Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 DOI 10.1007/s12664-015-0600-5

ABSTRACTS

Indian Society of Gastroenterology Plenary session

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PLE-1

Overexpressed autophagic system by activated dendritic cells in celiac disease—Is it a mere standby phenomenon

Combination of antioxidants and pregabalin in the management of pain recurrence in chronic pancreatitis after ductal clearance: A randomized, double-blinded, placebo-controlled trial

Rupjyoti Talukdar, Sundeep Lakhtakia, D Nageshwar Reddy, G Venkat Rao, Rebala Pradeep, Rupa Banerjee, Rajesh Gupta, Mohan Ramchandani, Manu Tandan, H Vivekananda Murthy Department of Medical Gastroenterology, Asian Institute of Gastroenterology 6-3-661, Somajiguda, Hyderabad 500 082, India; Wellcome-DBT Laboratory, Asian Healthcare Foundation, Hyderabad, India; Department of Surgical Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India; and Department of Biost Aim: This study aimed to evaluate the effect of an antioxidantpregabalin combination in chronic pancreatitis (CP) patients with pain recurrence post-endotherapy/longitudinal pancreaticojejunostomy (LPJ). Methods: CP patients with pain recurrence post-endotherapy/LPJ were randomized to receive an antioxidant-pregabalin combination or matching placebo for 2 months, followed by open-label antioxidants to both groups for the next 4 months. Compliance, daily pain, and adverse events were captured weekly and at the end of the study. Primary outcome was pain improvement; secondary outcomes were complete pain resolution, painful days, QOL, adverse events. Tools used were the following: visual analog scale (VAS) and Izbicki scale for overall pain, pain DETECT for neuropathic pain, and EORTC-QLQ30Pan28 for QOL. Effect size was expressed as Hedges’ G (95 % CI), number needed to treat (NNT), and risk ratio (RR) (95 % CI). Analysis was intention-to-treat. Results: After sample size calculation (80 % power; 0.05 alpha; adjusted for 10 % dropout), we randomized 42 and 45 patients in the treatment and placebo arms, respectively. Five patients in the treatment arm and 3 in the placebo lost to follow up. Both arms matched for age, gender, duration between endotherapy/LPJ and enrolment, exocrine and endocrine insufficiency, type of ductal decompression, and pain scores. At 2 months, there was significantly higher reduction in VAS [−45.5 (±28.5) vs. −24.0 (±32.6); p =0.002]. 46.5 % of patients in the treatment arm had complete pain resolution (p =0.04); NNT was 5.1. Mean (SD) number of painful days was lower in treated patients [14.7 (15.2) vs. 21.8 (17.4) days; p =0.05]. At 6 months, significantly higher pain reduction persisted in the original treatment group. 23.8 % and 38.1 % of treatment arm patients experienced nausea/vomiting and drowsiness, respectively. Conclusion: The antioxidant-pregabalin combination results in significant relief in CP pain recurrence after endotherapy/LPJ.

Kim Vaiphei, Biman Saikia, Rakesh Kochhar Departments of Histopathology, Immunopathology and Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Introduction: Celiac disease (CD), an immune-mediated disorder, associates with accumulation of dendritic cells (DCs) in duodenal mucosa. Besides other complementary serology markers, CD patients are positive for HLADQ. Autophagy has recently been implicated in autoantigen formation. Aim: This study aimed to analyze duodenal histology and expressions for LC3 and beclin1. Methods: Ninety IgA tissue transglutaminase-positive patients were further tested for HLA-DQ. All patients underwent endoscopic duodenal biopsies for histological assessment and immunohistochemistry (IHC) assessment of DCs and autophagic proteins using CD11c, CD86, LC3A and beclin1, and duodenal mucosal RNA extracts for quantitative analysis of LC3 and beclin1. Statistical analysis was carried out using chi-square, Fisher’s exact, and McNemar-Bowker tests with significance of p value <0.05. Results: The dominant clinical symptom was diarrhea. HLA-DQ2 and HLA-DQ8 alleles were present in 100 % of patients. Grade 2 mucosal inflammation was the most frequent, and majority of patients had associated basement membrane (BM) thickening. Six months of gluten resulted in a significant decrease in mucosal inflammation and reduction in BM thickening. There was increased accumulation of activated DCs with increased LC3 and beclin1 expressions by IHC. QPCR further confirmed IHC findings. There were significant differences in pre- and posttreatment biopsies by IHC and QPCR. These parameters showed correlation with the degree of mucosal inflammation. Conclusion: Activated DCs expressing increased LC33 and beclin1 play an important role in disease pathogenesis in CD. None of the parameters except mucosal inflammation showed a significant association. Optimized activation of DCs and autophagy genes may be an important alternative feasible treatment modality for CD patients. PLE-3 Geographic variations in the prevalence of celiac disease in adults in India

B S Ramakrishna, Govind K Makharia, Kamal Chetri, Sangitanjan Dutta, Prashant Mathur, Vineet Ahuja, Ritvik Amarchand, Ramadass Balamurugan, Sudipta Dhar Chowhury, Dolly Daniel, Anup Das, Gemlyn George, Siddhartha Datta Gupta, Anand Krishnan, Jasmin Helan Prasad, Gurvinder Kaur, Srinivasan Pugazhendhi, Anna Pulimood, Kartik Ramakrishna, Anil K Verma

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Departments of Gastrointestinal Sciences, Transfusion Medicine and Community Health, Christian Medical College, Vellore 632 004, India, Departments of Gastroenterology and Human Nutrition, Pathology, Community Medicine, and Transfusion Medicine and Immunohematology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, Department of Gastroenterology, International Hospital, Lotus Tower, Shillong Road, Christian Basti, Guwahati 781 005, India, Department of Medicine, Guwahati Medical College, GMCH Complex, GMCH Road, Bhangagarh, Guwahati 781 032, India and Indian Council of Medical Research (ICMR), Ansari Nagar East, New Delhi 110 029, India Background: While celiac disease (CeD) affects 1 % of people in the northern part of India, it is believed to be uncommon in the southern and northeastern parts because of significant differences in dietary pattern and ethnicity. We estimated the prevalence of CeD in these three populations. In a subset, we also investigated differences in the prevalence of the HLA-DQ2/8 allelotypes and dietary cereal consumption. Methods: 23,331 healthy adults were sampled from three regions of India—northern (n=6207), northeastern (n=8149), and southern (n= 8973)—and screened for CeD using IgA anti-tissue transglutaminase (anti-tTG) Ab. Positive tests were reconfirmed using a second ELISA. CeD was diagnosed if the second test was positive and these participants were further investigated. A subsample of participants was tested for HLA-DQ2/-DQ8 and underwent detailed dietary evaluation. Results: The age-adjusted prevalence of celiac autoantibodies was 1.23 % in northern, 0.87 % in northeastern, and 0.10 % in southern India (p<0.0001). The prevalence of CeD and potential CeD, respectively, were 8.53/1000 and 3.70/1000 in the northern part, 4.66/1000 and 3.92/1000 in the northeastern part, and 0.11/1000 and 1.22/1000 in the southern part. The population prevalence of genes determining HLA-DQ2 and/or HLADQ8 expression was 38.1 % in northern, 31.4 % in northeastern, and 36.4 % in southern India. Mean daily wheat intake was highest in the northern (455 g) compared to those in the northeastern (37 g) or the southern part (25 g), while daily rice intake showed an inverse pattern. Conclusions: CeD and potential CeD were most prevalent in northern India and least in southern India. The prevalence correlated with wheat intake and did not reflect differences in the genetic background.

PLE-4 Terlipressin is noninferior to noradrenaline in cirrhotic patients with septic shock admitted to an intensive care unit—An open-label RCT (identifier: NCT01836224)

Ashok Choudhury, Chandan Kumar Kedarisetty, Chitranshu Vashishtha, Deepak Saini, Sachin Kumar, Rakhi Maiwall, Manoj Kumar, Ajeet Singh Bhadoria,Guresh Kumar, Shiv Kumar Sarin Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims: Cirrhosis with septic shock has high mortality. Noradrenaline is the preferred vasopressor for septic shock. Terlipressin improves microcirculation in addition to vasopressor action. We compared the efficacy and safety of noradrenaline and terlipressin in patients of cirrhosis with septic shock. Methods: Patients of cirrhosis with septic shock after initial fluid resuscitation were openly randomized to receive a continuous infusion of either terlipressin at a dose of 1.3–5.2 μg/min or noradrenaline at a dose of 7.5– 60 μg/min, so as to achieve a target mean arterial pressure (MAP) of >65 mmHg, on failing which a combination of the two was used as salvage therapy. The primary end point was to achieve a MAP of >65 mmHg at 6 h. The tissue perfusion and hemodynamic parameters were monitored till death or 28 days follow up. Results: The patients were critically ill with the Model for End-Stage Liver Disease (MELD) (34.9±12.5 vs. 33.8±9.9, p=0.65) and Sequential

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Organ Failure Assessment (SOFA) score (13.7 ± 3.1 vs. 14.7 ± 2.6, p=0.10) in the terlipressin and noradrenaline groups, respectively. The major source of sepsis at admission was spontaneous bacterial peritonitis (SBP) followed by pneumonia. Most of the patients achieved target MAP at 6 h in both the groups (90.5 % vs. 78.6 %, p=0.13). But, terlipressin use was associated with a better maintenance of MAP with lesser shift to salvage therapy (26.2 % vs. 61.9 %, p=0.05) and also a greater discontinuation of vasopressor (33.3 % vs. 11.9 %, p<0.05) at 48 h. None of the patients in the terlipressin group developed variceal bleed (0 % vs. 9.5 %, p=0.01 with resolution of AKI on the fifth day (37.5 vs. 8.3, p=0.08). A reduction of mortality in the first 48 h (4.8 % vs. 28.5 %, p=0.003) was seen with terlipressin use. Increased adverse effects (40.5 % vs. 21.4 %, p=0.06), yet nonfatal and reversible, were seen with terlipressin. Conclusions: Terlipressin is noninferior to noradrenaline as a vasopressor and associated with early survival benefit and reduced risk of variceal bleed but with marginal increase in adverse effects.

