCP and ERCP. Results A total of 30 patients underwent ERCP for symptomatic ascariasis. Majority (n=25, 83%) of patients were female. Mean age was 32 (range=1.5 to 60 yrs) years. Non-vegetarian food habit (n=18, 60%) was predominantly observed. Most common presentation was biliary pain (n=20, 67%) followed by acute cholangitis (n=8, 26%) and pancreatitis (n=2, 7%). 3 (10%) patients had simultaneous worm in stomach. Common bile duct was dilated in 23 (77%) whereas IHBRD was observed in 18 (60%) patients. History of cholecystectomy was present in 3 (10%) patients. Previous endoscopic papillotomy was found in 6 (20%) patients. Out of 25 patients who had linear filling defect in cholangiogram ascaris was removed in 17 (57) and stenting was done in 8 (27%) patients.

Rest 5 patients had passed out worm. Repeat ERCP was required in 9 (30%) patients. Overall 3 (10%) complications happened out of which 2 were retroperitoneal perforations and one was mild pancreatitis. No mortality occurred. Two (8%) patients developed benign CBD stricture as a long-term complication. Conclusion Ascaris can cause biliary diseases in children as well as adults. It is more common in females, and those with non-vegetarian food habits. Previous cholecystectomy and endoscopic papillotomy may be a risk factor. ERCP is an effective and safe modality of treatment. BT-13 Etiological spectrum of extrahepatic biliary obstruction. A study in a tertiary care Centre of south India N S Ravichandra, Ajit Kumar, B Sukanya, N Joshi, Y Raghavendra, S Rahul, Vineeth Chaudary, J Risab, R Gaurav, Sumaswi, C Bhushan Correspondence- Ajit [email protected] Deparment of Medical Gastroentrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Background Extrahepatic biliary obstructive (EHBO) is a common problem encountered in clinical practice. There are only few published studies in India with respect etiological spectrum of EHBO, most of these studies are from north India. Aim This study was done to assess the etiological spectrum of EHBO in a tertiary care centre of south India. Methodology Retrospectively analyzed the data of all patients with EHBO who were evaluated in Department of Gastroenterology, Nizam’s Institute of Medical Sciences, over a period of 2 years from July 2015 to July2017. Results A total of 548 patients with EHBO were studied, male 295 (53.8), female 253 (46.2), mean age 51.3±14.9. Benign etiology was found in 287 patients (52.3%), malignant etiology in 261 (47.7%). Among the benign causes choledocholithiasis present in 226 (41.2%), benign biliary stricture in 60 (10.9%), CBD polyp 1 (0.2%). Among malignant causes, cholangiocarcinoma 120 (21.9%), Ca head of pancreas (HOP) 60 (10.9%), periampullary carcinoma 55 (10.1%), carcinoma gallbladder 25 (4.56%), carcinoma stomach with portal nodal metastasis 2 (0.4%). Mean age of choledocholithiasis, benign stricture, cholangiocarcinoma, carcinoma HOP, periampullary carcinoma, carcinoma gallbladder was 46.7±15.6, 44.3±9.2, 64.5±9.7, 61.2±8.1, 54.6±7.5, 58.2±10.5, respectively. Incidence of choledocholithiasis, carcinoma gallbladder, cholangiocarcinoma was more among females (51.3%, 75.0%, 55.0% respectively), whereas incidence of benign biliary strictures, carcinoma head of pancreas, periampullary ca was more in male (66.0%, 61.7%, 60.7% respectively). Conclusion The study showed benign etiology is slightly more common than malignant etiology. Increasing incidence of choledocholithiasis in male, increasing trend of cholangiocarcinoma, rising trend of carcinoma gallbladder as once it was very rare in south. BT-14 Clinical profile and outcome of pancreatobiliary malignancy in coastal Eastern India–A single center experience Prakash Chandra Dalai1, Kedarnath Panda1, Bijay Misra1, Brundaban Nahak2, Manoranjan Mohapatra3, Adya Kinkar Panda3 Correspondence-Bijay [email protected] 1 Department of Gastroenterology, Institute of Gastro and Kidney Care B h u b a n e s w a r, O d i s h a 7 5 1 0 1 5 , I n d i a , 2 D e p a r t m e n t o f Gastroenterosurgery, Institute of Gastro and Kidney Care Bhubaneswar, Odisha 751 015, India, and 3Department of Radiology, Institute of Gastro and Kidney Care Bhubaneswar, Odisha 751 015, India

Indian J Gastroenterol

Background Early detection of pancreatobiliary malignancy can help clinicians to treat accurately and thus will improve quality of life of patient and particularly the survival rates. The present study aimed at clinical profile and treatment outcome of patients with pancreatobiliary malignancy. Methods Consecutive patients of pancreatobiliary malignancy attending gastroenterology clinic in 2015 to 2017 were included in the study. Result Total no of patients were 136 with M: F 1.2:1 and mean age of 63.04+5.63 years. Out of 136 patients who were treated, most common malignancy was carcinoma gallbladder (68.38%), followed by pancreatic malignancy (16.16%), ampullary malignancy (6.6%), cholangiocarcinoma (5.8%) and hilar cholangiocarcinoma in 2.9%, only 7.35% (10/136) patients undergone definite surgery, 8% undergone palliative bypass due to luminal obstruction. Rest of the patient 84.55% had undergone palliative biliary stenting with self expanding metal stent (SEMS) for obstructive jaundice. Overall median duration of survival was 6 months in patients with palliative treatment. Conclusion Majority of patient with pancreatobiliary malignancy in this study were over the age of 60 years and received palliative stenting and palliative surgery due to advanced disease. Carcinoma gallbladder was the most common cause followed by pancreatic malignancy. Awareness and early diagnosis is needed to provide definitive therapy in more number of patients.

BT-16 Endoscopic management of bile leak following a laparascopic cholecystectomy - Prospective study K Sibithooran, Ratnakar Kini, K Premkumar, Kani Sheikh Mohammed, B Thinakarmani Correspondence- K Sibithooran [email protected] Madras Medical College, Chennai 600 003, India A total of 46 patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) for bile leak following a laparascopic cholecystectomy were studied. The bile duct injuries were classified according to the strasberg classification. Nineteen were type A and 17were type D. Two belonged to type B and C. Eight patients were in type E category. ERCP was successful in 14/19 patients with type A and 9/17 patients with type D bile duct injuries. Other patients required surgical repair. Conclusion ERCP is a very encouraging treatment options in type A and to some extent type D bile duct injuries. PANCREAS P-01 Natural history of inflammatory pancreatic masses

BT-15 Successful endoscopic management of bile leak: A single center experience in a tertiary care hospital in Western India Sanjay Chandnani, Vinay Pawar, Vinay Zanwar, Nikhil Sonthalia, Ravi Thanage, Ravindra Surude, Qais Contractor, Pravin Rathi Correspondence- sanjay [email protected] Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India Background and Aims Bile leak is a rarely encountered complication commonly occurring in the setting of biliary tract surgery. This study aims to determine the impact of endoscopic and surgical management in treating symptomatic bile leak. Methods In this retrospective study of patients between 2012 and 2015, 27 patients with bile leak were identified. Site and extent of bile leak was evaluated using CECT, MRCP, ERCP. ERCP was mainly used as a therapeutic tool rather than a diagnostic tool. Apart from routine medical care, wherever feasible ERCP was used as a primary mode of definitive treatment in all our patients. Percutaneous biliary drainage was used in technically difficult cases. Results Twenty-seven patients with symptomatic bile leak were identified in aforesaid period. Bile leak in 21 (88.88%) patients was due to post-laparoscopic cholecystectomy injury, mostly to cystic duct stump and duct of Lushka, while in 6 (12.22%) patients it was associated with liver abscess. Major bile duct injury (defined as injury to CBD, CHD or ducts at porta) was seen in 10 patients with post cholecystectomy status and in 5 patients with liver abscess. Out of 27 cases, 25 (92.59%) were treated with ERCP and 2 (7.40%) with percutaneous drainage. Surgery was not required in any of the patients. Sphincterotomy with stent placement for 6 weeks was effective in 23 (92%) patients and only sphincterotomy was effective in 2 (8%) patients undergoing ERCP. There was no mortlity due to bile leak. Conclusion Most patients presenting with bile leak including major bile duct injury without complete bile duct transection can be successfully treated by endoscopic therapy without the need for surgery.

Paul K Vincent, Rajesh Gopalakrishna, Suprabha Panicker, Rama P Venu Correspondence - Rajesh Gopalakrishna- [email protected] Department of Gastroenterology, Amrita Institute of Medical Sciences, Peeliyadu Road, Ponekkara, Edappally, Ernakulam, Kochi 682 041, India Background Differentiation and characterization of pancreatic masses in setting of CP remains a clinical dilemma. The natural history of inflammatory masses is unclear with variable outcomes described by anecdotal experience and case reports. Methods We prospectively followed up patients with chronic pancreatitis with inflammatory pancreatic masses (mass forming CP) in our Pancreas clinic. Contrast enhanced CT using pancreas protocol and EUS-FNA was used to exclude malignancy. Results There were 10 patients (7 males, 3 females). The etiology was ACP in 3 and ICP/TCP in 7 patients. One patient who had previously undergone Frey’s procedure presented with a mass 15 years post surgery. Median age of patients was 40.0+/- 16.9 years. Serum CA 19-9 levels were normal (<37 units/mL) in 4 patients. Six patients were diabetic at time of diagnosis of pancreatic mass while 2 patients developed diabetes on follow up. Complete resolution was seen in 2 patients and decrease in size was seen in 1 patient. Smoking and alcohol use carried an increased risk for non-resolution. One patient developed biliary obstruction and pancreatic cancer after 8 years. Four patients who underwent pancreaticoduodenectomy were confirmed as benign masses in surgical specimen. Three of these 4 had elevated CA19-9. Of the 4 patients who developed biliary obstruction and needed biliary stenting, 1 patient who had ACP and was a smoker developed pancreatic cancer. Only 1 patient with biliary obstruction was found to have resectable mass which was confirmed as benign postoperatively. Conclusions Smoking and alcohol were predictors of nonresolution as well as development of cancer but not for biliary obstruction. Although the risk for developing diabetes in CP with inflammatory mass appears to be higher than in CP alone, diabetic status was not a predictor for non-resolution or development of cancer in this setting.

Indian J Gastroenterol

P-02 Role of thrombophilia in splanchnic venous thrombosis in acute pancreatitis Sobur Uddin Ahmed, Surinder S Rana, Jasmina Ahluwalia, Neelam Varma, Rajesh Gupta, Ravi Sharma, Mandeep Kang, Deepak K Bhasin Correspondence - Surinder Rana- [email protected] Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, Background Data on the frequency, risk factors, outcome and natural history of splanchnic venous thrombosis (SVT) in acute pancreatitis (AP) is lacking. Coagulation abnormality has been implicated but not proven as a cause of SVT in AP. Objective To study the frequency, risk factors and extent of SVT in patients with AP and the role of trombophilia in causation of SVT. Methods Patients with AP presenting to our centre between January 2015 and June 2016 were prospectively evaluated with contrast-enhanced computed tomography (CECT) abdomen for presence of SVT and were subjected to coagulation analysis. Outcome was assessed in terms of necrosis, severity, organ failure, need for intervention and mortality. Follow up Doppler was performed to look for the status of SVT. Results Ninety-six patients AP were evaluated of which 26 (27.1%) had SVT. Single, double and tripple vessels were involved in 19 (73.1%), 3 (11.5%) and 4 (15.4%) patients respectively. SV, PV and SMV were involved in 22 (84.6%), 11 (42.3%) and 4 (15.3%) patients respectively. Necrotizing pancreatitis, CTSI >6 and modified CTSI >6 were found in significantly more patients with SVT than without SVT. Coagulation analysis showed protein C, protein S and AT III deficiency in 10 (23.8%), 14 (33.3%) and 13 (31.0%) patients respectively. β2GPI and lupus anticoagulant were positive in 2 (4.8%) and 5 (11.9%) patients respectively. Anticardiolipin antibody was negative in all. Factor V Leiden mutation analysis was positive in 2 (6.1%). No correlation was found between abnormal coagulation results and outcome of AP or development of SVT. Doppler study done in 7 patients with SVT showed spontaneous resolution in 5 (71.4%). Conclusion SVT in AP is more common in patient with necrotizing pancreatitis and higher CTSI and MCTSI suggesting the role of local inflammation in its causation. Thrombophilia in some form is seen in one third of the patients with AP but does not increase the risk of SVT. P-03 To prospectively study the outcome of adult patients with acute interstitial pancreatitis, acute necrotizing pancreatitis and acute pancreatitis with extra pancreatic necrosis alone

EPN alone. Patients with EPN alone had higher occurrence of organ failure (20% vs. 0%), persistent organ failures (20% vs. 0%), and need for intervention [30% vs. 0 %] as compared to patients with AIP. Patients in PN group had higher frequency of multi organ failure (27.4% vs. 0%), persistent organ failure (72.5% vs. 20%), need for intervention (66.7% vs. 30%) and mortality (25.5% vs. 0 %) than patients with EPN alone. Similarly patients with extensive EPN (n=40) had significantly higher frequency of ascites (75% vs. 38.1%), organ failure (82.5% vs. 28.6%), multi-organ failure (35% vs. 0%) and persistent organ failure (82.5% vs. 28.6%) than patients with limited EPN. However, mortality (27.5% vs. 9.5%) and need for intervention (62.5% vs. 57.1%) was comparable in both groups. Conclusion Patients of EPN alone have a clinical course that is severe than AIP but milder than PN and hence should be considered as a separate category. Patients with extensive EPN despite having higher frequency of multi-organ failure, persistent organ failure and ascites have comparable mortality or need for intervention compared to patients with limited EPN. P-04 Characterization of biofilms adhering to indwelling pancreatic stents Chetana Vaishnavi, Rakesh Kochhar Correspondence - Chetana Vaishnavi - [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India Biofilms comprise of matrix-enclosed bacterial population which get attached to surfaces such as that of stents. We quantified the components in biofilms and analyzed predisposing factors involved in occluding pancreatic stents. Clinical details of 24 patients (M:F 15:9) with pancreatic stent retrieval were noted and stents processed for quantification of biofilm protein and polysaccharide and molecular identification of bacteria. The patients’ age ranged from 16-62 years. Cholangitis was present in 79% patients. The retrieved stent size was 5Fr (20.8%), 7Fr (75.0%) and 10 Fr (4.2%) with 90 days median insertion duration. Multiple organism were detected in several of the stents inclusive of Pseudomonas, Citrobacter, Klebsiella, Staphylococcus, Escherichia coli and several other uncultivable organisms. The mean biofilm protein was 0.58 mg/mL and polysaccharide 0.054 mg/mL and were higher in stents of patients with cholangitis. Protein was significantly lower in the 10 Fr stents. Factors such as etiology of stenting and number of microorganisms present in the occluded stents shall be analyzed and presented. P-05

Gaurav Muktesh, Surinder S Rana, Ravi Sharma, Lovneet Dhalaria, Mandeep Kang, Rajesh Gupta Correspondence- Gaurav Muktesh- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Natural history of patients with extra-pancreatic necrosis and it’s comparison with other forms of pancreatitis has been sparsely studied and hence this prospective study was planned. Methods Seventy-eight patients of acute pancreatitis were prospectively observed till clinical recovery or death. Contrast-enhanced computerized tomography of the abdomen was done after day 5 of onset of symptoms and patients were categorized into 3 groups: AIP, ANP and EPN alone. EPN was termed extensive if it extended to paracolic gutters and/or pelvis. All groups were compared with respect to outcomes (surgery/intervention, organ failure and mortality). Results 12.8% patients had interstitial pancreatitis, 65% had pancreatic necrosis (PN) alone or combined with EPN and 12.8% had

ERCP in pancreas divisum - A single center experience Allwin James, E Rabindranath, Prem Kumar Karunakaran, Kani Sheikh Mohammad, Rathnakar Kini Correspondence- Allwin [email protected] Madras Medical College, Madras Medical College, Chennai 600 003, India Introduction Pancreas divisum (PD) is the most common anomaly of pancreas seen in 5% to 10 % of general population, however only 5 % of the patients with PD become symptomatic with recurrent pancreatic pain, acute chronic pancreatitis and its complications. Here we present a study of pancreas divisum and management of its complications at our institute. Methodology All patients with pancreatitis in any form in whom imaging features suggestive of pancreas divisum were included in the study. The study period was from January 2015 to June 2016. Patients were assessed

Indian J Gastroenterol

on their demography, clinical findings, presentation, complication, type of pancreas divisum, management. Results Of the 190 patients presented with pancreatitis of any form during the study period, 10 (5%) had imaging features of pancreas divisum were included. All patients were less than 25 years of age except for two patients who were more than 45 years of age. Seven were males. Eight (80%) had type 1 PD and 1 (10%) had type 2 and 1 (10%) had type 3 PD. Eight (80%) were considered idiopathic, 1 (10%) had I GG4 related disease and 1 (10%) had significant ethanol intake. Seven patients presented with recurrent acute pancreatitis without any local complications. Three had features of chronic calcific pancreatitis and one having pseudocyst communicating with the pancreatic duct. Two (20%) had biliary strictures and 1 (10%) had pancreatic duct stricture at neck, in the of patient with ethanol related CCP and pseudocyst. Successful selective cannulation of the minor ampulla was achieved in 70% patients with stent placement. Minor ampullary endoscopic sphincterotomy was done in all patients. Conclusion Pancreas divisum is the most common anomaly of pancreas with altered anatomy of the ductal system. Type 1 pancreas divisum is the most common type in our study. Local expertise is a major factor in treating such patients. P-06 Effect of percutaneous catheter drainage of pancreatic collections on serum inflammatory markers, organ failure and outcome in acute pancreatitis Bipadabhanjan Mallick1, Narender Dhaka1, Vikas Gupta2, Thakur Deen Yadav2, Sunil K Arora3, Anupam Lal4, Saroj K Sinha1, Rakesh Kochhar1 Correspondence- Narender [email protected] Department of Gastroenterology1, General Surgery2, Immunopathology3, and Radiodiagnosis4, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Peripancreatic collection in acute pancreatitis associated with increased serum inflammatory markers and percutaneous catheter drainage (PCD) of pancreatic collections improves survival. Data is lacking, that change of inflammatory markers with PCD these collections and correlation with outcome. Methods Inflammatory markers; C-reactive protein (CRP), IL-6, IL-10 and endotoxin were measured one day before PCD, day three and seven after PCD and its trend compared with organ failure, need for additional endoscopic or surgical intervention and mortality. Results Total 59 patients who have undergone PCD included for analysis; 44 (74.5%) had severe acute pancreatitis (SAP) and 15 (25.5%) had moderately severe acute pancreatitis (MSAP). PCD was indicated for organ failure in 40 (67.7%) patients and for fever in 19 (32.3%) patients. Forty-nine (83%) patients improved with PCD, four patients required surgery and six patients died. IL-6 and IL-10 concentration was significantly higher in SAP then MSAP patients (p=0.008 and 0.016 respectively). The concentration of CRP, IL-6 and IL-10 were significantly higher with increasing number of organ failure (p<0.01). No difference in the concentration of markers between infected collection and noninfected collection. Only IL-6 level correlated with final outcome of patients (p<0.01). Significant fall of all markers noted on day three and seven after PCD (p<0.01) but these fall did not correlated with outcome. Conclusion IL-6 and IL-10 correlated with severity of pancreatitis and concentration increases with increase in number of organ failures. IL-6 concentration before placement of PCD correlated with final outcome. PCDs were associated with significant fall in concentration of CRP, IL-6, IL-10 and endotoxin but these falls did not correlated with improvement in organ failure and final outcome.

P-07 Recurrent pancreatitis due to pancreatic divisum: Role of endotherapy B Thinakar Mani, S Ratnakar Kini, K Prem Kumar, M Kani Sheikh, Thangavelu Pugazhendhi, Mohammed Ali Correspondence – B Thinakar [email protected] Institute of Medical Gastroenterology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai 600 003, India Introduction BPancreas divisum^ one of the most common congenital anomaly in which the ventral and dorsal pancreatic glands drain separately into the duodenum. It occurs mainly due to failure of fusion of the ventral and dorsal ducts during the seventh week of gestation and it is characterized by the predominant drainage via the dorsal duct of Santorini. Gonoi and co-workers concluded that PD should be considered as a predisposing factor for chronic and recurrent pancreatitis. Aim of this study is to analysis various presentation, treatment modalities and outcome of pancreatic divisum. Methods The study setting is tertiary referral centre and observational study. The subjects were people with recurrent pancreatitis with pancreatic divisum. A total of 30 patients of pancreatic divisum with recurrent pancreatitis with various age group has been studied for various type of presentation and treatment modalities and outcome. Results (Age range, 20-50 years) people with acute recurrent pancreatitits were 24/30, chronic pancreatitis 6/30, subject underwent endotheraphy were 22/30, successful endotheraphy done for 13/22, people underwent surgery for pancreatic divisum with chronic pancreatitis with failed endotheraphy (2/6). Conclusion Pancreas divisum (PD) is the most common congenital variant of the pancreas and has been implicated as a cause of acute recurrent pancreatitis and acute on chronic pancreatitis. However, endoscopic treatment is mandatory in symptomatic pancreatic divisum. Totally 30 consecutive pancreatic divisum in five-year period analyzed for various presentation and endoscopic and surgical intervention. It is our experience that minor papilla sphincterotomy offers advantages over chronic stent therapy in treating patients with pancreas divisum. Although endotheraphy preferred over surgery for acute recurrent pancreatitis in many setting to avoid major surgery with very good success rate. P-08 Role of endotherapy in management of traumatic pancreatic injury: Retrospective study B Thinakar Mani, K Prem Kumar, M Kani Sheikh, S Ratnakar Kini, Thangavelu Pugazhendhi, Mohammed Ali Correspondence- Thinakar Mani [email protected] Institute of Medical Gastroenterology, Madras Medical College, Rajiv Gandhi Government Medical College, Chennai 600 003, India Introduction The management of pancreatic injury is complex. Aim of this study is to analysis various presentation, treatment modalities and outcome of pancreatic injury in tertiary care centre Methods All patients hospitalized in tertiary care centre between 2013 and 2017 for pancreatic injury were retrospectively analyzed. Traumatic injuries of the pancreas were classified according to the American Association for Surgery of Trauma (AAST) in five grades. Mortality and morbidity were analyzed Results A total of 50 patients were analyzed. Forty-two patients had a blunt trauma and 8 patients had penetrating injury. Twenty-six patients underwent exploratory laparotomy and the other 24 patients had nonoperative management. Among the fifty patients, 10 had pancreatic injury ≥grade 3. Overall, in hospital mortality was 18%. Among the patients with grade three and more with pancreatic injury, seven patients

Indian J Gastroenterol

underwent endotheraphy, four patients had a stent placement in the pancreatic duct and three patients underwent endoscopic drainage of a pancreatic pseudocyst Conclusion Operative management of pancreatic trauma leads to a higher mortality. This must not be necessarily related to the pancreas injury alone but also to the associated injuries of major intra abdominal organ and vascular injury which may cause impaired outcome more than pancreas injury. The diagnosis of pancreatic injuries requires a high index of suspicion. The main stream of therapy for pancreatic injuries is surgical, and is determined by the grade and location of injury. However, in cases in which pancreatic main duct injury with ascites and pseudocyst require endoscopic intervention, some of the surgical resection procedures are indicated, such as distal pancreatectomy (with or without splenectomy) or cephalic duodenopancreatectomy (trauma Whipple). P-09 Role of endotherapy in management of chronic pancreatitis and its complications Chandra Shekar Patil, E Rabindranath, K Prem Kumar, M Kani Sheikh, S Ratnakar Kini Correspondence- Chandrashekar [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction In the setting of chronic pancreatitis (CP), pancreatic ductal obstruction, ductal leak, pseudocyst formation and biliary obstruction present many challenges for endoscopists and management of these complications is complex. Here we present an observational study of endotherapy in patients with chronic pancreatitis with its complications. Methodology The study was conducted from January 2015 to June 2017 at Madras Medical College. Patients diagnosed as CP with complications based on clinical, biochemical and imaging features were included in the study. Results Total of 447 patients admitted with chronic pancreatitis with pain and other complications at our centre. Among 447 cases 134 cases posted for endotherapy (male 96, 71.6% and female 38, 28.4%). Following were indications of therapy symptomatic pseudocyst communicating with MPD 58 cases (43.2%), pancreatic ascites with pancreatic pleurofistula 32 (23.8%), stricture with stones 18 (13.4%) and CBD stricture 10 (11.9%). Patients were treated with PD stent placement across the leak in pancreatic ascites/effusion and strictures dilated with retrieval of stones with stent placement in appropriate patients. CBD stricture treated with DP stent placement. In 24 (17.9%) patients could not able to cannulate PD due to various reasons and procedure aborted. Ten (7.46%) patients developed procedure related complications in which 8 had mild interstitial pancreatitis and 2 had mild bleeding managed conservatively. Conclusion Endotherapy is effective, less invasive than surgery, offers good results and is associated with low morbidity and mortality. It can be repeated and does not interfere with any subsequent surgical procedure. It is therefore advisable to offer endotherapy as the first line treatment in properly selected patients with CP.

Objective Few studies have looked into the clinical profile and outcome among patients of recurrent acute pancreatitis (RAP). The aim of this study was to evaluate the course and outcome in patients of RAP. Methods We evaluated consecutive patients of recurrent acute pancreatitis in a tertiary care center located in north India and studied their epidemiological profiles, etiological factors as well as outcome and compared visa-vis initial acute pancreatitis episode. Results Forty-five patients of RAP with mean age of 33±11 years were evaluated. Majority of the patients were male (73%) and alcohol was the most common detectable etiology while no etiology could be identified in 40% patients after extensive laboratory investigations and imaging. Mild pancreatitis was noted in majority (58%). No patient developed persistent organ failure and there was no mortality; 31% patients had necrotizing pancreatitis majority of whom had both pancreatic as well as extrapancreatic necrosis. ERCP was carried out in 6.6% patient while one patient (2.2%) was subjected to PCD insertion. Conclusion To conclude, this study demonstrated that RAP has a milder disease course and lesser morbidity and mortality as compared to the initial attack of pancreatitis. Early diagnosis and elimination of the etiological factor is essential for optimum outcome. P-11 Acute on chronic pancreatitis: Analysis of clinical profile and outcome Dibya Jyoti Sharma1, Bipadabhanjan Mallick1, Narender Dhaka1, Vikas Gupta2, Saroj K Sinha1, Rakesh Kochhar1 Correspondence- Narender Dhaka- [email protected] 1 Department of Gastroenterology, and 2 Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

P-10

Objective Few studies have looked into the clinical profile and outcome among patients of acute on chronic pancreatitis (SAP). The aim of this study was to evaluate the course and outcome in patients of acute on chronic pancreatitis. Methods We evaluated consecutive patients of acute exacerbation of chronic pancreatitis (CP) in a tertiary care center located in north India and studied their epidemiological profiles, etiological factors as well as outcome and compared with outcome in acute pancreatitis without CP. Results Forty-five patients of ACP with mean age of 37±13 years were evaluated from January 2015 to June 2016. Majority of the patients were male (75%) and alcohol was the most common detectable etiology while no etiology could be identified in 35% patients after extensive laboratory investigations and imaging. Moderately severe pancreatitis was noted in majority (73%) and 49% patients had necrotizing pancreatitis majority of whom had both pancreatic as well as extrapancreatic necrosis (33%). ERCP was carried out in 31% patient while five patients (11%) were subjected to PCD insertion. Persistent organ failure was noted in 9% patients and two (4.5%) of whom died. Conclusion To conclude, this study demonstrated that ACP has a milder disease course and lesser morbidity and mortality as compared to the initial attack of pancreatitis. Early elimination of the etiological factor is essential for optimum outcome.