PLE-5 Microparticles predict immune cell stress and trigger sterile inflammation and outcomes in patients with alcoholic liver disease

S Sukriti, J S Maras, S Sharma, M Premkumar, S Das, M S Hussain, D Kumar, S M Shastry, A Choudhary, G Kumar, N Gagoi, C Mukhopadhyay, N Trehanpati, S K Sarin Department of Research and Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India, and Special Center for Molecular Medicine, Jawaharlal Nehru University, New Delhi 110 067, India Background and Aims: Microparticles (MPs) are the membrane-bound vesicles released during cellular stress. Disease-specific MP signatures may aid disease progression or treatment outcomes. Severe alcoholic hepatitis (SAH) has a rapid progression and poor response to current therapies. Reliable non-invasive tools are needed for early assessment of progression and treatment response. We investigated the correlation between MPs released in SAH, steroid responders (R), and non-responders (NR). Patients and Methods: MPs were isolated from plasma using differential ultracentrifugation followed by flow cytometry. MPs were determined at days 0 and 7 in all 44 patients with SAH: untreated (NTx) (n=12), steroid responders (R) (n=20), NR (n=12), and healthy controls (n=20). THP1 cells were stimulated with MPs to identify the role of MPs in the activation of sterile inflammation. Results: MPs associated with hepatic stellate cells, HSCs (CD34+), macrophages (macs, CD68+), and T cells (CD3+CD8+) were higher in NR at day 0 (p<0.03). After 7 days of steroid therapy, CD34+ and CD8+ MPs remained higher (p<0.00; p<0.04) in NR than in R, whereas macs MP levels were unchanged. In responders, neutrophil MPs were lower at day 7 than that at day 0 (p<0.03), but not in NR. In untreated SAH, the MPs of macs, neutrophils, NK, CD8+, and ASGPR+ were lower comparing both R and NR (p<0.05). The levels of CD68+, CD34+, and CD8+ MPs correlated with MELD and Lille scores (p<0.05). The AUROC of CD34+ MPs (0.93) was highest in NR, whereas that of CD68+ MPs was 0.91 in untreated SAH. CD34+, CD68+, and CD8+ MPs were able to differentiate steroid R from NR (cutoff <25.5, <98, and <1.1 mps/μL in R). Plasma proteomics of NR showed 157 differentially regulated proteins, 58 of which were associated with circulating MPs (p<0.05; ≤1.5-fold). Interestingly, we also found that MPs from both were able to trigger sterile inflammation by activating NLRP3 and its signaling genes. Conclusions: Different classes of MPs could reliably identify and differentiate stressed immune cells in SAH. Importantly, high MP levels of CD34+, CD68+, and CD8+ suggest apoptosis of myeloid progenitor cells, macrophages, and T cells, which indicates bone marrow suppression and depressed immune reserves in severe alcoholic hepatitis. MP signatures could also help assess response to steroid therapy.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 PLE-6 Prevalence and risk factors of preneoplastic lesions in the gallbladder mucosa among patients with symptomatic gallstones in areas with high incidence of gallbladder cancer

Harshal S Mandavdhare, U Dutta, U Nahar, L Kaman, S Bhattacharya, A Pal, Anu Sharma, Neha Thakur, S S Rana, D K Bhasin Departments of Gastroenterology, Histopathology, General Surgery, Biophysics, and Biochemistry, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Background and Aims: Understanding the pathogenesis of gallbladder cancer (GBC) is necessary to prevent it. We conducted a study to determine the prevalence, nature, and predictors of preneoplastic lesions of the gallbladder epithelium among patients with symptomatic gallstones (GS) undergoing cholecystectomy. Methods: This is a prospective study in which patients with symptomatic GS were assessed for their clinical/radiological/serological (IgGHelicobacter pylori Ab)/histopathological profile of the GB specimen using H&E and PAS-AB to assess preneoplastic lesions. Special stains were used and PCR analysis was performed to detect H. pylori. The physical and chemical nature (using FTIR) of GS was studied. Univariate and multivariate analyses were performed to identify predictors of preneoplastic lesions (SPSS v 20). Results: Most patients (n= 69; mean age 44□14.5 years; 94 % F) had multiple GS (80 %) of mixed/pure cholesterol type (93 %) which were irregular in shape (67 %) with rough surfaces (51 %). The epithelium showed presence of hyperplasia (42 %), dysplasia (3 %), incomplete intestinal metaplasia (IIM) (46 %), and/or gastric metaplasia (28 %). There was significant muscle hypertrophy in 76 % of patients. Hpylori serology was positive in 54 % but not identifiable in the GB tissue. H&E staining alone was unable to appropriately classify the nature of metaplasia. Preneoplastic lesions were associated with epithelial hyperpl as i a ( p = 0 . 00 5 ) , mo d e r a t e / s e v e r e m u s c l e h y p e r t r o ph y (p < 0.0001), rough gallstones (p = 0.022), and inflammation (p =0.081). The independent predictors for preneoplastic lesions were hyperplasia (OR 3.4; CI 1.04–11), moderate/severe muscle hypertrophy (OR 21.8; CI 2.4–192), and rough stones (OR 3.9; CI 1.2–13). Conclusion: Preneoplastic lesions are highly prevalent (49 %) in patients with symptomatic GS. Predictors for preneoplastic lesions were epithelial hyperplasia, moderate/severe muscle hypertrophy, and rough GS. Cholecystectomy done to provide symptom relief may have inadvertently interrupted the pathogenesis of GBC in a subset of them. Young Investigator Award YIA-1 Role of HEV antigen detection in HEV-related acute viral hepatitis and acute liver failure

Saurabh Mishra, Premashis Kar Department of Medicine, B L Taneja Building, Maulana Azad Medical College and L N Hospital, Bahadur Shah Zafar Marg, New Delhi 110 002, India Background and Aims:Detection of HEVantigen in serum, in conjunction with IgM ant-HEV, presents as an interesting diagnostic modality to identify acute HEV infection. This study was done to evaluate the relative efficacy of currently available diagnostic tests for HEV-related AVH and ALF with detection of HEV antigen in serum. It also aimed to determine

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the correlation between HEVantigen detection and the severity of disease and whether it can be used as a cheaper alternative to HEV RT PCR to ascertain viremia. Methods: The study included 36 cases of ALF and 64 cases of AVH. The tests performed to detect acute infection were as follows: IgM anti-HAV, HBsAg and IgM anti-HBcAb, anti-HCV, and IgM anti-HEV. The HEV antigen was detected using ELISA. HEV RNA was detected by PCR. Results: Forty-five out of 64 cases of AVH and 22 out of 36 cases of ALF had evidence of recent HEV infection. Positivity of IgM anti-HEV, HEV RNA, and HEVantigen was 34/45 (75.56 %), 26/45 (57.77 %), and 21/45 (46.66 %) in the AVH group and 16/22 (72.72 %), 14/22 (63.63 %), and 12/22 (54.54 %) in the ALF group, respectively. Moderate concordance was present between HEVAg and HEV RNA in both the AVH group (k= 0.516) and the ALF group (k=0.441). HEVantigen detection in serum did not correlate with the severity of disease or influence the final outcome in either AVH or ALF cases. Conclusions: HEV antigen detection can be used as a valuable marker of active viremia in both HEV-related AVH and ALF, as an alternative to HEV RT PCR, especially in the window period (in outbreaks) and in immunocompromised patients.

YIA-2 MicroRNA 192 in combination with serum CA19-9 as a non-invasive prognostic biomarker in periampullary carcinoma

K Murali Manohar, K V S R R Yesaswini, V Sunil, M Sasikala, H V V Murthy, Ch Ramji, S Dhanalakshmi, G V Rao, R Pradeep, D N Reddy Institute of Basic Science and Translational Research, Asian Healthcare Foundation, and Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Although the clinical presentation and treatment options for periampullary carcinoma (PAC) subtypes are similar, prognosis is worse in the pancreatobiliary type of PAC. Recent studies demonstrated that specific circulating miRNA expression may serve as a non-invasive biomarker for early diagnosis/ prognosis of human cancers. Therefore, we aimed to assess the prognostic relevance of circulating miRNAs in PAC. Methods: Whole blood from healthy volunteers and tumor, adjacent normal tissue, and whole blood from PAC patients were obtained (n=82 each). Nine differentially expressed miRNAs were evaluated in tissue and plasma of preoperative samples in two phases (training and validation sets) by qRT-PCR. Data analysis was performed using the ΔΔCt method. ROC, logistic regression, and survival analyses were employed on individual miRNAs and in combination with CA19-9 to identify a prognostic biomarker. Results: Five miRNAs (miRNA 192, 375, 31, 196a, and 194) showed significant differential expression in circulation. Among these, miRNA 192 showed a significant increased expression and a positive correlation between tissues and plasma (p<0.0001, r=0.958). In addition, increased expression of miRNA 192 is associated with tumor stage and tumor aggressiveness. Increased miRNA 192 in plasma correlated with stage III and poor survival. The AUCs of the miRNA 192 + CA19-09 panel for stage III was 0.877 (95 % CI, 0.715 to 0.959) and for tumor aggressiveness 0.924 (95 % CI, 0.770 to 0.88), which were significantly higher than the AUCs of miRNA 192 (p=0.04, p<0.05) and serum CA19-9 (p<0.01, p<0.01) alone. Conclusion: Circulating miRNA 192 in combination with serum CA19-9 may serve as a non invasive biomarker to determine the tumor stage, prognosis, and survival in PAC.

A4 YIA-3 Evidence for alternate pathways involved in colorectal cancer pathogenesis suggests lack of Bpolyp^ and Badenoma carcinoma sequence^ in Indian patients

Sandhya Singh, V Sharanya, Govardhan Bale, M Sasikala, Hrushikesh P Chaudhari, Sundeep Lakhtakia, G V Rao, D Nageshwar Reddy Asian Healthcare Foundation, 6-3-661, Somajiguda, Hyderabad 500 082, India, and Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Colorectal cancer (CRC) pathogenesis in the western population develops through a multistep Badenoma carcinoma sequence,^ unlike that in the Indian population. Wnt pathway dysregulation accounts for 90 % of sporadic CRC cases in the western population, while only 54.6 % in our population. We aim to elucidate differential CRC pathogenesis in our population. Methods: We investigated tumor and matched normal tissue specimens of 16 CRC patients for mRNA expression for APC, β-catenin, c-Myc, and cyclin D by qRT-PCR and β catenin protein level by immunohistochemistry. Mutational analysis of the Bmutation cluster region (MCR)^ of the APC gene and Bexons 2–5^ of the β-catenin gene was performed by sequencing PCR product for patients showing APC downregulation and β-catenin upregulation. Result: β-Catenin upregulation was found in 25 % of carcinomas, of which 75 % of patients showed concomitant APC downregulation, while 25 % of patients with high β-catenin upregulation were independent of APC downregulation. APC downregulation with no β-catenin upregulation was observed in 19 % of patients. The extent of β-catenin stabilization did not correlate with APC downregulation. Wnt target gene, c-Myc, and cyclin D upregulation was observed only in 13 % of patients, while only c-Myc upregulation was observed in 50 % of patients. In addition, cMyc upregulation in 38 % of patients was independent of APC downregulation and/or β-catenin upregulation. No mutations were found in APC and β-catenin. Conclusion: Our data shows, in contrast to the CRC pathogenesis in the western population, a role of a novel alternative pathway in βcatenin and c-Myc upregulation in the CRC pathogenesis of Indian patients. YIA-4 Prevalence and association of Mycobacterium avium subspecies paratuberculosis with disease course in patients with ulcero-constrictive ileocecal disease

Imteyaz Ahmad Khan, Sucharita Pilli, A Surendranath, Sudhir Kumar Chauhan, Veena Tiwari, Ritika Rampal, Venigalla Pratap Mouli, Saurabh Kedia, Prasenjit Das, Govind Makharia, Vineet Ahuja Department of Gastroenterology and Human Nutrition and Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background: The association of Mycobacterium avium subspecies paratuberculosis (MAP) and Crohn’s disease (CD) has been controversial due to contradictory reports. Therefore, we determined the prevalence of MAP in patients with CD and intestinal tuberculosis (ITB) and its association with clinical course. Methods: Blood and intestinal biopsies were taken from 69 CD patients, 32 ITB patients, and 41 patients with hemorrhoidal bleed who served as controls. qPCR targeting the MAP-specific IS900 gene was used to detect the presence of MAP DNA. qPCR results were further validated by sequencing. Immunohistochemistry (IHC) was used to detect the presence of the MAP antigen in biopsy

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

specimens. CD and ITB patients were followed up for disease course and response to therapy. Results: The frequency of MAP-specific DNA in biopsies by qPCR was significantly higher in CD patients (23.2 %, p=0.03) as compared to controls (7.3 %). No significant difference in intestinal MAP presence was observed between ITB patients (12.5 %, p=0.6) and controls (7.3 %). MAP presence in the blood of CD patients was 10.1 % as compared to 4.9 % in controls, while no patients with ITB were found to be positive (p=0.1). Using IHC for detection of the MAP antigen, the prevalence of MAP was 2.9 % in CD patients, 12.5 % in ITB patients, and 2.4 % in controls. However, long-term follow up of the patients revealed no significant associations between the clinical course of the disease with MAP positivity. Conclusion: We report a significantly high prevalence of MAP in intestinal biopsies of CD patients. However, the presence of MAP does not affect the disease course in either CD or ITB patients.

YIA-5 Patients with mild enteropathy have apoptotic injury of enterocytes similar to that in advanced enteropathy in patients with celiac disease: Implications on the treatment of celiac disease

Prasenjit Das, Gaurav P S Gahlot, Ritu Mehta, Archita Makharia, Anil K Verma, Siddhartha Datta Gupta, Subrat K Panda, Vineet Ahuja, Govind K Makharia Departments of Pathology, Gastroenterology, and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Introduction: Severity of villous atrophy in patients with celiac disease (CeD) is a trade-off between immune-mediated enterocyte loss and the regenerating capacity of crypts. A positive effect of gluten-free diet has been shown even in mild enteropathy, with high anti-tTG titer, recently. In order to understand the comparative rate of enterocyte loss and regeneration, in the mild vs. advanced enteropathy CeD, we conceived this study. Materials and Methods: Duodenal mucosal biopsies from anti-tTG Abpositive mild enteropathy (modified Marsh grade 0/1) (n=26), advanced enteropathy CeD (n=41), and 12 controls were subjected to immunohistochemical staining for end apoptotic markers (M30, H2AX); markers of cell death (perforin and annexin V); apoptotic pathway mediators (caspase-9, FAS, and FAS ligand); and cell proliferation (Ki67). Composite H-score based on the intensity and distribution of these markers was compared. Results: Composite H-scores of markers of the end product of apoptosis (M30 and H2AX) as well as cell death (perforin) were significantly higher both in mild and advanced enteropathy CeD, in comparison to controls, but there was no difference between mild and advanced enteropathy. Ki67 labeling index was significantly higher in the crypts of mild enteropathy, in comparison to controls, suggesting higher cell regeneration in them. Conclusions: Even in mild enteropathy patients, a higher rate of enterocyte apoptosis is compensated by enhanced regeneration at crypts; hence, villous height is maintained in them. These findings of immunemediated damage even in mild enteropathy raise a question mark on the existing practice of not treating patients with mild enteropathy. YIA-6 Irritable bowel syndrome, particularly constipation-predominant, has more \Methanobrevibacter smithii, which is associated with higher methane production

Ratnakar Shukla, Ujjala Ghoshal, Deepakshi Srivastava, Uday C Ghoshal

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Departments of Microbiology and Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Background: Since Methanobrevibacter smithii produces methane delaying gut transit, we evaluated the quantity of M. smithii among patients with irritable bowel syndrome (IBS) including constipationpredominant sub-type (IBS-C) and healthy controls (HC). Methods: Quantitative real-time PCR (qPCR) was performed in feces of 47 patients with IBS (Rome III) and 30 HC for M. smithii. On lactulose hydrogen breath test (LHBT, done in 25 IBS), fasting methane ≥10 ppm or increased by ≥10 ppm after 10 g lactulose defined methane producers. Results: Of 47 IBS, 20 had IBS-C, 20 had diarrhea (IBS-D), and 7 were not sub-typed. M. smithii 16S rRNA copy number was higher among IBS than HC (log105.4, IQR [3.2–6.3] vs. 1.9 [0.0–3.4], p<0.001), particularly among IBS-C than IBS-D (log106.1 [5.5–6.6] vs. 3.4 [0.6–5.7], p= 0.001); copy number was lower among patients passing more than three stools/week than without (n=25/47, log103.6, IQR [2.4–5.6] vs. 22/47, log105.9, IQR [4.9–6.6], p=0.002), which negatively correlated with stool frequency (r=−0.420, p=0.003). IBS-C patients produced methane more often than IBS-D (8/12 [67 %] vs. 3/13 [23 %], p=0.047). M. smithii copy number was higher among methane producers than non-producers (log106.4 [5.7–7.4] vs. 4.1 [1.8–5.8], p=0.001). Using receiver operating characteristic (ROC) curve, the best cutoff of M. smithii to identify methane producers was log106.0 (sensitivity 64 %, specificity 86 %, area under the curve [AUC] 0.896). AUC for breath methane correlated with M. smithii copy number among methane producers (r=0.74; p=0.008). Abdominal bloating was commoner among methane producers (n=9/11 [82 %] vs. 5/14 [36 %], p=0.021). Conclusions: Patients with IBS, particularly IBS-C, had a higher copy number of M. smithii than HC. On LHBT, breath methane levels correlated with the load of M. smithii. Esophagus E-1 To predict the therapeutic response of pneumatic balloon dilatation in different subtypes of achalasia based on a newer Chicago classification

Pankaj Asati, V K Dixit, A K Jain, S K Shukla, S Budhiraja, A B Abhilash Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background/Aims: High-resolution esophageal manometry (HRM) with pressure topography is used to classify achalasia cardia, which has different therapeutic responses. The aim of this study was to compare the clinical characteristics, manometric variables, and treatment outcomes among the achalasia subtypes—types I, II, and III—based on the HRM findings. Methods: This study was carried out in the Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, from 2014 to 2015. Forty-six newly diagnosed achalasia patients (F:M—18:28; age 19–54 years, mean 28) fulfilling inclusions criteria were enrolled in the study. Subjects underwent physical examination, esophageal manometry, endoscopy, and radiographic assessment. Symptoms (weight loss, dysphagia, retrosternal pain, and regurgitation) were assessed using the Eckardt score. Patients present with usually dysphagia and regurgitation. Patients underwent pneumatic dilatation (Rigiflex balloon). Patients were re-evaluated at 3 months after treatment and considered unsuccessful if the Eckardt score >3. Repeat PD was done for recurrent symptoms on follow up. The clinical and manometric variables and treatment outcomes were compared.

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Results: Among 54 patients of dysphagia who underwent HRM, 46 were diagnosed as achalasia cardia (type I—14, II—29, III—9). Of these 46– 32 were managed with pneumatic dilatation rest patients managed by laparoscopic Hellers myotomy. Table: Response of pneumatic dilatation in patients with achalasia No. of patients with response Percentage p value to pneumatic dilatation Type I achalasia Type II achalasia

8 21

5 17

Type III achalasia

4

1

60 84

<0.05 <0.05

33.33

<0.05

Conclusions: Type II achalasia cardia is the most common type of achalasia on HRM having the best response to pneumatic dilatation than the other types. E-2 Clinical and manometric evaluation of achalasia cardia

Mayank Jain, Amit Bundiwal, Sandip Ware, Rahul Agrawal, Sandip Kaulavkar, Suresh Hirani, Shohini Sircar, Ajay K Jain Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aim: The aims of this study were (1) to assess clinical symptomatology based on type of achalasia and (2) to analyze manometric findings in various types of achalasia. Materials and Methods: All patients presenting to the Manometry Unit of the Department of Gastroenterology, Choithram Hospital and Research Centre, formed the study group. Detailed history and manometric evaluation was done in all patients. The study period was from January 2013 to January 2015. The tests were done using water perfusion, a 16-channel system (Ready Stock, Australia). All recordings were done by a single observer in the right lateral position using ten wet swallows in each patient. The results were interpreted using the Chicago classification v 3.0. Results: A total of 61 patients formed the study group. Type 2 achalasia was the commonest (29/61) followed by type 1 (27/61) and type 3 (5/61) achalasia. Panesophageal pressurization was noted in 96 % of swallows in patients with type 3 achalasia, 63.5 % of swallows in type 2 achalasia, and 5.95 % of swallows in type 3 achalasia. Conclusion: The following conclusions can be drawn from the study: (1) Type 2 achalasia is the commonest subtype in our setting followed by type 1 achalasia; (2) dysphagia to solids and liquids is noted in all subtypes of achalasia, regurgitation is more common in types 1 and 3, and more patients with type 2 and 3 subtypes reported using maneuvers to improve esophageal emptying; and (3) panesophageal pressurization with preserved distal peristalsis is noted in 96 % of swallows in type 3 achalasia and panesophageal pressurization is seen in 63.5 % of swallows in type 2 achalasia. E-3 Jackhammer esophagus: clinical profile and characteristics on high-resolution manometry

K Arivarasan, Sanjeev Sachdeva, A S Dahale, A K Mantri, Amit Soni, Ajay Kumar, A S Puri Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

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Background and Aim: Jackhammer esophagus (JE) is an uncommon esophageal motility disorder depicting an extreme phenotype of hypercontractility. This is truly an enigmatic entity brought to the spotlight by the Chicago classification of esophageal pressure topography (EPT). We aimed to study the clinical profile and esophageal motor function in patients with JE. Methods: Clinical and manometric features of 11 patients with Jackhammer esophagus were evaluated. High-resolution manometry (HRM) was performed using a 16-channel esophageal manometry catheter (Dentsleeve, Canada) perfused with water using a pneumatically activated manometric pump (Kangaroojef, Melbourne, Australia). The HRM criterion used for the diagnosis of JE was presence of at least a single propagated swallow with a distal contractile integral (DCI) of >8000 mmHg cms, with all other HRM study parameters being normal. Results: Out of 11 patients, 7 (63.6 %) were females. Median age was 37(23–69)years. Clinical presentation included dysphagia in 11 (100 %), retrosternal chest pain in 10 (90.9 %), heartburn in 5 (45.5 %), globus sensation in 3 (27.3 %), and recurrent hiccoughs in 2 (18.2 %). Median duration of symptoms at presentation was 4(1–13)years. All patients had normal basal lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP), contraction front velocity (CFV), and distal latency (DL). Median maximal DCI was 10,167(8954–11,748)mmHg cm s. High DCI (hypercontractility) was associated with multipeaked contractions in 10 (90.9 %) patients. Conclusions: In our limited experience with JE, dysphagia and chest pain were the dominant presenting symptoms. Esophageal contractions with very high DCI and multipeaked morphology were the HRM hallmarks of this intriguing motility disorder.