Recurrent acute pancreatitis: Analysis of clinical profile and outcome

P-12

Dibya Jyoti Sharma1, Bipadabhanjan Mallick1, Narender Dhaka1, Vikas Gupta2, Saroj K Sinha1, Rakesh Kochhar1 Correspondence- Narender Dhaka- [email protected] 1 Department of Gastroenterology, and 2 Department of Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Pancreatic endotherapy in pediatric patients R B Harshavardhan, Paul K Vincent, A V Beula, P Suprabha, V P Bhanu, Rama P Venu Correspondence- Harshavardhan [email protected] Amrita Institute of Medical Sciences, Kochi 682 041, India

Indian J Gastroenterol

Background Pancreatic endotherapy with endoscopic retrograde cholangiopancreatography (ERCP) is used for several therapeutic indications in pancreatic disorders of adults. However, ERCP experience in children has been limited due to multiple factors. In this study, we have reviewed all patients who underwent pancreatic endotherapy in pediatric patients, in an effort to delineate indications, safety and long-term efficacy in terms of pain relief, hospital admissions and need for surgery. Methods This was a retrospective study done in Amrita Institute of Medical Sciences, Kochi. All patients (<18 years of age) who underwent ERCP for pancreatic disorders between January 2009 to December 2016 were studied. Data on patient demographics (age, gender, symptoms), indication and details of ERCP (therapeutics, number, endoprosthesis) and outcome were recorded in pre-designed performa. Statistical analysis was carried out using SPSS software version 20.0. Results A total of 48 patients underwent ERCP for pancreatic disorders (Mean age 11.71±4.8). Recurrent acute pancreatitis was the most common indication seen in 28 patients (58.3%). Successful cannulation was achieved in 45 patients (93.8%). Endotherapy success defined as a successful therapeutic procedure after cannulation and was achieved in 41 patients (81.4%). Older age (p-0.05) and CCP with pancreas divisum had reduced rates of endotherapy success (58%). Two (4.2%) patients had mild post ERCP pancreatitis. Twenty-nine patients (70.7%) had pain relief on follow up and only 3 (6.25%) patients required surgery. Conclusions Pancreatic endotherapy with ERCP is safe and efficacious in the pediatric population. CCP with abdominal pain and recurrent acute pancreatitis are the most common indications for ERCP in this population P-13 Endoscopic ultrasound guided tissue acquisition in patients with chronic calcific pancreatitis: Factors that can optimize diagnostic yield Arjun Prakash, B Harshavardhan Rao, Anoop Koshy, Chandrashekar Sorakhe, Rama P Venu Correspondence- Arjun Prakash- [email protected] Amrita Institute of Medical Sciences and Research Center, Kochi 682 024, India Background Endoscopic ultrasound–guided fine-needle aspiration (EUSFNA) is standard of care for the diagnosis of suspicious pancreatic lesions. However, the diagnostic yield of EUS-FNA may be significantly hampered by the presence of calcifications in chronic calcific pancreatitis (CCP) patients. We assessed the factors that impact the yield for EUS-FNA in these patients in an attempt to optimize diagnostic yield and improve patient care. Methods Retrospective study where all patients carrying a diagnosis of PDAC from January 2015 to December 2016 were identified, of which, patients who had undergone EUS-FNA were studied. All relevant data including demographics, lesion size, location, number and size of calcifications, diagnostic modality and treatment were recorded in a predesigned performa. Statistical analysis was performed using SPSS version 20.0. Results Ninety patients of PDAC were included, of which EUSFNA was performed in 34/90 (31%) patients [mean age 62.58 ±14.9 years;(M:F=1.57:1)]. Overall diagnostic yield for EUSFNA was 68%. This dropped down to 42.9% in patients with CCP (n=20) as compared to 77.8% yield in non-CCP (n=14) patients (p value <0.05). In univariate analysis, younger age, calcification size <1 cm, number less than 5, size of the tumor >2.5 cm and histology showing poorly differentiated adenocarcinoma were found to significantly improve diagnostic yield (p value <0.05). Conclusions Despite improvements in technology and technique of EUSFNA, the presence of calcifications in CCP patients significantly hampers the diagnostic yield possibly due to poor visualization and sub-optimal

access. Calcification-size less than 1 cm and number less than five along with tumorsize >2.5 cm are ideal candidates for EUS-FNA in the background of CCP. P-14 Acute pancreatitis and a fundal lesion to ponder Abhinav Kumar1, Avinash Balekuduru1, Kiran Reddivari1, Lokesh Locheruvapalli1, Ravi Kiran1, Satyaprakash Bonthala Subbaraj1 Correspondence- Avinash Balekuduru- [email protected] M S Ramaiah Hospitals, B E L M S Ramaiah Nagar, RIT Post, M S Ramaiah Nagar, Mathikere, Bengaluru 560 054, India Splenic vein thrombosis may occur after pancreatitis in 12% of the cases and can lead to left-sided portal hypertension1. Venous drainage from the spleen then occurs through the short gastric vessels, resulting in fundal varices. We report a case of acute pancreatitis with a fundal lesion. A 30-year-old man, with history of alcoholism for 10 years and sober for 3 months presented with epigastric pain for 3 months duration. He was evaluated in an outside hospital with blood investigations, computed tomogram and was referred to our hospital for further management. Investigations were consistent with acute necrotizing pancreatitis with peripancreatic fluid collection. There was a suspicion of a fundal lesion probably gastric varix on imaging. Esophagogastroduodenoscopy was done which revealed no esophageal varices, extrinsic compression in duodenum and a 2cm submucosal lesion in fundus. On probing the lesion was soft. Before glue injection, endoscopic ultrasound (EUS) was done using Pentax linear echoendoscopeEG-3870 UTK connected to a Hitachi Avius estiva ultrasound machine (2012). On EUS, there was a 2.5cm x 1.8cm hypo echoic lesion arising from muscularis propria on the greater curve. Splenic vein was partly thrombosed with normal flow in the portal vein. Using 22 Guage Wilson cook fine needle aspiration needle, transgastric puncture was made and 15 mL of hemorrhagic fluid was aspirated. Fluid analysis revealed amylase level 132600 IU/mL and Carcino embryonic antigen of 3.25ng/mL. A diagnosis of intramural gastric pseudocyst was made. A literature review revealed only few published cases of gastric intramural pseudocysts secondary to acute pancreatitis and the intramural pseudocyst can considered as a differential diagnosis for fundal varix. Reference Ahmed M, Aziz MU, Mansoor MA, Anwar S. Vascular complications in cases of acute pancreatitis - CT scan based study. J Pak Med Assoc. 2016; 66:977-89. P-15 Plasma miRNAs to distinguish benign pancreatic head mass from malignant ones Bishnupriya Chhatriya, Srikanta Goswami Correspondence- Srikanta Goswami- [email protected] National Institute of Biomedical Genomics, Kalyani, Bidhanpally, Kolkata, West Bengal 741 235, India Formation of a clinico-radiological mass, predominantly in the head of the gland is common in PDAC, while in majority of the patients, benign focal chronic pancreatitis also present as a mass. Therefore, one of the major diagnostic challenges for the clinicians is to distinguish between the benign and the malignant mass for which the treatment procedure varies radically. Therefore, considering the prevalence of the disease in India as well as in our state, the proposed study will be very important to the clinicians trying hard to bring down the impact of the disease on public health. Objective To analyze what are the changes in plasma miRNA profile between TCP and PDAC patients having benign and malignant pancreatic head and find out whether those characteristic changes have the

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potency to function as biomarkers in future, to distinguish between benign and malignant head masses. Study of differential gene expression changes in pancreatic tissues are also planned. Study Design Pancreatic tissue and whole blood is being collected from TCP and PDAC patients. Comparison of the total plasma miRNA expression pattern is being done using miRNA microarray. Similarly, we also plan to compare the plasma miRNA profile to that isolated from the pancreatic tissue and correlate with the gene expression pattern obtained from gene expression microarray. Results will be validated in another set of samples by quantitative RT-PCR. Result We have conducted a pilot study using miRNA microarray from plasma of normal individuals, TCP and PDAC patients (four samples each). We have found 24 miRNAs to be uniquely deregulated among these groups. Interestingly, 11 of these miRNAs show a progressive upregulation and one miRNA shows progressive downregulation as the disease progresses from TCP to PDAC which make them good candidates for biomarkers to be tested further. P-16 Acute pancreatitis: A study of urine trypsinogen-2 measurement as a point of car Nayana Joshi, Rishabh Jain, Gaurav Ratnaparkhi, B Sukanya, Y Raghavendra Correspondence- Nayana Joshi- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background Acute pancreatitis can often be treated successfully if diagnosed early. Serum amylaze and lipase have been used for diagnosis but neither is a definitive test. Ultrasound abdomen has a limited role. CT abdomen is most accurate noninvasive test but is expensive and not universally available. Recently a point of care test (POCT) urinary trypsinogen is available. Aims The accuracy of a new rapid urinary trypsiniogen-2 test strip was evaluated for detection of acute pancreatitis in patients with acute abdominal pain. Methods Eighty patients with acute abdominal pain admitted to emergency department were included in this prospective study. The patients were tested for serum amylase, lipase and urinary trypsinogen by dip stick method (actim pancreatitis). They also underwent US abdomen and or CT abdomen. The diagnosis was based on clinical features, raised amylase and/or lipase (two times the upper limit of normal) and diagnostic findings on CT or ultrasonography. Results The 80 patients included 61 males and 19 females in the age range of 12 years to 70 years. Sixty patients had confirmed diagnosis of acute pancreatitis (Group 1) and 20 patients had other causes of acute pain abdomen (Group 2). The actim pancreatitis was positive in 50 cases (sensitivity 85%) in group 1. It was positive in 2 cases in group 2 (specificity 95.2%). The PPV was 98% and NPV was 69%. Conclusion The POCT actim pancreatitis has a high sensitivity, specificity and PPV in diagnosis of acute pancreatitis. It may be used reliably as a point of care test at bedside to make a positive diagnosis. P-17 Endoscopic ultrasound guided transmural drainage of WOPN S Rajesh, Sudipta Dhar Chowdhury, Reuben Thomas Kurien, A J Joseph, Amit Kumar Dutta Correspondence- Rajesh S- [email protected] Christian Medical College, Vellore 632 004, India Bakground Endoscopic ultrasound (EUS) guided drainage has been widely used since it avoids the mortality and morbidity associated with radiological/surgical drainage. The success rate of endoscopic drainage

ranges from 87% to 97% with a complication rate of up to 34% and a mortality rate of 1% in various studies. Method The objective of the present study is to assess the safety and efficacy of transmural drainage of WOPN without stenting of pancreatic duct (PD). The present study was conducted at Department of Gastrointestinal Sciences, Christian Medical College, Vellore. Consecutive patients who underwent EUS guided transmural drainage of WOPN from 2015-2017 were enrolled. Baseline and procedure related data were collected. Results There were 24 patients (22 male and 2 female patients) who underwent EUS guided drainage during the above-mentioned period. Etiology of pancreatitis were being ethanol (8), idiopathic (8), trauma (3), biliary (2), hypercalcemia (2) and hypertriglyceridemia (1). The decision to use plastic/metal stent were decided based on percentage of necrotic material on EUS. If necrotic material was less than 30%, plastic stents were placed (i.e. in 17 patients) and when necrotic material was more than 30%, metal stent were used (i.e. 7 patients). Median duration before stent removal was 2.7 months (20 days-9 months). Nasocystic drain was placed in 5 patients in addition to plastic stents, 1 during initial cyst drainage and other 4 after necrosectomy. Post drainage GI bleeding happened in 2 patients, one of them requiring IR embolization of the feeding vessel and other settled with conservative management. One patient expired after 1 month of pseudocyst drainage due to ileal perforation not related to the procedure. None of the patient required ERCP for transpapillary drainage. Conclusions EUS guided pseudocyst/WOPN drainage has a high procedure success rate without the need for transpapillary drainage, with only minimal complications that can be managed easily. P-18 Diagnostic accuracy of qualitative and quantitative EUS elastography for differentiating benign versus malignant solid pancreatic mass Surinder S Rana, Ravi Sharma, Radhika Srinivasan*, Ritambhra Nada**, Rajesh Gupta***, Sobur Uddin Ahmed Correspondence- Surinder Rana- [email protected] Department of Gastroenterology, Cytology*, Histopathology**, and Surgery***, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Differentiating benign from malignant pancreatic solid mass is a diagnostic challenge. Endoscopic ultrasound (EUS) elastography allows analysis of tissue stiffness and can thus aid in solving this diagnostic dilemma. Objective To prospectively study the diagnostic accuracy of qualitative and quantitative elastography for differentiating benign and malignant masses. Methods All patients with pancreatic masses identified on cross sectional imaging (by means of computed tomography with or without magnetic resonance imaging) and seen between October 2014 and August 2016 were prospectively enrolled. After an informed consent, EUS elastography was performed with a linear echoendoscope. A stable image for at least 5 seconds was used for quantitative analysis and strain ratio estimation. Results Eighteen patients (12 Males; age range 26 years–76 years) with pancreatic head mass were enrolled. All patients had abdominal pain and 16 patients had jaundice on presentation with serum bilirubin ranging from 6 to 28 mg/dL. CECT revealed a mass in the head of pancreas ranging from 2.2 cm to 6.3 cm. Final diagnosis was: adenocarcinoma (12 patients), neuroendocrine tumor (2 patients), inflammatory mass (3 patients) and tuberculosis (1 patient). Elastography revealed hard pattern in all patients with adenocarcinoma, 1 patient with neuroendocrine tumor, 2 patients with inflammatory mass and 1 patient with tuberculosis. One

Indian J Gastroenterol

patient each with inflammatory mass and neuroendocrine tumor had mixed pattern. The mean strain ratio of patients with adenocarcinoma was 21.9±15.8, whereas in inflammatory mass it was 8.4±3.3 and in neuroendocrine tumor it was 6.4±2.5. The strain ratio in patient with tuberculosis was 14.2. There was no significant difference in the strain ratio between different groups (p=0.19). Conclusions The pancreatic adenocarcinoma have higher strain ratio on EUS elastography as compared to other causes of pancreatic mass but the difference between benign and malignant masses is not significantly different. P-19 Role of 18F-Fluorodeoxy glucose positron emission tomography/ computed tomography in the evaluation of cystic pancreatic lesions Chandan Peddapulla, S S Rana, R Srinivasan, R Gupta, R Nada, R Sharma, B R Mittal, M Kang, R Kumar, V Sharma, U Dutta Correspomndence- Surinder Singh Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background The frequent use of imaging has resulted in increased detection of cystic pancreatic lesions. There are no reliable clinical or radiologic criteria for better characterization of pancreatic cystic lesions for preoperative diagnosis. The study was planned to assess clinical and demographic profile of cystic pancreatic lesions and discriminating value of 18F-FDG PET/CT for differeniating malignant lesions from benign ones. Methods The prospective observational study was carried out from January 2016 to July 2017 in PGIMER, Chandigarh. A total of 19 patients with cystic pancreatic lesions were enrolled and underwent 18FDG-PET/CT to characterize the lesions and differentiate them into benign and malignant ones. Final diagnoses of the pancreatic lesions were based on biopsy/EUS- FNAC/clinical and radiological follow up. Results Mean age of the participants was 51.26±16.7 years of which 7 were male and 12 were female. Of 19 lesions, 11 were benign and 8 malignant. Most common clinical presentation were pain abdomen (52.6%) and loss of appetite (52.6%) followed by weight loss and nausea/and vomiting whereas 8 patients were asymptomatic. Malignant lesions were intraductal papillary mucinous neoplasm (IPMN) and solid papillary epithelial neoplasm (SPEN) two each, followed by adenocarcinoma with cystic degeneration, mucinous cystadenocarcinoma, myxoid leiomyosarcoma and renal cell carcinoma one each. The sensitivity, specificity, PPV, NPV and accuracy of 18FDG-PET based on visual analysis were 87.5%, 90.9%, 87.5%, 90.9% and 89.5% respectively. SUVmax cut off value of 2.55 obtained from ROC curve has high sensitivity (100%) and specificity (83%) for detecting malignant pancreatic lesions Conclusion 18F-FDG PET CT has good diagnostic accuracy for discriminating malignant cystic pancreatic lesions from benign ones. Visual finding of focally increased glucose uptake is a reliable criterion for pancreatic malignancy. SUVmax cut off value of 2.55 has high sensitivity and specificity for detecting malignant pancreatic lesions. P-20 Clinical profile, imaging features and role of EUS -FNA in pancreatic cystic lesions Ravi Kumar Sharma, Surinder Singh Rana, Rajesh Gupta, Radhika Srinivasan, Ritambhra Nada, Lovneet Dhalaria Correspondence- Surinder Singh Rana- [email protected]

Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Pancreatic cystic lesion (PCL) are being increasingly diagnosed because of availability of cross sectional imaging. There is paucity of data on their clinical and imaging profile from India. Methods We enrolled consecutive patients with PCL over last 2 years. Clinical and imaging features were recorded. Final diagnosis was made on basis of cytology and histopathology or follow up at least 6 month with no increase of size of cyst. Result Forty-five patients with PCL (mean age 50.07±15.15 years; 27 females) were studied. The symptoms on presentation were pain abdomen (37), loss of weight (15), loss of appetite (10), jaundice (6) and 8 patients asymptomatic. Contrast enhanced computed tomography (CECT) revealed PCL with size of 5.3±3.9cm and were located in head (27), body (8) and tail (10). On EUS, the cystic lesion were anechoic in 38 patients (unilocular in 25, macrocystic in 3 and microcystic in 10), heterogeneously echotextured in 4 patients and hypoechoic in 3 pateints. Mural nodule was present in five, calcification in cyst wall in 3, and dilated MPD in 7 patients. The mean cyst fluid amylase was 4630 ±1457 U/L, lipase 22846±9788 U/L and CEA was 92.77±28.12 ng/mL. Mucin was detected in 19 patients and cytology revealed solid pseudopapillary neoplasm (SPEN) in 3, mucinous adenocarcinoma in 3, carcinoma in 1 and granulomatous inflammation in one patient respectively. The cytological examination was non-contributory in 21 patients. The final diagnosis was: intraductal papillary mucinous neoplasm (IPMN) in 12 (6 main duct and 6 branch duct), mucinous cystadenoma in 6, serous cystadenoma in 11, SPEN in 6, pseudocyst in 3, mucinous adenocarcinoma in 3, carcinoma, granulomatous inflammation, myxoid leiomyosarcoma and adenocarcinoma in 1patient each. Conclusion PCL encompasses a wide range of pathologies with EUS and FNA with cyst fluid analysis having a moderate diagnostic accuracy. P-21 Endoscopic management in chronic pancreatitis: A single centre experience V P Krishna, Hemant K Nayak, Gaurav Pande, Samir Mohindra, Vivek Anand Saraswat Correspondence- V P Krishna - [email protected] Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Introduction Chronic pancreatitis has varied morphological complications, including intraductal stones, main pancreatic ductal strictures, distal biliary strictures, and pseudocysts. Endoscopic therapy provides a less invasive alternative to surgery. Objective To evaluate intermediate term results pancreatic endo therapy of patients with CP Methods Consecutive symptomatic patients of chronic pancreatitis (CP)±stones admitted in our unit since 2012 to July 2016 who underwent ERCP±ESWL were followed up from retrospective data base. All these patients had routinely 6-8 weeks stent exchange. Telephonic or OPD records were assessed till date. The number of sessions of ERCP, pain relief was documented. Failure of endoscopic intervention was regarded when patients didn’t achieve visual analog score (VAS) pain reduction by >3 points or required surgery after adequate therapeutic intervention. Results Data records of 84 patients (M:F; 63:21),age 31.75±13 yrs were reviewed. Mean follow up was 20.5±17 months. Fourteen (16.7%) had alcohol induced CP, 6 had structure after duct disruption (7.1%) following acute exacerbation of CP and rest had idiopathic CP (77.2%). Type A pain was seen in 70 patients. Fifty-seven had pancreatic stricture (length-13.3 ±7.2 mm) with papillary stenosis in 3, head stricture in 28, genu stricture in 17, proximal body 6, and multiple strictures in 3 patients. Thirty-nine patients had stones (10±0.6 mm) of which 22 had stones and stricture.

Indian J Gastroenterol

ESWL required in all of them with 10 requiring 2 sessions. Post ESWL complete stone clearance failed in 4 patients (10%). Cannulation failed from both major and minor papilla for 1 patient (1.2%). These 5 patients (5.9%) were referred for surgery. Minor papilla endotherapy was required for 12 (14.3%) patients. Twenty patients (23.7%) had associated distal CBD stricture with 19 of them undergoing CBD drainage and stenting. Conclusions Endoscopic drainage of CP provides excellent intermediate term results with no improvement in exocrine functions. P-22 Spectrum of EUS findings in chronic pancreatitis and unexplained pain abdomen in 2 tertiary referral hospitals in the state of Telangana, Department of Gastroenterology and Hepatology, MaxcureHospitals and Continental Hospitals, Hyderabad M Asha Subbalakshmi, Abdul Wadood Ahmed, T Vinod Kumar Correspondence- Asha Subbalakshmiu [email protected] Maxcure Hospitals, Madhapur, Hyderabad, Telangana, Continental Hospitals, FinancialDistrict, Hyderabad 500 032, India Aim To study the spectrum of EUS findings in chronic pancreatitis and unexplained pain abdomen in 2 tertiary referral hospitals in the state of Telangana, Department of Gastroenterology and Hepatology, Maxcure Hospitals and Continental Hospitals, Hyderabad. Methods This prospective study between January 2015 and July 2017 analyzed the EUS findings of patients with previously known pancreatitis and patients with unexplained pain abdomen using Olympus EUME1 linear echoendoscope under monitored anesthesia care. EUS findings were scored according to Rosemont Criteria. Results Three hundred and five patients with chronic pancreatitis and patients with unexplained pain abdomen with normal MRCP and CECT abdomen were studied. Male: Female ratio was 1.9:1. Age range -15 to 85, mean age:35 years. 57.4% (n=175) patients were Indians and 42.6% (n=130) international patients mainly from Middle East and Africa. EUS findings were consistent or suggestive of pancreatitis in 93.4% (n=285) and normal in 6.5% (n=20) patients. EUS features were classified in the basis of Rosemont criteria. Dilation and increased MPD wall echogenicity were the most frequent ductal abnormality, irregular echogenic strands, accentuated lobular pattern, small parenchymal cysts (>2 mm) were the parenchymal abnormalities. Etiology of pancreatitis was classified on the basis of history, blood analysis, radiological and EUS findings. The etiology was alcohol (46.5%, n=142) biliary CBD stones and strictures (39.6%, n=121), autoimmune (6.8%, n=21), pancreas divisum (3.9%, n=12), idiopathic (1.9%, n=6) and traumatic (0.6%, n=2). MRCP and CECT normal in 122 (40%). Conclusion 1. EUS is the investigation of choice for pancreatic pathology early pancreatitis presenting as unexplained pain abdomen. 2. The most common feature consistent with pancreatitis as seen on EUS is MPD dilatation. 3. Commonest etiology of pancreatitis in our study was alcohol consumption. P-23 Efficacy of EUS guided metal versus plastic stent for transmural drainage of peripancreatic fluid collection: Experience from a tertiary care centre Hemanta Kumar Nayak, Alok Kumar, V P Krishna, Gaurav Pande, Vivek Anand Saraswat, Samir Mohindra Correspondence- Samir Mohindra- [email protected] Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Aims and Background Endoscopic ultrasonographic guided (EUS) guided transmural drainage of pancreatic pseudocyst and walled

of pancreatic necrosis (WOPN) by using either double-pigtail (DP) plastic stents or fully covered biflanged self-expanding metal stents has been successfully demonstrated in previous studies. This retrospective study evaluated the impact of type of stent on clinical outcome, success rate, adverse events of peripancreatic fluid collection, as such data are scanty from India. Methods Retrospective review of prospectively maintained hospital records of consecutive patients undergoing EUS guided drainage of PPC from January 2013 to March 2017 was undertaken. Results A total of 43 (pseudocyst: 23, WOPN: 20) patients were analyzed. Forty-three patient (31 males), median age of 38 years (range, 20–68), underwent EUS guided drainage of peripancreatic fluid collection with 100% technical success. Initially, DP plastic stent was used in 30 and double flanged self-expanding metal stents in 13 and with additional endoscopic nasocystic drainage (ENCD) in 33 patients (75%). Eleven patients (11/13, 84%) in double flanged self-expanding metal stents had complete cyst resolution, 1(1/13) in each required surgical necrosectomy and additional percutaneous PCD placement. Twenty-six patient (26/30, 86%) had complete resolution of cyst, with 2 patient required additional PCD placement, one (1/30) in each required surgical necrosectomy and double flanged self-expanding metal stent placement. Complications (n=6, 13%) included persistent of cyst (6), recurrence (1) stent occlusion and migration (4), bleeding (2), perforation (1). All the stents were removed at a variable period of 3-6 month. Conclusion In patients with peripancreatic fluid collections, EUS-guided drainage was technically successful in 100% cases. Peripancreatic fluid resolution equal in both DP plastic stent and biflanged metal stent group. This study doesnot support routine placement of biflanged metal stents for transmural drainage of peripancreatic fluid in financial constraint countries like India. However large randomized trials are needed to justify the use of metal stents for PFC drainage. P-24 Symptomatic pancreatic fluid collection - An insight and managing the endoscopic way….! Mamata Sanjay Lotlikar, Vikas Pandey, Meghraj Ingle, Prabha Sawant Correspondence- Mamata Sanjay [email protected] Department of Gastroenterology, Lokmanya Tilak Muncipal Medical College and Hospital, Mumbai 400 022, India Introduction and Aims Inflammatory pancreatic fluid collections (PFC) are classified into acute peripancreatic fluid collection (APFC), pseudocyst, acute necrotic collection (ANC) and walled off necrosis (WON) according to revised Atlanta classification 2013. Our aim was to study the etiology, clinical profile and outcome of management in patients with symptomatic PFC. Methods We prospectively evaluated 68 patients with clinical and laboratory evaluation suggestive of acute or chronic pancreatitis and radiological evidence of PFC over a 15 month period (August 2015-December 2016) at tertiary care hospital in India and followed them for 3 months. Results Out of the 68 cases, 85% were males and 59% were in the age group of 20-40 years. Abdominal pain (100%) and significant weight loss (44%) were common presentations; etiology most common being alcohol (50%) followed by idiopathic (22%) and trauma (11.7%). 38.23% patients had acute necrotising pancreatitis, whereas 35.29% had acute interstitial pancreatitis and 26.47% chronic pancreatitis. We observed pseudocyst in 57.35% patients, WON in 17.6%, AFPC in 10.32% and ANC in 14.72%. Endoscopic ultrasound-guided drainage was performed in 26 patients (38%); of which 7 required further interventions like nasocystic drainage (3), necrosectomy (1), percutaneous drainage (4). Pancreatic duct (PD) stenting was done in 10 (14.7%) patients. Technical success was seen in 100% and clinical success in 96.2%

Indian J Gastroenterol

patients at 3 months in the endoscopic drainage group. All patients with PD stenting had clinical success at 3 months. Mortality due to sepsis was observed in one patient with necrotizing pancreatitis. Overall clinical response was 94.2% irrespective of mode of management. Conclusions Pseudocyst followed by walled off necrosis are the commonest causes of symptomatic inflammatory pancreatic fluid collections; majority associated with acute interstitial and necrotising pancreatitis. They can be successfully managed endoscopically with minimal complications. P-25 Expression of Notch and Hedgehog associated microRNAs in pancreatic ductal adenocarcinoma Safoora Rashid, Sumaira Rashid, Surabhi Gupta, * N R Dash, ** Hemchandra Sati, ***Shyam S Chauhan, Anoop Saraya Correspondence- Anoop [email protected] Department of Gastroenterology, * Gastrointestinal Surgery, ** Biostatistics, ***Biochemistry, All India Institute of Medical Sciences, New Delhi 110 029, India Introduction The role of circulating microRNAs (miRNAs) as noninvasive biomarkers has been elucidated for diagnosis, prediction and prognostication of many cancers. Pancreatic ductal adenocarcinoma (PDAC) is a lethal malignancy with a 5-year survival rate of less than 4%. The overexpression of many signal transduction pathways like Notch and Hedgehog pathway has been found in PDAC involving a number of miRNAs. Therefore diagnosis of this lethal malignancy at an early stage is crucial for improving the outcome. The purpose of this study was to see if these microRNAs can be used for early detection of PDAC Methods Circulating miRNA was extracted from serum of patients with PDAC (n=105), chronic pancreatitis (CP) [n=31] and healthy controls (n=36) using Exiqon’s miRNA isolation kit. A set of three miRNAs associated with notch and hedgehog pathway i.e. miR-25, miR-107 and miR-326 were selected using different miRNA databases and on the basis of their expression in different cancers. Relative miRNA expression was analyzed using q-PCR. Appropriate statistical tests were used. A p-value of <0.05 was considered statistically significant. Results Mean age of patients with PDAC, CP and healthy controls was 55.9±12.0, 37.3±11.9 and 38.9±14.8, respectively. miR-25 was found to be significantly overexpressed in PDAC compared to CP. In contrast, the levels of miR-107 and miR-326 were found to be significantly decreased in PDAC as compared to healthy controls. It was also found that the levels of all these miRNAs were significantly reduced in CP than that of healthy controls. Additionally miR-326 levels were significantly decreased in PDAC compared to CP. Conclusion miR-25, miR-107 and miR-326 circulating levels can be used as differentiating markers in patients with benign and malignant disease of pancreas i.e. CP and PDAC respectively. Since these markers can be measured in serum, so they can be used as non-invasive biomarkers for early detection of PDAC. P-26 Long-term outcome of PD disruption managed by endoscopic sphincterotomy or transpapillary stenting Mayank Agarwal, K Arivarasan, Alok Mantri, Shiva Kumar Varakanahalli, V Krishnapriya, Sukrit Sood, Ankush Pawar, Manish Gupta, Bimal Sahu, Ashok Dalal, Ajay Kumar, Siddharth Srivastava, Sanjeev Sachdeva, Amarender Singh Puri Correspondence- Amarender Singh [email protected] G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Aim To study long-term outcome of patients with PD disruption presenting with pancreatic ascites, pancreatico-pleural fistula or organized fluid collection managed by endoscopic transpapillary stent insertion or endoscopic sphincterotomy. Materials Patients presenting with pancreatic ascites or pancreaticopleural fistula or with organized pancreatic fluid collection underwent ERCP. Endoscopic management consisted of either PD sphincterotomy or PD stenting. Long-term results were obtained by evaluating patients prospectively with ultrasound, CT, ERCP and clinical examination. Therapeutic success was defined as clinical resolution of ascites, fluid collection or fistula, and resolution of the PD disruption at the final ERCP. Results Of the 47 patients included 70% had acute pancreatitis. Males predominated with 87% (M:F, 6.7:1). Most cases were due to alcohol (40%). Idiopathic biliary and traumatic cases constituted 34%, 10% and 15% respectively. Among these 34% had pancreatic ascites, 19% pancreatico-pleural fistula and 68% an organised fluid collection. PD cannulation was done in 46 (98%). Forty-three (93%) patients had evidence of PD disruption. Most common site of leak was the genu at 30% followed by tail and body at 25% each. The head (7%) and neck (5%) were uncommon sites. Forty-four patients were initially treated endoscopically, 2 surgically and 1 managed conservatively. Of the patients managed endoscopically 25 (57%) underwent PD stenting and across the leakage in 11 of them. Nineteen (43%) underwent PD sphincterotomy. Only 3 patients required surgical management due to failure of endotherapy. DPTS was placed in 3 (6%), SEMS in 2 (4%) and PCD in 9 (19%) patients. Mean duration of follow up was 12.4 months. Nine patients were lost to follow up and 3 expired. Mean duration between ERCP and relief of symptoms was 6 weeks. Conclusion Endoscopic management of pancreatic duct disruption is a safe and effective method in situations where leak is demonstrable. P-27 Rare earth nanoparticles abates acute pancreatitis by modulation of p65-NFkB and inhibits pancreatic fibrosis by suppressing epithelial to mesenchymal transition Amit Khurana, Mohd Aslam Saifi, Chandraiah Godugu Correspondence- Chandraiah [email protected] Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad 500 037, India Introduction To assess the pharmacological potential of nanoceria in Cerulein induced acute pancreatitis (AP) and L-Arginine and Cerulein induced chronic pancreatitis (CP). Methods Nanoceria was well characterized by particle size analysis, FTIR, SEM and pXRD. The animals were treated with nanoparticles at two dose levels (0.2 and 2.0 mg/Kg). The anti-AP effects were assessed by measurement of serum amylase and lipase levels whereas the antifibrotic effect of nanoceria in CP was assessed by hydroxyproline level estimation. The oxidative stress parameters (MDA, GSH and NO), proinflammatory cytokine profile (IL-1B, IL-6, IL-17, p65-NFkB, TGF-B1 and TNF-a) were estimated by ELISA method. Pancreatic fibrosis in CP was quantified by picro Sirius red staining. In addition, EMT inhibition was studied by multiplex analysis of TGF-B pathway. Results Interestingly, in case of AP we observed significant improvement in serum amylase and lipase levels (p<0.01) after treatment with nanoceria. Moreover, in case of CP the levels of fibrotic marker hydroxyproline were impressively reduced in nanoceria treated rats (p<0.01). In both AP and CP models, nanoceria could significantly attenuate the levels of oxidative stress markers (MDA, GSH, NO) and inflammatory cytokines (IL-1B, IL-6, TNF-a). The levels of EMT markers in TGF-β

Indian J Gastroenterol

pathway were significantly reduced in CP. Immunohistochemistry for CD-31, MPO and nitro-tyrosine in AP mice showed improvement by nanoceria intervention. The picro Sirius red staining and TUNEL assay in CP study exhibited ameliorative effect of nanoceria on pancreatic fibrosis (p<0.001) and apoptosis respectively. Estimation of nuclear levels of p65-NFkB in AP mice and CP rat pancreas revealed the inhibition of NF-kB activity. In addition, immunohistochemical analysis of alphaSMA, Vimentin and fibronectin further supported the results. Conclusion We, to the best of our knowledge, report for the first time that nanoceria can significantly reduce AP and pancreatic fibrosis and holds a substantial potential for therapy of pancreatitis. P-28 Sustained release curcumin microparticles for effective treatment of acute pancreatitis and type 1 diabetes mellitus Chandraiah Godugu1, Anchi Pratibha1, Amit Khurana1, Debasish Swain2, G Samanthula2 Correspondence- Chandraiah [email protected] 1 Department of Regulatory Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad 500 037, India, and 2 Department of Pharmaceutical Analysis, National Institute of Pharmaceutical Education and Research (NIPER), Balanagar, Hyderabad 500 037, India Introduction To assess pharmacological potential of sustained release curcumin microparticles (CuMPs) in cerulein induced acute pancreatitis (AP) (1 day study) and multiple low doses of Streptozotocin (MLD-STZ) induced type 1 diabetes model (T1DM) (28 days study). Methods PLGA loaded CuMPs were formulated and characterized by DSC, FT-IR, optical microscopy, SEM and HPLC. The animals were treated with CuMPs at one dose level in AP and at two dose levels (single and repeated dose) in T1DM. AP was evaluated by serum amylase and lipase levels and T1DM by glucose and insulin estimation and intraperitoneal glucose tolerance test (IPGTT). Cytokines (IL-1β, IL-6, TNF-α) were assessed by ELISA. Histopathology was observed by Hematoxylin & Eosin staining and protein expression by western blotting and immunohistochemistry (IHC). Results Optical microscopy studies indicated that CuMPs had an average diameter of 14±3 μm. SEM studies indicated that microparticles had a smooth, spherical morphology with 28% (w/w) loading and 86% entrapment efficiency. Microparticles sustained the release of curcumin over a 4-week period. CuMPs showed superior decrease of serum amylase and lipase levels, compared with free form of curcumin in AP and significantly reduced diabetogenesis (16.6% and 14.4%) in comparison to diabetic control (100% diabetes) and improved glucose levels in T1DM. We observed better alleviation of oxidative stress (MDA, GSH and NO) with CuMPs in comparison to oral curcumin. Moreover, CuMPs impressively decreased levels of inflammatory cytokines (IL-1β, TNF-α). Histomorphology was reverted in treatment with CuMPs when compared with the free form in both models. IPGTT, insulin ELISA and IHC for insulin showed significant improvement of β cell mass. Western analysis revealed the involvement of Nrf-2 behind the therapeutic effects. Conclusion The sustained tissue concentrations of curcumin by using CuMPs may prove to be a significant step in the translation of the preclinical efficacy of curcumin to the clinic. ENDOSCOPY ES-01 Self expanding metallic stents placement-A tertiary care experience N Radhakrishnan, E Rabindranath, M Kani Sheikh, S Ratnakar Kini, K Prem Kumar

Correspondence- Radhakrishnan Natarajan [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Esophageal cancer is often diagnosed at an advanced stage, with many patients having locoregional or metastatic disease at the time of diagnosis. Endoscopic treatment modalities like esophageal self expanding metallic stents (SEMS) placements had been a major landmark in the management of advanced esophgeal cancer leading treatment efforts to focus more on palliation like relieving dysphagia, managing oropharyngeal secretions, reduce aspiration risk, and maintain caloric intake orally. Aim To study the series of cases of esophageal cancer managed by endoscopic placement of esophageal SEMS and observe their outcomes, which were done in our centre during the period of January 2015July 2017. Methods Totally 36 cases of esophageal cancer with varied indications which presented to our centre during January 2015-July 2017 were managed by endoscopic esophageal SEMS placement and their outcomes were observed. Results Out of 36 cases, 24 were males and 12 were females. Indications.1—Locoregional spread—A-Vertebral and Vascular involvement—23 cases. B-Tracheoesophageal fistula—8 cases. 2— Metastasis——5 cases. Site of involvement—A—Between 19— 25cm—6 cases—Squamous cell carcinoma. B—Between 25—33cm— 30 cases—Adenocarcinoma. SEMS used———NITI-S covered stent in all cases. Follow up results -2 months—A—27 cases did better. B——3 cases expired. C—4 cases had distal migration—repositioined D—2 cases had tumor ingrowth— TELESEMS done. Conclusion Esophageal stenting thus proved to be a safe and effective tool in treating advanced cases of esophageal cancer. Recent advances in stent technology have reduced peri- and postprocedural complications, resulting in improved quality of life for the patients. Esophageal stents have also become the therapy of choice for palliation of dysphagia with further investigation aimed at providing continued and prolonged relief of symptoms. ES-02 Use of self-expanding metal stent in management of benign esophageal diseases such as perforations, fistulas and anastomotic leaks Anoop John1, Reuben Thomas Kurien1, Deepu David1, Amit Kumar Dutta1, Ebby George Simon1, A J Joseph1, Vijay Abraham2, S Inian2, Sudipta Dhar Chowdhury1 Correspondence- Anoop [email protected] 1 Department of Gastroenterology, Christian Medical College, Vellore 632 004, India, 2Department of Surgery (Upper GI), Christian Medical College, Vellore 632 004, India Introduction Placement of self-expanding metal stents (SEMS) has emerged as a minimally invasive treatment option for esophageal ruptures and leaks. The aim of the present study was to assess the role of SEMS for the management of benign esophageal diseases such as perforations, fistulas and anastomotic leaks. Methods Between May 2012 and February 2017, 36 patients underwent esophageal stenting of which 28 of them were for benign indications. Patients with esophageal tumor overgrowth and malignant stricture were excluded. A data analysis was done into their specific indications, type of stents used, duration, complications and outcomes. Results Indications for SEMS placement included anastomotic leaks 50% (n=14), fistulas 28 % (n=8) and perforations 21% (n=6). Fully covered SEMS (FCSEMS) was placed in all except in 6 who had a partially covered (PCSEMS) placement. Stent placement was successful in all

Indian J Gastroenterol

patients (n=28). Five patients did not report for follow up after stenting. Amongst the patients on follow up, 82 % (19/23) had healing of mucosal defect. Two patients had reactive hyperplasia within the PCSEMS, which made endoscopic removal difficult, and they required surgical removal. One patient did not have healing of her congenital fistula and required surgery for the same. Another patient presented to emergency with hematemesis 5 weeks after stent placement. Endoscopy revealed dehiscence of anastomosis and displacement of stent in the mediastinum. Intraop the stent was noted to have injured left subclavian artery which required vascular repair. Stent migration occurred in 3 (13%) patients who required repeat stent repositioning and clipping? Conclusion Covered stent placement for a period of 8 weeks is a safe and effective treatment for esophageal perforation and fistulas. ES-03 Can narrow band imaging predict duodenal histology in celiac disease? A prospective double blind pilot study Saroj K Sinha, Pradeep K Siddappa, Jahangeer Basha, Kim Vaiphei, Kamal K Prasad, Sreekanth Appasani, Neha Berry, Munish Ashat, Kartar Singh, Rakesh Kochhar Correspondence - Saroj Kant Sinha- [email protected] Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Introduction Celiac disease (CD) is characterized by varying degrees of villous atrophy. Image enhancement with narrow band imaging (NBI) delineates villous patterns better than routine endoscopy. Hence, this study was conducted to compare the diagnostic accuracy of NBI with histopathology in predicting the duodenal villous morphology in CD. Methods Amongst the 220 subjects (mean age-28.04±12.57 years, 124females) included in the study, 147 were suspected to have CD (serology positive), 47 were follow up patients on gluten-free diet and 26 had dyspepsia with no evidence of CD on complete evaluation. CD was diagnosed on the basis of modified European Society for Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) criteria. They underwent esophagogastroduodenoscopy (EGD) with duodenal biopsies along with NBI using an Olympus GIF-180 gastroscope to evaluate the villous pattern of duodenal mucosa. Villous patterns on NBI were classified into normal-villous pattern (NVP), distorted and bluntedvillous pattern (DVP) and absent-villous pattern (AVP). Histopathology was graded according to modified Marsh criteria. NBI findings were correlated with histopathology. Chi-square test was used for statistical analysis. Results The NBI pattern in controls was NVP in 25, DVP in 1 with none having AVP, while on histopathology, all 26 had no villous atrophy. In those with CD (CD suspected and follow up, n=194) 95 had AVP, 72 had DVP and 27 had NVP on NBI, while on histopathology 98 had total villous atrophy, 77 had partial villous atrophy and 19 had no villous atrophy. Scalloping and grooving was seen in in 74.7% of CD subjects. Significant correlation was observed between NBI and histopathological examination (correlation coefficient 0.797, p<0.001). The overall sensitivity and specificity of NBI for delineating villous pattern were 93.71% and 88.89%, and the positive and negative predictive values were 97.04 % and 78.43% respectively. Conclusion NBI can predict villous atrophy with high sensitivity, specificity and positive predictive value in CD. ES-04 Prevalence of ultrashort segment celiac disease among North Indian patients with celiac disease Saroj Sinha, Pranab Maiti, Kaushal Prasad, Anmol Bhatia, Neha Berry, Narendra Dhaka, Ishani Jhamb, Rakesh Kochhar

Correspondence - Saroj Kant Sinha- [email protected] Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Introduction Ultrashort celiac disease (USCD) is an emerging concept when first part of duodenum is the only site of villous atrophy in newly diagnosed celiac disease (CD). The aim of this study was to assess the importance of D1 biopsy in diagnosing CD in adults and to study prevalence in North Indian patients. Methods Patients with history suggestive of malabsorption (chronic diarrhea, weight loss, iron deficiency anemia) or serologic suspicion of CD (positive IgA tTG) attending PGIMER, Chandigarh from October 2016 to May 2017 were enrolled in the study. We performed hemogram, biochemical parameters and IgA tTg for all patients. Esophagogastroduodenoscopy was done in all patients where the first (D1) and second part (D2) of duodenum were initially evaluated with white light followed by narrow band imaging. Biopsies were obtained from D1 and D2 in separate containers. Clinical data from patients diagnosed with USCD was compared with patients with conventional celiac disease (CCD) (villous atrophy beyond D1). The number of intraepithelial lymphocytes (IELs) were compared between D1 vs D2 in patients with CD. Results Total 48 patients (28 females, 20 males) were included in this study. Of these 5 patients were found to have evidence of USCD, giving a prevelance of 10.4%. The average age of patients in USCD group was 24.40±8.44 years and in the CCD group was 28.80±11.53 years (p=0.405). Although the tTg titres were higher in the CCD group (93.02±9.35 IU/mL) than the USCD group (40.80±22.03 IU/mL), this did not reach significance (p=0.074). IELs in the USCD and CCD groups were 60.80±39.23 and 83.07±32.16 in D1 (p=0.158), and 44±10.10 and 81.51±30.89 in D2 (p=0.010). Conclusion Prevalence of USCD in North Indian patients with CD was found to be 10.4%. A bigger sample size will more clearly bring out the differences in profile of USCD and CCD. ES-05 Retrospective analysis of endoscopic findings in patients presenting with dysphagia Shivam Sachan, V K Dixit, S K Shukla, S K Singh, Gaurav Garg Correspondence – V K Dixit- [email protected] Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background Dysphagia is one of common complaints for which esophagogastroduodenoscopy (EGD) evaluation is necessary. In this study we analyzed the endoscopic findings of patients with dysphagia and its utility as a initial test. Aims and Objectives To analyze the initial endoscopic findings in patients presenting with dysphagia. Methods This is a retrospective analysis of patients who underwent EGD for dysphagia and was retrieved from the database of endoscopy unit. Patients who had undergone prior esophageal evaluation, or who had a history of prior upper GI pathology were excluded. Results A total of 400 patients with dysphagia (mean age 45.2 years, M:F 3:2) were analyzed. Abnormal findings at EGD were found in 52.5% (210) of the patients, and a significant pathology was seen in 37.5% (150). Male gender (p=0.0001), heartburn (p=0.0001), and odynophagia (p=0.0001) were associated with the presence of major pathology. Malignant strictures were found in 17.5% (70) of patients and was associated with male gender (p=0.001), age (p=0.01), and weight loss (p=0.03). Benign strictures were found in 11.2% (45), GERD was found in 7.5% (30) of patients, Dilated esophagus was seen in 1.25% (5) patients, other findings were seen in 15% (60) of patients. The esophagus

Indian J Gastroenterol

was normal in 47.5% (190) of patients and was predicted by female gender (p=0.001) and the absence of heartburn (p=0.004). Conclusions EGD is a useful diagnostic tool for initial evaluation of dysphagia. ES-06 Inoperable hepatobiliary malignancy: Role of endotherapy B Thinakar Mani, M Kani Sheikh, S Ratnakar Kini, K Prem Kumar, Thangavelu Pugazhendhi, Mohammed Ali Correspondence- B Thinakar Mani- [email protected] Institute of Medical Gastroenterology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai 600 003, India Introduction Endoscopic biliary stenting has become a standard palliative treatment for obstructive jaundice due to malignancies of the pancreas and the hepatobiliary system. Recently the introduction of self expandable metal stents (SEMS) has significantly improved the duration of stent patency and increases the life expectancy but the cost is relatively higher. Aim of this study to analysis various presentation, treatment modalities includes endoscopic and surgical in inoperable hepatobiliary and pancreatic malignancies Methods The study setting is Tertiary referral center and observational study. The subjects were People with inoperable hepatobiliary and pancreatic malignancies. A total of 80 patients of inoperable hepatobiliary and pancreatic malignancies with various age group has been studied for Type of presentation and treatment modalities and outcome Results (Age range, 35-86 years) people with hepatobiliary and pancreatic malignancies were 80 over periods of three years. Among 80, people with inoperable hepatobilary and pancreatic malignancy were 36. Among inoperable patients cholangiocarcinoma were 12, pancreatic malignancy were ten, gallbladder malignancy six, hepatocellular carcinoma with biliary infiltration were four, colonic malignancy with liver secondaries presenting us obstructive jaundice 2, renal cell carcinoma with biliary infiltration one, neuroendocrine tumor with obstructive jaundice one. Among 36 patients twenty three patients underwent biliary metal sems, 7 patients undergone PTBD (percutaneous transhepatic biliary drainage), five patients underwent palliative diversion surgery. Conclusion Biliary stents have been used in various malignant and benign biliary obstructions. SEMS has been traditionally used for inoperable malignant biliary obstructions. Regardless of the number of stents deployed, drainage of more than 50% of the liver volume is important for longer patient survival, and endoscopic bilateral metallic stenting could be the preferred treatment for inoperable hepatobiliary and pancreatic malignancies. ES-07 Yield of colonoscopy with biopsy in the evaluation of chronic diarrhea Dharshan Channaiah, Kani Shaik Mohammad, Ratnakar Kini, K Prem Kumar Correspondence- Dharshan Channaiah [email protected] Institute of Medical Gastroenterology, Madras Medical College and Rajiv Gandhi Government General Hospital, Chennai 600 003, India Introduction Colonoscopy is widely used for the workup of chronic unexplained diarrhea. However, the prevalence of chronic diarrhea from a colonic disease and the value of colonoscopy with biopsy in daily practice has not been extensively explored. Mehods Patients with chronic diarrhea (loose stools and frequent bowel movements for atleast four weeks) were examined with colonoscopy and

biopsy sampling for systematic histologic examination; even in patients with a normal-appearing mucosa. Patients with the following were excluded: a diagnosis of HIV infection/AIDS, previous colon surgery, known inflammatory bowel disease. Results A total of 309 patients were included (171 female, 138 male, mean age 52 years). Colonoscopy was normal in 246 patients (79.6%). Among them histopathological analysis showed, microscopic colitis (lymphocytic colitis and collagenous colitis combined) in 18 (6%), nonspecific changes in 52 (16.8%) and normal mucosa in remaining 176 patients. 63 patients (20.4%) had abnormal colonoscopy findings, mainly tuberculosis in 19 (6.1%), colonic malignancy in 16 (5.2%), ulcerative colitis in 12 (3.9%), parasitic infections in 10 (3.2%), Crohn’s disease in 4 (1.3%), eosinophilic colitis in 2 (0.6%). Colonoscopy with systematic biopsy sampling allowed making a specific diagnosis in 81 patients (26.2%). Conclusion Colonoscopy with systematic biopsy sampling is very useful in the study of patients with chronic diarrhea, since it established a specific diagnosis in 26.2% of patients. 6% of patients were also diagnosed with microscopic colitis, all of them with normal mucosa. It is necessary to consider random colonic mucosal biopsy in all patients of chronic diarrhea with normal colonoscopy findings. ES-08 Evaluation of multiplex PCR for rapid diagnosis of gastrointestinal tuberculosis Sarthak Malik, Kusum Sharma, Kim Vaiphei, Neha Berry, Narendra K Dhaka, Rakesh Kochhar, Saroj K Sinha Correspondence- sarthak malik- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aims and Objectives Prompt and accurate diagnosis of gastrointestinal tuberculosis (GITB) is highly challenging. Current conventional techniques like smear, histopathology and culture lack sensitivity and are time-consuming. Aim of the current study was to evaluate the role of Multiplex PCR for the diagnosis of gastrointestinal tuberculosis. Materials It was a prospective study conducted from July 2015 to November 2016. Cases of clinically suspected GITB more than 18 years of age were recruited. All patients underwent mantoux test, CECT abdomen, esophagogastroduodenoscopy or colonoscopy. Multiple biopsies for tissue diagnosis were taken from the lesions by a single observer. All specimens were subjected to Ziehl-Neelsen staining for detection of acid fast bacilli. Tissues obtained were analyzed by H&E by two independent histopathologists. Multiplex PCR using specific primers against IS6110, MPB64 and Protein b was also performed. The performance of the assay was assessed using a composite gold standard for diagnosis of tuberculosis, which comprised a combination of clinical characteristics, microbiology smear showing acid fast bacilli, bactec culture, histopathology showing caseous necrosis with granulomatous inflammation and response to antitubercular therapy. Results A total of 55 cases of clinically suspected GITB were recruited. A final diagnosis of tuberculosis was made in 32 cases. The sensitivity, specificity, positive predictive value and negative predictive value of histopathology for diagnosis of tuberculosis was 53.13 %, 100%, 100% and 59.46% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of Ziehl-Neelsen staining for diagnosis of tuberculosis was 36.6 %, 100%, 100% and 56.8% respectively. The sensitivity, specificity, positive predictive value and negative predictive value of multiplex PCR for diagnosis of tuberculosis was 86.33 %, 100%, 100% and 86.2% respectively. Conclusion Multiplex PCR has a higher sensitivity compared to conventional techniques for the diagnosis of gastrointestinal tuberculosis.

Indian J Gastroenterol

ES-09 Argon plasma coagulation in the management of gastrointestinal hemorrhage: Experience from a tertiary referral centre Rabindranath Eswaran, D Allwin James, K Premkumar, Ratnakar Kini, Kani Shaik Mohammad Correspondence- Rabindranath Eswaran- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Argon plasma coagulation (APC) is a noncontact electrocoagulation device which uses high-frequency monopolar alternating current conducted to target tissues through ionized argon gas (argon plasma). Tissue desiccation leads to loss of electrical conductivity at the tissue surface, so that the plasma stream shifts to adjacent non-desiccated (conductive) tissue, which limits the depth of tissue injury. Endoscopists experienced with APC generally find it helpful for targets that are difficult to reach by direct contact, for treating multiple lesions at the same session, with lack of smoke and safety as key advantages. Methods Retrospective data analysis of 49 patients was done who underwent endoscopy guided APC for various gastrointestinal (GI) lesions who were admitted in Institute of Medical Gastroenterology, Madras Medical College between February 2014 and February 2017. Criteria for APC application were endoscopic GI lesion with history/ evidence for bleeding and anemia. Results In our study, there were 30 female cases (61.23%) and 19 male (38.77%). Mean age of the cases were 52.6 years (range: 23-85 years). The various GI lesions were radiation colitis (36.73%), GAVE (26.53%), angioectasia (26.53%), tumor bleed (6.12%), Dieulafoy's lesion (2.04%) and telangiectasias in Osler-Weber-Rendu disease (2.04%). Thirty-six patients (73.5%) required transfusions for severe anemia before APC. The colorectal allocations of the radiation colitis were proctitisproctosigmoiditis in 14 patients (77.78%) and only sigmoiditis in 4 patients (22.22%). The most frequent endoscopic evidence of radiation colitis was telengiectasia. The etiology for GAVE lesions were cirrhosis liver (76.92%), systemic sclerosis (15.38%) and idiopathic (7.69%). APC’s success rate in achieving hemostasis is very high and complication rate is very low. Only 2 cases (4.09%) had minimal complications as abdominal distension, anal, rectal and abdominal pain. Conclusion In our experience, APC is feasible, effective and safe in routine practice to manage bleeding GI lesions. ES-10 Narrow band imaging guided biopsy improves the yield of histology for the diagnosis of gastrointestinal tuberculosis Sarthak Malik, Kim Vaiphei, Kusum Sharma, Abin Koshy, Neha Berry, Narendra K Dhaka, Rakesh Kochhar, Saroj K Sinha Correspondence- Sarthak Malik- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim To compare the utility of narrow band imaging with magnification versus high definition white light imaging guided endoscopic biopsy for diagnosis of gastrointestinal tuberculosis (GITB). Method It was a prospective study conducted from July 2015 to November 2016. Cases of clinically suspected GITB more than 18 years of age were recruited. All patients underwent mantoux test, contrastenhanced computed tomography (CECT) of abdomen, esophagogastroduodenoscopy or colonoscopy using both high definition white light endoscopy (HD-WLE) and narrow band imaging with magnification (NBI-M) with biopsy (as indicated) by a single observer. Histopathological examination was done by two independent pathologists. Multiplex PCR was also performed for diagnosis of

tuberculosis. A final diagnosis of GITB was made if acid fast bacilli were seen in tissue or grown in culture, or histopathology showed caseous necrosis with granulomatous inflammation, or clinical/radiological and endoscopic features were suggestive of tuberculosis and patient had good clinical response to antitubercular therapy. Results A total of 55 cases of clinically suspected GITB were recruited. A final diagnosis of tuberculosis was made in 32 cases (duodenal n=4, ileocolic n=28). NBI guided biopsy confirmed the diagnosis of GITB in 46.8% while HD WLE guided biopsies confirmed diagnosis of GITB in 28.1% (p, 0.05). The two sets of biopsies together confirmed diagnosis of GITB in 53.1%. The area under curve for NBI-M plus HDWLE, NBI-M alone and HDWLE alone were 0.77 (0.63-0.87), 0.73 (0.60-0.85) and 0.64 (0.50-0.77) respectively. Patients were started on antitubercular therapy for 9 months. Four patients underwent surgery for intestinal obstruction while on antitubercular therapy. Twenty-eight completed full therapy and improved. Conclusion NBI–M guided biopsy improved the yield of histology for the diagnosis of GITB. ES-11 Corrosive ingestion in adults: Endoscopic evaluation and predicting outcome of esophageal and gastric injuries Sreedevi Sunkara, P Sravan Kumar, M Umadevi Correspondence- sreedevi sunkara- [email protected] Gandhi Hospital, Secunderabad 500 003, India Introduction Ingestion of corrosive agents can cause serious damage of the upper gastrointestinal (UGI) tract. The aim of the study is to evaluate extent of gastrointestinal injuries by UGI endoscopy within 24 hrs, to assess the role of 6 point endoscopic classification of caustic injury in predicting outcome in patients with corrosive ingestion. Methods A total of 50 patients with history of corrosive ingestion admitted to Gastroenterology Department of Gandhi Hospital, Secunderabad were studied prospectively from December 2015 to November 2016. Data collected include detailed history, physical examination and relevant investigations. All patients were subjected to endoscopy within 24 hrs of ingestion to determine severity and extent of injuries. All surviving patients were followed up for 2 months to look for development of complications with repeat endoscopy and barium studies. The demographic and clinical data were presented as percentages. P-value was calculated to know the statistical association between grade of injury and development of strictures. Results Out of 50 cases studied, 22 (44%) were women, 28 (56%) were men. Mean age group was 31.1 yrs. Mean time interval of admission was 14.27 hrs. Symptoms noted were epigastric pain (100%), hematemesis (92%), vomiting (88%), odynophagia (88%), oral burns (80%), dysphagia (80%), sialorrhoea (60%), heart burn (50%). On initial UGIE severe esophageal injury (grade IIB or more) found in 86%, while 10% had mild (grade I) and 4% had moderate injury (grade IIA). Sixty-eight percent had severe gastric injury, 6% had mild injury, 4% had moderate injury, 22% had normal study. On repeat endoscopy after 4 weeks, 43 (86%) patients with >grade IIB esophageal injury had developed stricture (p<0.005). Thirty-three (66%) patients with gastric injury grade IIB and beyond had developed strictures (p-0.04). Barium study between 4th and 8th week done showed all patients (100%) with >grade IIB esophageal injuries developed strictures (p-0.034). All the 33 patients with grade IIB injury and beyond in the stomach had developed strictures (p<0.05). All esophageal strictures occurred in lower 2/3rd of esophagus, while all gastric strictures in pyloric antrum irrespective of initial extent of injury. No perforation, fistula and mortality were noted. Conclusion UGI endoscopy was found to be reliable tool to identify the extent and severity of injury. There was statistically significant association between initial high grade of injury and development of strictures.

Indian J Gastroenterol

ES-12 Periampullary diverticulum – 5 years ERCP experience from a referral centre Rabindranath Eswaran, S R Chandrashekar Patil, Ratnakar Kini, K Premkumar, Kani Shaik Mohammad Correspondence- Rabindranath Eswaran- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Periampullary diverticula (PAD) are mucosal outpouchings commonly situated on the medial aspect of second part of duodenum, usually within 2-3 cm of the ampulla of Vater. PAD are usually asymptomatic incidental findings during side viewing scopy. We aimed to analyze the influence of PAD in the management of patients who underwent ERCP during the past 5 years in our centre. Methods Patients between the ages of 13 and 74 with the diagnosis of pancreaticobiliary diseases and were candidate for ERCP, referred to Institute of Medical Gastroenterology, Madras Medical College between January 2012 to June 2017 underwent the procedure and the data of these patients are taken in to account for retrospective analysis. We assessed and compared ERCP results in patients with and without PAD. Results A total of 3157 patients underwent ERCP that of these 178 (5.64%) patients had PAD. Among the 3157 cases, the incidences of PAD in patients age group less than 50 years was 2.6% and age group more than 50 years was 8.1% (p<0.001). Successful biliary cannulation was achieved in 77.52% (n=138) of patients with PAD and 92.6% of patients of patients without PAD (p<0.001). Of that in patients with PAD, for 28.65% (n=51) cases underwent precut needle papillotomy. The papilla was undetectable in 5 cases with PAD. Incidence of CBD stones was higher in PAD group (72% vs. 59%, p=0.003), but the incidence of CBD stricture had no difference (11.5% vs. 9.7% p=0.87). Complete clearance of CBD stones was achieved lesser in patients with PAD (82.5% vs. 92.8% p=0.02). Conclusion The frequency of PAD increases with age and occurs more in choledocholithiasis. Our experienced showed decreased rate of cannulation success with PAD, increased difficulty in cannulation and decreased rate of successful stone retrieval. ES-13 Colonoscopic findings in patients with lower gastrointestinal bleeding Lavkush Prasad Tiwari, K Prem Kumar, S Ratanakar Kini, M Kani Sheikh Correspondence-Lavkush [email protected] Medical Gastroenterology, Rajiv Gandhi Government General Hospital (RGGGH), Park Town, Chennai 600 003, and Madras Medical College, Chennai 600 003, India Background Lower gastrointestinal bleeding (LGBI), defined as bleeding occurring distal to the ligament of Treitz is a frequently encountered clinical problem that may be due to serious colonic pathology. Colonoscopy is generally accepted as the diagnostic procedure of choice. Decisions as to whether to carry out colonoscopy or not, are not well defined. Objectives To establish the etiological diagnosis of lower GI bleeding based on colonoscopic findings. Methods This retrospective study was carried out at a tertiary healthcare centre in south India from June 2015 to May 2017. All patients of age more than 15 years were enrolled in study who presented with gross LGIB or two consecutive positive occult blood tests with at least 1-week interval between tests. Colonoscopy was performed

in all patient after proper informed consent and after adequate bowel preparation. Results Total 630 patients were included in study, in which 59.52% were males and 40.48% were females. Mean age of patients was 47.42±10.68 years. Most common findings were hemorrhoids (33.3% cases), growth (23.01%), polyps (7.6%), radiation proctitis (7.1%), no abnormality (7.1%), non-specific colitis (6.06%), IBD (6.03%), diverticula (3.3%), solitary rectal ulcer (1.5%), fissure (1.4%), rectal varix (1.2%), rectal prolapse (0.8%), multiple polyposis coli (0.8%) and colonic stricture (0.8%). Conclusion Colonoscopy is the investigation of choice for patients of lower gastrointestinal bleeding. The more frequent colonoscopic findings were hemorrhoids followed by colorectal cancer in our environment. It is recommended that colonoscopy should be used routinely for cancer screening and surveillance in our society in case of lower gastrointestinal bleeding. ES-14 Gastric antral vascular ectasia – A tertiary care experience Shubha Immaneni, K Premkumar, Kani Sheikh, Ratnakar Kini Correspondence- Shubha Immaneni- [email protected] Rajiv Gandhi Government General hospital, Madras Medical College, Chennai 600 003, India Introduction Gastric antral vascular ectasia (GAVE) is an uncommon but often severe cause of upper gastrointestinal (GI) bleeding causing about 4% of non-variceal upper GI hemorrhage. The diagnosis is mainly based on endoscopic pattern and for uncertain cases histology. Aim To observe the various clinical manifestations, etiology and endoscopic pattern of gastric antral vascular ectasia among the patients diagnosed on esophagogastroduodenoscopy between June 2016 and May 2017. Methods A total of 35 cases of GAVE were observed. The pathognomonic endoscopic appearance, age, sex predilection, clinical manifestations, endoscopic pattern and etiology was observed. Results Among the 35 patients 22 were female and 13 were male patients. The average age was between 55-65 years. Clinical presentations – 13 cases had chronic iron deficiency anemia, 10 patients presented with melena, 5–occult GI blood loss, 4-severe acute upper GI bleeding and 3 patients were asymptomatic. Among the 35 patients, associated systemic diseases and etiologies observed–12-liver cirrhosis with portal hypertension, 7-isolated portal hypertension, 6-systemic sclerosis, 3- systemic lupus erythematosus, 2Sjogren’s syndrome, 3 patients-chronic renal failure, 1-associated cardiac disease and 1-idiopathic. On EGD watermelon stomach was observed more commonly than scattered lesions or honeycomb stomach. Conclusion Gastric antral vascular ectasia also known as watermelon stomach is a significant cause of severe anemia and occult or profuse GI blood loss. It can develop in the setting of many autoimmune disorders, systemic diseases and liver cirrhosis. Based on our observation incidence of GAVE is in more common in elderly females with liver cirrhosis. The most common clinical presentation was iron deficiency anemia. ES-15 Anti-reflux mucosectomy for refractory gastroesophageal reflux disease – Initial clinical experience Nachiket Dubale, Amol Bapaye, Mahesh Mahadik, Rajendra Pujari, Tarun Bharadwaj, Sandip Vare, Suhas Date, Jay Bapaye Correspondence- Amol Bapaye- [email protected]

Indian J Gastroenterol

Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India PPI’s and laparoscopic fundoplication are mainstay for treatment of gastroesophageal reflux disease (GERD) and refractory GERD respectively. Various endoscopic procedures have been attempted with limited success. Anti-reflux mucosectomy (ARMS) is a recently introduced endoscopic therapy for refractory GERD. This study describes initial clinical experience of ARMS. Methods Prospectively maintained database of consecutive patients undergoing ARMS for refractory GERD was abstracted. Inclusion criteria–GERD symptoms >1 year, daily PPI usage >6 months; absence of hiatus hernia >3 cm on esophagogastroduodenoscopy (EGD) and normal esophageal body motility on high-resolution manometry (HRM). Exclusions – hiatus hernia >3 cm, poor or absent esophageal body motility, poor-risk candidates for anesthesia. Pre-ARMS evaluation–EGD, esophageal manometry, 24-hour ambulatory esophageal pH studies, PPI requirement and GERDHRQL questionnaire. ARMS performed using cap endoscopic mucosal resection (EMR) technique. Follow up protocol–EGD at 2–4 weeks, GERD-HRQL questionnaire, pH studies and PPI requirement at 4–6 weeks. Parameters for data analysis-pre-and postARMS GERD-HRQL questionnaire and Deemester scores, Hill’s grading of gastroesophageal valve on EGD, PPI requirement and adverse events (AE). Results N=15. Mean age–40.8 years (Range 22–69); M: F–11: 4. Mean GERD-HRQL score improved significantly from preARMS–40.4 to post-ARMS–7.6 (p<0.05). Mean Deemester score decreased from 85.8 pre-ARMS to 5.9 post-ARMS (p<0.05). Mean Hill’s valve grade decreased pre-ARMS=2.8; postARMS=1.6 (p<0.05). Three AE’s–muscle injury-2 (treated by endoclips), grade I dysphagia–1 (resolved after EGD). At 4 weeks follow up, 11/15 patients (73.3%) had discontinued PPI, 4/11 (36.3%) had >50% reduction in PPI dosage. Conclusions Current study shows impressive short-term results for ARMS. Larger randomized studies with longer term follow up are recommended. ES-16 Safety, efficacy and closure techniques of endoscopic full thickness resection-Initial clinical experience Tarun Bharadwaj, Amol Bapaye, Mahesh Mahadik, Sandeep Ware, Rajendra Pujari, Suhas Date, Nachiket Dubale Correspondence- Amol bapaye- [email protected] Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India Introduction Endoscopic full-thickness resection (EFTR) for subepithelial gastrointestinal (GI) tumors (SET’s) from muscularis propria (MP) layer is rarely described; possibly due to technical challenges in dissection. Current study describes our experience of EFTR for treatment of MP layer SET’s. Methods Prospective database of patients undergoing EFTR for SET’s over 6-years. Pre EFTR–endoscopy, endoscopic ultrasound (EUS), contrast-enhanced computed tomography (CECT) in all. Inclusionencapsulated lesions, predominantly endophytic component. Exclusion– patients unfit for GA, EUS features of malignancy. EFTR under GA with endotracheal intubation. Submucosal (SM) elevation by Gelofuscin, mucosal incision and SM dissection performed to expose SET. SET resected by enucleation from muscle layer. Resultant MP layer defect closed endoscopically. Results Total N=18 (M=11), mean age–53.6 years (28-78). Presentation– GI bleed–7 (38%), abdominal pain–4 (22%), rectal mass–1, incidental–7 (39%). Location–Stomach–13 (72%), duodenum–2, rectum–2, proximal jejunum–1. Mean size–3.3 cm (1–7). Mean procedure time–182 mins