E-4 Peroral endoscopic myotomy for the treatment of spastic esophageal disorders

Zaheer Nabi, Radhika Chavan, Mohan Ramchandani, Nageshwar Reddy, Santosh Darisetty, Deepesh Sharma Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 E-5 Peroral endoscopic myotomy for sigmoid-type achalasia

Radhika Chavan, Zaheer Nabi, Mohan Ramchandani, Nageshwar Reddy, Mohsin Aslam, Santosh Darisetty Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Peroral endoscopic myotomy (POEM) is a novel treatment option for achalasia cardia. The efficacy and safety of this procedure in advanced achalasia with a sigmoid-shaped esophagus are not known. Objective: The purpose of this study was to evaluate the feasibility and efficacy of POEM in patients with sigmoid-type achalasia. Methods: Eleven consecutive patients with sigmoid-type achalasia (S1 type—9 and S2 type—2 patients) were prospectively included. Primary outcome was symptom relief, defined as an Eckardt score ≤3. Secondary outcomes were procedure-related adverse events, the resting lower esophageal sphincter (LES) pressure, barium emptying on timed barium esophagogram (TBE), clinically significant reflux symptoms, and procedure-related parameters. Results: All patients underwent POEM successfully. The mean operation time was 100 min (range 50–190 min). No serious complications related to POEM were encountered during a mean follow up period of 10 months (range 1–20). Post POEM, there was significant decrease in mean Eckardt score (7±2.1 vs. 1.7±1.1, p<0.05). Mean LES pressure also decreased from 28.6±5.6 to 13.3±4.5 mmHg after POEM (p<0.05). However, there was no significant improvement in emptying of barium seen on TBE (6.9±0.47 vs. 6.5±0.47, p=0.07). Two patients experienced only partial symptom relief and additional balloon dilations were carried out for them. Erosive esophagitis was seen in 27 % of patients at 6 months. Conclusions: POEM is safe and efficacious for achalasia with a sigmoid esophagus. Further studies with a large sample size are required to establish our results.

E-6 Hypersensitive esophagus: It is not uncommon

Background: Peroral endoscopic myotomy (POEM) is a novel treatment option for achalasia cardia (AC). Limited data exists on the utility of POEM for spastic esophageal disorders. Objective: This research aimed to study the efficacy and safety of POEM for the treatment of patients with diffuse esophageal spasm (DES), Jackhammer esophagus (JHE), nutcracker esophagus (NCE), and type III (spastic) achalasia (AC). Methods: A total of 20 patients (DES—11, JHE—1, NCE—2, and spastic AC—6) underwent POEM from September 2013 to January 2015 for spastic esophageal disorders. Retrospective analysis of prospectively collected data was done. Eckardt score and timed barium esophagogram (TBE) were used to evaluate the results. Patients were followed at 3 and 6 months. Results: POEM was successfully completed in all 20 patients. The technical success rate of POEM was 100 % with a mean procedure time of 101.5±20.6 min. Mean myotomy length was 14.8 cm (range 7–19 cm). There was a significant decrease in Eckardt scores after POEM (6.75±1.9 vs. 1±0.9, p<0.05) and also significant improvement of esophageal emptying seen on TBE (13.4±1.53 vs. 4.5±0.68, p<0.05). Overall, clinical response was observed in 17 (85 %) patients during a median follow up of 360 days. There was significant improvement in chest pain noted in 14/20 patients (70 %). Erosive esophagitis was seen in 3/15 (30 %) patients at 6 months. No serious complications related to POEM were seen. Conclusion: POEM is safe and effective for spastic esophageal disorders. Further prospective studies with a large number of patients are required to confirm our results.

Vinod Narkhede, Sanjay Kumar, Sachin Munjal, Sandesh Sharma, Ajit Sewkani Gastrocare Liver and Digestive Disease Centre, 120-121, Link Road Number 3, E-3, Arera Colony, Bhopal 462 016, India Introduction: Heartburn and noncardiac chest pain are common symptoms. It is known that excessive intraesophageal acid exposure causes the symptoms of retrosternal pain and burning, but many patients with chronic heartburn symptoms have no endoscopically or histologically discernible esophageal mucosal damage and many of them even do not have positive reflux as per 24-h pH monitoring. Methods: A retrospective study was carried out from July 2014 to July 2015. A total of 53 eligible study subjects (35 males, 18 females; range 19 to 62 years) presented to the OPD of our hospital were included. All study subjects who were having endoscopically negative gastroesophageal reflux disease (GERD) and who were not responding or partially responding to the standard dose of a proton pump inhibitor (PPI) were considered for 24-h esophageal pH monitoring (after stopping PPI for 7 days). Acid contact time, DeMeester score, symptom index, and symptom-associated probability were recorded. Result: Out of 53 subjects, 73.6 % had heartburn and chest pain as their presenting complaints while 26.4 % had other symptoms of GERD. Twenty-two (41.5 %) were having hypersensitive esophagus (HE), 10 (22.6 %) had nonerosive reflux disease (NERD), 12 (18.9 %) had NERD with HE, and 9 (17 %) had normal pH monitoring.

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Conclusion: In patients presenting with endoscopy-negative reflux symptoms refractory to PPI, on pH monitoring, a hypersensitive esophagus is the commonest finding. Therefore, apart from PPI, reduction of the stimulus intensity is desirable in clinical practice. E-7 Peroral endoscopic myotomy in achalasia patients with failure of prior treatment

Zaheer Nabi, Mohan Ramchandani, Radhika Chavan, Rakesh Kalapala, Santosh Darisetty, Rama Kotla, Nageshwar Reddy Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Introduction: Peroral endoscopic myotomy (POEM) is an emerging treatment for achalasia. The impact of prior treatment (pneumatic dilation, botulinum toxin injection, and previous myotomy) on the success of POEM is not well known. The purpose of this study was to assess the safety and efficacy of POEM in patients who had undergone prior treatment for their achalasia. Methods and Procedures: All patients who underwent POEM with a history of failure to prior treatment were retrospectively analyzed. Symptom improvement (Eckardt score ≤3) was considered as the primary outcome. Secondary outcomes included esophageal emptying and procedure-related complications. Results: Two hundred and eighty-six patients underwent POEM at our center. Ninety-five (33 %) patients (male—62, female—33) had undergone prior treatment (botox injection—1, pneumatic dilation—79, Heller’s myotomy—15, both pneumatic dilatation and Heller’s myotomy—4). Mean age of the patients was 38.5 years (range 9–74). Ninety patients underwent POEM successfully with a mean operative time of 90± 25 min. POEM could not be completed in 5 patients due to submucosal fibrosis. Anterior myotomy was done in 68 patients, posterior in 21 and greater curvature myotomy in one patient. Mean myotomy length was 11.8 ±2.8 cm. Procedure-related minor complications included pneumoperitoneum (5), mucosal injury (1), and bleeding (2). Sixty-three patients completed 1 year of follow up. Eckardt score (6.7±1.5 vs. 1.1±0.5, p<0.05) and esophageal emptying as measured by timed barium swallow (11.2±2.1 vs. 3.8±0.98 cm, p<0.05) were significantly better post POEM. Conclusion: Per oral endoscopic myotomy is a safe and effective treatment for achalasia patients who have failed to respond to prior therapy. E-8 Safety of per o ral endoscopic myotomy in patients with severe comorbidities

A Bapaye, N A Dubale, K Sheth, P Desai, N Mehta, M Kabrawala, R Pujari, S Date, J A Bapaye, M Kulkarni, V Vyas, M Mahadik Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Near Mhatre Bridge, Erandawne, Pune 411 004; Surat Institute of Digestive Sciences, Vijay Nagar Society, Majura Gate, Surat 395 002; and Vedanta Institute of Gastroenterology, Ahmedabad, India Introduction: Per oral endoscopic myotomy (POEM) is an emerging treatment modality for achalasia cardia with encouraging results comparable to laparoscopic Heller’s myotomy (LHM) or endoscopic balloon dilatation (EBD). In this multicenter study, we analyze the safety and efficacy of POEM in patients with severe cardiorespiratory diseases’ relative contraindications for LHM or EBD. Aims and Methods: Consecutive patients with achalasia cardia confirmed by endoscopy, high-resolution manometry (HRM), and barium swallow and undergoing POEM at three centers were included. Associated comorbidities

were recorded as per the American Society of Anesthesiologists (ASA) classification. Eckhardt dysphagia score was recorded pre- and postprocedure. Procedure time, technical success, and complications were noted. Follow up was by EGD, by HRM at 4 weeks, and then by telephone monthly. Results: Eighteen out of 61 (29.50 %) patients undergoing POEM had severe systemic diseases (ASA class 3 or 4). Mean age was 57.41 years (females—6) and median symptom duration was 54 months. Comorbid diseases included cardiac disorders (5), pulmonary diseases (5), hypertension (11), diabetes (4), and morbid obesity (1). Eight patients (44 %) had >1 comorbid illnesses. No intra- or postprocedural complications or deaths occurred. Postoperative hospital stay was <48 h for all patients. Clinical success was 100 %. Significant reduction was seen in Eckhardt score 7.2 vs. 1.42 (p=0.001) and mean LES pressure 36.78 vs. 10.06 mmHg at 4 weeks and was maintained after a mean follow up of 9 months. Conclusion: POEM is a safe and effective treatment for achalasia cardia even in patients with severe systemic diseases that may preclude surgical intervention. E-9 Prevalence of eosinophilic esophagitis in patients with gastroesophageal reflux disease: A cross-sectional tertiary care hospital-based study

Bhaskar Jyoti Baruah, Tarun Kumar, Prasenjit Das, Bhaskar Thakur, Vineet Ahuja, Siddhartha Datta Gupta, Govind Makharia All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 016, India Background: Eosinophilic esophagitis is an increasingly recognized clinical entity all over the globe; the data from India is however lacking. We screened patients with symptoms of gastroesophageal reflux disease (GERD) for the presence of eosinophilic esophagitis. Methodology: Consecutive patients with symptoms suggestive of GERD underwent gastroduodenoscopy, and multiple esophageal biopsies were obtained from pre-defined upper (5 cm below the upper esophageal sphincter) and lower (5 cm above the gastroesophageal junction) ends of the esophagus and any other from endoscopically visible abnormal mucosa. Demographic profile, symptomatology, endoscopic findings, peripheral blood eosinophil count, and use of proton pump inhibitors were recorded to assess their correlation with the presence of eosinophilic esophagitis. Stool examination was done to rule out parasitic infection. Eosinophilic esophagitis was defined when eosinophil infiltration was >20 per high-power (400 magnification) field. Results: From a total of 190 consecutive patients, 6 were diagnosed to have eosinophilic esophagitis, making a prevalence of 3.15 % of all patients with GERD. Univariate analysis showed a history of allergy, non-response to proton pump inhibitors, and absolute eosinophil counts were associated with an increased prevalence of eosinophilic esophagitis. However, the presence of eosinophilic esophagitis did not correlate with the severity of reflux symptoms. Multivariate analysis showed a history of allergy and non-response to PPI were associated with eosinophilic esophagitis. Conclusion: In our hospital-based data from North India, the prevalence of eosinophilic esophagitis in patients with GERD-like symptoms was 3.15 %. Eosinophilic esophagitis should be considered as one of the differential diagnoses especially in those with GERD-like symptoms but not responding to PPI. E-10 Prevalence of gastroesophageal reflux disease in a rural population in the northern part of India: A population-based study

Urvashi Hooda, Ritvik Amarchand, Anil K Verma, Vineet Ahuja, Anand Krishnan, Govind K Makharia