(60–345), mean hospital stay–4 days. AEs–2 (11%)–esophageal laceration during specimen retrieval–1 (endoclips closure), failure–1 (undetected large exophytic component–surgery). HPE-GIST–9 (50%), NET–3 (16%), others–5. Closure–16/18 (two defects in distal extra-peritoneal rectum left open intentionally for healing by secondary intention); techniques–through-the-scope (TTS) clips–7, over-the-scope clip–4, omental patch+clip–2 (TTS–1, OTS–1), endoscopic suturing–1, endoloop+clip– 1. Mortality–nil. Follow up EGD at 4 weeks–healing in all 17. Median follow up–2 months. Conclusions EFTR is safe and effective for resection of MP layer SET’s. Pre EFTR EUS and CECT may be useful to select appropriate candidates. Secure endoscopic closure of defect is feasible. ES-17 Endoscopic resection of duodenal lesions and a single center experience Pankaj Nemade, Tarun Bharadwaj, Amol Bapaye, Mahesh Mahadik, Sandeep Ware, Rajendra Pujari, Suhas Date, Nachiket Dubale Correspondence- Amol Bapaye- [email protected] Deenanath Mangeshkar Hospital and Research Center, Pune 411 004, India Background Endoscopic resection (ER)–either endoscopic submucosal dissection (ESD) or endoscopic full-thickness resection (EFTR) are treatment modalities for mucosal and sub epithelial lesions in the gastrointestinal (GI) tract. ESD or EFTR for duodenal lesions has been infrequently reported. This retrospective case series reports the results of ER for duodenal lesions. Methods Eighteen consecutive patients with duodenal lesions over a sixyear period (2010-16). All patients underwent pre-procedure radial endosonography (EUS). EMR, ESD or EFTR was performed in all patients under general anesthesia. A high definition gastroscope (GIF-HQ190, Olympus ) was used. EMR was performed using a diathermy snare. For ESD and EFTR DualknifeTM (Olympus) or HybridknifeTM (ERBE GmBH, Germany) was used. Hemostasis was achieved using CoagrasperTM (Olympus). For EFTR, closure was achieved using hemoclips (Olympus) or PadlockTM clip (Aponos Medical, USA). Results N=18, 14 males, mean age: 62.5 years (36-85). Thirteen (72%) lesions in duodenal bulb and 5 (28%) in descending duodenum. Layer of origin–mucosa–12 (67%), submucosa (SM)–5 (28%), muscularis propria (MP)–1. Mean cross sectional area of lesions-758 sq.mm (10-5600). EMR was performed in 8 (44%), ESD in 7 (39%) and EFTR in 3 (17%). EFTR defect was closed using omental patch and hemoclips in 1 and full-thickness clip in two patients. No intra procedural adverse events occured. Two delayed adverse events occurred (11%)–delayed hemorrhage–1, delayed perforation–1. No mortality. Final histology– NET– 11, hyperplastic polyp–3, adenoma–2, GIST–1, and gangliocytic paraganglioma–1. HPE showed clear margins in all. Follow up EGD at 46 weeks showed complete healing in all. Conclusions ER for duodenal lesions is safe and effective. Type of procedure–EMR, ESD or EFTR depends on the layer of origin of the tumor. ES-18 A survey of sedation practices in gastrointestinal endoscopy Shibi Mathew, Prakash Zacharias, John Mathews, M Prashanth, Maya Peethambaran, Aby Somu, Mathew Philip Correspondence- Shibi Mathew- [email protected] Department of Medical Gastroenterology, PVS Memorial Hospital, Kochi 682 017, Kerala, India Introduction Gastrointestinal endoscopies can cause an unpleasant experience to the patient. In India, most endoscopists follow a common

Indian J Gastroenterol

institutional policy for sedation. Aim of this study was to analyze the sedation practices in various endoscopy centers across south India. Methods Data was collected with the help of a structured questionnaire given to a senior endoscopist of the endoscopy center. Data from the completed questionnaire was later analyzed. Results Data was obtained from 19 centers across south India. All endoscopy suites had central oxygen supply and emergency cart. Defibrillator was available in 12 centers (63.16%). Common criteria followed for administering sedation included therapeutic procedures (84.21%), patients who requested for sedation (63.16%), children (63.16%), high risk procedures (57.89%) and uncooperative patients (57.89%). Monitoring methods included pulse oximetry alone in 6 centers (31.58%), pulse oximetry+blood pressure in 5 centers (26.32%) and pulse oximetry+blood pressure+ECG in 8 centers (42.11%). For advanced procedures like EUS and ERCP, sedation use was universal. An anesthetist was available in the endoscopy suite in 8 centers (42.1%). Five endoscopists practiced propofol sedation without anaesthetist’s help (26.32%). Thirteen centers had a written protocol for preprocedure risk assessment of the patient (68.42%). A dedicated post-procedure observation area was available in seventeen centers (89.47%). Seven centers followed a written post-sedation discharge protocol (36.84%). Conclusion Significant variations exist in the practice of sedation among endoscopists. There is an urgent need to formulate guidelines by endoscopy societies for ensuring better patient outcomes in endoscopy. ES-19 Etiological profile of upper gastrointestinal bleed: A changing paradigm Rajan Mittal, P Padmanabhan, Paul Joyes Correspondence- Rajan Mittal- [email protected] Meenakshi Medical College, Enathur, Karrapettai Post, Kanchipuram 631 552, India Background To determine the causes of upper gastrointestinal (GI) bleed in patients undergoing endoscopy. Methods In this prospective descriptive study 250 patients, with first episode of upper GI bleeding over the two year study period, who underwent endoscopic examination within 24 hours of their admission were included. Results Mean age was 52.8 years. Males (94%) outnumbered females (6%) with male to female ratio of 15.6:1. Seventy-six percent of the patients presented with hemetemesis followed by melena. The most common etiology was varices noted in more than half of the study population (62%). The next common etiology was gastric ulceration (12%) followed by duodenal ulceration, erosive gastritis, and mallory weiss tear. In 6 % patients no cause of upper GI bleed was found. The commonest diagnosis was cirrhosis of liver with portal hypertension noted among 56% of the patients with alcohol being the major etiology factor, followed by viral hepatitis and nonalcoholic steatohepatitis (NASH). Conclusion Based on the findings of this study it may be concluded that, esophageal varices is the commonest cause of upper GI bleeding in this region. The other etiologies are gastric ulceration, duodenal ulceration and erosive gastritis. Upper GI bleeding is widely prevalent among males, likely to present with hemetemesis as common symptoms and with history of liver disease. Present study findings, do not coincide with studies describing peptic ulcer as the major cause of upper GI bleed with variceal bleeding emerging as the front runner with possibility of increased prevalence of NASH related cirrhosis.

ES-20 Accuracy of ASGE risk stratification in the patients with suspected common bile Nitin Jagtap, Vaibhav Ajmere, Sundeep Lakhtakia, Mohan Ramchandani, Rajesh Gupta, Rakesh Kalapala, Jahangeer Basha, G V Rao, D N Reddy Correspondence- Nitin Jagtap- [email protected] Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Aim In patients with suspected common bile duct stones (CBDS), ASGE recommend risk stratification according to biochemical testing and ultrasound abdomen. Our aim was to determine accuracy of ASGE criteria to classify patients with suspected CBDS. Methods We retrospective analyzed data of patients who underwent preoperative EUS and/or ERCP for suspected CBDS between January 2013 to March 2017. Patients with CBD strictures, chronic liver disease and portal biliopathy were excluded. After biochemical testing and ultrasound, all patients were stratified according to ASGE criteria into high, intermediate and low likelihood of CBDS. Sensitivity, specificity, positive and negative predictive value were calculated. Results A total of 1028 patients were included in the study. Out of 236 patients in high risk group, 140 (59.32%) had CBDS with sensitivity 52.24% (CI 46.08–58.35) and specificity 87.37% (CI 84.08–89.65). Out of 706 patients in intermediate group, 122 (17.28%) had CBDS with sensitivity 45.52 % (CI 39.45–51.69) and specificity 23.16 (CI 20.20–26.32). PPVand NPVof high risk criteria was 59.32% (CI 53.94–64.49) and 83.84 (CI 82.03–85.50) respectively. PPV and NPV for intermediate risk criteria was 17.28% (CI 15.4-19.32) and 54.66% (50.43-58.82) respectively. Diagnostic accuracy for high risk and intermediate criteria was 78.21% and 28.98% respectively. Conclusion ASGE criteria can be used for risk stratification in patients with suspected choledocholithiasis, however more one third of patients in high probability group would not have choledocholithiasis. ES-21 Causative factors responsible for renal dysfunction in cirrhosis and the impact Rishabh Jain, Ajit Kumar, Y Raghavendra, B Sukanya, Nayana Joshi, Vineet Chaudary, N Ravichandra, R Gaurav Correspondence- Rishabh Jain- [email protected] Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Introduction Cirrhotic patients with renal dysfunctions have high mortality rates. This study investigated the prevalence, cause and clinical outcome in patients with cirrhosis and renal dysfunction. Methods This was a prospective observational study of consecutive patients admitted with cirrhosis at a tertiary centre. Renal dysfunction was classified according to revised recommendations by International Club of Ascites, causes and outcome were analyzed. Results Total 356 patients were admitted during the study period from 1st January 2016 to 31st December 2016. Renal dysfunction was present in 112 (31.4%) patients. Presentation with abdominal distension, altered sensorium, diuretic use and oliguria at admission, presence of infective foci, ascites, diuretic use and hepatic encephalopathy were associated with higher renal dysfunction. Urinary tract infections (UTI) were most common infection in renal dysfunction (29.5%) as well as without renal dysfunction (11.1%). Renal dysfunction with infection (49.1%) was most common cause followed by hypovolemia (28.7%), hepatorenal syndrome

Indian J Gastroenterol

(HRS) (18.7%) and parenchymal renal diseases (3.5%). Acute kidney injury (AKI) stage II (41.1%) at presentation was most common, followed by stage I (39.3%) and III (19.1% ).The mean days of hospital stay (9.07±3.54) and mean ICU days stay (4.75±3.4) were significantly higher in patients with cirrhosis with renal dysfunction. The in-hospital mortality was 13.48%, which was significantly higher in patients with cirrhosis with renal dysfunction (29.5%) than as compared to patients without renal dysfunction (6.1%) [p<0.001]. Conclusion Renal failure has a high prevalence in cirrhotics and is associated with high mortality and morbidity. Infections are most common cause of renal failure. ES-22 Percutaneous catheter drainage followed by endoscopic transluminal drainage/necrosectomy Surinder Rana, Rajesh Gupta, Mandeep Kang, Ravi Sharma, Gaurav Muktesh, Subour Uddin Ahmed, Ujjwal Gorsi Correspondence- Surinder Rana- [email protected] Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Background Infected pancreatic necrosis (IPN) in early phase is treated with Bstep up approach^ involving initial percutaneous catheter drainage (PCD) followed by necrosectomy. There is paucity of data on combined approach of initial PCD followed by endoscopic drainage/necrosectomy. Aim Retrospectively study safety and efficacy of initial PCD followed by endoscopic transluminal drainage/necrosectomy in IPN. Methods Retrospective analysis of data of 23 patients with IPN who were treated with combined approach. Patients were divided in two groups: patients with central necrosis in whom PCD catheter and endoscopic drainage were done in same collection (n=11) and patients with combined central and peripheral necrosis where PCD was placed in peripheral necrosis and endoscopic drainage was done for central necrosis (n=12). Results Endoscopic drainage could be done successfully in all 23 patients with mean time for resolution being 4.0 ± 0.9 weeks. Fifteen (65.2%) patients were successfully treated using multiple plastic stents while DEN was needed in 8 (34.8%) patients and FCSEMS was inserted in 6 (26%) patients. The number of endoscopic sessions needed were 3 in 3 (13%), 4 in 9 (39%) patients, 5 in 5 (22%), 6 in 3 (13%) and 7 in 3 (13%) patients respectively. Patients of central WOPN with PCD catheter in situ needed more endoscopic sessions for resolution as well as more frequently needed DEN in comparison to patients with central WOPN with no PCD catheter. Conclusion Combined approach of initial PCD followed by endoscopic drainage/necrosectomy is safe and effective treatment alternative for patients with infected pancreatic necrosis. ES-23 Safety and efficacy of angioembolization followed by endoscopic ultrasound guide Surinder Rana, Amit Kumar, Ravi Sharma, Mandeep Kang, Ujjwal Gorsi, Rajesh Gupta Correspondence- Surinder Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background and Aims Arterial pseudoaneurysms associated with pancreatic fluid collections (PFC’s) are serious complication of pancreatitis. There is insufficient data on safety of endoscopic ultrasound (EUS) guided drainage in these patients.

Aim To retrospectively analyze results of combination of angioembolisation followed by EUS guided transmural drainage of PFC’s associated with pseudoaneurysms. Methods Retrospective analysis of data base of eight patients (all males; mean age: 36.9+ 9.2 years; age range: 26-51 years) who underwent angioembolization of pseudoaneurysm followed by EUS guided transmural drainage of the PFC’s. Results The median size of PFC was 6.5 cm (range 5-14 cm) with 7 patients having acute pancreatitis and one patient having idiopathic chronic pancreatitis. The etiology for acute pancreatitis was alcohol in 5 patients, trauma and gallstones in one patient each. Six patients had walled off pancreatic necrosis (WOPN) and 2 had pseudocysts. The pseudoaneurysm was located in splenic artery (5 patients), gastroduodenal artery (2) and short gastric artery (1). All patients underwent successful digital subtraction angiography followed by angioembolization. EUS guided transmural drainage was successfully done through stomach in 7 patients and via duodenum in one patient. The PFC’s resolved in 3.9+2.5 weeks with no recurrence of either PFC or bleed over a follow up period of up to 24 months. No significant complications were observed in any patient. Conclusions Arterial pseudoaneurysms associated with PFC’s can be successfully and safely treated with combination of initial radiological obliteration of the pseudoaneurysm followed by EUS guided transmural drainage. ES-24 Endoscopic submucosal dissection: Experience in a tertiary care centre Sudarshan Patil, Aby Somu, P Maya, M Prashanth, Shibi Mathew, John Mathews, Prakash Zacharias, Mathew Philip Correspondence- Sudarshan Patil- [email protected] PVS Institute of Digestive Diseases and PVS Memorial Hospital, Kaloor, Kochi 682 017, India Introduction Endoscopic submucosal dissection (ESD) represents significant advance in therapeutic endoscopy comprising of minimally invasive, organ sparing endoscopic en-bloc removal of benign and early malignant lesions of gastrointestinal (GI) tract. However, ESD is technically demanding and experience in India is evolving. Methods Retrospective analysis of patients who underwent ESD for epithelial and subepithelial lesions of upper and lower GI tract from January 2014 to July 2017. Variables analyzed were clinical profile of patients, procedure details and lesion characteristics. Under anesthesia, lesions limited to mucosa and submucosa were selected for ESD procedure. Results Out of 119 patients who underwent endoscopic resection procedures, ESD was performed in 34 patients. There were 18 females and 16 males with mean age 58.2 years (36-74). Upper GI lesions were seen in 10 (29%) patients (stomach-7, GE junction-2, esophageal-1). Average size of the lesions was 28.2 mm (range 22-40). Morphologically (Paris classification) 6 lesions type 0-Is, 2 lesions type 0-IIb, 2 lesions type 0-III. Mean procedure time was 151.5 min (30-360). Histologically, neuroendocrine tumor and dysplastic lesions were most common except one early gastric cancer. Lower Gl lesions were seen in 24 (71%) patients (rectosigmoid-24). Average size of lesions was 46.3mm (range 2772). Morphology (Paris classification) Type 0-Is 22 lesions, Type 0-Ip 2 lesions. Mean procedure time was 178 min (range 75-540 mins). Histologically, tubulovillous adenoma with high grade dysplasia and tubulovillous adenoma with intramucosal carcinoma were most commonly noted. Enbloc resection achieved in 29 (83%). Immediate post procedure bleed noted in 4 (11%) all controlled with hemoclips. There were no perforations except one incomplete muscle defect closed by hemoclips.

Indian J Gastroenterol

Conclusions ESD is a promising and relatively safe procedure for enbloc resection of mucosal and submucosal lesions in upper and lower GI tract. ES-25 Adverse effects and tolerability profile of split dose polyethylene glycol and oral sodium sulphate preparations for colonoscopy in South Indian patien Aniruddha Pratap Haripal Singh, Srijaya Sreesh, Krishnadas Devadas, Gopu Babu, Varun Tadkalkar, Rathan Joseph, K V Anoop, Biji Benny Correspondence- Aniruddha Pratap Haripal [email protected] Department of Medical Gastroenterology, Thiruvananthapuram 695 011, India Introduction Bowel preparation is an important quality indicator for colonoscopy, the present study aims to compare common bowel preparations for their efficacy, adverse effects and tolerability. Aims Prospective double blinded RCT in a tertiary care centre in Kerala, India comparing bowel preparation using split dose polyethylene glycol (PEG) with oral sodium sulphate (OSS using Ottawa bowel preparation scale (OBPS). Settings and Design Consecutive patients coming to Gastroenterology OP greater than 18 years of age were randomized to receive OSS or split dose PEG and efficacy of bowel preparation was assessed with OBPS. Methods Two hundred and thirty consecutive patients were assessed for eligibility and 206 randomly allocated, 194 patients were included in the analysis of which 83 patients received OSS and 111 patients received split dose PEG and colonoscopy was performed and efficacy of bowel preparation was assessed using OBPS. Statistical analysis used SPSS software (version 19.0; SPSS Inc., Chicago, IL, USA), and p< 0.05 was considered significant. Results Efficacy of bowel preparation was similar in both groups. SplitPEG preparation was better tolerated than OSS (p=0.006), patient receiving split PEG had the better experience with preparation (p=0.01), decreased nausea as compared to OSS (p=0.029). For OSS preparation was significant for serum sodium, PR and diastolic BP. For split-PEG preparation laboratory values were significant for serum potassium (p=0.009) and urea (p=0.013). Diastolic BP also differed significantly p 0.013 between pre and post preparation with no significant clinical effects. Conclusions OSS and split dose PEG were equivalent with regard to bowel preparation before colonoscopy and split dose PEG was better tolerated and had better experience and less adverse effects as compared with OSS. ES-26 Is it worth to repeat ERCP after failed precut? Short report from a tertiary care hospital in north India Kumar Shwetanshu Narayan, Gaurav Kumar Gupta, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, J L N Marg, Jaipur 302 004, India Aim To determine the success rate of biliary cannulation in cases where endoscopic retrograde cholangiopancreaticography (ERCP) is repeated after failed precut sphincterotomy. Method In this retrospective study, consecutive ERCPs performed between August 2013 and June 2017 were included. Data was analyzed for indication of ERCP, success rate at initial cannulation attempt, use of precut sphincterotomy, biliary access rate after precut, repeat ERCP rate and associated complications. Results A total of 1872 ERCPs were included in the study. Of these, 55% were done for common bile duct (CBD) stones, 37% for malignant biliary

obstruction and 8% for biliary leak. During initial ERCP, 84.9% cases had successful biliary cannulation. 86.8% cases undergoing precut sphincterotomy achieved biliary access. Repeat ERCP was done in 28 cases after a median interval of 3 days and biliary cannulation was achieved in 78.5% cases. Conclusion Repeat ERCP after 3 days in cases of failed initial precut sphincterotomy should be practiced and recommended as this allows definitive biliary therapy in majority of such patients and prevents morbidity and mortality from other invasive alternative therapies. ES-27 Incidence and patterns of post ERCP pancreatitis in malignant extrahepatic biliary obstruction Sridhar Sundaram, Mukund Virpariya, Shaesta Mehta, Prachi Patil Correspondence- Prachi Patil- [email protected] Department of Digestive Diseases and Clinical Nutrition, Tata Memorial Hospital, Mumbai 400 012, India Introduction Post ERCP pancreatitis (PEP) is a known to occur in upto 5% of all ERCP procedures. Malignant extrahepatic biliary obstruction (MEBO) is frequently associated with difficult biliary cannulation, axis deviation and papillary infiltration. The incidence and pattern of PEP in patients with MEBO is unknown. Methods A retrospective review of all patients with MEBO who underwent ERCP at Tata Memorial Hospital, a tertiary cancer center between June 2013 and June 2017 was done. Incidence of PEP and associated demographic and procedural risk factors for the same were noted. Also severity of PEP was defined using the Cotton criteria. A total of 979 ERCPs were included in the study after excluding 45 patients who had a non-malignant disease. Results Ninety-seven patients developed PEP (9.9%) in the cohort studied of which 61 (63%) had proximal (CHD and above) obstruction and 33 (34%) had CBD (distal) obstruction. Fifty percent of patients developing PEP were female. Fifty patients had undergone a sphincterotomy (15.4 %) and 60 patients had history of PD cannulation or injection (62%). Four patients who developed PEP had undergone Intraductal ultrasound (4%). In 9 patients (9.3%), technical success of ERCP could not be achieved while 57 had single SEMS placement (59%), 24 had a single plastic stent placement (25%) and 7 had bilateral SEMS placement done (7%). Seventy-six patients had mild pancreatitis (78%) while 9 patients had severe pancreatitis (9.3%). Two patients developed WOPN which required radiologic intervention. There were 5 deaths in the cohort–4 due to severe pancreatitis and 1 sudden cardiac death in a patient recovering from mild pancreatitis. Conclusions The rates of PEP are higher in patients with MEBO than described in literature. Prospective studies looking at risk factors and the benefit of rectal NSAIDs/ prophylactic PD stenting in this subgroup of patients are warranted. ES-28 Single center clinical experience with a recently developed fullthickness endoscopic clip Tarun Bharadwaj, Sandip Vare, Amol Bapaye, Mahesh Mahadik, Rajendra Pujari, Suhas Date, Nachiket Dubale, Jay Bapaye Correspondence- Amol Bapaye- [email protected] Deenanath Mangeshkar Hospital and Research Center, Erandawne, Pune 411 002, India Background Endoscopic clips are used in variety of clinical situations in gastrointestinal (GI) endoscopy–for arrest of bleeding, closure of bowel

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perforations or chronic fistulae etc. Conventional TTS clips often cannot provide optimum results; therefore full-thickness OTS clips have been devised. Current study describes clinical experience of use of recently developed FT OTS clip (Padlock™, Aponos Medical). Methods Data from a prospectively maintained database of all patients undergoing the new FT OTS clip was abstracted. Patient demographics, diagnosis, h/o previous endotherapy, endoscopic procedure, indications for FT OTS clip usage, technical and clinical success, early and delayed A/E were recorded. Results Total 21 clips were used in 19 patients. M: F–12:7, mean age– 57.9 years (range–24-84 years). Indications for FT OTS clip use–severe GI bleeding–7 (36.8%) (DU bleed–5, rectal ulcer–1, bleed during ESD for rectal LST–1); for closure of bowel perforation during endoscopic resections–7 (36.8%) (gastric–3, duodenum–2, rectum–2); and closure of chronic bowel fistulae–5 (26.3%) (esophagus–3, duodenum–1, rectum–1). Previous h/o endotherapy i.e. OTS Clip as secondary therapy–3 patients (all with bleeding); primary therapy in 16. Technical success was 100%. Two patients needed two clips each due to large sized defect. Clinical success–bleeding arrested in 7/7 (100%), bowel perforation sealed–7/7 (100%); fistula closure successful–4/5 (80%). In one patient of chronic duodenal fistula, fistula reopened 12 weeks after initial sealing of fistula and required surgery. F/U at 4 weeks revealed no delayed A/E in any patient. Conclusion The new OTS Clip (Padlock™, Aponos) is safe and effective for treatment of severe bleeding, closure of post ER full-thickness defects and chronic fistulae. Further studies are recommended. ES-29 Endotherapy in the treatment of caustic esophageal stricture: A retrospective study B Thinakar Mani, S Ratnakar Kini, K Prem Kumar, M Kani Sheikh, Thangavelu Pugazhendhi, Mohammed Ali Correspondence- Thinakar Mani- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Endoscopic procedures, such as balloon/bougie dilation, have gained increasing potential as the treatment of corrosive esophageal stricture. Endoscopic bougienage or balloon catheter dilatation was performed for patients who had an esophageal stricture with severe dysphagia. Endoscopic bougie dilatation was performed with the Savary-Gilliard dilators. Dilators with 7-, 9-, 10-, or 11-mm-diameters were inserted under endoscopic guidance. Thereafter, dilation was performed under fluoroscopic control. Each treatment session consisted of two or three dilations, with the size of the dilator increasing incrementally by no more than 3 mm. Balloon catheters were used in patients with a long stricture with a minimum of 6 mm to a maximum 16 mm diameter under fluoroscopic control. Aim of this retrospective study to analysis various clinical outcomes of endoscopic therapy of esophageal strictures after caustic injury. Methods Between December 2015 to December 2016, thirteen admitted patients that developed esophageal stricture after caustic agent ingestion underwent endoscopic therapy at the tertiary care center analyzed. Data such as age, gender, caustic agents, site of burn, type of treatment, effectiveness and outcome of endoscopic therapy were recorded. Results The average follow up was a range of 19–50 months. Successful endoscopic therapy was achieved in nine patients. Duration of stricture resolution was between 6 and 28 months. Among them, nine patients required dilations only, Three patients underwent pharyngo coloplasty for both esophageal and stomach injury, One patient treated with esophageal stenting. There were no severe complications in these patients. Conclusion These data suggest that endoscopic therapy is feasible, less invasive and effective for the management of caustic esophageal stricture.

After repeat dilation, patients can achieve stricture resolution and avoid surgery in esophageal stricture. ES-30 Percutneous endoscopic gastrostomy: A three-year single center experience Ankur Gupta Correspondence- Ankur [email protected] Department of Gastroenterology Max Hospital, Mussoorie Diversion Road, Malsi, Dehradun, Uttarakhand 248 001, India Introduction Percutaneous endoscopic gastrostomy (PEG) is recommended method for long-term enteral feeding for patients with functioning gastrointestinal tract. We review our experience with PEG placements done over three-year duration. Methods Charts were reviewed retrospectively for patients who were referred for PEG placement for past three years. Complications and procedural success were reviewed. ‘Pull up’ method was used in all patients. All patients received antibiotic prophylaxis. Procedures were done with moderate sedation and local anesthesia. A single endoscopist performed all the procedures and assisted by the same nurses trained in the procedure throughout the study duration. Patient or caregivers were provided with caretaking instructions. Results Of 72 patients referred for PEG, it was contraindicated in one patient, 52 (72.2%) were male. Indications included, stroke 40 (55.6%), other neurologic disorders 16 (22.2%), head injury 6 (8.3%) and malignancy 10 (13.9%). Technical success was achieved in 69 of 71 patients (97%) patients. Median age of patients was 64, range 16- 91 years. Complications occurred in 7/ 69 (10.1%) patients, including death of one patient from peritonitis. Conclusion PEG is a useful procedure for enteral feeding. Although procedural success is high, it may be accompanied by significant complications. Infection was the most common complication. Technical success, number (%) Complications, number (%) Infection Inadvertent tube removal Anesthesia related respiratory depression Peritonitis Death due to complication

69 (97.2) 3 (4.3) 2 (2.9) 1 (1.4) 1 (1.4) 1

ES-31 Full thickness resection of appendiceal orifice adenomas using Ovesco full thickness resection device Afrasyab Khan, Ravinder Ogra Correspondence- Ravinder Ogra- [email protected] Counties Manukau Health, Middlemore Hospital, Auckland 2025, New Zealand Introduction Complete endoscopic resection of colonic adenomas with submucosal adherence and those at the appendiceal orifice can be challenging. These lesions are traditionally treated with surgical resection with attendant risks and morbidity. The recent development of the endoscopic full-thickness resection device (FTRD; Ovesco Endoscopy, Tübingen, Germany) has resulted in a viable endoscopic safer option. The system consists of an OTSC clip and a special thin snare loaded on a plastic hood a made for purpose grasping forceps. Resection is carried out using 160 Watt dry cut current to minimise

Indian J Gastroenterol

thermal damage. Snare resection is carried out immediately after release of the OTSC clip that closes the potential perforation. Cases and Management Case 1 A 81-years-old man presented for endoscopic resection of a 30 mm high risk traditional serrated adenoma arising from within the appendiceal orifice. First attempt at EMR resulted in incomplete resection and post resection appendicitis leading to 7 day hospital admission. Follow up exam revealed adherent recurrence of the adenoma. Full-thickness resection (EFTR) was undertaken successfully without complications. Histology showed full thickness resection of a serrated adenoma as well as the appendiceal stump. Case 2 A 68-years-old woman had a recurrent tubulovillous adenoma at the appendiceal orifice after two unsuccessful attempts at EMR. EFTR was done with the OTSC system without complications as a day procedure. Histology showed complete full thickness resection of the tubulovillous adenoma. Conclusion The Ovesco FTRD system is a novel endoscopic device that allows full thickness resection of GI lesions that were until now only able to be undertaken surgically. This device has become a useful tool for resection of adenomas around the appendiceal orifice as well as adherent adenomas, early cancers and submucosal lesions that require full thickness resection. ES-32 Endoscopic management of staple line leaks post laparoscopic sleeve gastrectomy (LSG): Large Bariatric centre experience David McGouran, TienHuey Lim,Thomas Southwell, Ravinder Ogra Correspondence- Ravinder Ogra- [email protected] Counties Manukau Health, Middlemore Hospital, Auckland 2025, New Zealand Introduction Laparoscopic sleeve gastrectomy (LSG) is one of the most commonly performed bariatric procedures for treatment of morbid obesity. The most serious complication is the staple line leak occurring in 1.9% to 2.4% and can be life threatening and difficult to manage. A variety of endoscopic techniques are used for successful closure of leaks and our experience over 10 years has prompted development of a purpose-built stent. Methods This is a prospective review of all 31 patients managed at Middlemore hospital. Variety of stents used included 18-24 mm stents of varying lengths, partially uncovered Ultraflex, plastic biliary and purpose built Ogra stents. Complementary therapies included OTSC clips, hemoclips, cyanoacrylate injection and overstitching. The Ogra stent has 10 mm of uncovered area proximally allowing mucosal ingrowth and fixation. Results 30/31 (97%) achieved closure with endoscopic therapy. 29/31 (94%) required complementary endoscopic treatment.

Primary closure Secondary closure

Number

Mean days to leak resolution

Mean In patient stay

20/31 (65%) 10/11 (91%)

59

31

119

65

sleeve leaks, however migration is the limiting factor for optimal management. Improvements in stent design, such as the custom made Ogra stent show. Earlier use of SEMS seems to reduce the time till closure as well as the total hospital stay. ES-33 Endoscopic management of symptomatic stenosis postlaparoscopic sleeve gastrectomy for obesity. Experience at a large Bariatric surgery centre David McGouran, Anurag Sekra, Ravinder Ogra Correspondence- Ravinder Ogra- [email protected] Counties Manukau Health, Middlemore Hospital, Auckland 2025, New Zealand Introduction Symptomatic stenosis is an uncommon complication following laparoscopic sleeve gastrectomy (LSG) to treat morbid obesity with incidence of 3% to 3.9% is reported in current literature. Currently controlled radial expansion (CRE) balloon dilatation up to 20 mm is the most commonly used first line endoscopic treatment. We have compared the success rates and safety of the use of CRE balloon, the achalasia balloon 30-40 mm, and self-expanding metallic stents (SEMS). Methods A prospective review of all patients managed at Middlemore hospital are reported. Achalasia Balloon (30-40 mm) dilatation was carried out using metal Savary guidewires. SEMS included 18-24 mm wide fully covered removable stents. Results Symptomatic stenosis developed in 59 (4.06%). Most 56 (95%) were located at the incisura. Endoscopic management Overall CRE balloon dilatation (<60 days post-surgery) Achalasia balloon overall (>180 days post-surgery) Achalasia balloon as first line Achalasia balloon as second or third line

Success rate 45/59 (83%) 14/34 (41%) 23/38 (61%) 13/21 (62%) 10/17 (59%)

SEMS overall SEMS as first line (Severe early stenosis) SEMS as second or third line (>90 days post LSG)

14/18 (78%) 4/4 (100%) 9/14 (64%)

Ten patients required surgery of whom 9 had Roux en Y conversion. Discussion The most common site of stenosis is at the level of the incisura. The findings at endoscopy can be misleading as in many cases the endoscope can pass with minor resistance. A twist is often observed and this in combination with any physical narrowing causes a functional stenosis of the sleeve. Our data demonstrates that achalasia balloon dilatation is superior and safe. There were no complications and the dilatations did not affect the weight loss adversely. We recommend graduated achalasia dilatation (30-40 mm) as first line treatment over CRE dilatation. If this approach fails use of wide 24 mm fully covered stent should be tried before referral for surgery. ES-34

Significant stent migration and failure occurred in 6/31 (19%). No migration occurred with the Ultraflex and custom made Ogra stent. Those referred within 2 weeks had mean inpatient stay of 47 days compared with >2 weeks had inpatient stay of 105 days. 2/31 (6%) developed new leaks distal to the stent. One patient died after failure of multiple endoscopic and surgical treatments. Conclusion The use of SEMS in conjunction with complementary endotherapy has been shown to be both safe and effective in treating

Simultaneous occurrence of upper aerodigestive tract malignancies with postcricoid Web – DDHD experience Sachin K Dhande, T Rajkumar Solomon, A Aravind, K Caroline Selvi, R Balamurali, G Ramkumar, K Muthukumaran, S Kavitha, Vaishnavipriya, A Anand, Ravi. Anand, Umalakshmi, S B Malipatil, Sravan, S Ragvendra Correspondence- Rajkumar Solomon- [email protected]

Indian J Gastroenterol

DDHD, Government Peripheral Hospital Annanagar, Kilpauk Medical College, Chennai Introduction Plummer-Vinson syndrome is characterized by dysphagia, iron deficiency anemia and postcricoid esophageal web. The increased incidence of upper aerodigestive tract carcinoma in patients with Plummer-Vinson syndrome has been well established. The reported rates range from 4% to 16%, with almost all cases occurring at the postcricoid location. But from the study at our center we noted that there is an increased occurrence of esophageal malignancies (nonpostcricoid region) and stomach malignancies with postcricoid web. Methods In a retrospective analysis, we reviewed the case records of 100 consecutive patients with dysphagia, anemia and postcricoid web diagnosed for the first time on video endoscopy at our center from the period 1/2016 to 6/2017 (over the period of 18 months). The endoscopic features and the biopsies of associated lesions were analyzed. Results Total no of endoscopies for the period of 18 months–5369, total patients with detected postcricoid web first time on endoscopy–100, females 81 (81%), males–18 (18%), incidence of postcricoid web at our center–1.86%, total biopsy proven esophageal malignancies associated with postcricoid web–8 (8%), stomach malignancies–3 (3%), esophageal malignancies in females-6 (7.4%), esophageal malignancies in males–2 (10.52%), the incidence of biopsy proven stomach malignancies in females and males were– 1 (1.23%), 2 (10.52 %) respectively. Conclusions There is a significant occurrence of esophageal and stomach malignancies in patients with postcricoid web presenting for the first time at our center. Hence it is mandatory to do screening UGI scopy after dilation of postcricoid web. ES-35 Ultrathin gastrointestinal endoscopy: An experience with 280 patients Avnish Kumar Seth, Varun Gupta Correspondence- Avnish Seth- [email protected] Fortis Memorial Research Institute, Gurugram 122 002, India Background To review our experience with use of ultrathin endoscopy. Methods Prospectively collected data on consecutive patients undergoing ultra-thin GI endoscopy with Olympus GIF XQ160, outer diameter 5.9 mm, channel 2 mm between January 2009 and July 2017 was analyzed. Trans-nasal route was used in patients with restricted mouth opening/ cervical spine injury, oro-pharyngeal corrosive injury/malignancy, nasogastric or naso-enteral tube placement to avoid mouth to nose transfer (rail-road) or unsedated endoscopy in high risk patients. Semi-left lateral position was used most often and conscious sedation was used in patients with difficult lesions. Results Median age was 44 years (range 11 months to 89 years). Transnasal route was used in 222 (79.2%) patients. in The indications are summarized in Table:Indication Restricted mouth opening/ cervical spine injury or surgery Oropharyngeal-laryngeal corrosive injury/malignancies Esophageal benign and malignant strictures Nasoenteral tube placement in neurological disorders

Number Remarks 29 Trans-nasal route; neck flexion avoided 31 Evaluation/nasogastric tube placement 105 Evaluation/nasogastric tube placement 50 Mouth to nose transfer (railroad) avoided 17

Gastroduodenal benign and malignant strictures

Evaluation/naso-enteral tube placement

Infants and children below 1 year PEG placement Esophageal SEMS placement /evaluation Transgastrostomal endoscopy

7 17 4

Unsedated trans-nasal endoscopy in high risk patients Total

18

2

Per-oral Trans-nasal 6, per-oral 11 Assessment of length of growth, stent obstruction PEG-J, retrograde esophageal stricture evaluation Cardio-pulmonary comorbidities

280

Transnasal route could be used when intended in all adults except one with bilateral epistaxis and another with markedly deviated nasal septum and large nose-ring. The only adverse event noted with transnasal endoscopy was self-limiting epistaxis in 2 patients. Inability to deliver endotherapy due to small working channel was a limitation. Conclusion Ultra-thin endoscopy is a useful modality in the endoscopy theatre. ES-36 A study of clinical and endoscopic profile of acute corrosive injury of the UGI tract - a single centre study Ravi Anand, K Caroline Selvi, A Anand, T Rajkumar Solomon, A Aravind, G Ra mkumar, R Balamurali, K Muthukumaran , Vaishanavipriya, S Kavitha, Umalakshmi Premnath, Sachin Kashinath Dhande, Sravan Thumati, S B Malipatil, S Ragvendra Correspondence-K Caroline [email protected] Government Royapettah Hospital and Department of Digestive Health and Diseases (DDHD), Government Kilpauk Medical College, Chennai 600 010, India Introduction Corrosive injuries are one of the important public health issues especially in developing countries like India causing a spectrum of complications. Aim To review clinical and endoscopic findings of patients with acute corrosive injury and management of these patients. Methods In this prospective study, clinical data of 61 patients were collected from July 2016 to July 2017 who came at our centre with corrosive ingestion within 48 hrs. Full clinical examination was done and chest X-ray was taken. Patients with no evidence of perforation underwent upper GI endoscopy and initial conservative management was instituted. Corrosive injuries were graded by Zargar’s classification. Results Out of 61 patients, complete evaluation was possible only in 53 patients. Thirty-seven male and 16 female patients were evaluated and mean age was 29 years. Mean time interval of presentation was 17 hours and volume of corrosive ingestion was 20 to 150 mL. Most common corrosive in our study were acids that included hydrochloric acid (n=28), phenyl (n=9), sulphuric acid (n=2), nitric acid (n=2), aqua regia (n=1) along with alkali (n=9) and 2 cases of kerosene ingestion. Five cases were accidental while 48 cases were of suicidal ingestion. Most common clinical feature in our study were oropharyngeal injuries (n=43), epigastric pain (n=34), sialorrohea (n=31), vomiting (n=30), odynophagia (n=25) and dysphagia (n=23). Forty-six patients had esophageal injuries (grade I= 27, IIa=9, IIb=5, III=5) while 40 patients had gastric injuries(grade I=18, IIa=9, IIb=5, III=8). Ryle’s tube (RT) insertion were done in 6 patients with grade IIb and III injuries. Patients who came for review after 4 to 8 weeks improved spontaneously with grade I and IIa injuries. Five patients with IIb and III injuries required feeding

Indian J Gastroenterol

jejunostomy initially while all 6 patients with RT required dilatation after 4 weeks. Conclusion Patients with acute corrosive injury can be assessed reliably and accurately by upper GI endoscopy and proper clinical examination and managed accordingly. ES-37 Preoperative intrabiliary acetylcysteine infusion for biliary obstruction in a case of chronic pancreatitis with pancreatic head IPMN Paul K Vincent, Hasim Ahamed, Rajesh Gopalakrishna, Ramachandran Menon, Rama P Venu Correspondence- Rajesh Gopalakrishna- [email protected] Amrita Institute of Medical Sciences, Kochi 682 041, India Background Successful biliary drainage in case of IPMN with thick mucus by ERCP and internal drainage alone is usually inadequate. The mucolytic properties of acetylcysteine offer a therapeutic benefit in this setting. Case Report A 50-year-old male patient, who had been diagnosed with chronic pancreatitis since 5 years and was on pancreatic enzymes, presented with features of obstructive jaundice. CECT abdomen showed a cystic lesion in the pancreatic head with markedly dilated CBD and IHBRD. Duodenoscopy showed patulous ampulla with mucus plug and mucous extruding from orifice ("fish mouth" appearance). Pancreatoscopy performed using Spy Glass system showed dilated duct with calculi and large quantities of mucinous material and papillary projections suggestive of IPMN ("fish egg" appearance). ERCP and biliary decompression with placement of plastic stent was performed in the same sitting. However, as he had recurrent episodes of biliary obstruction due to mucous occlusion despite multiple stent exchanges, placement of nasobiliary catheter and infusion of acetylcysteine was performed which resulted in significant improvement of jaundice. He later underwent open cholecystectomy with placement of T tube through which infusion of acetylcysteine was continued till he had complete resolution. Subsequently, after nutritional rehabilitation, he underwent Whipple’s resection. Conclusion This case report highlights the role of intrabiliary acetylcysteine infusions for mucous occlusions in IPMN. ES-38 Profile of esophageal strictures and response to dilatation in Central India Sudhir Jagdishprasad Gupta, Nitin Ranrgrao Gaikwad, Amol Samarth,Tushar Sankalecha,Harit Kothari Correspondence- Nitin Gaikwad- [email protected] Department of Gastroenterology, Government Medical College and Super Speciality Hospital, Nagpur 440 009, India Introduction Various types of benign and malignant strictures of esophagus can cause progressive mechanical dysphagia. Among the vast variety of benign esophageal strictures Peptic strictures, account for up to 80% of cases. Other benign causes are corrosive, radiation induced strictures and eosinophilic esophagitis. The primary indication for dilation is to provide immediate and durable and symptomatic relief of dysphagia. Aim To know the prevalence of the various types of the benign esophageal strictures in the present era of increasing use of proton pump inhibitors and to see their response to dilatation. Methods We retrospectively analyzed the data of patients with esophageal strictures who underwent dilatation in the Department of Gastroenterology from January 2013 to December 2016.

Results Total patients 63. Male to Female ratio was 29:36. Average age of patients was 48.68±4.2 years. Youngest was of 20 years and oldest was of 70 years. Peptic stricture was present in 35 (55.55%), corrosive stricture in 15 (23.80%), and radiation induced stricture in 13 (20.63%) patients. Mean stricture length was longest in corrosive (3.85 cm) followed by radiation stricture (3.23 cm) and smallest in peptic stricture (2.028 cm). Commonest site for peptic stricture was lower third of esophagus (51.42%). Frequency of corrosive stricture was equally more in upper and mid esophagus (40%). Radiation stricture was common in mid esophagus (53.84%). Multiple esophageal strictures were more commonly seen in corrosive injury 2 (13.13%). Average number of dilatation required in peptic stricture were 1.48, in corrosive 2.866 and in radiation stricture it was 1.79. Refractory strictures were more common in corrosive group 4 (26.66%) followed by radiation stricture 1 (7.69%), and least common in peptic stricture group 2 (5.71%). Conclusion Despite the increased use of proton pump inhibitors, peptic stricture is still the commonest cause of esophageal stricture and is more responsive to dilatation. Corrosive esophageal strictures are more refractory to dilatations than peptic and radiation induced strictures. ES-39 Severe esophageal injury caused by accidental button battery ingestion in a child A Keerthi, P Shravan Kumar, M Umadevi Correspoondence- Keerthi A - [email protected] NTRUHS, Hyderabad 520 007, India Background Over the last few years there is a rise in use of button batteries in various toys and other electronic gadgets. Easy availability and small size of these batteries pose a significant risk of ingestion in small children. Button battery ingestion can lead to serious health hazards very rapidly. Case Report A healthy five-year-old girl was referred to our institution due to accidental button battery ingestion. She presented with abdominal pain. Chest X-ray image showed a circular 20 mm foreign body in esophagus. Endoscopy was performed, and a 20-mm button battery presented was found at lower end of esophagus at gastroesophageal junction. It was covered in debris and stuck to esophageal mucosa, which a 3-cm burn along 2/3 of the esophageal circumference. Button battery was removed, and exploration completed without evidence of further damage. Treatment with PPI and sucralfate was established. Six hours later, the patient started oral intake without any incidence. She underwent control endoscopy, four weeks after the event and esophageal stenosis was found. It was treated by balloon dilatation without complications. Conclusion Incidence of button battery ingestion is increasing now a days and the early diagnosis when they become lodged in esophagus, is of capital importance to diminish the risk of potential fatal complications. Endoscopic removal and a close follow up are essential to deal with complications. ES-40 External radio opaque markers as a guide to maintain the axis of dissection during sub mucosal tunneling in per oral endoscopic myotomy procedure for achalasia cardia T S Chandrasekar, S Sathiamoorthy, B J Gokul, K Raja Yogesh, M S Prasad, V S Shanthi, T C Viveksandeep Correspondence- T S Chandrasekar [email protected] MedIndia Hospitals, Nungambakkam, Chennai 600 034, India, and The University of Kansas Medical Center, Kansas City, US

Indian J Gastroenterol

Introduction Per oral endoscopic myotomy (POEM) is a newly emerged, minimally-invasive, innovative endoscopic procedure for the treatment of achalasia cardia. For a successful outcome of POEM procedure, a proper axis of dissection should be maintained from the mucosal incision site, up to the esophago-gastric junction (EGJ) during sub-mucosal dissection and myotomy. As the esophageal lumen in achalasia is often tortuous, maintaining the right axis is a technical difficulty. Hence we adopted a new technique which would avoid frequent endoluminal check endoscopy to ascertain the axis of dissection. Placement of three external radio-opaque markers (at the level of mucosal incision, EGJ and 3 cm beyond the EGJ) before the procedure under endoscopic and fluoroscopic guidance, helps as a guide to maintain the axis of dissection and significantly reduces the procedure time and inadvertent complications. Method Eligible patients with primary achalasia were subjected to POEM procedure in a standard manner: mucosal incision, sub-mucosal-tunneldissection, myotomy and mucosal closure. Before the start of the procedure, under endoscopic and fluoroscopic guidance three radiopaque markers, each 5 cm in length were secured externally over the skin, the first one at the mucosotomy site, the second at EGJ and the third, 3 cm beyond the EGJ. Axis of dissection and scope advancement within the sub mucosal space was verified periodically by a short fluoroscopic screening at regular intervals. Results and Conclusions This simple novel method of placing external markers to guide the axis of dissection during sub-mucosal tunneling avoids repeated endoluminal check endoscopy routinely being performed during POEM procedure to verify the right axis of dissection. We observed that the second marker helped in identifying the EGJ accurately. The third marker identified the end-point of myotomy objectively. This technique therefore reduced the procedure time and inadvertent complications. ES-41 Reuse of EUS-FNA needle does not affect adequacy of tissue sampling Avnish Seth, Varun Gupta, Neeraj Garg, Alka Ganda Correspondence- Avnish [email protected] Fortis Memorial Research Institute. Gurugram 122 002, India Background To study impact of re-use of EUS-FNA needle on adequacy of tissue sampling. Methods Data collected prospectively for consecutive EUS-FNA over 3year period was analyzed. Material obtained by single user with Wilson Cook EUS needle 22G without suction was subjected to field staining and rapid on-site evaluation (ROSE). For re-use the needle was sterilized with ETO. Lesions were classified as pancreatic solid lesions (PSL), pancreatic cystic lesions (PCL), solid masses of hollow viscous (SMHV) and lymph nodes (LN). The adequacy of tissue sampling was correlated with location and size of lesions and number of passes required for adequate sampling. Fisher’s exact test was applied for group comparison of categorical variables (reuse of needle) and Mann-Whitney U test for comparison of continuous variables. Results Of a total of 160 procedures, adequate material could be obtained in 156/160 (97.5%). Adequate sample was obtained in 77/79 (97.4%) with new needle, 51/52 (98%) with first re-use (p=0.653), 25/26 (96.1%) with second re-use (p=0.578) and 3/3 (100%) with third re-use (p=0.928). The average number of passes required were 1.7 with new needle, 1.5 with first re-use (p=0.197), 1.4 with second reuse (p=0.104) and 1 with third re-use (p= 0.139). Positivity rate for lesions below 10 mm was 11/11 (100%): 6/6 (100%) with new needle and 5/5 (100%) with first reuse. For lesions 11 mm to 20 mm positivity was 30/31 (%): 13/14 (92.8%), 12/12 (100%) and 5/5 (100%) with new needle, first reuse and second reuse respectively. For lesions >20 mm positive sampling could be obtained in 115/118 (97.4%): 58/59 (98.3%), 34/35 (97.1%), 20/21

(95.2% and 3/3 (100%) with new needle, first, second and third re-use respectively. Adequate sample was obtained in 14/15 (93.3%) for PSL, 9/9 (100%) for PCL, 13/13 (100%) for SMHV and 120/123 (97.5%) for LN and was not affected by needle re-use. Conclusion Needle reuse does not affect results of tissue sampling. ES-42 Clinical profile, safety and efficacy of endoscopic management of patients presenting with foreign body ingestion in a tertiary care centre Pratik Tibdewal, A Jain, N Ramani, A Karad, P Bhatt, A Sadalage, D Gupta, S Bhatia Correspondence- Shobna [email protected] K E M Hospital, Mumbai 400 012, India Background Foreign body (FB) ingestion is a frequent gastrointestinal emergency. Data on FB ingestion in India are lacking. The aim of present study was to assess the profile, safety and efficacy of endoscopic management of patients presenting with FB ingestion. Methods Patients with FB ingestion who had undergone endoscopic removal at our institution (K E M Hospital, Mumbai) between August 2016–June 2017 were assessed retrospectively. The demographics, nature of FB, interval between ingestion, presentation and endoscopic procedure, success and complications were analyzed. Results Fifty patients [Median age 6 years (range 1-75 years), 30 males] presented with FB ingestion. Coin was the most common foreign body (56%), followed by button battery (20%). Others include pins, door handle, fish bone, denture, food bolus, seed, bangle and key. None of the patients had any known psychiatric illness. The median interval between ingestion to presentation and presentation to retrieval were 6 hours (2-198 hours) and 3 hours (1-24 hours), respectively. Twenty-four (48%) of foreign bodies were found in the esophagus, 14 (28%) in stomach, 3 (6%) at the upper esophageal sphincter, 2 (4%) in the proximal part of small intestine, while 7 (14%) foreign bodies were not accessible by flexible upper gastrointestinal endoscope. Median duration of endoscopic procedure was 10 minutes (range, 2-40). Five out of 10 (50%) patients with button battery ingestion developed grade 3 mucosal injury while 1 of 3 (33%) sharps developed microperforation and all were managed conservatively. Conclusions Caution and early intervention should be sought in patients with button battery and sharp ingestion. ES-43 Narrow band imaging findings of patients of gastrointestinal tuberculosis Sarthak Malik, Rakesh Kochhar, Kim Vaiphei, Kusum Sharma, Neha Berry, Narendra K Dhaka, Saroj K Sinha Correspondence- Sarthak Malik [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim To study Narrow band imaging findings in patients of gastrointestinal tuberculosis (GITB). Methods It was a prospective study conducted from July 2015 to November 2016. Cases of clinically suspected GITB more than 18 years of age were recruited. All patients underwent CECT abdomen, routine esophagogastroduodenoscopy or colonoscopy along with narrow band imaging with magnification (NBI-M) with biopsy. Diagnosis of GITB was made if AFB were seen in tissue or grown in culture, or histopathology showed caseous necrosis with granulomatous inflammation, or clinical/radiological and endoscopic features were suggestive of tuberculosis patient with good response to antitubercular therapy.

Indian J Gastroenterol

Results Fifty-five cases of suspected GITB were recruited. NBI findings in ileum were broadened and thickened villus pattern was the most common one seen in 39.2% of cases, marked blunting and atrophy seen in one and a normal villous pattern seen in four patients. Eleven patients had dilated and meandering vessels with a short-circuit pathway in the lesions with five patients having regular, unbranched with semi-circle pattern of vessels. Assessment of payer’s patches revealed abnormal and indistinct domes in nine and two cases respectively. Assessment of vascular pattern in payer’s patches revealed dilated and meandering vessels with a shortcircuit pathway in eight, regular, unbranched with semi-circle pattern of vessels in four and irregular, sparse vessel pattern in four patients. Lesions suspicious of granuloma were seen in four patients. Corresponding histopathology confirmed the narrow band imaging finding in three. The colon findings revealed Type 1 pit pattern in twenty-three (82%) cases. Assessment of vascular pattern revealed clearly visible vessel pattern as the most common pattern in 17 (60.7%). The vascular pattern showing dilated caliber of unusually large capillaries was seen in six cases. Conclusion NBI helps in better demarcation and targeted biopsy from lesions of GITB. ES-44 Evaluation of efficacy of endoscopic self expanding metal stent placement in malignant biliary obstruction: A single centre experience Ankit Gupta, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] S M S Medical College, Jaipur 302 015, India Introduction Patients with inoperable malignant biliary obstruction are often suited only for palliative treatment by endosopic self expanding metal stent (SEMS) placement. This study aims to report a single centre experience demonstrating the efficacy of endoscopic biliary SEMS in the management of malignant biliary obstruction. Methods Between February 2016 and February 2017, 110 patients (73 males, mean age 61.75 year) with inoperable malignant biliary obstruction who underwent endoscopic SEMS placement were included in this prospective single centre study. Patients were followed up at predefined intervals for upto 6 months. Main outcome assessed were: 1) reappearance of biliary obstructive complications post–SEMS insertion during follow up; and 2) the need for biliary reintervention. Results Uncovered SEMS were placed in all patients. Technical success was achieved in 94.5% patients. Nine percent patients developed post– ERCP cholangitis and were managed conservatively. Biliary obstructive complications developed in 10% patients at 1 month, in 38.24% patients at 3 months and in 14% patients at 6 months. Nine percent patients required re-intervention at 1 month and 36.3% patients required reintervention at 3 months due to appearance of biliary obstructive complications. At the end of 6 months, 49% patients were alive with a patent stent. Conclusion Endoscopic SEMS placement for management of malignant biliary obstruction has limited efficacy to achieve successful biliary decompression. Further long-term data are required to confirm this observation. ES-45 Palliation of malignant gastroduodenal obstruction with selfexpandable metal stent using side-and forward-viewing endoscope: Feasibility and outcome Vinay Kumar, Uday C Ghoshal, Samir Mohindra, Abhai Verma, Vivek A Saraswat Correspondence- Uday Chand [email protected] Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226 014, India

Background Endoscopic placement of self-expandable metal stent (SEMS), an alternative to surgical bypass for palliation of malignant gastric outlet obstruction (GOO), is commonly performed using forward-viewing endoscope with wide therapeutic channel; however, due to limited availability, most Indian centres use side-viewing duodenoscope. We studied the feasibility and outcome of SEMS placement using side- and forward-viewing endoscopes. Method Data of patients undergoing SEMS placement using side- and forward-viewing endoscopes with therapeutic channel for palliation of malignant GOO presenting during a 5-year period were analyzed retrospectively. Follow up data were obtained from records and telephonic interview and technical, clinical success, complications, and survival evaluated. Results Of 114 patients (age 56.5±11.6-y, 59 [52%] female), 90 (79%) and 24 (21%) underwent SEMS placement using side- and forwardviewing endoscopes, respectively. Technical (89, 98.9% vs. 24, 100%, p=ns) and clinical success (84, 93.3% vs. 23, 95.8%, p=ns), complication rate (3, 3.3% vs. 0, p=ns) between side- and forward-viewing endoscopes were comparable. However, SEMS could be placed in shorter time using forward- than side-viewing endoscope (21 min [inter-quartile range 19.5 to 35] vs. 34 min [25 to 45], p=<0.001). SEMS could be deployed successfully with forward-viewing endoscope in two patients in whom initial attempts using side-viewing endoscope failed. GOOSS improved following stent placement (median 0, range 0-2 vs. 2, 0-3, p=0.0001). Survival of patients undergoing SEMS placement using side- and forward-viewing endoscopes was comparable. Conclusion Though side- and forward-viewing endoscopes are equally effective for antro-duodenal SEMS placement, the procedure can be performed faster using the latter. ES-46 Clinical and colonoscopic correlation with colonic thickening on computed tomography Harshad Khairnar, Shamshersingh Chauhan, Prabha Sawant Correspondence- Harshad [email protected] Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Introduction CT is often useful in patients suscipicious of TB, malignancy, IBD or the other gastrointestinal disorders. Clinical guidelines regarding colonoscopy when CT reported bowel wall thickening are lacking. We conducted this study to determine utility of colonoscopy in management of patients with abdominal symptoms who were found to have colonic thickening on CT. Study design This was observational study conducted at tertiary care centre wherein 102 patients were enrolled from June 2016 to July 2017 who had abdominal symptoms with CT abdomen showing colonic wall thickening. Colonoscopy was done in these patients. Patients with past history of abdominal Koch’s, colonic malignancy, IBD and those who had undergone colonoscopy in past were excluded from the study. Clinical, endoscopic and pathologic correlation was done in all patients. Written informed consent was taken and approval for the study was taken from ethics committee. Results One hundred and two cases were enrolled in the study. Of these 40% cases had tuberculosis. All of them except for one case had tuberculosis involving IC junction. One case had rectal tuberculosis. Fifteen percent had colonic malignancy of which except 1 had adenocarcinoma. One case had signet cell carcinoma involving rectum and transverse colon. Left colon was involved in 59% cases while 41% had right colonic involvement. Rectum or rectosigmoid was involved in 50% cases, which was commonest site of malignancy in our study. Three percent cases had Crohn’s colitis and solitary rectal ulcer syndrome each. Of all cases with colonic thickening on CT scan 25% had normal colonoscopy. Of them

Indian J Gastroenterol

95% cases had mild thickening (<5 mm) of which 74% had left colonic and 16% had right colonic involvement; rest others had significant thickening (>5 mm). Pain in abdomen was the chief complaint in all cases with normal colonoscopy. Conclusion Colonoscopy is most useful in symptomatic cases with CT abdomen showing significant bowel wall thickening. However, despite showing mild bowel wall thickening on CT, colonoscopy should be planned if there is high possibility of GI pathology based on the clinical presentation. ES-47 Efficacy of Simethicone versus N-acetyl cysteine versus combination of Simethicone and N-acetyl cysteine as premedication prior to upper gastrointestinal endoscopy – A prospective double blinded randomized placebo controlled trial K Veeraraghavan, George Kurian C o r r e s p o n d e n c e - Ve e r a r a g h a v a n K r i s h n a m u r t h y [email protected] Pondicherry Institute of Medical Sciences, Pondicherry 605 104, India Aim The aim of this study was to detect the efficacy of Simethicone with N-acetylcystiene combination as premedication before upper gastrointestinal endoscopy improves mucosal visualization. Methods Study design - 2x2 factorial. Analysis - SPSS software. Institutional ethical committee approval was taken before starting the study. A total of 768 consecutive patients were recruited. They were randomized into four treatment groups: (A) N-acetylcysteine alone; (B) Simethicone alone; (C) Combination of Simethicone+N-acetylcysteine; (D) placebo. After randomization each patient participating in the study will be asked to drink a bottle of 115 ml solution. Each bottle will contain 115 mL solution (15 mL of Emulsion+100 mL of water; each 15 mL of emulsion contains B 150 mg+C 600 mg for one group, B 150 mg alone in another group, A 600 mg in one group) and just plain water as placebo in last group. After 20 minutes of consuming the solution, gastroscopy will be done and multiple images will be taken from esophagus, stomach and duodenum. The endoscopist was blinded to patient preparation. Based on the various images obtained the total mucosal visibility score will be calculated. Results The upper body of stomach had the worst visibility score for all groups. TMVS of groups B and C were significantly lower than those of group A and D with p=0.03. The total duration of the procedure also got reduced in group C compared to group A, B and D with p=0.021. The number of lesions detected in group C and B were more compared to group A and D with p=0.035. Conclusion Premedication with N-acetylcysteine and simethicone markedly improves mucosal visibility and reduces the time taken during gastroscopy. This low-cost and well tolerated intervention may improve detection of lesions and early neoplasia. ES-48 Does score matter? - Comparative analysis of scoring systems in upper gastrointestinal bleed Anurag Lavekar, H V Aradya, H P Nandeesh, Deepak Suvarna, Suryaprakash Kothe, Indrajit Suresh, T R Vijaykumar Correspondence- Anurag [email protected] J S S Medical College and Hospital, Mysore 570 004, India Introduction Upper gastrointestinal (GI) bleed is one of the most common emergencies in Gastroenterology. Early risk assessment forms the cornerstone in deciding effective timing of endoscopy.

A variety of scoring systems are available for determining the risk of rebleeding and mortality. Aim To compare utility of different risk scoring systems. Methods Prospective study involving 145 patients coming to a tertiary health care centre with upper GI bleed were enrolled for study. Patients in whom upper GI Scopy was not possible were excluded from study. Detailed history and clinical examination was done. Complete hemogram, LFT, RFT, upper GI Scopy was done for included patients. Statistical analysis was done using SPSS 17. Chi-square test was used for studying association between studied parameters and rebleed risk and mortality. Comparison of different scoring systems (Rockall, Blatchford, AIMS 65) was done using ROC curve in predicting risk of rebleed and mortality. Results ROC for AIMS 65 is 0.877; 0.79 for Rockall and 0.687 for Glassgow Blatchford system for predicting mortality. ROC was 0.815 for AIMS 65, 0.621 for Rockall and 0.53 for Blatchford scoring system for predicting rebleed. Rockall, Blatchford, AIMS 65 all scores had 100% negative predictive value and 100% sensitivity in predicting mortality in upper GI bleeding. Specificity, positive predictive value in predicting mortality as well as rebleeding risk was better in AIMS 65 score. Conclusions AIMS 65 was a better predictor of risk of rebleed and mortality as compared to Rockall and Glassgow Blatchford scoring system. NUTRITION N-01 Effect of antioxidants and exercise on oxidative stress in geriatric cancer patients Satyavati Rana1, Gaurav Sharma1, Ram Rattan Negi1, Manju Mohanty1, Pragya Sharma2, Rakesh Kapoor1 Correspondence- Satyavati Rana- [email protected] 1 Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India, and 2College of Nursing, AIIMS Introduction Cancer related oxidative stress is common in cancer patients during and after radiotherapy. Therefore, present study was planned to investigate effect of antioxidant supplementation and physical exercises on oxidative stress and anti-oxidant levels in geriatric cancer patients receiving radiotherapy. Methods Ninety geriatric cancer patients (≥60 years) receiving radiotherapy were randomly assigned in three groups (30 in each group) to receive antioxidant therapy, physical exercises and control (treatment as usual) group. Oxidative stress and anti-oxidant levels were measured in hemolysate of each group using standard methods. Results Out of 90 patients, 16 were males in exercise group, 18 in anti-oxidant group and 15 in control group with age range 60-78 years. LPO in geriatric patients was significantly (p<0.05) increased in all the groups before starting radiotherapy. The level of reduction in oxidative stress was more in those patients who received anti-oxidants during treatment as compared to exercise group. Whereas, there was least reduction in oxidative stress levels in control group (as usual) as compared to other two groups. GSH was significantly decreased (p<0.05) whereas SOD and Catalase were significantly higher in exercise as well as antioxidant groups as compared to control group. Conclusion In conclusion, effect of exercise or antioxidants appeared to decrease oxidative stress in geriatric cancer patients receiving radiotherapy. Thus, antioxidant supplementation and physical exercises could be integral part of supportive care for geriatric cancer patients receiving radiotherapy.