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Departments of Gastroenterology and Human Nutrition and Community Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 016, India Introduction: The prevalence of gastroesophageal reflux disease (GERD) in India varies from 10 % to 15 % based on hospital-based studies. There is a paucity of data from the general population, especially the rural population. We conducted a population-based study to estimate the prevalence of GERD in the rural population. Methodology: This study was conducted in Ballabgarh Block in Faridabad District in the northern part of India. Thirty villages were selected using the PPS technique; households were selected by systematic random sampling and a couple was selected per household by the KISH method. Participants were administered a questionnaire asking for the presence, frequency, and severity of heartburn and regurgitation along with risk factors and socio-demographic features. A score was derived for each symptom (multiplying severity with frequency), and a final GERD score was obtained by adding the scores for the two symptoms. Subjects having a score of 4 or more were considered to have GERD. Score ranges of 4–8, 9–13, and 14–18 were classified as mild, moderate, and severe GERD, respectively. Results: Of 4779 individuals interviewed, 8.45 % (95 % CI 7.66–9.24) had GERD. Prevalence was higher in females (9.35 %; 95 % CI 8.26– 10.44) as compared to males (7.26 %; 95 % CI 6.14–8.38). Of these, 37.9 %, 46.8 %, and 15.3 % were mild, moderate, and severe GERD, respectively. In univariate analysis, smoking (p=0.005), increasing age (p= 0.003), and being non-vegetarian (p=0.01) were positively associated with GERD. Conclusion: The prevalence of GERD in the rural population of India is 8.45 % and poses a significant burden, contrary to a belief that GERD is uncommon in the Indian rural population. E-11 Esophageal acidification during nocturnal acid breakthrough and comparison of ilaprazole and omeprazole in causing it among patients with gastroesophageal reflux disease

Arun Karyampudi, Rajan Singh, Abhai Verma, Vivek A Saraswat, Asha Misra, Uday Chand Ghoshal Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Background: Though nocturnal acid breakthrough (NAB) is common among patients with gastroesophageal reflux disease (GERD), its clinical importance depends on its ability to cause esophageal acidification, which, however, has been shown to be uncommon in two small studies. Ilaprazole, a long-acting proton pump inhibitor (PPI), may cause NAB infrequently. Accordingly, we studied the (a) frequency and degree of esophageal acidification during NAB and (b) the frequency and severity of NAB during treatment with ilaprazole vs. omeprazole. Methods: Fifty-eight consecutive patients with GERD on once-daily ilaprazole, 10 mg (n=28), or omeprazole, 20 mg (n=30), for >1 month underwent 24-h impedance-pH monitoring. NAB was defined as intragastric pH <4 for >1 h at night and esophageal acidification as pH <4 for any duration. Nocturnal symptoms (heartburn, regurgitation, and chest pain) were also studied. Results: Of 58 patients (age 35.5 years, IQR 27.5–45.75, 38, 65.5 % male), 42 (72.4 %) showed NAB. Though patients with NAB had lower nocturnal intragastric pH than without (2.86 [2.06–3.96] vs. 5.77 [4.73– 6.76], p<0.0001), the frequency and duration of nocturnal esophageal acidification (17/42 vs. 4/16, p=0.36 and 0 [0–1] vs. 0[0–0.3]min, p= 0.26, respectively) and nocturnal symptoms were comparable (13/42 vs. 6/16, p=0.75). Frequency, duration, and mean intragastric pH during NAB were comparable between ilaprazole and omeprazole groups (19/

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28 vs. 23/30, p=0.45; 117 [0–321] vs. 159[66–300]min, p=0.5; 1.02 [0.72–1.38] vs. 1.04 [0.44–1.3], p=0.63, respectively). Conclusion: Though the frequency of NAB while on PPI was high, esophageal acidification was uncommon. Ilaprazole was comparable to omeprazole in terms of frequency and severity of NAB.

E-12 Genetic studies on esophageal carcinoma in a tertiary care center in South India—Chennai

S Kavitha, Arun Kani Sheik, Rathnakar Kini, K Premkumar, T Pugazhendhi, A K Munirajan, Mohammed Ali Department of Medical Gastroenterology, Madras Medical College, Rajiv Gandhi Government General Hospital, Chennai 600 003, India, and Dr. A L M Postgraduate Institute of Basic Medical Sciences, Taramani, Chennai 600 113, India Introduction: Esophageal squamous cell carcinoma (ESCC) is one among the most aggressive types of malignant tumor in humans. HOX transcript antisense RNA (HOTAIR), which is expressed from the homebox C gene (HOXC) locus, capable of reprogramming chromatin organization and promoting cancer cell metastasis and can simultaneously bind polycomb repressive complex 2, leads to cancerogenesis. Clinically, the overexpression of HOTAIR is a powerful predictor of tumor progression and overall survival in patients with diverse cancers. Aim: This study is proposed to identify the long coding RNA HOTAIR expression profile with esophageal cancer. This study could help us to identify the unique expression of HOTAIR in ESCC and their clinicopathological correlation in the South Indian population. Materials and Methods: The study was done between August 2014 and February 2015. Patients confirmed with having esophageal squamous cell carcinoma by histopathological examination were included in the study. We used quantitative real-time PCR to determine the level of HOTAIR in the biopsy specimen. Results: Twenty-nine patients had HOTAIR expression in the tissue. A notably higher level of HOTAIR expression was found in ESCC tissues. High expression levels of HOTAIR in ESCC patients correlated positively with smoking, alcohol, histological differentiation, and prognosis. A high level of HOTAIR expression was found to be an independent prognostic factor in patients with ESCC. Conclusion: HOTAIR expression may be used as a poor prognostic marker in survival of ESCC patients. Patients with a high level of HOTAIR expression should be on constant follow up in debulking the tumour burden by either surgery or chemoradiotherapy. E-13 Clinical profile of carcinoma of the esophagus in a tertiary care hospital—A case series

Kiran Reddyvari, Avinash Balekuduru, A S Koushik Kirthi, M G Janaki, Umesh Jalihal, Satyaprakash Subbaraj Bonthala Department of Gastroenterology, M S Ramaiah Memorial Hospital, New BEL Road, Bengaluru 560 054, India Background and Aim: Carcinoma of the esophagus is aggressive and advanced at the time of presentation. The aim is to study the clinical pattern of cases with carcinoma of the esophagus with special reference to clinical features, treatment, and follow up. Patients and Methods: The clinical data, treatment, and outcomes of 50 cases of primary carcinoma of the esophagus over a 2-year period at a tertiary care hospital were retrospectively studied and analyzed.

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Results: There were 28 men and 22 women with a mean age of 62.8 years. The presenting symptom of all the cases was dysphagia. All underwent either once or multiple endoscopies with 7 being the maximum number per patient. Majority (48 cases; 96 %) had squamous cell carcinoma and the remaining 2 had adenocarcinoma. The commonest site was the middle third of the esophagus (23 cases; 46 %). Forty-seven underwent external radiation to a dose of 5040 cGy/28 fractions/5 Fr/week by conformal planning along with a weekly or 3-week concurrent chemotherapy with either cisplatin or cisplatin and 5-fluorouracil based on general condition. Three cases underwent surgery. Ten cases had SEMS placement and 5 had dilatations. One SEMS case had double stenting for distal tumor overgrowth relapsing after dilatation. All SEMS cases had a maximum follow up of 1 year after SEMS placement. Conclusions: Squamous cell carcinoma in the middle third of the esophagus was the commonest type and site. Majority of cases were locoregionally advanced at presentation. With proper care and a multidisciplinary team approach, majority of carcinoma of the esophagus patients can be salvaged. E-14 Association between Helicobacter pylori infection and esophageal squamous cell carcinoma

Nikhil Suraj, Chethan Govindraju, Prasanth Thayyil Sudheendran, Kadavanoor Srijith, Deni Joseph, Ramu M Pillai, Gopu R Babu, Shanid A Sathaar, Sreejaya S Sreesh, Devadas Krishnadas Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background and Aim: Esophageal cancer is the eighth most common type of cancer worldwide and is the sixth leading cause of cancer deaths. Esophageal squamous cell carcinoma is the most common type of esophageal cancer. Despite advances in molecular mechanisms of carcinogenesis, the etiology remains unclear. Helicobacter pylori has a causal association with a number of malignancies, but the relationship between H. pylori infection and esophageal squamous cell carcinoma is still inconclusive. In this study, we aim to evaluate the association of H. pylori infection with esophageal squamous cell cancer. Methods: The study design was as a case-control study and was conducted from January 2014 to January 2015. All cases of squamous cell carcinoma of the esophagus (n=88) who presented to us during the study period were enrolled in the study as cases. All the patients were diagnosed to have esophageal squamous cell carcinoma after upper gastrointestinal (GI) endoscopy and histopathology report. The controls (n=88) had normal upper GI endoscopy and histopathology reports and were matched for age, sex, smoking, and alcohol consumption. Patients who had a history of documented treatment for H. pylori infection were excluded from the study. H. pylori infection was defined as positivity for antibodies against H. pylori whole-cell antigen. Statistical analysis was done using SPSS 17. Results: A total of 88 cases and controls were taken. There was no statistically significant association between H.pylori infection and esophageal squamous cell carcinoma. (OR, 0.84; 95 % CI, 0.56–1.34; p=0.46). Conclusions: Our study results suggest that there is no statistically significant association between H.pylori infection and esophageal squamous cell carcinoma. E-15 Mutational status of the epidermal growth factor receptor gene in distal esophageal adenocarcinoma in North Chennai

R Nithya, H Devaraj, A R Venkateshwaran, M Manimaran, S Chitra, R Murali, S Revathy

Unit of Biochemistry, Department of Zoology, University of Madras, School of Life Sciences, Maraimalai Campus, Guindy, Chennai 600 025, India, and Department of Medical Gastroenterology, Stanley Medical College and Hospital, 305 OSH Road, Royapuram, Chennai 600 001, India Background: The presence of somatic mutations in the epidermal growth factor receptor (EGFR) is a known predictor of response to tyrosine kinase inhibitors (TKIs) in many human epithelial tumors. In esophageal adenocarcinoma, EGFR overexpression has been reported but the mutational status of EGFR studies was inadequate. This study was performed to determine the prevalence of mutations in EGFR tyrosine kinase domain exons 18–21 in esophageal adenocarcinoma to explore the potential for molecular targeted therapy with TKIs. Methods: Genomic DNA was isolated from 93 patients who presented with symptoms of reflux esophagitis, and 13 resected specimens of EAC were obtained before the initiation of chemotherapy. PCR was carried out to amplify DNA products, and exons 18–21 of EGFR were sequenced by direct sequencing to analyze mutations. Results: EGFR mutations were detected in 15 of the 106 samples analyzed, and they were higher among patients who reported symptoms of GERD, rather than patients who did not report such symptoms at the time of the first visit to the hospital. Among the patients studied, 11.11 % (3/27) of cases of BE, 13.79 % (4/29) of cases of low-grade dysplasia, 12.5 % (3/24) of cases of high-grade dysplasia, and 19.23 % (5/26) of cases of adenocarcinoma samples showed mutations in exons 18, 19, and 21 of EGFR. Mutations were not detected in exon 20 for any of the stages studied. Conclusion: Mutations identified in exons 18, 19, and 21 of the EGFR tyrosine kinase domain could be used as a TKI target in ameliorating cancer.