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N-02

PEDIATRIC GASTROENTEROLOGY

Assessment of body composition by bioelectrical impedance analysis in patients with chronic pancreatitis

PG-01 Primary intestinal lymphangiectasia in children

Namrata Singh*, Indu Grover*, Deepak Gunjan*, Hem Sati**, Anoop Saraya* Correspondence- Anoop [email protected] * Departments of Gastroenterology and Human Nutrition, and ** Department of Biostatistics. All India Institute of Medical Sciences, New Delhi 110 029, India Background The patients with chronic pancreatitis are usually malnourished. The body composition in patients with chronic pancreatitis is not well characterized. Aim To assess body composition of the patients with chronic pancreatitis. Methods Body composition was assessed by bioelectrical impedance analysis (Tanita TBF-215 leg to leg portable impedance analyzer). The results are expressed as total body weight (TBW)=fat mass (FM)+fat free mass (FFM). Patients were categorized based on body mass index (BMI) by WHO criteria. Results Patients [n=106, mean age 31.44±11 years, mean duration of disease 50.09±60.04 (range 2-300) months, calcification 90.5%] categorized as underweight, normal weight and overweight were 43.4%, 45.3% and 11.3% respectively. Analysis based on gender, etiology, diabetes, steatorrhea and education are given in Table. Conclusion Approximately 43% patients were undernourished. Though the BMI is similar for both genders, males have a higher FFM as compared to female patients. As the educational status improves the FFM increases. Table Body composition of patients with chronic pancreatitis (n=106) Variables Gender

N

BMI (kg/m2) n

FM (kg)

Male Female p value Etiology Idiopathic Alcohol p value Diabetes Absent Present p value Steatorrhea Absent Present p value Education Illiterate Schooling

81 19.68±3.51 25 19.19±3.97 0.553

76 6.2 (0.4-23.6) 76 48.95±9.08 24 8.95 (0.8-17.6) 24 36.52±3.09 0.268 <0.001

83 19.58±3.70 23 19.49±3.34 0.914

79 7.1 (0.4-23.6) 21 5.8 (1.5-20.1) 0.915

79 45.39±9.08 21 48.14±6.73 0.199

76 19.58±3.40 30 19.53±4.16 0.954

71 6.5 (0.4-23.6) 29 6.2 (0.8-21.4) 0.715

71 46.74±7.84 29 44.08±10.38 0.167

89 19.67±3.40 17 18.99±4.65 0.476

84 7.2 (0.4-23.6) 84 45.95±8.711 16 4.25 (1.0-21.4) 16 46.06±8.85 0.471 0.964

13 19.06±2.78 58 19.28±3.25

13 7.3 (1.9-16.2) 55 6.2 (0.4-17.6)

13 40.26±8.53 55 45.28±8.53

Graduate p value

35 20.22±4.37 0.420

32 7.4 (0.5-23.6) 0.738

32 49.47±8.56 0.003

Values are expressed as mean±SD, median (min-max)

N

FFM (kg)

Durga Prasad, Anshu Srivastava, Anil Tambe, Moinak Sen Sarma, Ujjal Poddar, Surender Kumar Yachha Correspondence- Anshu [email protected] Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Introduction and Aim Intestinal lymphangiectasia is an important cause of protein-losing enteropathy. It can be primary (congenital) or secondary to conditions causing obstruction of intestinal lymphatics. Pediatric data is scanty, especially in terms of follow up and outcome. We evaluated the clinico-laboratory profile, response to therapy, complications and outcome of children with primary intestinal lymphangiectasia (PIL). Methods An audit of hospital records (2007-2017) was done to identify children with PIL. Diagnosis was based on suggestive clinical presentation, biochemical parameters, histology showing dilated intestinal lacteals and exclusion of secondary causes. Data on clinical presentation, lab parameters including endoscopy and histology, treatment and outcome in follow up was recorded. Results Twenty children (13 boys, age 7 [1-14] years) with PIL were enrolled. Median age of symptom onset was 12 (1-120) months; 15 (75%) cases being symptomatic in the first 5 years. Chronic diarrhea (17, 85%), anasarca (15, 75%) and failure to thrive (12, 60%) were the most common symptoms. Ascites, pleural and pericardial effusion were seen in 13 (65%; chylous in 4), 4 (20%) and 2 (10%) cases respectively. Limb lymphedema (n-3), tetany (n-4), fat soluble vitamin deficiency (n-4) and recurrent infections (n-3) were the other clinical features. All cases had typical small bowel histology (duodenal-17, jejunum-1, ileal-2). Majority had hypoproteinemia (95%), hypoalbuminemia (95%) and hypocalcaemia (90%), while 35% had lymphopenia (absolute lymphocyte count <1500/mm3). Patients were managed by dietary modification, calcium and vitamin supplementation and supportive therapy (paracentesis, albumin infusion, octreotide, total parenteral nutrition). Eighteen cases with good compliance showed improvement in clinico-laboratory profile over a follow up of 49.8 (6120) months. One patient each developed abdominal B cell lymphoma and Budd-Chiari syndrome after 5 and 6 years of PIL diagnosis. Conclusion Dietary therapy of PIL is rewarding and leads to improvement in majority. Close follow is essential for monitoring compliance, growth and complications. PG-02 Biochemical and echocardiographic assessment of children with celiac disease Y M Bhavika, Vivek Dewan, Ranjit Nath Correspondence- vivek [email protected] Department of Pediatrics and Cardiology, Dr Ram Manohar Lohia Hospital, New Delhi 110 001, India Introduction Recently, heart diseases including autoimmune myocarditis, cardiomyopathy, ischemic heart disease etc. are being reported among the celiac patients. These may be attributed to the chronic systemic inflammation, early atherosclerosis, unfavorable biochemical profile and the autoimmune process itself. Several studies have also demonstrated subclinical cardiac

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dysfunction in children and young adults with celiac disease using M mode echocardiography. Clustering of many traditional cardiovascular risk factors is evident in childhood and persists into young adulthood. Thus, we planned this study for biochemical and echocardiographic assessment of children with celiac disease. Methods A cross sectional observational study was conducted in the Department of Pediatrics and Department of Radiodiagnosis in PGIMER, Dr R M L Hospital among thirty-six children (aged 116 years) newly diagnosed with celiac disease and age and sex matched controls. Venous blood samples were assessed for serum C-reactive protein, folic acid, vitamin B 12 and homocysteine levels and fasting lipid profile including total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides levels using appropriate methods. Echocardiographic parameters were measured by M mode ultrasonography and variables like LAd, LVEDD, RVDD, IVSd, LVPWd, ARd and EF were measured and assessed accordingly. Statistical analysis was performed by SPSS program for Windows, version 17.0. with appropriate methods. Results Significantly lower levels of serum total cholesterol, HDLcholesterol and LDL-cholesterol with normal triglycerides, Creactive protein, vitamin B12 and folic acid levels with significantly increased serum homocysteine levels were noted among cases. Among the echocardiographic parameters, ejection fraction was significantly lower while other parameters like LAd, LVEDD, RVDD, IVSd, LVPWd and ARd showed no significant increase among the cases. Conclusion Our study being conducted in children though did not demonstrate any significant structural alterations, significant difference in EF and obvious presence of biochemical risk factors for cardiovascular diseases warrants further detailed evaluation on follow up with regular monitoring of cardiac functions. PG-03 Carotid intimal medial thickness in children with celiac disease V M Bhavika, Vivek Dewan, Namrita Sachdev Correspondence- vivek [email protected] Department of Pediatrics and Radio-Diagnosis, Dr Ram Manohar Lohia Hospital, New Delhi 110 001, India Introduction The increasing cardiovascular risk in celiac disease as evident by many previous studies may be attributed to the chronic systemic inflammation and unfavorable biochemical profile leading to accelerated atherosclerosis. Carotid intimal medial thickness (CIMT) has emerged as direct marker of early atherosclerosis as compared to traditional biochemical screening markers. Hence, we planned this study with an aim to evaluate CIMT in children with celiac disease aged 1-16 years in comparison to age and sex matched controls. Methods A cross sectional observational study, conducted in the Department of Pediatrics and Department of Radiodiagnosis in PGIMER, Dr R M L Hospital from 2015-2017. Thirty-six children with celiac disease with age and sex matched controls were enrolled and the IMT for far and near wall thickness on each side and the mean CIMT were obtained. Statistical analysis was performed by the SPSS program for Windows, version 17.0 using appropriate statistical tests. Results Mean right sided CIMT was significantly higher in cases (0.053 ±0.009 cm vs. 0.039±0.007 cm, p value of 0.000). Mean left sided CIMT did not significantly differ between the groups (0.051±0.009 cm vs. 0.048 ±0.055 cm, p value 0.702). Average CIMT (right and left carotid artery together) was not significantly different (0.052±0.008 cm and 0.044 ±0.029 with p value of 0.114). But, a significant positive correlation between age of the patients, age at onset of symptoms and CIMT was noted.

Conclusions Though the average CIMT (right and left combined) did not show significant difference between cases and controls, there was a differential affection of right and left CIMT with significant results in the right carotid artery. Thus, further studies in the field with a detailed evaluation of children with celiac disease for cardiovascular risk profile and early signs of atherosclerosis are needed. EPIDEMIOLOGY EP-01 Prevalence of osteoporosis and osteopenia in patients with inflammatory bowel disease Chintan M Mori, K R Palaniswamy, A T Mohan, P Piramanayagam, S Parameswaran, U Srinivas, U Dhus, M Hariharan, M S Revathy, V P Seshadri, M Preethi Correspondence - Chintan M Mori - [email protected] Department of Medical Gastroenterology Apollo Hospitals, Chennai 600 006, India Introduction Patients with inflammatory bowel disease (IBD) are associated with low bone mineral density (BMD) which leads to osteopenia and osteoporosis. There are few studies evaluating BMD in patients with IBD, but none have used ICMR database for comparison. Here we propose to study prevalence of low BMD in patients with IBD and its relation to various risk factors. Methods Randomly selected 50 patients of IBD (27–ulcerative colitis (UC), 23-Crohn’s disease (CD) were included in crosssectional study at Gastroenterology Department, Apollo Hospitals, Chennai and their BMD was measured at lumber spine and left femur neck with DEXA scan. BMD was compared with standard ICMR database and Caucasian Hologic database; prevalence of osteopenia and osteoporosis, their relation with disease type, disease duration, extent, steroid use, BMI, calcium and vitamin D level were assessed. Results Thirty-two (64%) out of 50 patients had low BMD (25– osteopenia and 7-osteoporosis). Osteopenia and osteoporosis was present respectively in 61.5% and 3.8% patients with UC and 37.5% and 25% patients with CD. Low bone mineral density was present in 60% patients using long-term steroids. Sixty-six percent patients with abnormal vitamin D level had low BMD. Twenty percent patients were reclassified (10%-from osteoporosis to osteopenia; 10%-from osteopenia to normal) when BMD was compared with ICMR database instead of Hologic database. Conclusion Osteopenia and osteoporosis is common in Indian patients with inflammatory bowel disease. ICMR database should be considered instead of hologic database to diagnose low bone mineral density in Indian patients. EP-02 Epidemiological profile of carcinoma esophagus at a centre in northwest India Awanish Kumar, Sandeep Nijhawan Correspondence- Sandeep Nijhawan- [email protected] Sawai Man Singh Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur 302 004, India Introduction The incidence of esophageal adenocarcinoma (AC) has shown a dramatic increase in several populations over the past 25 years, particularly in developing countries. This observation makes it essential that studies are made periodically in every region to describe the patterns of this disease with the idea to do

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work on their prevention. There is a paucity of studies describing the current epidemiological profile of esophageal carcinoma (EC) in north western part of India. Methods This was a retrospective study of 170 histologically confirmed cases of EC evaluated at S M S Medical College and Hospital, Jaipur, between January 2012-December 2016, regarding their demographic and clinical profile. Results Out of the total 170 patients (M:F=2.54: 1), majority of the patients were elderly with mean age of 71 years. Seventy percent had rural background. Most of the patients belonged to BKuppuswamy Socio-economic Class^ scale (KSS) IV and V. Tobacco consumption was reported in 79.4 % of patients. Progressive dysphagia and weight loss were the most common presenting symptoms. The middle third esophagus (57%) was the most frequent anatomical site for EC followed by lower third (33.5%). Squamous cell carcinoma (87.6%) was the most common histopathological type. AC was diagnosed in 11 patients. Of 140 staged patients, 83.5% were diagnosed with advanced esophageal cancer (Stages III and IV). Distant metastasis was documented in 25% of the staged patients. Conclusion elderly male, low socioeconomic status, tobacco exposure were the risk factors for EC. For early diagnosis and effective intervention there is a need for screening of high-risk population as most of the patients present with an advanced stage of disease. EP-03 Gastrointestinal tuberculosis - Clinicopathological profile from tertiary care center from Western India Suhas Udgirkar, Sanjay Chandanani, Sunil Pawar, Samit Jain, Ravindra Surude, Pravin Rathi Correspondence- Suhas [email protected] Department of Gastroenterology T N M C and B Y L Nair Hospital, Mumbai 400 008, India Background Abdominal tuberculosis has varied mode of clinical presentation from abdominal pain to intestinal obstruction to ascites. Hence careful approach to the patients and supportive investigation data are necessary to make the final diagnosis. This study was undertaken to evaluate the clinicopathological profile of patients with abdominal TB in a tertiary care centre in western India. Methods This was a prospective follow up study conducted in the Department of Gastroenterology in tertiary care hospital. Total 162 patients with abdominal TB diagnosed on the basis of clinical profile and investigation like colonoscopy, computed tomography, diagnostic laparoscopy and histologically proven cases. Results Out of the 162 patients, 80 were males with age ranging 8-70 (Mean 34.25±14.7) years. Most cases were from lower economic class. Abdominal pain was the most common presenting symptom in 134 (80.86%) followed by ascites in 20, per rectal bleed in 11 cases. Family history of tuberculosis was present in 11 cases. Cecum and IC junction (28.39%) was the most common involved segments on CT and colonoscopy. Colonoscopy revealed ulceronodular lesion in 54 (37.5%) patients, ulceration in 27 (18.75%) nodularity in 15 (10.41%) and stricture in 5 (3.4%). Skip areas were present in 3 patients. Histopathology showed granuloma in 122 (75.30%) cases. Tb MGIT (mycobacterium growth indicator tube) positive in 41 (25.30%) cases and Gene X-pert was positive in 4 (26.54%) cases. Five patients had MDR tuberculosis and 1 had XDR tuberculosis. Four cases had associated upper gastrointestinal tract involvement. Weight gain and improved appetite was earliest indicator of treatment response. Three patients died due to TB meningitis. Only 2 patients required surgical management. Drug induced hepatitis was rare occurrence (1 case).

Conclusions Abdominal TB is still a commoner disease in developing countries with varied presentation and can be successfully treated with early diagnoses. EP-04 TPMT versus NUDT15 genotyping in predicting thiopurine toxicity in Indian population Swarup A V Shah, Minal Paradkar, Devendra Desai, Tester F Ashavaid Correspondence- Tester [email protected] Research Laboratories, Departments of Gastroenterology, and Biochemistry, P D Hinduja National Hospital and Medical Research Centre, Mumbai 400 016, India Introduction Inter-individual variation seen in the thiopurine metabolism is attributed to the genetic variant in Thiopurine methyltransferase (TPMT) gene leading to myelosuppression. In Asians, the thiopurine-induced toxicity is not completely explained by TPMT variants. A genetic variant (C415T) in nucleoside diphosphate-linked moiety X-type motif 15 (NUDT15) gene is associated with thiopurine intolerance and may be more relevant in Asians. We aimed to determine which of these two are more relevant in clinical practice. Methods Till date 370 samples have been received for routine TPMT testing, of which 193 samples were available for NUDT15 genotyping. TPMT (*2, *3A, *3B and *3C) and NUDT15 (C415T) genotyping were performed using amplification-refractory mutation system–polymerase chain reaction and restriction fragment length polymorphism technique. Results were validated by DNA sequencing. Results TPMT variants were seen in 12 (3.2%) patients (Heterozygous for one of TPMT variant) whereas NUDT15 was seen in 33 (19.1%) patients [CC, CT and TT genotypes were found to be 80.8%, 17.1% and 2.1% respectively). Patients with heterozygous TPMT genotype were treated with half the dose of thiopurine. Information on thiopurine toxicity was available for 73 patients. Of the 60 patients without NUDT15 variant, none developed leukopenia, whereas out of 13 patients with NUDT15 variant, 10 developed leukopenia. (p value <0.0001). TPMT variants were absent in all. In predicting toxicity, NUDT15 variant was more effective than TPMT in terms of sensitivity (100% vs. 0%) and specificity (95.2% vs. 100%). Furthermore, NUDT15 genotype testing is more cost effective than TPMT. Conclusions NUDT15 genotype appears to be more clinically relevant than TPMT genotype in our population. Preemptive NUDT15 genotyping approach before thiopurine therapy should therefore be adopted, which would help to effectively manage Indian patients on thiopurine therapy and minimize the incidences of adverse toxicity. EP-05 Clinical profile, Diagnosis and Burden of abdominal tuberculosis: a 2-year retrospective study from a tertiary care center Kanishka Uthansingh, Chinmayee Kar, Jimmy Narayan, Manas Kumar Behera, Manoj Kumar Sahu, Ayaskanta Singh Correspondence- Dr Ayaskanta [email protected] IMS and SUM Hospital, Bhubaneswar; All India Institute of Medical Sciences, Bhubaneswar 751 003, India Aim To review all cases of abdominal tuberculosis (ATB) for demographic details, clinical profile, burden and diagnostic work up.

Indian J Gastroenterol

Methods This was a retrospective analysis of patients diagnosed with ATB from June 2015 to June 2017 at the Gastroenterology D ep a r t m e n t o f I MS a n d SU M Ho s p i t a l, B h u b a n es w a r. Demographic data and clinical information was collected from electronic patient records, including radiology, endoscopy, microbiology, histology, biochemistry and serology. Patients were classified as either confirmed ATB [biopsy proven or ZN stain positive] or presumed ATB [high clinical suspicion]. All those patients who clinically responded to ATT were included. Subtypes of ATB were classified as tuberculosis (TB) peritonitis, luminal TB, lymph node TB, solid organ TB or from a combination of sites. Results Out of 1670 inpatient admissions in the Gastroenterology Department, a total of 31 cases with ATB (1.8%) were identified. Mean age was 43 years, 54% females. Sixteen patients (51%) had confirmed ATB. Out of these 16 patients, half were diagnosed using gastrointestinal endoscopy biopsy while the rest half were diagnosed using USG/CT guided biopsy or paracentesis. The rest, 15 patients were treated as presumed ATB. Only two patients had co-existing sputum culture positive for MTB, and 30.8% had an abnormal chest X-ray. Subtypes of ATB: 8 (25.8%) had TB peritonitis; 20 (64.5%) had luminal TB; 4 (12.9%) had solid organ TB;5 (16.1%) had lymph node involvement and 22.5% had a combination of these. Luminal involvement included 12 patients at the terminal ileum or ileo cecal valve, 4 at colon, 1 each at gastric, duodenum and esophagus. Only two patients were HIV positive. Conclusion Despite all the efforts, ATB is clinically significant and mainly affects the middle aged adults. Most common site of involvement is terminal ileum and IC valve followed by the peritoneum. Almost 50% of patients have difficulties in confirming diagnosis despite a range of noninvasive and invasive diagnostic tests. MISCELLANEOUS M-01 Study of cognitive function of long standing irritable bowel syndrome patients Shivam Sachan, V K Dixit, S K Shukla, S K Singh, Gaurav Garg Correspondence - Shivam Sachan - [email protected] Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction Irritable bowel syndrome (IBS) is the most common functional gastrointestinal (GI) disorder Worldwide. Central nervous system (CNS) dysfunction is a prominent feature of IBS. However, the neurobiological and cognitive consequences of key pathophysiological features of IBS, such as stress-induced changes in hypothalamic pituitary adrenal (HPA) axis functioning, is unknown. Aims To study the cognitive function of long standing IBS patients and to compare it with normal healthy population. Methods The present case control study, was conducted at Gastroenterology Department of Institute of Medical Sciences, Banaras Hindu University. It was mainly centered on long standing IBS patients. Screening was done in each patient to assess the cognitive impairment using Mini-Mental State Examination (MMSE) and Clock drawing test (CDT). Exclusion criteria Significant other acute or chronic coexisting illness, use of psychoactive medications, antibiotic use within the prior 4 weeks, alcohol abuse. Age, sex and education matched controls were taken. They belonged to same socioeconomic background. Complete physical and mental examination was done. exclusion criteria was same as above, informed consent was taken.

Results In this study 48 patients IBS were studied. Forty-eight controls were also taken. Out of the 48 diagnosed IBS patients, cognitive impairment, on the basis of MMSE was found in 16 (33.33%) cases while it was present in only 7 (14.58%) controls, p value=0.031 which was significant suggesting that there is a association between cognitive impairment and long standing IBS on the basis of MMSE. On CDT cognitive impairment was found in 19 (39.58%) cases while it was present in only 15 (31.25%) controls, p value=0.393. Conclusion On the basis of MMSE there was a significant association between long standing IBS and cognitive impairment. Cognitive function declined as age increased in both cases and controls. Limitations-small sample size, single centre study. M-02 Pattern of low bone mineral density in patients of inflammatory bowel disease: A cross sectional study Zohaib A W Khan, Shiran Shetty, Girisha Balaraju, C Ganesh Pai, Nagesh Kamath Correspondence- Zohaib [email protected] Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal 576 104, India Introduction Patients of inflammatory bowel disease (IBD) are at increased risk of metabolic bone disease. We aimed to evaluate the frequency of low bone mineral density (BMD) in patients with IBD. Methods Patients with IBD seen in the Department of Gastroenterology from March 2016 to June 2017 were included in this cross-sectional study. The risk factors for bone disease including steroid usage, duration, extent, activity, behavior of IBD and body mass index (BMI) were prospectively recorded. Serum 25-hydroxyvitamin D was measured. BMD was assessed using a radial quantitative ultrasound (QUS; Sunlight Omnisense 8000P) and the data were compared with randomly selected healthy matched controls and also in the subgroups with IBD. Results Ninety-two patients of IBD [ulcerative colitis (UC)=60, Crohn’s disease (CD)=32; mean (SD) duration of illness [61.6 (6.2) vs. 56.6 (5.1) months respectively, p=0.729)] were included and compared with 30 controls. Low BMD was equally prevalent in IBD patients and controls (39.1% vs. 43%, p=0.889) and in UC and CD (38.3% versus 40.6%, p=0.830). Significantly more patients with CD were underweight (18% UC vs. 40.6% CD, p=0.007) and were vitamin D deficient (60% of UC vs. 87.5% of CD, p=0.006). The behavior, extent, severity, duration, number of flares and frequency of steroid usage did not differ with prevalence of low BMD. Low BMD prevalence was higher in males with CD <50 years and pre-menopausal females than controls (30.8% vs. 0%, p=0.014). The same subgroup had a higher prevalence of underweight (50% vs. 0%, p=0.001) and of vitamin D deficiency (92% vs. 31%, p=<0.001) compared to controls. Conclusions All IBD patients are not at higher risk of low BMD compared to their healthy counterparts as previously thought. It is the younger patients of CD who require preventive measures and will probably require treatment. M-03 Tracheoesophageal fistula: Case series B Thinakar Mani *, Bharat Narasimhan**, S Ratnakar Kini*, K Prem Kumar*, M Kani Sheikh*, Thangavelu Pugazhendhi*, Mohammed Ali* Correspondence- Thinakar Mani- [email protected] * Institute of Medical Gastroenterology, Madras Medical College, Rajiv Gandhi Government General Hospital, Chennai 600 003, India* and ** Department Of General Medicine, Kasturba Medical College, Mangalore 575 004, India

Indian J Gastroenterol

Introduction Tracheoesophageal fistula (TEF) is a relatively rare condition that poses a technical challenge to manage. This case series describes our experience in the treatment of esophagorespiratory fistula in our centre. Aim of this study is to analysis various presentation, treatment modalities and outcome of TEF. Methods The study setting is tertiary referral centre and retrospective analyti cal study, The s ubjects were people with tracheoesophageal fistula. A total of 20 patients with TEF of various age group has been studied for presentation, treatment modalities and outcome. Results A retrospective review of case records of 20 patients with esophagorespiratory fistula was done. There were fifteen tracheoesophageal fistulae and five bronchoesophageal fistulae. Among them, one was secondary to corrosive injury, four was secondary to erosion because of prolonged endotracheal intubation, and Fifteen was due to carcinoma of esophagus. Of the 20 patients, there were sixteen males and four females. The age of presentation range of 15-83 years. Ten patients underwent esophageal stents placement, five patients had a definitive surgical intervention. The surgical procedures including fistula repair, fistula closure with pedicled muscle flap or omentum major, esophageal bypass surgery and lesion resection. Conclusion Most malignant TEF patients having a short survival time. The treatment of TEF is a tough challenge. Although the efficacy has been achieved after application of interventional theraphy. The current standard of palliative theraphy for patients with TEF is endoscopic or radiologic placement of covered self expanding metallic stents (SEMS), which allow closure of the fistula. Other, less common treatment options for selected patients with malignant TEF include chemotheraphy and radiation, surgical bypass, esophageal exclusion, and fistula resection and repair.

M-04 Clinical and laboratory profile of infective v/s non-infective diarrhea in kidney- transplant recipients and its effect on renal function: A prospective study Ajinkya Sonambekar, Devendra Desai, Philip Abraham, Alan Almeida, Jatin Kothari, Rasika Sirsat, Anand Joshi, Tarun Gupta, Vatsal Mehta Correspondence- Ajinkya Sonambekar- [email protected] P D Hinduja National Hospital and Medical Research Centre, Mumbai 400 016, India Introduction Diarrhea affects 18% to 50% of kidney transplant recipients and can impact graft function. We aimed to prospectively study the clinical profile, laboratory findings and outcome of kidney transplant recipients with diarrhea (infective and noninfective). Methods Kidney transplant recipients presenting with diarrhea were included. The diarrhea work up was as per the treating physician. Demographic, clinical and laboratory data, increase in serum creatinine, treatment administered and outcome were noted with a 3 months follow up. Results Forty-seven patients [13 women; median age: 45 years; range: 1678 years] had 64 episodes of diarrhea. Thirty-three (51.5%) episodes were attributed to infections [culture negative (25); amoebic (2); cryptosporidium (1), cyclospora+cryptosporidium (1), Cytomegalovirus (1), Clostridium difficile (1), rotavirus (1) and giardia (1)]. Eleven (17%) were immunosuppressant induced [Mycophenolate (8), tacrolimus (2) and cyclosporine (1)]. Twenty (31%) were due to other causes [antibiotics (5), laxatives (3), irritable bowel (3), sepsis (8), GVHD (1)]. Mean time for resolution was 3.8 days. Mean increase in serum creatinine in the infectious group was 45% and 95% in non-infectious group

(p=<0.05). With improvement in diarrhea, improvement in eGFR was noted in 87% of all episodes. Recurrence was seen in 27% of infective and 26% of non-infective cases. Conclusion Nearly half (48.5%) of the episodes were non-infective. Seventeen percent cases were attributed to immunosuppressants requiring dosage modification. More than 80% episodes were associated with a worsening of graft function and was more significant in the non-infective episodes as compared to that in infective episodes. Recovery of graft function was seen in most cases with resolution of diarrhea. M-05 Gastrointestinal lymphomas: Data from tertiary care center in South India Siddharth Dharamsi, L Venkatakrishnan, Mukundan Swaminathan, Vishnu Abishek, Prudhvi Krishna Ch. Correspondence- Siddharth Dharamsi- [email protected] PSG Institute of Medical Sciences and Research, Coimbatore 641 004, India Background and Aim Gastrointestinal (GI) tract is the most common extra-nodal site of lymphoma. Primary gastrointestinal lymphoma (PGIL) are rare, accounting for only 1% to 4% of all gastrointestinal (GI) malignancies. Up to 75% of PGIL involve the stomach, followed by small intestine and colon. Majority of PGIL are of the B-cell origin. Presentation is most often non-specific with symptoms such as abdominal pain, vomiting, diarrhea and weight loss. Tissue diagnosis with immunohistochemistry is the gold standard. The aim of the study is to evaluate various presentations of GI lymphomas and to identify the histological subtypes. Methods A retrospective study was undertaken to identify the clinical features, anatomic distribution and histological subtypes of GI lymphomas presenting to a tertiary care hospital in south India, in a period of 3 years. Detailed case history was taken. Biopsies were taken from affected areas and diagnosis of lymphoma was identified using standard staining and immunohistochemistry markers were used to identify subtypes. Results Twelve cases of GI lymphomas were identified which included 4 cases of PGIL and 8 cases of nodal lymphomas. Gastric PGIL was seen in 1 case, identified to be diffuse large B-cell lymphoma (DLBCL). Small intestinal PGIL was identified in 3 cases and all were of B-cell origin, including 2 cases of DLBCL and 1 case of mantle cell lymphoma (MCL). Eight cases of nodal lymphomas with GI symptoms were identified. All cases were of B-cell origin, including 7 cases of DLBCL and 1 case of follicular lymphoma. Conclusion Considerable variation exists in the literature with respect to incidence, sites of involvement and histological subtypes of GI lymphomas. In this study we establish that small intestinal PGIL may be more common than gastric PGIL in south India and DLBCL is the commonest histological subtype. M-06 Gastrointestinal bleed in inpatient cases of liver abscess Sudhir Singh1, Vinod Dixit1, Sunit Shukla1, Gaurav Garg1, Shivam Sachan1 Correspondence- Sudhir Singh- [email protected] Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction Our aim was to study the presentation, endoscopy findings and clinical outcome in patients admitted with liver abscess who

Indian J Gastroenterol

developed gastrointestinal (GI) bleed before or during the course of hospitalization at our centre. Methods We analyzed 87 consecutive cases of liver abscess admitted in our centre and selected 16 out of them who had GI bleed and evaluated them in terms of their presentation, colonoscopic or esophagogastroduodenoscopic findings and clinical outcome. Results Out of 87 cases admitted with liver abscess 16 (18.4%) presented with GI bleed. Of these 12 (75%) presented with hematochezia while 4 (25%) presented with melena. Colonic ulcers were cause of GI bleed in 12 (75%) of these and out of these 11 patients (91.7%) had ulcers in proximal colon while 1 had scattered ulcers in the whole colon. In 3 patients (18.7%) internal hemorrhoids was the cause of GI bleed while 1 patient was detected to have esophageal variceal bleed. Conclusions 18.4% of inpatients with liver abscess had GI bleed. Colonic ulcers mainly in proximal colon was cause of bleed in 75% cases. Internal hemorrhoids was cause in 18.7% cases. Esophageal varices were uncommon cause of GI bleed in liver abscess patients. Clinical outcome was good in these patients with no fatalities in our study. M-07 Plummer-Vinson's syndrome - Case series P Padmanabhan, Rajan Mittal, P Bibin, Paul Joyes, S N K Chenduran Correspondence- P [email protected] Meenakshi Medical College, Enathur, Karrapettai Post, Kanchipuram 631 552, India Introduction Plummer-Vinson or Paterson-Brown Kelly syndrome is characterised by classical triad of dysphagia, iron deficiency anemia and post cricoid web. Most of the patients are middle aged women with koilonychia, iron deficiency anemia presenting with painless intermittent or progressive dysphagia for solids. It is associated with increased frequency of upper gastrointestinal cancer. Aim To study the clinical, endoscopic and hematologic profile of patients with Plummer-Vinson's syndrome (PVS). Methods This is descriptive study of patients diagnosed as PVS in our hospital during the period of July 2015 to June 2017. Results Total number of patients 19; Male:Female 3:16; Age ranged from 27 to 70 years; median age+/- SD 46.05+/_12.9 years; median duration of symptoms 8 months; presentation include dysphagia/hold up at throat 100%; food bolus and tablet impaction repeatedly 21%; predominant features of anemia 26.3%; endoscopic evaluation: single cricopharyngeal (CP) web 68.4%; multiple CP webs 31.5%; web at 35 cms of esophagus in addition to CP web 5.2%; other findings-esophageal moniliasis 10.5%, antral ulcers 10.5%; Savary-Gilliard (SG) dilation done in 52.6%; scope fracture of web 47.3%; 26.3% needed blood transfusion; hematologic evaluation: median hemoglobin was 7.8 gms/dL; range 1.4 to 11.2 gms%; all patients had microcytic hypochromic anemia. Serum ferritin estimated in 2 was <1ng/mL each and in 1 it was1.2 ng/mL. 15.5% stool examination showed ascaria and hookworm ova. Discussion 1. In this study 15.7% were males; 2. 26.3% patients needed blood transfusion indicating the severity of anemia. 3. One patient had web at 35 cms of esophagus. 4. 52.6% needed SG dilation. Conclusion Considering the necessity of blood transfusion (26.3%) and SG dilation (52.6%), PVS and its cause iron deficiency anemia though benign, needs attention from public health aspect. M-08 Spectrum of esophageal tuberculosis: Clinical features, diagnosis and outcome Amol Sonyabapu Dahale, Ajay Kumar, Siddhartha Srivastav, Sanjeev Sachdev, Shivakumar Varakanahalli, Amarender Singh Correspondence- Ajay Kumar- [email protected]

G B Pant Institute of Post Graduate Medical Education and Research, 1, J L N Marg, New Delhi 110 002, India Introduction Esophageal involvement in tuberculosis is rare and usually secondary to adjacent mediastinal lymph node or pulmonary involvement. Data on esophageal tuberculosis is scarce. We aimed to analyze clinical, radiological, endoscopic, and histopathological features of proven esophageal tuberculosis cases and their response to anti tubercular therapy (ATT). Methods We retrospectively identified patients with proven esophageal tuberculosis from January 2014 to December 2016 at GIPMER, New Delhi. Well defined granuloma with or without caseation and/or acid fast bacillus on staining either from esophageal biopsy or adjacent mediastinal lymph node fine needle aspiration cytology specimen along with clinical features and response to ATT were collectively taken as definite tuberculosis. The epidemiological, clinical, endoscopic, endosonographical, radiological, histopathological, treatment and follow up data was collected and analyzed. Results Total of 14 patients had definite esophageal tuberculosis and median age of patients was 37 years (14-65 years) and 8 were females. Most common presenting symptom was dysphagia (n-11, 78%) followed by odynophagia (n-7, 50%), two had cough with swallowing and another two had hemetemesis. Constitutional symptoms like anorexia, weight loss and fever was present in more than half of patients. On endoscopy mid esophagus was most common site of involvement and ulcer was most common finding (n-12), followed by underlying elevated lesion seen in five while fistula was seen in three patients. The mediastinal lymphadenopathy was present in all with parenchymal lesion seen in two patients. The endoscopic mucosal biopsies were diagnostic in 8 patients, in remaining 6 patients EUS guided FNAC from mediastinal lymph nodes was diagnostic. Thirteen patients completely responded to ATT while one had partial response with persistent fistula requiring additional treatment. Conclusion Esophagus involvement is rare in tuberculosis, endoscopic mucosal biopsy and EUS guided FNAC are diagnostic and response to ATT is excellent. M-09 Interaction of oxidative stress, cytokines, gastrointestinal motility and small intestinal bacterial overgrowth iT1DM patients Aastha Malik, Rajesh Kumar Morya, Sanjay Kumar Bhadada, Satyavati Rana Correspondence- Satyavati Rana- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background In type 1 diabetes, body is unable to make insulin. This leads to hyperglycemia. This hyperglycemia can induce oxidative stress which is a major risk factor in progression of diabetes. It can further increase cytokine production via several different mechanisms. Inflammation can affect gut neural apparatus that may lead to dysmotility which may exaggerate occurrence of bacterial overgrowth in intestine of patients. Aim To understand the role of oxidative stress, inflammatory cytokines, gut motility and small intestinal bacterial overgrowth (SIBO) in type1 diabetic mellitus patients Methods Sixty type 1 diabetic patients and 60 healthy controls were enrolled. SIBO and OCTT were measured using noninvasive glucose and lactulose hydrogen breath tests, respectively. Plasma levels of IL-6, TNF-α and IL-10 were measured in all subjects by ELISA. Oxidative stress i.e. lipid per-oxidation and all anti-oxidant parameters (reduced GSH, SOD, Catalase) were measured by standard methods. Results Out of 60 T1DM patients, 29 were males with mean±SD age 21.7 ±4.9 years. IL-6, TNF-α and IL-10 in T1DM patients were significantly higher (p<0.05) as compared to controls. LPO in T1DM patients was

Indian J Gastroenterol

significantly increased (p<0.05) while GSH was significantly decreased (p<0.001) whereas SOD and Catalase were significantly higher as compared to controls. OCTT was delayed and SIBO were significantly higher in patients as compared to controls. Conclusion This study shows that oxidative stress would have cause inflammation in gut wall. Cytokines further would have affect on gut neural apparatus leading to delayed OCTT. This gut dysmotility would have led to bacterial overgrowth in intestine of patients. M-10 Digestive oncology survey of Indian Gastroenterologists 2017 Vivek Mohan Sharma¹, Chris Franca², C J Mulder³, Mohandas K Mallath4 Correspondence- Vivek Mohan Sharma- [email protected] ¹V U Medisch Centrum, Amsterdam, The Netherlands, ²V U Medisch Centrum, Amsterdam, The Netherlands, ³V U Medisch Centrum, Amsterdam, The Netherlands, and 4Tata Medical Center, Kolkata, India Introduction The practice of digestive oncology in India is diversified and digestive oncology as a sub-speciality of gastroenterology is still at it’s nascent stage. This survey was intended to gauge the concepts and prospects of digestive oncology among Indian gastroenterologists in order to improve the outcomes of Indians with gastrointestinal (GI) cancers. Methods A web-based questionnaire containing 20 questions was emailed to 2,356 practising Indian gastroenterologists selected from the national database. Two hundred and one responses were collected over the period of 5 weeks. Five responses were excluded due to repetition. A total of 196 responses were analyzed. Results The response rate was only 8.53%. Female respondents were 7%. Majority of respondents (78.1%) were gastroenterologists who were also member of ISG. 40.5% respondents attended 6-10 new GI cancer patients per month. Majority of them (53.3%) rarely participated in multi-disciplinary team (MDT) meetings. 50.7% primarily did only diagnostic and therapeutic endoscopies and were not involved in chemotherapy, nutrition and palliation of the patients. 29.1% were almost always involved in staging and work up of the patients. 55.7% accepted to have reasonable knowledge of current treatment of GI cancer. Only 15% would often administer chemotherapy. 62% gave cancer prevention advise to the patients. 81.5% felt that delayed diagnosis due to poor health literacy was responsible for poor survival of GI cancer patients. 85.5% felt need for enhancing digestive oncology curriculum. 83% opined that there is scope for digestive oncology as a sub-speciality in India like in European Union. 45% felt that the current GI training program in India had adequate theory and inadequate practical. Conclusion There are very few practising female gastroenterologists in India. MDT meeting is rare. GI training lacks adequate practical exposure. A large majority felt that delayed diagnosis due to poor health literacy was responsible for poor survival of GI cancer patients and that there is scope for digestive oncology as a sub-speciality in India. M-11 Chylous ascites: A report of 10 cases Harshal S Mandavdhare, Vishal Sharma, Usha Dutta Correspondence- Harshal Mandavdhare- [email protected] Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction Chylous ascites is an uncommon clinical entity which results from abnormalities involving the abdominal lymphatics. Various

etiologies have been described ranging from abdominal tuberculosis, malignancy, post radiotherapy to idiopathic to name a few. Here we report our experience of patients who presented with chylous ascites. Methods This is a retrospective case series of patients with chylous ascites. Results We encountered 10 patients of chylous ascites over 3 years. The mean age of the patients was 35.5 years (range 15-72) and 6 were males. Mean duration of presentation was 10.35 months (15 days-84 months) and the presenting complains were abdominal distension in 9, abdominal pain in 8, loss of weight/appetite in 7, lymphadenopathy in 3 and fever in 2. The underlying etiology was 2 had tuberculosis, 1 each had acute and chronic pancreatitis, constrictive pericarditis after radiotherapy for esophageal cancer, carcinoma stomach signet ring type with liver metastasis, carcinoma body of pancreas, lupus nephritis, primary lymphangiectasia and Milroy disease. One patient developed deep venous thrombosis and another had infrarenal inferior vena cava and splenic vein thrombosis. Two patients had cardiomyopathy and one of whom also had a left atrial clot. Two patients died in the index admission while six improved. The therapeutic modalities used were with medium chain triglyceride based diet with/without octreotide, pancreatic duct stenting (for chronic pancreatitis), pigtail drainage of the ascitic fluid (Milroy) and antitubercular therapy (Tuberculosis). No patient underwent surgery. Conclusion Chylous ascites can occur due to various etiological factors and management of the underlying condition may help in resolution. M-12 A prospective study on clinical profile of upper gastrointestinal bleeding in a tertiary care hospital Ansuman Dash, Sushant Kumar Sethi Correspondence- Sushant Kumar Sethi- [email protected] Department of Gastroenterology, Apollo Hospital, Bhubaneswar 751 011, India Background Acute upper gastrointestinal (GI) bleeding is a common medical emergency with a hospital mortality of approximately 10 percent. Higher mortality rate is associated with rebleeding. Rockall scoring system identifies patients at higher risk of rebleed and mortality. Objective To study the clinical profile of acute upper GI bleed to know the etiology, clinical presentation, severity of bleeding and outcome. Method This is a prospective hospital based study conducted in Gastroenterology Dept. of Apollo Hospital, Bhubaneswar from May 2016 to June 2017. It included 63 serial cases presenting with manifestations of upper GI bleed. Their clinical and endoscopic profiles were studied. Rockall scoring system was used to assess their prognosis. Result Out of 63 patients, 52 were male, 11 were females. Median age of affected patients was 52.5 years. Most common presentation was malena in 46 patients, while both hematemesis and melena occurred in 19 patients.4 patients had syncope. History of antiplatelet and NSAID intake was there in 19 patients. Nineteen patients had excessive alcohol intake (>60 gm/day) and 12 patients were smoker. Twenty-four patients presented with shock. Nineteen patients had Hb <7 g/dL. Most common cause of UGI bleed was duodenal ulcer (15 cases) followed by gastric ulcer (13 cases), erosive gastritis (12 cases), esophageal varices (9 cases), UGI malignancy (5 cases), esophageal ulcerations (3 cases) etc. H. pylori RUT was positive in 20 cases. Twenty patients required endoscopic therapy. ICU care was required in 20 patients. Thirty-five patients were discharged in <7 days. Death occurred in 3 patients and all were due to causes other than UGI bleed and had Rockall score >8. Conclusion Acute upper gastrointestinal bleeding is a medical emergency. In our study we found mortality is associated with massive bleeding, co-morbidities and Rockall score >6. Urgent, appropriate hospital management definitely helps to reduce morbidity and mortality.

Indian J Gastroenterol

M-13 Clinical spectrum of gastrointestinal malignancies Rima Kamat, Ravi Thanage, Sanjay Chandanani, Sunil Pawar, Ravindra Surude, Samit Jain, Qais Contarctor, Pravin Rathi Correspondence- Ravi Thanage- [email protected] Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India Background The spectrum of primary gastrointestinal (GI) malignancies varies in different geographical areas. The main purpose of this study was to analyze the spectrum of GI tract malignancies with respect to incidence, various sites and histomorphological parameters in western India. Methods This study is a retrospective analysis carried out in Department of Pathology in a tertiary care hospital. Total 401 cases were studied over a period of 5 years. During this period all GI biopsies and resected specimens received from the Department of Gastroenterology and Department of Surgery for suspected GI malignancy were analyzed. The clinical records of the patients were studied. Results The maximum incidence of GI malignancy was found in age group of 40 to 60 years (47.38%) followed by those above 60 years (31.42%). The incidence of GI malignancy was found to be higher in males (61.35%) than females (38.65%). The commonest symptom was pain in abdomen (92.26%). Commonest received specimen in cases of GI malignancies was of left hemicolectomy 46 cases (41.81%). Most common histological type of the GI malignancy was adenocarcinoma (69.07%). Of these cases the most common grade was moderately differentiated (85.92%). Overall incidence of adenocarcinoma was reported highest in colorectum (53.79%). Higher incidence of squamous cell carcinoma was seen in middle esophagus (51.06%). Neuroendocrine tumors were seen one each in stomach, duodenum and ileum. Non-Hodgkins lymphoma (4 cases) were seen; 2 each in stomach and ileum. Conclusions The most common sites of GI malignancy were colorectum (40.64%) followed by esophagus (25.18%) and stomach (20.69%). In colorectum the most common site of malignancy was rectum (42.94%). M-14 Clinicopathological spectrum of abdominal tuberculosis: A 5-year retrospective study in a tertiary care hospital Shubham Jain, Richa Verma, Reema Kamat, Suhas Udgirkar, Vinay Zanwar, Samit Jain, Ravindra Surude, Pravin Rathi Correspondence- Shubham Jain- [email protected] Topiwala National Medical College and B Y L Nair Hospital, Mumbai Central, Mumbai 400 008, India Background Abdominal TB continues to give diagnostic and therapeutic challenges. This study was aimed to study clinical profile of abdominal tuberculosis in resource poor settings. Aims To study the incidence of abdominal tuberculosis with analysis of distribution of various sites of involvement and todemonstrate various microscopic features and theircorrelation with clinical diagnosis. Methods A retrospective analysis carried out in a tertiary carehospital. Total180 cases were studied over 5 years, from January 2010 to December 2014. All resected specimens, biopsies and medical autopsies diagnosed to have abdominal tuberculosis were analyzed histopathologically. The data was analyzed and compared using descriptive statistics. Results Out of 8100 gastrointestinal (GI) pathology related tissue specimens over four years,180 (2.2%) had TB. Most common presenting complaint was abdominal pain (70.6%), followed by fever (35%), vomiting (31.1%) and intestinal obstruction (23.3%). Past

history of TB was found in 18.3% of cases. Colonoscopy helped in diagnosis of abdomen Koch’s in 50.3% cases. The most common sites of involvement were the ileocecal junction (48.3%) and small intestine (47.2%). In this study 89.3% cases were ulcerative type and 10.7% were of the hypertrophic type of tuberculosis. On gross morphology ulcers (41.6%), tubercles (30.6%) and strictures (22.8%) were the common features. 35.6% had evidence of mesenteric lymph node involvement. Commonest histopathological feature was epithelioid granuloma (98.9%). Conclusion In our study of tuberculosis most common complaint was abdominal pain. Most common sites of involvement were the ileocecal junction (48.3%) and small intestine (47.2%). 89.3% cases were ulcerative type. Histopathology has high diagnostic yield in our study. M-15 Health-related quality of life in inflammatory bowel disease Amey Sonavane, Anil Pal, Deepak Amarapurkar Correspondence- Amey [email protected] Bombay Hospital and Institute of Medical Sciences, MumbI 400 020, India Introduction Health-related quality of life (HRQoL) is a broad multidimensional concept that includes self-reported measures of physical and mental health. Inflammatory bowel disease (IBD) often has a relapsing course with significant social, sexual, psychological and financial repercussions that significantly impacts the patient's quality of life. The inflammatory bowel disease questionnaire (IBDQ) is a widely used questionnaire for QoL assessment specific for IBD. The aim of this study was to validate the IBDQ in the Indian setting. Methods Both hospitalized and outdoor patients consecutively attending our hospital between 2014 and 2016 were administered the IBDQ which contains 32 questions distributed over four health domains: bowel symptoms, systemic symptoms, emotional function and social function. Disease severity was evaluated using the ulcerative colitis disease activity index (UCDAI) for UC and Harvey Bradshaw Index (HBI) for Crohn’s disease (CD). The control group consisted of healthy volunteers who also solved the IBDQ. Results Two hundred and sixteen IBD patients (120 men, 96 women; age 41.78±15.34 years) and demographically matched controls solved the IBDQ. Out of the 216 IBD patients, 69% had UC; 30% had CD and 1% patients were diagnosed with indeterminate colitis. There was a significant negative correlation between UCDAI and IBDQ in patients with UC and between HBI and IBDQ in patients with CD (p<0.0001). All the health domain components of the IBDQ were significantly different between the IBD cohort and the control cohort (p<0.0001). There was no statistical difference between the mean IBDQ score amongst the UC and CD subgroups (p=0.4811). Chronic continuous type of disease had the worst total IBDQ and IBDQ domain scores. Weight, number of flares, extraintestinal manifestations, use of mesalamine and other immunosuppressants and anemia had significant negative co-relation with HRQoL on multivariate analysis. Conclusion In this first study for Indian patients with IBD, the IBDQ thus stands validated. M-16 Cerebrospinal fluid ascites: A rare complication of ventriculoperitoneal shunt Tarun Sebastian Joseph, P Mallikarjun, Deepak Ganga, Vishnuvardhan Reddy, G Balaji, Syed Shafiq, Harshad C Devarbhavi Correspondence- P Mallikarjun- [email protected]

Indian J Gastroenterol

St. Johns Medical College and Hospital, Bangalore 560 034, India Background Ascites is a common accompaniment to liver disease. However a number of other diseases cause ascites. Ventriculoperitoneal (VPS) surgery is generaly used for treatment of hydrocephalus. But this procedure may rarely cause gastrointestinal complications like small bowel obstruction due to adhesions, ascities and loculated/encysted peritoneal collection. Aims We report two cases of ascites secondary to ventriculoperitoneal shunt. Methods We present two cases, 35-year-old female and a 26-year-old female who underwent ventriculoperitoneal shunts 6 and 22 years back respectively for different reasons presented with ascites, one for 4 months and another for 2 months. Both had high SAAG ascites with normal liver functions. One of them had high counts and the other, normal counts. Imaging revealed normal liver with no evidence of portal hypertension apart from ascites. One had an encysted collection and the other, diffuse non loculated ascites. Both the patients underwent transposition of shunt. Ventriculoperitoneal shunt was converted into vantriculoatrial shunt following which the ascites disappeared. Conclusions Cerebrospinal fluid ascites is a rare complication of VP shunt, which has to be kept in mind while evaluating a patient with ascites and may save unnecessary expenditures and trauma of procedures such as liver biopsy and other invasive ones and is easily treatable. M-17 Etiological profile of dysphagia in a tertiary care hospital in coastal Odisha, India Subhendu Panigrahi, Debakanta Mishra, Chitta Ranjan Khatua, Sambit Kumar Behera, Suryakanta Parida, Kaibalya Ranjan Dash, Prasanta Kumar Parida, Preetam Nath, Shivaram Prasad Singh Correspondence- Subhendu [email protected] Department of Gastroenterology, S C B Medical College, Cuttack 753 007, India Introduction Dysphagia is a common health problem worldwide. There are various causes of dysphagia which vary from region to region. The aim of this study was to determine the various etiologies of dysphagia. Methods Consecutive patients who presented with history of dysphagia to the Gastroenterology Department of S C B Medical College, Cuttack were included in the study. Period of study was December 2016 to July 2017. Patients were evaluated for dysphagia with meticulous history, clinical examination, upper gastrointestinal endoscopy, chest X-ray, barium swallow study and endoscopic biopsy with histopathological study when required. Results Out of 146 patients, 56.85% were males and 43.15% were females. Mean age of patients was 44.37±17.395 years. The common etiologies were benign stricture (38.35%) and carcinoma esophagus (35.62%). Other findings included achalasia cardia (4.79%), upper esophageal web (3.42%), pharyngeal cancer (3.42%), esophageal candidiasis (3.42%), reflux esophagitis (2.05%), Barrett’s esophagus (1.36%), foreign body esophagus (1.36%), esophageal diverticulum (0.68%). In 5.47% of cases no etiology was detected. Most of the benign strictures were due to corrosive injuriy to esophagus (82.4%) followed by peptic stricture (10.6%), sclerotherapy induced stricture (3.56%) and pill induced stricture (3.56%). Among the corrosive injuries of esophagus, most common cause was acid injury (69.56%) followed by alkali injury (21.73%). Most of the corrosive injuries were due to suicidal intake rather than accidental exposure. Conclusion In this study, benign stricture was the most common etiology of dysphagia due to a high incidence of suicidal intake of corrosives in the young. Carcinoma esophagus, achalasia cardia, esophageal web, pharyngeal cancer, reflux esophagitis, esophageal candidiasis, Barrett’s esophagus, foreign body and diverticulum were other etiologies. Measures

should be taken for adequate treatment of predisposing factors and public awareness including various injury prevention advocacy and legislative intervention. M-18 Comparison of risk scores in upper gastrointestinal bleed in a tertiary care hospital in Western India Sanjay Chandnani, Suhas Udgirkar, Vinay Zanwar, Nikhil Sonthalia, Shubham Jain, Ravindra Surude, Qais Contractor, Pravin Rathi Correspondence- Sanjay [email protected] Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Ch. Hospital, Mumbai 400 008, India Background and Aims Upper gastrointestinal bleed (UGIB) causes significant morbidity and mortality. Our aim of study was to identify risk scores predicting mortality, admission, need of intervention. Methods Consecutive patients having UGIB were enrolled prospectively from April 2016 till March 2017. Using clinical, laboratory, and endoscopic variables, PNED (Progetto Nazionale Emorrahia Digestiva), Rockall, GBS (Glasgow Blatchford score), AIMS65 scores were calculated at time of admission. Follow up upto 28 days was done. Risk scores were compared for predicting in terms of short-term mortality, admission, need for blood transfusion and intervention using AUROC. Results Three hundred patients of UGI bleed presented to hospital during 1 year. Males (69%) were more common than females. Most common presentation was hematemesis (95%), followed by only melena (5%). Variceal bleed was seen in 53% and 42% were non-variceal, while 4.33% had negative upper GI endoscopy. Using AUROC, Rockall score with cut off 4 (0.729) was more sensitive than other scores while PNED score >4.5 (0.746) was more specific for predicting death at 28 days. Composite score of PNED and Rockall score was more sensitive and specific (0.767). Rebleed was seen in 15% cases, better predicted with PNED score of >6 (0.797) with highest PPV. GBS scores with <10 had less likely requirement of blood transfusion. Rockall score >6 had greater duration of hospital stay and rebleeding, while score 0 could be managed on outpatient basis. Conclusion PNED is a better predictor for need of rebleed and mortality, while Rockall and AIMS65 perform equally. Composite PNED-Rockall score (0.767) was more sensitive and specific for predicting mortality. Rockall score of 0 and GBS score less than 6 termed as low risk can be managed on outpatient basis. M-19 Validation of indigenous point–of-care test for celiac disease among children and adults in a tertiary hospital in north India Shivani Deswal1, Rohan Malik2, Govind K Makharia2, Alka Singh2, Prashant Singh2, Shinjini Bhatnagar3, Tapish Pandey2, Rajni Yadav2, Savita Saini2, Prasenjit Das2 Correspondence- Shivani [email protected] 1 PGIMER and Dr R M L Hospital, New Delhi; 2All India Institute of Medical Sciences, New Delhi; 3Translational Health Science and Technology Institute. Introduction Traditional serological assays for diagnosis of celiac disease (CD) such as tTG (IgA) and AEA are expensive, not readily available and require a well-equipped laboratory with a long turnaround time. An indigenous human recombinant tTG based point of care test (POCT) for CD in collaboration with AIIMS, ICGEB (International Centre for Genetic Engineering and Biotechnology) and J Mitra Pvt. Ltd has been developed. This detects anti-tTG antibodies (both IgA and IgG based) present in serum within 20 minutes. We validate this POCT in a tertiary care hospital.

Indian J Gastroenterol

Methodology Total of 109 cases and 55 controls were enrolled from pediatric and adult outpatient Gastroenterology Clinic over a period of six months (December-May 2017). Sera of newly diagnosed celiac cases based on TTG/AEA positivity and duodenal biopsy: Marsh Grade 2 or more villous atrophy were collected. Simultaneously sera were taken from controls who underwent upper gastrointestinal endoscopy for reasons other than suspicion of celiac disease and had TTG/AEA negative and duodenal biopsy normal. Patients already on GFD were excluded. Sensitivity and specificity of index test was measured against the reference tests. The positive reference test was defined as a combination of duodenal biopsy showing >grade 2 changes using modified Marsh criteria and positive AEA and/or tTG and the negative reference test was defined as combination of negative anti-tTG and AEA in the presence of normal IgA levels. Results POCT agreed with 79/109 positive and 55/55 negative diagnoses based on the reference tests. Sensitivity of the index test was 72.4% and specificity was 100%. The positive predictive value (PPV) and the negative predictive value (NPV) were 100% and 64.7% respectively. Conclusion We have validated the indigenous card test in our setting. More studies are needed to validate the kit in different settings. M-20 Spectrum of sequence variations in Indian patients with progressive familial intrahepatic cholestasis show several novel polymorphisms Anjali Sharma, Ujjal Poddar, Shikha Agnihotry, Shubha R Phadke, S K Yachha, Rakesh Aggarwal Correspondence- Rakesh [email protected] Departments of Gastroenterology, Pediatric Gastroenterology and Medical Genetics Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Background Progressive familial intrahepatic cholestasis (PFIC) is caused by variations in ATP8B1, ABCB11 or ABCB4 genes. Data on genetic variations in Indian patients with PFIC are lacking. Methods Coding and flanking splice regions of the three genes were sequenced in unrelated Indian children with clinical, biochemical and histological features of PFIC. Any sequence variations identified were also looked for in parents, 30 healthy persons, and variation databases, and their effect on protein function was assessed in-silico. Results Among 25 children studied (aged 1-144 months), 9 (36%) had ‘pathogenic’ or ‘likely pathogenic’ (P/LP) genomic variations (ATP8B1: 4, ABCB11: 3 and ABCB4: 2); each patient had a different variation. The variations included (i) four amino acid substitutions (ATP8B1: c.1660G>A/ p.Asp554Asn and c.2941G>A/p.Glu981Lys; ABCB11: c.548T>C/ p.Met183Thr; ABCB4: c.431G>A/p.Arg144Gln);(ii) one nucleotide substitution that created a premature stop codon at its location (ABCB4: c.475C>T/ p.Arg159Ter); (iii) one 3-nucleotide deletion causing loss of an amino acid (ATP8B1: c.1587_1589delCTT/p.Phe529del), (iv) one single-nucleotide deletion leading to frame-shift and premature termination (ABCB11: c.1360delG/p.Val454Ter); (v) a complex inversion of 4 nucleotides with a single-nucleotide insertion leading to frame-shift and premature termination (ATP8B1: c.[589_592inv;592_593insA]/p.Gly197LeufsTer10), and (vi) a splice-site variation likely to cause abnormal splicing (ABCB11: IVS8+ 1G>C); last three of these were novel. The variations were homozygous in seven patients, and heterozygous in two (ABCB11: IVS8+1G>C and c.1360delG). P/LP variations were commoner in patients with history of consanguinity (5/7; 71%) than in those without (4/18; 22%) (p<0.05). Conclusions P/LP sequence variations, including some novel variations, in the three PFIC genes were identified in 36% of Indian children with PFIC; none of these was particularly common. No variation was identified in nearly two-thirds of patients; these cases may be related to variations in in promoter and intronic regions of the three PFIC genes, or in other bile-salt transport genes.

M-21 Portal hemodynamics predicts the outcome in severe alcoholic hepatitis? Presenting as acute-on-chronic liver failure Shakti Choudhury1, Ashok Choudhury 1, Manoj Sharma1, Rakhi Maiwall1, Priyanka Jain3, Mamun A Mahtab4, Yogesh K Chawla5, Soek S Tan6, Qin Ning7, Harshad Devarbhavi8, Deepak N Amarapurkar9, Chang Wook Kim C. W. K. Chang Wook Kim10, Saeed S Sadiq11, Amna S Butt11, C Eapen12, Hasmik Ghazinyan13, Chen yu14, Ajit Sood15, Guan H Lee16, Zaigham Abbas17, Gamal Shiha18, Laurentius A Lesmana19, Diana A Payawal20, .kadir A. Dokmeci21, George K Lau G K L George K. Lau22, Irene Paulson, Priyanka Jain, Guresh Kumar, Shiv Kumar Sarin for ACLF working party Correspondence- Shakti [email protected] 1 Hepatology and Liver Transplant, 2 Hepatology, 3Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India, 4 Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 5 Hepatology, PGIMER, Chandigarh, India, 6 Selayang Hospital University of Malaya, Malaysia, 7Department of Infectious Disease, Tongji Hospital of Tongji Medical College, Huazhong University of Science and Technology,, Wuhan, China, 8St John Medical College, Bangalore, 9Bombay Hospital and Medical Research Centre, Mumbai, India, 10Division of Hepatology, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea, South, 11 Aga Khan university Hospital, Karachi, Pakistan, 12Hepatology, CMC, Vellore, India, 13Nork Clinical Hospital of Infectious Diseases, Armenia, Armenia, 14Hepatology Institute Capital Medical University, Beijing, China, 15CMC, Ludhiana, India, 16Department of Gastroenterology and Hepatology, National University Health System, National University of Singapore, Singapore, 17Sindh Institute of Urology and Transplantation, Karachi, Pakistan, 18Egyptian Liver Research Institute And Hospital, Egypt, Egypt, 19Digestive Disease and Oncology Centers, Medistra Hospital, Jakarta, Indonesia, 20Fatima Medical University Hospital, Manila, Philippines, 21Ankara University School of Medicine, Ankara, Turkey, 22Institute of Translational Hepatology, Beijing, China Background and Aims Development of variceal bleed, sepsis and organ failures in acute-on-chronic liver failure (ACLF) often related to the severity of portal hypertension in addition to the inciting acute injury. Aim is to study portal and systemic hemodynamics in ACLF and their influence on organ failure and survival in severe alcoholic hepatitis (SAH) as compared to other etiologies? Methods ACLF patients as defined by APASL were enrolled into the AARC database and followed prospectively for initial 90 days. Clinical events, laboratory parameters, disease severity score, survival were compared for the acute insult i.e. SAH against other etiologies. median stiffness (LSM), transjugular portal hemodynamic parameters (HVPG), cardiac catheterization [mean pulmonary artery pressure (MPAP), PCWP, and formula based systemic hemodynamic variables [SVRI,PVRI, cardiac output (CO), cardiac index (CI)] were compared in predicting AKI, sepsis, organ failure, variceal bleed and survival? Results Three hundred and eight patients (150 SAH, 158 other etiologies) were analyzed. At baseline the MELD, SOFA, bilirubin, creatinine, systemic hemodynamics, mortality (51.5% vs. 48.5%, p=0.29) were comparable. SAH group were younger [(40.8+8.7) vs. (46.6+12.8) years, p<0.001] with high HVPG [(18.5+5.0) vs. (16.7+5.1) mm of Hg, p=0.003]. LSM, HVPG, PCWP, MPAP, variceal grade, INR, serum Na were predictors of 90 days mortality. In multivariate analysis HVPG [OR=1.02, 95CI (1.01-1.13), p=0.01], MPAP [ OR=1.04, 95CI (1.031.12) were independent predictor of mortality. HVPG >17.2 mmHg correlated with variceal bleed (p=0.03), AKI (p=0.09) and sepsis (p=0.07) within 15 days while HVPG >19.5 mmHg associated with mortality (28 % vs. 42 %, p<0.01). HVPG level correlated to low platelet (p=0.02) and presence of red color sign (RCS) (p=0.003) but not to the grade of varices.