E-16 Polyflex stenting in esophageal leaks and fistulae: Our experience

Shrihari Anikhindi, Piuyush Ranjan, Munish Sachdeva, Mandhir Kumar Department of Gastroenterology, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Background: Surgery has been the preferred treatment for esophageal leaks and fistulae. Self-expanding plastic stents (SEPS) provide a good alternative, yet there is scarce published literature regarding their indications and efficacy. We present our experience with SEPS in these conditions. Patients and Methods: Consecutive patients admitted in SGRH who underwent SEPS insertion from February 2012 to February 2015 were retrospectively evaluated. Patients underwent prior endoscopic and CECT assessment. SEPS (23 mm flares, 18 mm diameter) were placed under fluoroscopic guidance. A silk thread tied to the upper end was routed through the nostril and fixed to prevent stent migration. A nasojejunal (NJ) tube was inserted in all patients, and an intercostal drain (ICD) was inserted in case of hydro/pyopneumothorax. Results: Twelve patients [9 M, median age 45.3 years (19 to 65 years)] were included. Etiologies were Boerhaave syndrome (n=2), corrosive fistulas (n=2), tubercular fistulas (n=4), invasive Candida esophagitis (n=1), iatrogenic causes (n=2; 1 achalasia dilatation, 1 obesity surgery), and pancreaticoesophageal fistula due to a ruptured pancreatic pseudocyst (n=1). Stent placement was successful in all patients with no immediate postprocedure complications. Mean duration of follow up was 88.45 days (8– 190 days). Successful healing was seen in 9 patients (75 %). Two patients with SEMS failure had multiple tubercular fistulae, and 1

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had a large spontaneous perforation with severe mediastinitis. Healing was observed earliest at D13. Stent migration occurred in 4 patients (33.3 %), and none had early migration (<72 h). These were successfully retrieved in all cases, except one. Conclusion: SEPS is a safe, well-tolerated treatment with a good success rate (75 %). Migration may be reduced by mechanically fixing the upper end. NJ feeding helps in early enteral feeding and recovery. E-17 Importance of recognizing alcian blue-positive non-goblet columnar cells in lower-end esophageal biopsy

Poonam Bhaker, Rakesh Kochhar, Babu Ram Thapa, Saroj Kant Sinha, Kim Vaiphei Departments of Histopathology, Gastroenterology, and Peadiatric Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

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was designed to evaluate the efficacy of herbal medicine (UNIM-701). The study was conducted to evaluate the efficacy of herbal medicine in duodenal ulcer. Methods: Eighty-five cases of duodenal ulcer assessed for a clinical trial (56 males and 29 females) with endoscopically proven duodenal ulcer were subjected to trial (UNIM-701 divided into two doses) for a period of 8 weeks. H. pylori infection was assessed by diagnostic tests, rapid urease, direct smear, and histological exam. Clinical assessment was done every week and repeat endoscopy was performed at the end of the therapy. Results: Seventy-five patients completed the trial and 10 patients dropped out. H. pylori became negative in 56 out of the 75 patients who completed the trial according to the protocol. Twenty-eight patients were cured and 39 patients relieved symptomatically, whereas 8 patients had no response to the therapy. The drug was well tolerated and there was no complaint of any side effects. Conclusions: These results demonstrate that our compound, UNIM-701, exhibits bactericidal activity against H. pylori. This may have potential as a new and safe agent for the treatment of duodenal gastric diseases. S-2

Background: The significance of non-goblet (GC) columnar mucosa (CM) present at the lower end of the esophagus (LEE) remains controversial, and there is limited information of the follow-up data. Aim: This study aimed to evaluate the outcome of Barrett’s mucosa (BM) and NGCM in long-term follow up biopsies. Methods: Biopsies reported as columnar mucosa (CM) with and without GC and correlated with clinical outcome were retrospectively evaluated. Results: There were 178 patients (mean age of 52.1±15.6, 7<20 years, M:F=5:1); 70 % had reflux symptom and 30 % had dysphagia. Endoscopy results were as follows: only BM in 130 (73 %), ulceronodular in 17 %, stricture in 5 %, and small polyps in 5 %. Sixty (34 %) cases had long segment (LSBM) and 70 (54 %) short segment (SSBM); 11 % had hiatus hernia. For the histology, GCs were identified in 83 % of the biopsies, 94 % with LSBM. Dysplasia was observed in 65 (37 %), low grade (LGD) in 68 % and high grade (HGD) in 32 %; 26 (14 %) had carcinoma associated with BM and HGD. Thirty (17 %) biopsies with no GC showed alcian blue (AB)-positive cells, 7 (4 %) had LGD, 3 (2 %) had HGD, and none had associated carcinoma. Follow up biopsy showed regression and normalization of mucosa and symptomatic relief in many. Majority of LGD remained static with few progressing to HGD. Majority of HGD progressed to frank carcinoma over the years. Conclusion: A high percentage of non-GCCM showed AB positivity and associates with dysplasia. Many cases with BM, LGD, and HGD developed carcinoma. Ulceronodular and stricturous lesions associate frequently with BM and carcinoma. The present study emphasizes the equal importance of follow up biopsy in BM and NGCM. Stomach S-1 Evaluation of the safety and efficacy of the UNIM-701 compound in the treatment of Helicobacter pylori-positive duodenal ulcer patients

Patients from Iraq and Afghanistan have the highest prevalence of H. pylori infection amongst medical tourists with dyspepsia

Avnish Seth, Pawan Rawal, Tanya Kant Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Sector-44, Gurgaon 122 002, India, and University of Birmingham, UK Background: Variation in the prevalence of Helicobacter pylori is dominated by the differences between communities in the incidence of infection during childhood. This study was carried out to determine the prevalence of H. pylori infection in medical tourists coming to India for treatment of dyspepsia. Methods: Consecutive patients undergoing UGI endoscopy for dyspepsia between April 2003 and May 2015 who were tested for H. pylori with rapid urease test (RUT) were studied. Biopsies from the gastric corpus and antrum were placed in commercially available kits and observed for color change for 24 h. Results: RUT was performed during 2813 out of 4268 UGI endoscopic procedures. The test was positive in 1028 (36.5 %) patients and negative in 1786 (63.5 %). Out of 1028 positives, 636 were from India, 215 from Iraq, 53 from Afghanistan, and the rest were from other countries. The prevalence of H. pylori was highest in patients from Iraq (54 %) followed by Afghanistan (46 %) and India (32 %). Out of the total positives for H. pylori, 64 % were males and 34 % females. There were no significant gender differences between countries. Prevalence by age group was 14.4 % (age 31 to 35), 13.1 % (age 36 to 40), 12.7 % (age 41 to 45), 11.3 % (age 26 to 30), and 10.4 % (age 46 to 50). Prevalence by age was also similar in patients from different countries. Conclusion: Residents from Iraq and Afghanistan have the highest prevalence of infection with H. pylori amongst patients from foreign countries visiting India for treatment of dyspepsia. S-3

M A Raheem Rafeeq, Avinash Bardia, Md. Aejaz Habeeb, Aleem A Khan Central Research Institute of UNANI Medicine, Hyderabad 500 058, India, and Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Hyderabad 500 058, India Introduction: The gastric pathogen Helicobacter pylori has been a major cause of peptic ulcer disease and is an early risk factor for gastric carcinoma. It is the second most common chronic bacterial infection in humans. Eradication of H. pylori is an important event in overcoming gastric diseases. Many regimens are currently available but none of them could achieve 100 % success in eradication. Therefore, the present study

Nodular gastritis and Helicobacter pylori: A strange coincidence in children

S Sakthi Dasan, K Padma, T Ramesh, S S Sakthi Gnanavel, N Dinakaran Departments of Biochemistry, Pediatrics, and Medicine, C R R I, Department of Gastroenterology, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu 603 319, India Introduction: Nodular gastritis is a frequent endoscopic finding in the adult population often historically interpreted as nonspecific chronic

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gastritis. Though many possibilities are postulated in adults, we find a close relationship between Helicobacter pylori infection and nodular gastritis in children. We assessed the value of endoscopic nodular gastritis in diagnosing of H. pylori infection in children and its relationship with severity of its gastritis. Aim: The study aimed to assess the relationship of endoscopic nodular gastritis and H. pylori infection among children. Methodology: Over a period of 36 months, 104 children aged from 8 to 16 years with various GI symptoms were included, to whom upper gastrointestinal endoscopy and gastric mucosal biopsy for rapid urease test and histological study for gastritis and H. pylori were done. Results: Main symptoms were pain in the abdomen, poor appetite, and poor weight gain of more than 12 months in duration. Age ranged from 8 to 16 years (mean age 12.4±1.2). Exclusion criteria included recent antibiotic use and PPI treatment. Endoscopic findings were normal gastric mucosa (15 %), erythema (22 %), erosion (28 %), nodularity (14 %), duodenal lesion (9 %), positive rapid urease test (62 %), positive H. pylori in the gastric mucosa (74 %), nonspecific changes in histological variants (25 %), active chronic gastritis (31 %), chronic gastritis (39 %), granuloma (5 %), and positive H. pylori in nodular gastritis (84 %). No dysplasia was seen. Conclusion: Endoscopic nodular gastritis in children is related to the presence of H. pylori infection and histologically active chronic gastritis. This emphasizes the need for UGI endoscopy in children with chronic abdominal pain and poor weight gain.

S-4 Utility of red flag signs in elderly patients with dyspeptic symptoms

Dharmesh K Shah, Sudhir Gupta, Amol R Samarth, Bhumit R Patel, Tushar H Sankalecha Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Introduction: Dyspeptic symptoms are common in the general population, with frequencies ranging from 10 % to 45 %. The investigation of choice in persons with dyspepsia is endoscopy, which allows identification of erosive esophagitis, peptic ulcer, and gastric or esophageal cancer. A finding of significant lesion may be higher in the elderly population. Aim: This study aimed to evaluate the efficacy of red flag signs to predict abnormal endoscopy findings in the elderly population. Methods and Materials: Elderly patients (>60 years) visiting the gastroenterology OPD with dyspeptic symptoms were included in the study. Detailed history regarding red flag signs was obtained and patients were subjected to upper GI endoscopy. Results: Out of 120 patients included in the study, 70.6 % of patients were male. The mean age was 66.87±10.94 years (±2 SD). Among all the patients, 70 (58.33 %) patients had red flag signs. Common red flag signs were heartburn (26 %), persistent vomiting (17.6 %), anorexia (16 %), weight loss (15.7 %), dysphagia (12.6 %), and melena/hematemesis (11.8 %). All patients underwent upper GI endoscopy. Among all the patients, 79 % had a significant endoscopic abnormal finding. Common endoscopic findings were erosive esophagitis (18.5 %), duodenal ulcer (9.2 %), esophageal malignancy (7.6 %), hiatus hernia (6.7 %), benign gastric ulcer (5.9 %), and gastric malignancy (1.7 %). For patients with red flag signs to have abnormal endoscopy, the PPV (positive predictive value) is 86.67 % and the NPV (negative predictive value) is 80 %. Among the patients without red flag signs, 36 % had significant endoscopic abnormal findings.