Indian J Gastroenterol

Conclusions SAH is associated with higher portal pressure than other etiologies irrespective of variceal grade and is an independent predictor of mortality. Presence of RCS, low platelet correlate to portal hemodynamics. M-22 Acute-on-chronic liver failure has a better long-term survival than acute decompensation- a study of 4897 patients from APASL ACLF Research Consortium (AARC) with a follow up of 5 years

0.87), p<0.001] was lower with ACLF as compared to AD {Fig-2}. Higher short-term (90 days) {33.2% vs. 23%}, 6 months (35.2 vs. 24.9%), 12 months (37% vs. 26.8%) and 24 months (38.9% vs. 29.3%) mortality in ACLF (p<0.001) but not beyond 24 months where AD showed less survival [HR: 1.94 (1.17-2.21), p<0.01]. Conclusion ACLF had higher 90 days mortality due to severity of acute insult. Among the survivors at 90 days the hepatic reserve showed an improvement and beyond 2 years from index insult the survival is much better. M-23

Juned Ahmad Khan1, Ashok Choudhury1, Manoj Sharma1, Rakhi Maiwall1, Harshad Devarbhavi2, Z Duan, Chen Yu3, Q Ning, Ke MA4, S S Hamid, Amna S Butt, Wasim Jafri5, C E Eapen, Ashish Goel6, S S Tan7, Y K Chawla, Sunil Taneja8, Mamun Al Mahtab, Salimur Rahman9, Sombat Treeprasertsuk10, D J Kim11, G H Lee, S G Lim12, L A Lesmana, Cosmos R Lesmana13, Hasmik Ghazinyan14, P N Rao15, Z Abbas16, Deepak N Amarapurkar17, Jose D Sollano, Gian Carpio18, Diana A Payawal19, Manoj K Sahu20, Samir Shah21, G K Lau22, M F Yuen23, Md. Fazal Karim24, A Kadir Dokmeci25, V G Mohan Prasad26, Irene Paulson27, Priyanka Jain27, Guresh Kumar27, Shiv Kumar Sarin1 for ACLF working party Correspondence- Juned Ahmad [email protected] 1 Department of Hepatology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, 2St John Medical College, Bangalore, India, 3 Beijing You’an Hospital, 4 Tongji Hospital, China, 5 Aga Khan University Hospital, Karachi, Pakistan, 6CMC, Vellore, India, 7Hospital Selayang, Bata Caves, Selangor, Malaysia, 8PGIMER, Chandigarh, India, 9 Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh, 10 Chulalongkorn University, Bangkok, 11 Hallym University College of Medicine, 12Yong Loo Lin School of Medicine, National University of Singapore, 13 Medistra Hospital, Jakarta, Indonesia, 14Nork Clinical Hospital of Infectious Disease, Armenia, 15 Asian Institute of Gastroenterology, Hyderabad, India, 16Ziauddin University Hospital, Karachi, Pakistan, 17Bombay Hospital and Medical Research Center, Mumbai, India, 18University of Santo Tomas, Manila , Philippines , 19 Cardinal Santos Medical Center, Metro Manila, Philippines, 20 IMS &SUM Hospital, Odisa, 21 Global Hospital, Mumbai, India, 22 Humanity and Health Medical Group, China, 23 Queen Mary Hospital, Hong Kong, China, 24Sir Salimullah Medical College, Mitford Hospital, Bangladesh, 25Ankara University School of Medicine, 26VGM Hospital, Coimbatore, India, 27 Department of Reserch, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi Background and Aims Acute-on-chronic liver failure (ACLF) is a distinct entity with high short-term mortality due to severity of acute insult and rapid worsening of liver failure. It is not known whether patients surviving acute insult have a better long-term survival than those with decompensated cirrhosis. We studied the survival of ACLF patients beyond 90 days and compared with acute decompensation of previously decompensated cirrhosis. Methods Patients of cirrhosis with acute decompensation (AD) (within last 3 months) in presence of prior decompensation were compared with patients of ACLF for the survival outcome beyond 90 days. Patient from 40 centres across Asia from AARC cohort, since october 2012 to october 2016 were analyzed. Results ACLF (n=2743) and AD (2154) at enrolment were followed for 90 days, 1833 ACLF, and 1868 AD, were followed up to 5 years. ACLF patients were younger (49.69±10.86 vs. 47.23±11.67 yr, p<0.001) with higher alcoholic hepatitis (29.5% vs. 8.7%, p<0.001), HBV reactivation (7.9% vs. 2.3%, p<0.001), DILI (8.3% vs. 4.3%, p<0.001). The ACLF patients had significantly higher bilirubin, AST, ALT, INR, serum creatinine and severity scores with lower Hb, platelet, serum albumin and sodium (p<0.001) at baseline {Table-1} as well as high disease severity score (MELD 33.2±13.7 vs. 23.9±11.3, p<0.001). The 90 days [HR: 0.73 (0.66-0.82), p<0.01] and 5-years cumulative survival [HR: 0.79 (0.72-

Influence of socioeconomic status and lifestyle habits on the occurrence of Helicobacter pylori infection among dyspeptic patients in Assam, North-east India Anisha Sarma1, Lahari Saikia1 Correspondence- Lahari [email protected] 1 Assam Medical College and Hospital, Dibrugarh, Assam, Introduction A number of epidemiological studies on H. pylori, the gastric bacteria, have shown high prevalence of infection in both adults as well as in children. Therefore keeping in view the urgent need to evaluate the occurrence of infection based on epidemiological factors, our study examined the influence of socio-economic status and lifestyle habits on occurrence of H. pylori infection detected by culture and/or molecular methods. Methods A cross sectional hospital based study conducted between 2014 and 2017 included 351 dyspeptic patients of all age groups. All patients were interviewed via a structured questionnaire for collection of data evaluating their socioeconomic status, their living conditions, past family history and their personal habits such as smoking and alcohol intake. A single gastric biopsy sample was taken from each patient after obtaining their informed consent via upper gastrointestinal tract endoscopy and infection was identified by culture and/or molecular methods. Epi-Info software was used for data analysis. A p value of <0.05 was considered statistically significant. Results Among 351 patients, 218 patients (62.4%) were positive for H. pylori infection, with greater prevalence among male population than in females who were prone to habitual smoking and alcohol intake, with infection increasing with age. These personal habits as well as their socioeconomic status were significantly associated with infection (p<0.05). Lower and middle class individuals who live in rural areas were more prone to infection than upper urban population. However, no significant association was noted on the occurrence of infection when the patients were classified by gender and family history (p>0.05). Conclusion Poor socioeconomic conditions, smoking, alcohol intake and living conditions of individuals were associated with an increase risk of H. pylori infection. M-24 Current screening techniques are ineffective to predict the development of tuberculosis in Indian patients of inflammatory bowel disease on infliximab Ashish Agarwal, Saurabh Kedia, Saransh Jain, Sawan Bopanna, Dawesh P Yadav, Sandeep Goyal, Govind Makharia, Vineet Ahuja Correspondence- Vineet [email protected] All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Introduction With increasing disease burden of inflammatory bowel disease (IBD) in India, the use of biologicals is increasing. India being highly endemic for tuberculosis (TB), there is a high risk of reactivation of tuberculosis with biological use. Present study was aimed to assess the risk of TB reactivation on infliximab (IFX) and its predictors in Indian IBD patients.

Indian J Gastroenterol

Methods A retrospective review of consecutive IBD patients who received IFX and were following up at IBD Clinic, All India Institute of Medical Sciences, New Delhi from January 2005 – May 2017 was done. The data was recorded on age/disease duration at which IFX was started, indication for IFX, response to IFX, incidence of TB after IFX, duration at which TB developed and type of TB (pulmonary (PTB)/extra-pulmonary (EPTB)/disseminated). Results Fifty-nine consecutive IBD patients [(21 Ulcerative colitis (UC)/ 38 Crohn’s disease (CD)] were included (mean age:34+14 years, 49.2% males). Median follow up duration after IFX was 24 (IQR:8-56) months. 13.5% patients had primary non-response (remission: 78%/response: 8.5%). Thirgy-five (59%) and 23 (39%) patients continued treatment till 26 and 52 weeks respectively of which 83% and 78% maintained remission. Seven (11.8%) patients developed tuberculosis after a median of 14 weeks (IQR:6-24). Disseminated disease was documented in 4/7 (57.1%), EPTB in 2 and PTB in 1 patient. All patients were screened for tuberculosis with mantoux test and chest X-ray, CT was done in 6/7 and Interferon gamma release assay in 3/7 patients. None had any evidence of latent tuberculosis. No baseline factor including age, gender, disease duration, past history of TB, disease type (CD/UC), extent/ severity of disease or response to IFX could predict TB. Results There is good response to infliximab in Indian IBD patients, but is associated with a high rate of TB reactivation. Current screening techniques are ineffective and it is difficult to predict TB after IFX treatment. Further research is required to develop predictors of TB in patients on biologicals. CASE REPORTS CR-01 A rare case of multidrug resistant tuberculosis masquerading as metastatic mucinous cystadenocarcinoma Pallav Parikh, P Piramanayagam, K R Palaniswamy, A T Mohan, Usha Srinivas, Sarojini Parameswaran, Ubal Dhus, N Murugan, M S Revathy, M Hariharan, Seshadri Venkatesh, Preethi Mahalingam Correspondence - Pallav Parikh- [email protected] Apollo Hospitals, Chennai Tuberculosis of the stomach is quite rare, both as a primary or secondary infection and multidrug resistant tuberculosis of stomach is even rare. It can present as a facet of a multiorgan disease process and more common in immunocompromised or immunosuppressed patients. Here, we report a rare and interesting case of gastric tuberculosis in 46-years-old male who was on immunosuppressant for renal transplant and presented with 1 month history of epigastric pain and loss of appetite which was diagnosed on imaging as gastric mucinous cystadenocarcinoma with omental, peritoneal, liver and pancreatic metastasis. The disease was diagnosed by endoscopic ultrasound which showed cystic lesion in stomach and pus was aspirated which was positive for AFB and gene Xpert MTB was positive for rifampicin resistance. He was treated with second line antituberculosis treatment and he responded well to treatment. This case report highlights one such fact, where a malignant process was primarily considered depending on initial imaging findings and later due to high index of clinical suspicion diagnosis of tuberculosis was made with the help of endoscopic ultrasound. Although abdominal TB is usually located in the ileocecal region of the gastrointestinal (GI) tract, clinicians must bear in mind that tuberculosis can involve any site in GI tract, and may present with a variety of characteristics, specially in presence of an immunodeficient condition. CR-02 Bottle gourd (Lagenaria siceraria) juice poisoning Pinakin S Patel, Pravin M Rathi

Correspondence- Pinakin Patel- [email protected] Bombay Hospital and Medical Research Center, 12, Marine Lines, Mumbai 400 020, India Introduction The calabash or bottle gourd (Lagenaria siceraria) is popularly known as lauki, ghia or dudhi in India. In Ayurveda, bottle gourd is advocated for treatment of diabetes mellitus, hypertension, flatulence, cooling properties, liver diseases, weight loss and other conditions. In recent times it has been unearthed that bottle gourd juice with a bitter taste can cause severe toxic reactions and lead to symptoms such as abdominal pain, vomiting, diarrhea, hematemesis, hematochezia, shock and death. Case Report A 36-year-old woman presented to the ED with complaints of severe upper abdominal pain, multiple episodes of vomiting and fresh blood in vomitus since the morning. The episode had begun after 2 hrs of consumed 200 mL bottle gourd juice in the morning. She presented with pulse 110/minute, systolic BP 100 mmHg, respiratory rate 18/minute, room air saturation 100%, temperature 98°F, and random sugar 100 mg/dL. Her abdomen examination revealed a soft abdomen with epigastric tenderness. No organomegaly was appreciated. The rest of the systemic examination was unremarkable. The patient was given intravenous pantoprazole, ondansetron and hyoscine, and 2 litres of isotonic normal saline. After 2 litres of isotonic fluid resuscitation, blood pressure was recorded as 140/100 mmHg. She was shifted to the ward, with a diagnosis of bottle gourd poisoning with upper gastrointestinal bleeding associated with severe dehydration. Initial blood work showed signs of severe dehydration: HB 17.9 gm/dL, TLC 33200/cumm, packed cell volume 58.3%, SGOT 380 U/L, and SGPT 328 U/L, serum bilirubin 2.0 mg/ dL, and renal profile and coagulation profile were within normal limits. The patient underwent endoscopy which revealed pangastritis and severe duodenitis. Ultrasonography of abdomen was normal. She was managed with intravenous fluids; antibiotics, antiemetic, and proton pump inhibitors and discharged in a stable condition after 5 days. Repeat blood test was normal at the time of the discharge. CR-03 Auto immune hepatitis-primary biliary cirrhosis overlap syndrome: Beyond diagnostic and therapeutic Barriers-A case report B Mohammed Noufal, Kani Sheikh, Ratnakar Kini, K Prem Kumar, T Pugazhendhi Correspondence- B Mohammed Noufal- [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Introduction Primary biliary cirrhosis (PBC) and autoimmune hepatitis (AIH) are the two main immune-mediated liver diseases. The overlap of both AIH–PBC is very rare. The recognition of overlap syndromes are very important as they have implications for therapy. We report a case of AIH-PBC overlap syndrome who was treated with both steroids and UDCA and showed marked improvement. Case Report A 21-year-old female presented with history of jaundice with pruritus associated with fatigue of 6 months duration. She had history of low grade fever on and off, early satiety and vague right upper quadrant abdominal pain. Prior to the onset of jaundice she had multiple small joints pain and swelling. She was not an alcoholic and there was no exposure to hepatotoxic drugs. Family history was not significant. On physical examination she was found to be deeply icteric and had hepatosplenomegaly. Other system examination was unremarkable. This patient’s clinical, serological and histopathological examination were suggestive of direct hyperbilirubinemia with predominant elevation of alkaline phosphatase with hypergammaglobulinemia and strong positivity of ANA, LKM and AMA-M2 with histopathological features consistent of cholestatic hepatitis (PBC)/bile duct loss (ductopenia). Hence a

Indian J Gastroenterol

diagnosis of AIH-PBC overlap was made and was initiated on treatment with steroids (prednisolone 1 mg/kg/day) and azathioprine along with ursodeoxycholic acid (UDCA). Patient showed a remarkable improvement clinically and biochemically by 6 weeks with a marked reduction in bilirubin, ALP and aminotransferase levels. Discussion The overlap syndromes are not valid pathological entities, but their recognition is important because they can influence management strategies. They should be sought in all patients with AIH who are refractory to conventional corticosteroid therapy, have cholestatic features (PBC), or concurrent inflammatory bowel disease (PSC). Early diagnosis could prevent further complications and improve quality of life. CR-04 Ileal gastrointestinal stromal tumor presenting as obscure overt gastrointestinal bleed Sudhir Singh, Vinod Dixit, Sunit Shukla, Gaurav Garg, Shivam Sachan Correspondence- Sudhir Singh- [email protected] Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India A 32-years-old lady presented to our centre with history of melena of 10 days duration. She was admitted in our hospital 10 months prior to present episode with similar complaints and underwent upper GI endoscopy, colonoscopy and barium meal follow through which were normal. She was planned for further evaluation but she took discharge due to unspecified reasons. During current admission she was hemodynamically stable but had pallor and rest of general and systemic examination was normal. Investigations revealed anemia (Hb– 7.5g%) and rest of hematological and biochemical parameters including coagulation parameters were normal. Viral markers (HBsAg, anti-HCV and HIV) were negative. Ultrasound abdomen was normal. Chest X-ray was normal. she underwent upper GI endoscopy and ileocolonoscopy and both were normal. A contrast-enhanced computed tomography (CECT) abdomen revealed a suspicious submucosal soft tissue lesion with homogenous content in distal ileum. A CT enterography confirmed the presence of a 3 x 2 x 2 cm size lesion in distal ileum with radiological findings consistent with gastrointestinal stromal tumor (GIST). She was taken up for surgery and finding were confirmed intraoperatively and the lesion was excised. Histopathology confirmed the lesion was a GIST. She is on regular follow up and is asymptomatic now.

Conclusion Although abdominal cocoon syndrome is not a very rare entity, it is usually found in young females. However young males can also be affected. CR-06 An unusual case of chemical gastroesophagitis following Dettol poisoning Sunil Chacko Verghese, M Kani Sheikh, S Ratnakar Kini, K Prem Kumar Correspondence- Sunil Chacko Verghese- [email protected] Madras Medical College, Chennai 600 003, India Introduction Dettol is a common household disinfectant and a constituent of various anti-bacterial soaps and wound cleansing applications. It is commonly implicated in accidental ingestion in children younger than 6 years, suicidal attempts in adults and in patients with mental health problems. It contains Chloroxylenol (4.8%), Terpineol (9%) and Absolute alcohol (13.1%). Chloroxylenol is a phenol and is chemically related to the other phenolic disinfectants such as carbolic acid and cresols. Almost all the mortality in patients with Dettol poisoning is usually related to aspiration while its gastrointestinal corrosive action is underreported or overlooked. Case Report Forty-two-year-old male patient known case of schizophrenia on treatment presented to the emergency room with alleged h/o of consumption of liquid Dettol (400 mL), which was followed by recurrent episodes of vomiting, abdominal and retrosternal chest pain. Endoscopy was performed within 18 hours which revealed whitish membrane across the entire length of esophagus (GRADE IIA) with entire stomach inflamed and erythematous (GRADE I) Zargar classification. Patient was advised to start oral feeds after 24 hours and on follow up after 8 weeks repeat endoscopy showed complete healing of the esophageal mucosal surface. Conclusion Nearly all patients receive a gastric lavage in the ED. This just serves to highlight the extent of the deficit in our knowledge regarding the toxicity of Dettol. The mainstay of Dettol poisoning is supportive and gastric lavage should not normally be attempted, 30 mL/ kg of oral liquid paraffin can be administered to the patient per orally or by nasogastric and routine endoscopy in these patients is warranted in the acute setting due to its corrosive action. CR-07

CR-05 Hepatocellular cell carcinoma in non-cirrhotic liver Abdominal cocoon syndrome Deven S Gosavi, A R Venkateswaran, M S S Revathy, S Chitra, M Malarvizhi, R Murali, M Manimaran Correspondence- Deven Gosavi [email protected] Government Stanley Medical College, Chennai 600 003, India Abdominal cocoon is formed as a consequence of sclerosing encapsulating peritonitis. It consists of a partial or complete encasement of the small bowel by a rind of fibrous tissue. It is usually seen in young females. Etiological factors include CAPD, SLE, VP shunt, sarcoidosis, introduction of methotrexate or povidone iodine or other drugs and chemicals into the peritoneal cavity. Early features are nonspecific and not recognized until patient develops symptoms and signs of partial or complete intestinal obstruction. However, intestinal obstruction is uncommon. Diagnosis is on the basis of clinical, radiological, endoscopic, microbiological features. Types 1, 2, 3 are classified on the basis of extent of intestinal involvement. Treatment is excision of fibrocollagenous sac, adhesiolysis, resection and anastomosis and treatment of the underlying condition. Aim To describe a case of abdominal cocoon in a young male Methods Description of a single case.

Abhinav Gupta, Deepak Bansal, Atul Sachdev Correspondence- Deepak Bansal- [email protected] Department of Internal Medicine, Government Medical College and Hospital, Chandigarh 160 030, India Background Hepatocellular cell carcinoma (HCC) is most common primary tumor of liver, usually associated with underlying liver cirrhosis. However, in this case, non-tumoros part of liver did not have underlying cirrhosis on biopsy. Clinical Case 65-year-old male presented in the OPD with complaints of pain in the right hypochondrium and loss of apetite since 2 months. On ultrasound abdomen, 6X6 cms SOL was found in segment 5 of right lobe of liver. The rest of the liver parenchyma was normal on ultrasonography. The same findings were confirmed on CECT abdomen. Serum AFP levels were 432 ng/mL. Patient was also found to be positive for hepatitis C. Upper GI endoscopy was done to look for changes of portal hypertension but all findings were normal till second part of the duodenum. USG guided FNAC from the SOL revealed hepatocellular carcinoma. USG guided FNAC from the non-tumoros liver revealed normal liver architecture with features of low grade hepatitis in form of focal ballooning

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degeneration and microvesicular steatosis. The features were suggestive of chronic hepatitis grade 2 (scheuer system). There were no features suggestive of cirrhosis. Patient was taken up for surgical resection and underwent the operation successfully. Conclusion This is a case of HCV associated HCC in background of low grade hepatitis without cirrhosis of liver. CR-08 Primary eosinophilic gastroenteritis presenting as gastric outlet obstruction and spontaneous full thickness tear of stomach and esophagus. BRare presentation of a rare disease^. A case report N S Ravichandra, Ajit Kumar, B Sukanya, N Joshi, Y Raghavendra, S Rahul, Vineeth Chaudary, J Rishabh, R Gaurav, Sumaswi, C Bhushan Correspondence- Ajit [email protected] Department of Medical Gastroentrology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Introduction Primary eosinophilic gastroenteritis (EGE) is a rare inflammatory disease. The incidence is about 1–30/100000. Adults more affected than children. EGE is a rare cause of gastric outflow obstruction, which typically occurs when the muscular layer is affected. Spontaneous fullthickness tear, partial rupture are known but rare complications of EGE. Case Report A 20-year-old young male patient, presented to OPD with complains of epigastric abdominal pain for one-month, occasional nonbilious vomiting, H/o of aggravation of his symptoms on taking specific type of food like, wheat, milk, etc. Except mild pallor no other significant abnormalities in general or systemic examination. Lab values showed mild anemia leukocytosis with increase in AEC -2800, IgE-550, upper GI endoscopy showed edematous nodular mucosa of stomach, HPE of stomach showed features suggestive of eosinophilic gastritis. Skin allergen test was positive. Treated with modified SFED and oral steroid for 8 weeks, improved clinically endoscopically. Two months later patient had relapse of symptoms UGIE this time showed deformed antrum with narrowing, mucosal rent in stomach and lower esophagus. CT scan shows thickened antrum with narrowing pyloric canal, mucosal rent in stomach and esophagus. Steroid restarted after initial period supportive measures. Patient improved clinically and endoscopically. Discussion Primary EGE are defined as disorders that primarily affect the GIT with eosinophil-rich inflammation in the absence of known causes for eosinophilia. Associated with food allergies in about 70% of cases. Disease wax and wane chronically. Steroid is the treatment of choice. Conclusion Gastric outlet obstruction, spontaneous partial or full thickness tear are rare presentation of EGE. CR-09 Synchronous esophagogastric junction cancer and stomach cancer Case report Rabindranath Eswaran, S R Chandrashekar Patil, Kani Shaik Mohammad, Ratnakar Kini, K Premkumar Correspondence- Rabindranath [email protected] Institute of Medical Gastroenterology, Madras Medical College, Chennai 600 003, India Background The synchronous cancer associated with stomach cancer was more frequently found in colon and rectum, followed by lung and esophagus. We report two cases of synchronous esophagogastric junction (EGJ) cancer along with stomach cancer, with intervening normal mucosa. Case 1 Sixty-year-old female presented with 2 months history of progressive difficulty in swallowing for both liquids and solids, associated with loss of weight and anorexia. On clinical examination, patient had pallor.

Upper GI endoscopy showed ulceroproliferative growth at esophagogastric junction extending 2 centimeter into the cardia (Siewert type II) and unhealthy nodular mucosa in antrum along lesser curve.There was normal appearing healthy mucosa seen in between the two lesions. Both lesion biopsied and evaluated separately. Biopsy revealed poorly differentiated infiltrating adenocarcinoma in EGJ lesion and moderately differentiated infiltrating adenocarcinoma in antral lesion. Contrast enhanced CT scan showed EGJ growth and antral thickening with few perigastric nodes. The patient underwent esophagojejunostomy with total gastrectomy and removal of distalmost esophagus. Case 2 Seventy-five-year-old diabetic male presented with recurrent vomiting that is nonbilious, occurring within 1 hour of a meal containing undigested food particles. Patient had early satiety, epigastric fullness, anorexia, nausea, epigastric pain, and weight loss. Patient was malnourished, otherwise clinically normal. Contrast enhanced CT scan showed antropyloric growth along lesser curve with no significant lymphadenopathy. Upper GI endoscopy showed nodular growth in EGJ of size around 1 cm and a large proliferative growth in the antropyloric region, with normal appearing healthy mucosa seen in between the two lesions. EGJ lesion biopsy revealed poorly differentiated adenocarcinoma and antropyloric growth biopsy revealed well differentiated adenocarcinoma. Esophagojejunostomy was done with total gastrectomy and removal of esophagogastric junction. Postoperative specimen confirmed normal stomach mucosa in between the lesions. Conclusion Multiple primary neoplasm in case of gastric cancer should be considered, particularly in elderly, properly evaluated and treatment planned. CR-10 Multiple serrated adenomas of stomach: A case report Vineet Vijay Chaudhari, Ajit Kumar, Y Raghavendra, B Sukanya, S Rahul, N S Ravichandra, Rishabh Jain, Gaurav Ratnaparkhe Nizam Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Introduction Serrated adenoma is a newly described entity in the group of gastric adenomas. Until date only 20 cases of gastric serrated adenoma have been reported. It is an important entity to be diagnosed accurately as it has a very high risk of malignant transformation, especially those located in the cardia of stomach. Case Report A 55-years-old postmenopausal female patient, nonalcoholic and non-smoker, presented with dyspeptic symptoms like postprandial abdominal fullness and epigastric pain. On evaluation she had Iron deficiency anemia. UGIE showed multiple sessile polyps in body of stomach along greater curvature. Biopsy taken from polyp showed serrated adenoma without malignancy. Her CECT and USG abdomen were normal. Her colonoscopy was also normal. We went ahead with endoscopic polypectomy and removed all polyps. Polypectomy samples didnt show any evidence of malignancy with scattered positivity for Ki-67. She improved symptomatically, discharged and was advised surveillance for malignancy. Discussion Gastric serrated adenomas are histologically characterized by protruding glands with lateral saw tooth-like indentations lined with stratified dysplastic cells containing abundant eosinophilic cytoplasm. Since the first case of gastric serrated adenoma found in 2001, 20 additional cases have been reported. About 75 % of these cases showed coexisting invasive adenocarcinoma. Ki-67 staining helps to differentiate pure serrated adenoma from those associated with adenocarcinoma. Conclusion We present a rare case of multiple serrated adenomas of stomach without evidence of malignancy.

Indian J Gastroenterol

CR-11 A rare case of obstructive jaundice due to gastroduodenal artery pseudoaneurysm Mohit Gupta, Donna D'Souza Correspondence- Donna [email protected] Saraswathi Institute of Medical Sciences, India, and University of Minnesota 55455, USA Introduction Pseudoaneurysm is a rare but life threatening complication of pancreatitis. It is important to diagnose and timely manage a pseudoaneurysm for a better outcome. They can be fatal if they bleed. We report here a case of gastroduodenal artery pseudoaneurysm with rare clinical presentation of painless obstructive jaundice. Case Report A 46-year-old female patient with past medical history of recurrent pancreatitis was admitted with painless jaundice, abdominal discomfort and fatigue . CT scan of the abdomen was performed. She was found to have a pseudoaneurysm of gastroduodenal artery. She was successfully treated with coil embolization of the gastroduodenal artery with improvements in clinical and biochemical parameters. Conclusion Painless jaundice secondary to gastroduodenal artery pseudoaneurysm is rare, but should be considered in work up of patients with history of recurrent pancreatitis. This case thus highlights the importance for a treating medical professional to keep in mind pseudoaneurysms of gastroduodenal artery in a patient with history of recurrent pancreatitis who presents with painless jaundice. Gastroduodenal artery pseudoaneurysms can be safely and effectively treated with coil embolization. CR-12 Rare presentation of post-transplant lymphoproliferative disorder of gastrointestinal tract in two renal transplant patients Pallav Parikh, Sarojini Parameswaran, Ashok Parameswaran, P Piramanayagam, K R Palaniswamy, A T Mohan, Usha Srinivas, Ubal Dhus, M S Revathy, M Hariharan Seshadri Venkatesh, Preethi Mahalingam, Shankar Zanwar, Ankit Patel Correspondence- Pallav [email protected] Apollo Hospitals, Chennai 600 006, India Post transplant lymphoproliferative disorder (PTLD) represents a life threatening disorder occurring in immunosuppressed mainly after transplantation and presentation range from a polyclonal mononucleosis like illness to a monomorphic high grade neoplasm with cytological and histopathological evidence indicative of transformation to lymphoma. Apart from nonspecific symptoms, specific symptoms vary according to organ of origin. Treatment modalities consist of reducing dose of immunosuppressive thearpy, eradication of Epstein-Barr virus, surgical resection, systemic chemotherapy and monoclonal antibody therapy. We describe two cases of PTLD in post renal transplant patients limited to single organ (i.e. esophagus in one and stomach in second case) without an associated mass or locoregional lymphadenopathy on imaging by PET CT. Case 1 Sixty-five-year old post renal transplant gentleman presented with odynophagia and weight loss. On upper gastrointestinal endoscopy (OGD) he was found to have multiple irregular shallow ulcers in esophagus. Biopsy/immunohistochemistry (IHC) of which was consistent with EBV associated polymorphic PTLD. His immunosuppressants were reduced and rituximab therapy was planned. Case 2 Twenty-one-year-old post renal transplant gentleman presented with early satiety and weight loss. On OGD he has large excavated ulcer involving body and antrum of stomach. Repeated OGD and biopsies/IHC were negative for lymphoma and finally after 5 months fifth OGD biopsy/IHC was consistent with EBV associated polymorphic PTLD. His immunosuppressants were reduced and he was treated with rituximab.

In the post transplant setting, immunocompromised state, or EBV positive state, upper gastrointestinal symptoms should prompt investigation with an OGD/biopsy/IHC whenever necessary. This emphasizes the importance and diagnostic utility of early screening with OGD in patients after transplantation. CR-13 Cervical esophageal perforation during gastroscopy by pediatric gastroscope in an adult: A scary experience Apurva Shah, Shravan Bohra Correspondence- Apurva [email protected] Apollo Hospitals International Limited, Ahmedabad 383 330, India Cervical esophageal perforation is rare and associated with a high morbidity and mortality greater than 20% if misdiagnosed. At least half of the perforations are iatrogenic. We describe a case of an 83-year-old lady with a diagnosis of adenocarcinoma of lower oesophagus, admitted for palliative metallic stenting for dysphagia. Pediatric gastroscope was used for procedure under conscious sedation. A blind tract was noted just below pyriform fossa during insertion of the scope which was suspected to be a false passage created accidently in the wall of the esophagus. Since patient had no discomfort whatsoever scope was negotiated into esophagus from opposite pyriform fossa and metallic stenting done over guidewire for lower esophageal malignant stricture uneventfully. Six hours after procedure patient complained of mild throat pain but on examination vital parameters normal, no crepitus or subcutaneous emphysema noted. CT scan chest was advised next day to rule out upper esophageal perforation revealed significant pneumo mediastinum and minimal left pleural effusion with possibility of cervical esophageal leak and stent in lower oesophagus. Patient was kept nil by mouth, started on intravenous antibiotics, analgesics, fluids and proton pump inhibitors. Patient developed high grade fever 48 hours after procedure but due to contained leakage without systemic symptoms of infection, careful observation and conservative treatment continued after discussion with surgeon. Gastrograffin swallow on 6th day post procedure showed no contrast leak. Patient started on liquids followed by soft diet which was well tolerated. Patient remained asymptomatic, tolerating full diet at one month follow up. This case represents rare entity of esophageal perforation by pediatric gastroscope in an elderly lady, managed conservatively. Improved attention to nonspecific symptoms, signs and early diagnosis based on imaging may translate into better outcomes for patients, many of whom are elderly with significant comorbidity. CR-14 Rare case of splenic artery pseudoaneurysm secondary to gastric ulcer: A diagnostic dilemma Sonny Bherwani, Kaushal Vyas, Sushil Narang, Nilesh Pandav Correspondence- Sonny [email protected] V S Hospital, Ahmedabad 380 007, India Introduction Splenic artery pseudoaneurysm is a rare entity but still carries high risk of rupture (37% to 47% ) and mortality rate of 90% if left untreated . It can occur as a complication of chronic pancreatitis, trauma and rarely after peptic ulceration. Case Report A 32-years-old male, with past history of DM-1, was admitted to our centre with chronic constipation, foul smelling seminal discharge and working diagnosis of rectoseminal fistula was made. The patient underwent fistulectomy, omental repair with transverse colonostomy on 4th day of admission. The patient had been well but on post operative day 15 he developed 2-3 episodes of massive hematemesis and upper gastrointestinal (UGI) endoscopy was done which showed multiple ulcers with clean base in lesser curvature with adherent clots and sloughed off mucosa like tissue in fundus, body, antrum and

Indian J Gastroenterol

near pylorus with retained blood in stomach. In view of suspected malignancy, biopsy was taken which only revealed necrotic material. Subsequently, CT scan of thorax+abdomen, showed smooth enhancing wall thickening of fundus and body of stomach with air foci and possibility of clot. He was started on proton pump inhibitors (PPI) infusion and sucralfate through Ryle’s tube (RT) and became symptomatically better. However patient still developed intermittent episodes of hematemesis in following week and endoscopic diagnosis was inconclusive. Later CT angiography was planned which showed penetrating gastric ulcer with splenic artery pseudoaneurysm with multiple splenic infarcts. Conclusion To the best of our knowledge this is first case report from India of gastric ulcer leading to splenic artery pseudoaneurysm. We should not be misled by gastric ulcer in endoscopic view as the cause of repeated hematemesis. Pseudoaneurysm of splenic artery should be kept in mind and CT angiography should be done promptly as timely management by endovascular modality or surgical lapratomy prevent mortality. CR-15 IgG4 related disease - Presenting as obstructive jaundice Gul Javid, Altaf Hussain Shah, Mushtaq Ahmad Khan, Bhagat Singh Correspondence- Bhagat [email protected] Sher-I-Kashmir Institute of Medical Sciences, Srinagar, J&K

We present a case of 57-years-old male, chronic smoker, normotensive, non-diabetic presenting with progressive yellowish discoloration of eyes and body, high colored urine with clay colored stools and itching for last 2 weeks. There was associated history of presence of submandibular swelling on left side since 1 year. MRCP revealed diffuse enlargement of pancreas with dilated IHBR and proximal CBD with abrupt cut off of CBD at the level of pancreas. CECT chest and abdomen was suggestive of enlarged pre tracheal, prevascular and bilateral hilar nodes. Rest of the findings were similar to MRCP.Tumor markers were negative. ERCP demonstrated fixed smooth narrowing involving distal part of CBD with upstream dilatation. Brush cytology was taken from stricture which was found to be negative for malignancy. A 10 cm x 10F plastic stent was deployed. In view of suspicion for IgG4 related disease, serum IgG4 levels were done which were found to be markedly elevated. Following this, EUS guided biopsy was taken from pancreatic head which revealed lymphoplasmacytic infiltration with high concentrations of IgG4-positive plasma cells accompanied by obliterative phlebitis and storiform fibrosis compatible with findings of IgG4 related disease. Patient was started on steroid therapy and previously deployed stent was removed. Patient responded well to steroid therapy resulting in normalization of LFT and serum IgG4 levels with marked symptomatic improvement. Thus, in patients presenting with features of obstructive jaundice associated with pancreatic enlargement, a high index of suspicion should be kept for IgG4 related disease.