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Conclusion: Red flag signs are an important predictor of having abnormal endoscopic findings, but a considerable number of patients without such symptoms also had an abnormal endoscopy. S-5 High prevalence of multidrug-resistant Helicobacter pylori infection and the mechanism of clarithromycin resistance in India

Rajashree Das, Valentina Gehlot, Shweta Mahant, Asish Kumar Mukhopadhyay, Kunal Das Amity Institute of Biotechnology, Noida, India; National Institute of Cholera and Enteric Disease, P-C I T Scheme XM, Beleghata, 33, CIT Road, Subhas Sarobar Park, Phool Bagan, Beleghata, Kolkata 700 010, India; Yashoda Super Specialty Hospital, H1, Near Anand Vihar ISBT, Kaushambi, Ghaziabad 201 010, India; and Yatharth Wellness Superspeciality Hospital, Plot No. 1, Sector 110, Gautam Budh Nagar, Noida 201 304, India Background: Resistance to commonly used antibiotics against Helicobacter pylori is increasing very rapidly. Resistance of H. pylori to clarithromycin is associated with a single-base substitution in the 23S rRNA gene. Aim: The goals of this study were to determine the antimicrobial susceptibility pattern of H. pylori strains against commonly used antibiotics in H. pylori treatment and to analyze the mechanism of clarithromycin resistance in India. Methods: Minimum inhibitory concentration to different antibiotics was determined by agar dilution method of 68 H. pylori strains. The point mutation in clarithromycin-resistant strains was recognized by PCR-restriction fragment length polymorphism (RFLP) and DNA sequencing. Results: Of the 68 H. pylori isolates included in this study, 29.4 % (20/68) had no resistance. The prevalence of total drug resistance was 70.6 % (48/68) which includes the resistance against metronidazole (48.5 %), furazolidone (22.1 %), amoxicillin (17.6 %), tetracycline (16.2 %), and clarithromycin (11.8 %). Dual- and multiple-drug resistance were found in 26.5 % (18/68) and 8.9 % (6/68) of cases. In our study, A2143G point mutation in the 23S rRNA gene was found in 87.5 % (7/8) of clarithromycin-resistant strains. Conclusions: The emergence of dual- and multiple-drug resistance is of great concern, and there is an urgent need for regular antibiotic resistance surveillance studies. Metronidazole showed the maximum resistance. The point mutation at positions A2143G, A2142G, and T2182C is associated with clarithromycin resistance. Reference 1. Gao W, Cheng H, Hu F, et al. 2010. 2. Agudo S, Prez-Prez G, Alarcon T et al. S-6 Comparing the efficacy of two different drug regimens—pantoprazole+amoxicillin+clarithromycin and rabeprazole+amoxicillin and clarithromycin—for the eradication of H. pylori in patients with acid peptic disease

Syed Ibrahim Hassan Deccan College of Medical Sciences, DMRL X Road, Santosh Nagar, Kanchan Bagh, Hyderabad 500 058, India Material and Methods: Two hundred patients of both sexes above 18 years having symptoms of APD were endoscopically confirmed and detected H. pylori positive by IgM and by urease test with no comorbid conditions and no history of allergy to the antibiotics mentioned, not on NSAIDs and corticosteroids, and with no complications of APD, and nonpregnant females were included in the

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study after taking informed consent. Selected patients were asked for their symptoms and personal history. During pre-treatment, they underwent blood tests—CBP, blood urea, serum creatinine, UGIE, USG abdomen, and anti-HP antibody titers, and at the end of the treatment, they underwent CLO test at intervals of 10 days for a period of 1 month. Results: Regimen 1 PAC had 100 patients of which 43 % were males and 57 % were females. In regimen 2 RAM, 37 % were males and 63 % were females. The majority of patients in both groups were in the age group between 18 and 65 years. Tobacco chewing, smoking, and gutka chewing were present in both groups. Upper GI endoscopy showed the majority had reflux esophagitis, erosive gastroduodenitis, and duodenal ulcers. Pre-treatment H. pylori antibodies were positive in both the groups; post-treatment, the majority of them became negative as shown by the CLO test. Conclusion: Ulcer healing was seen in all the patients with similar eradication rates in both regimens, but the cost of the regimen was higher in regimen 1. S-7 Endoscopic profile of patients presenting with dyspepsia in a tertiary care center: A prospective study

Uday Kumar, A K Jha, S K Jha, V M Dayal, Amarendra Kumar, B Ahmed, Sarad Kr Jha Indira Gandhi Institute of Medical Sciences, Bailey Road, Shiekhpura, Patna 800 014, India

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Background: Gastric intestinal metaplasia (IM) is an important intermediatory process in the development of gastric adenocarcinoma. Helicobacter pylori is a major cause of the transdifferentiation into intestinal metaplasia. Literature review showed limited data regarding the prevalence of IM in India. Aim: The purpose of this study was to determine the prevalence of gastric IM and its relationship with H. pylori infection. Methods: We conducted a retrospective study of 3917 patients who underwent esophagogastroduodenoscopies with gastric biopsy between July 2014 and June 2015. Clinical, demographic, and histopathological data were analyzed. Results: IM was found in 154 patients with an overall prevalence of 3.9 %. Prevalence was age related, being more often in patients 50 years of age or older compared to those younger than 50 (65.6 % vs. 34.4 %). Males were predominant (69.4 % vs. 30.5 %). Seventy-two percent of patients were from Tamil Nadu and the remaining 28 % from Eastern India. Male patients were more affected in the latter group (67.6 % vs. 75.7 %). Non-erosive gastritis was the commonest endoscopic feature with antral involvement in 86.3 %. H. pylori was present in 102 (66.2 %) patients with IM. Chronic atrophic changes were seen in 11 patients. A moderate degree of metaplasia was present in 3 patients and extensive in 2 patients. Associated dysplasia and adenocarcinoma were seen in 4 and 2 patients, respectively. Conclusion: A significant increase in the prevalence of gastric IM with age was noted, but without a similar increase in H. pylori infection. Epidemiological studies are required to determine the development of IM independent of Helicobacter infection.

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Background and Aim: Dyspepsia is a common condition characterized by postprandial fullness, early satiety, epigastric pain and epigastric burning. As per present guidelines, esophagogastroduodenoscopy is indicated only for patients with warning signs such as weight loss, dysphagia, bleeding and age >55 years. Study regarding the indication of esophagogastroduodenoscopy for dyspepsia in India is limited. The aim of this study was to know the endoscopic profile of patients presenting with uninvestigated dyspepsia. Method: This prospective study was carried out in a tertiary hospital from January 2015 to June 2015. All uninvestigated dyspepsia patients were screened for eligibility and underwent esophagogastroduodenoscopy. Patients with alarm symptoms (except age criterion) were excluded. All study participants were systematically evaluated before undergoing endoscopy. Endoscopic findings were analyzed. Result: Out of 262 patients, 15 patients were excluded due to incomplete data collection and 10 patients were excluded as age <18 years. In 237 patients, esophagogastroduodenoscopy findings were normal in 155 (65.54 %). Abnormal endoscopic findings (n=82) were as follows: 46 (19.40 %) gastritis, 11 (4.64 %) hiatus hernia, 9 (3.79 %) peptic ulcer disease, 8 (3.37 %) carcinoma of the stomach, 4 (1.68 %) gastropathy, 2 (0.84 %) duodenopathy, and 1 (0.42 %) esophagitis and esophageal polyp each. After analyzing 8 patients with carcinoma of the stomach, 6 patients were of age 55 and above but 2 patients were below 55 years. Conclusion: Most of the patients are normal or have minor gastric pathology even in a tertiary care center. S-8 Prevalence of gastric intestinal metaplasia and its relationship with Helicobacter infection

Jerrin Thomas, Shanthi Vijayaraghavan, Shanmughanathan Subramanyam Sri Ramachandra University, 1, Ramachandra Nagar Porur, Chennai 600 116, India

HER2/neu expression in gastric adenocarcinoma is associated with poor survival in North Indian patients

V B Abhilash, V K Dixit, S K Shukla, M K Behera, A K Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Aim: The presence of HER2/neu has been reported in gastric cancer, but its impact on patient survival remains unclear. As in breast cancer, HER2 overexpression was found to correlate with a shorter overall survival in gastric cancer in the Western population. HER2 has been shown to possess predictive properties for treatment with the monoclonal antibody trastuzumab in breast cancer. The ToGA trial showed that gastric cancer patients with HER2 protein overexpression benefit from this type of anti-HER2 therapy. Accurate HER2-based patient stratification is essential to identify patients who may benefit from anti-HER2 therapy. The purpose of this study was to investigate the expression of HER2/neu in gastric cancer in northern India and its impact on survival. Methods: A total of 218 paired resected gastric cancer and corresponding normal specimens were collected. HER2/neu protein expression was assessed by immunohistochemical staining. The correlation between HER2/neu expression and patient clinicopathological parameters was evaluated and the prognostic significance of HER2/ neu expression was assessed by univariate and multivariate analyses. Results: Forty-one out of 218 (18.8 %) gastric cancer specimens showed HER2/neu-positive expression. No relationship was found between membranous HER2/neu expression and clinicopathological parameters. However, HER2/neu expression was correlated with poorer overall survival (p<0.001). In multivariate analysis, HER2/ neu expression was a significant independent prognostic predictor (p<0.001) and was associated with poor survival in gastric cancer patients.

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Conclusion: These data indicate that HER2/neu may play a major role in the therapeutic management of gastric cancer.

S-10 Association between base excision repair gene XRCC1 Arg194Trp and XRCC3 Thr241Met polymorphisms and risk of gastric cancer: A case-control study from the eastern Indian population

Kamalika Roy, Sushil Kumar, Tamal Kanti Ghosh, Uday C Ghoshal Midnapore Medical College and Hospital, Vidyasagar Road, Medinipur 721 101, and Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Background: Gastric cancer (GC) is a multi-factorial disease with a complex interplay between multiple genetic variants. Base excision repair (BER) polymorphic enzymes including XRCC1 and XRCC3 repair damage to avoid carcinogenesis. We aimed to investigate the association between XRCC3 Thr241Met and XRCC1 Arg194Trp polymorphisms and risk of gastric carcinogenesis in the eastern Indian population. Methods: A total of 508 subjects (168 age- and gender-matched patients with GC, 170 with gastritis, and 170 healthy controls [HC]) were prospectively collected for this study. Genotyping was performed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP). The presence of active infection of Helicobacter pylori was considered by any one positive out of two tests, e.g. rapid urease test and histopathology. Results: XRCC1 Arg194Trp genotypes were comparable among patients and controls (for the homozygous variant Trp/Trp: GC 37 [22 %] vs. gastritis 28 [16.5 %] vs. HC 45 [26.5 %], p=0.106, 0.694; for the heterozygous Trp/Arg variant: 73 [43.5 %] vs. 70 [41.2 %] vs. 62 [36.5 %], p= 0.288, 0.327, respectively). However, patients with GC had a lower frequency of XRCC3 Thr241Met heterozygous (Thr/Met) variant than HC (42 [25 %] vs. 83 [37.1 %]; OR 0.58 [95 %, CI 0.36–0.93], p=0.024), but the homozygous variant (Met/Met) was comparable among all patients and controls. Genotypes were also comparable among patients with GC having H. pylori infection and Lauren’s type of cancer than those without. Conclusion: XRCC1 Arg194Trp may not play a role in H. pyloriassociated gastric carcinogenesis. However, XRCC3 Thr241Met Trp/Met is associated with a lower risk of GC in the eastern Indian population. S-11 Does hOGG1 Ser 326 Cys polymorphism have any association with gastric cancer? A case control study from eastern India—Kolkata

Kamalika Roy, Sushil Kumar, Uday C Ghoshal, Tamal Kanti Ghosh Midnapore Medical College and Hospital, Vidyasagar Road, Medinipur 721 101, and Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Background and Aim: The DNA repair pathway is an essential defense mechanism in DNA damage related to a Helicobacter pylori (H. pylori)induced inflammatory process. The presence of inherited single nucleotide polymorphisms in the DNA repair gene may lead to H. pylori-associated carcinogenesis, including human 8-oxoguanine glycosylase 1 (hOGG1). Methods: In this prospective study, 168 patients with gastric cancer, 170 with gastritis, and 170 healthy controls were genotyped by PCR-RFLP. H. pylori was considered to be positive if any one test was positive by RUT or histopathology.

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Results: Neither the heterozygous nor the mutant allele of hOGG1 Ser326Cys was associated with GC than HC in comparison to the Ser/ Ser genotype (GC 76 [45.2 %] vs. HC 63 [36.8 %]; odds ratio [OR] 1.51 [95 % CI 0.97–2.35], p value=0.070, and 12 [12.1 %] vs. 8 [4.7 %]; OR 1.86 [0.58–3.47], p=0.436, respectively). Genotype was comparable among patients with gastritis than HC. However, the variant genotype had a decreased chance of regression among the intestinal than the diffuse type of GC (6/141 [4.3 %] vs. 6/27 [22.2]; OR=0.127 [0.034–0.478], p= 0.002). Active infection of H. pylori was present among patients with GC and gastritis by the above method (38/162 [23.5 %] and 80/170 [47.1 %], respectively). Genotype distribution is comparable among patients with GC with and without H. pylori infection (dominant model: Ser/Cys+Cys/ Cys 15/38 [39.5 %] vs. 68/124 [54.8 %], p=0.092). Conclusion: The polymorphism was not associated with GC, particularly among active infection of H. pylori. However, the variant genotype was associated with a low risk of the intestinal type of GC. S-12 Interleukin-6 and interleukin-10 promoter polymorphisms in patients of gastric carcinoma

Jitendra Kumar Choudhary, M K Tripathi, A Ranjan, S K Shukla, A K Jain, V K Dixit Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction: Interleukin-6 is a cytokine involved not only in inflammation and infection responses but also in the regulation of various physiological processes. IL-6 promoter polymorphisms (174 G/C) are associated with transcription differences. IL-10 is a pleiotropic cytokine with important immune regulatory, immune stimulatory, and antiinflammatory functions. Genetic polymorphisms of several inflammatory and immunoregulatory cytokines continue to be investigated for possible association with risk for specific Helicobacter pylori-associated disease. Aim: This research aimed to study interleukin-6 (−174 G/C) and interleukin-10 (−1082 A/G) promoter polymorphisms in patients of gastric carcinoma with H. pylori infection. Material and Method: A total of 27 patients having gastric carcinoma with a mean age of 58.77 years were enrolled in this study. All the patients were subjected to biopsy for ultra rapid urease test (URUT), DNA isolation, and histopathology. Polymerase chain reaction (PCR) for H. pylorispecific 16S DNA, IL-6 (174 G/C), and IL-10 (1082 A/G) polymorphism genotyping was done. Result: H. pylori infection was confirmed by 16S rDNA amplification. Twelve patients (44.44 %) were positive for URUT. The distribution of the IL-6 GG genotype was 23 (85.18 %) followed by the CG 3 (11.11 %) and CC 1 (3.70 %) genotypes having a frequency of the G allele of 90.74 % and of the C allele of 9.26 %, whereas the distribution of the IL-10 AA genotype was 15 (55.56 %) followed by the GG 5 (18.51 %) and AG 7 (25.92 %) genotypes having a frequency of the A allele of 68.52 % and of the G allele of 31.48 %. Conclusion: Distribution of the IL-6 GG genotype and the IL-10 AA genotype was found high with higher frequency of the IL-6 G allele and IL-10 A allele. S-13 Thalidomide for the treatment of gastric antral vascular ectasia refractory to argon plasma coagulation

B R Abhijith, Shiran Shetty, Girisha Balaraju, C Ganesh Pai

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Department of Gastroenterology and Hepatology, Kasturba Medical College, Manipal University, SH 65, Madhav Nagar, Manipal 576 104, India Introduction: Argon plasma coagulation (APC) has revolutionized the treatment of gastric antral vascular ectasia (GAVE) with its efficacy, ease of use, and safety profile. However, there are very few options for widespread lesions or in patients refractory to APC. Though surgical resection and estrogen-progesterone therapy are an option, complications limit their use. A few studies have proved the efficacy of thalidomide in GAVE refractory to other modes of therapy. Methods: Medical records of all patients with GAVE treated in the Department of Gastroenterology and Hepatology, Kasturba Medical College, from 2012 to 2014 were reviewed and details of patients on thalidomide compiled. Results: Two patients with GAVE presenting with iron-deficiency anemia refractory to APC were included. The cause was cirrhosis of the liver in one patient and idiopathic in the other. Their hemoglobin continued to be 10 g % during 1 year follow up without need for further transfusions. One patient who developed peripheral neuropathy with thalidomide was switched to tranexamic acid 1000 mg thrice daily and continued to be asymptomatic. Another patient redeveloped anemia (7.4 g/dL) after stopping thalidomide, which improved after restarting the same. Conclusion: Thalidomide is an effective therapeutic option for GAVE refractory to APC. Though effective, its long-term use may be limited by adverse effects. S-14 Does experience of an endoscopist have importance in the management of upper gastrointestinal bleed?

Amol Patil, Dheena Shurane, Ravi Kiran, Avinash Bhat Balekuduru, Satya Prakash Bonthala Subbaraj, Umesh Jalihal Department of Gastroenterology, M S Ramaiah Hospitals, MSR College Road, MSR Nagar, MSRIT Post, Mathikere, Bengaluru 560 054, India Background: The management of upper gastrointestinal bleed (UGIB) differs between a consultant (5 years’ experience) and a resident (3 years’ experience) in a teaching college. It may have undergone a change in the pattern of endotherapy and the outcome in UGIB. We therefore tried to assess time trends in UGIB over the past 3 years. Methods: Records of all consecutive patients with UGIB who had undergone endoscopy at our institution during the years 2012 (n=114) and 2015 (n=65) were retrospectively reviewed. The presentation, cause, treatment details, and outcome were recorded on a uniformed structured data form. Results: Of the 179 patients (age 41.7±12.7 years, 20 % females) during the two study periods, 130 (72 %) had non-variceal bleed. There was no significant difference in the frequencies of etiology of UGIB. Sclerotherapy (15:2) and hemoclip (7:0) were used more often in the consultant group than in the resident group. In both periods, one rebled, one underwent surgery, and no mortalities were observed. Conclusions: The etiology of UGIB has not changed but the management/aggressive endotherapy is used conservatively without the change in outcome by the residents. S-15 A retrospective, single-center study on benign versus malignant etiology of gastric outlet obstruction at central India

Bhumit R Patel, Sudhir Gupta, Niraj R Sawalakhe, Nitin R Gaikwad Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India

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Aim: This study aimed to evaluate benign vs. malignant etiology of gastric outlet obstruction at central India. Material and Methods: This retrospective study was conducted at the Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Nagpur, from July 2013 to June 2015. Patients having symptoms and endoscopic or radiological evidence of gastric outlet obstruction were included in the study. Patients having gastric retention due to diabetic or uremic gastroparesis or drug-induced delayed gastric emptying without mechanical obstruction were excluded. All patients underwent upper GI endoscopy and biopsy for confirmation of diagnosis. If this modality was not able to confirm diagnosis, then CT scan was done. Results: There were 104 patients with gastric outlet obstruction fulfilling the selection criteria during the study period. Gender distribution was predominantly male (n=69) making up about 66.35 % of the total patients. Mean age was 51 years. All patients underwent upper GI endoscopy and it was diagnostic in 90 patients. Fourteen patients were diagnosed on CT scan and these included pancreaticobiliary malignancies. Overall, 63 (60.5 %) patients were found to be having malignant lesions vs. 41 (39.40 %) benign lesions. Out of these 63 patients, carcinoma of the stomach was found in 33 (31.70 %), carcinoma of the pancreas 10 (9.61 %), Ca of the gallbladder 4 (3.85 %), cholangiocarcinoma 6 (5.77 %), ampullary carcinoma 7 (6.73 %), and duodenal carcinoma 3 (2.88 %) patients. Conclusion: The initial ratio between benign and malignant causes of gastric outlet obstruction is gradually reversing in favor of malignant lesions. This is probably due to a substantial decrease in peptic ulcer complications after the advent of proton pump inhibitors.

S-16 Enteral self-expanding metal stent for symptomatic malignant gastric outlet obstruction: Data review from a tertiary care center

Amit Soni, A S Puri, B C Sharma, Sanjeev Sachdeva, Siddharth Srivastava, Ajay Kumar, J P Singh, Ashok Dalal, Alok Sangam Department of Gastroenterology, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Aim: Self-expanding metal stents (SEMS) are a safe and less invasive palliative method for relieving symptoms due to malignant gastric outlet obstruction (GOO). This study reports our experience with the use of enteral SEMS for symptomatic malignant GOO. Methods: A retrospective data review from May 2012 to May 2015 was performed for all the patients who had symptomatic GOO due to malignancies and underwent antroduodenal stenting under endoscopic and fluoroscopy guidance for the same. Data was collected from hospital records and endoscopy database. Results: A total of 42 patients (19 male and 23 female) with mean age of 55.11 years (range 28–86) were identified with symptomatic malignant GOO. The malignancies were gallbladder in 18 (42.8 %), stomach 12 (28.5 %), pancreas 5 (11.9 %), periampullary 3 (7.1 %), cholangiocarcinoma 2 (4.7 %), and metastatic/unknown in 2 (4.7 %). Enteral SEMS was successfully deployed in 40 (95.2 %) patients in the first attempt, while in the rest of 2 patients, a second attempt was needed. No immediate procedure-related complications were noted. All patients were able to resume oral semisolid diet in 48 h. Four patients among these had a history of SEMS placement in the past too. The median duration of SEMS patency among these was 6 months (range 2– 10 months). Conclusion: Endoscopic enteral SEMS placement is an effective and safe palliative method for relieving symptoms due to malignant GOO.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 S-17 In high-prevalence gastrointestinal malignancy zones, overlooking iron-deficiency anemia is fatal: A lesson learnt from a case-control study

Showkat A Kadla, Nisar A Shah, Bilal A Khan, Muzafar A Bindroo, Javed A Basu, Adil Farooq, Rouf Tak, Jan Moamad, Bilal Wani, Wajeed Yousuf Government Medical College, Karan Nagar, Srinagar, Jammu and Kashmir 190 010, India Background/Aims: Kashmir is known for a high incidence of gastric cancer, though lower gastrointestinal (LGI) malignancies are also on the rise. Colonic cancer, gastric cancer, and celiac disease are the most important gastrointestinal causes of iron-deficiency anemia (IDA) throughout the world. About 9 % of patients with IDA, when evaluated, have a sinister lesion in the GI tract. Gastrointestinal evaluation of IDA without GI symptoms and a possible lesion accounting for blood loss has not been studied in this high-prevalence GI malignancy zone of the world. We aimed to evaluate IDA patients without GI symptoms to find out the most plausible cause of their blood loss. Patients and Methods: A hundred cases and 250 controls were enrolled in a prospective, non-randomized case-control study. Those patients having a significant lesion, proportionate to their anemia in the upper GI, were not subjected to further evaluation if not strongly indicated. Results: Twenty-nine patients (29 %) had malignancy, 13 gastric cancer, and 16 colonic malignancies. Other apparent causes of GI blood loss included peptic ulcer disease in ten (10 %); hemorrhoids in 22 (25 %); polyps in eight, three in the upper GI and five in the lower GI; gastric erosions in eight (8 %); and angiodysplasia, diverticulitis, and trichuriasis in two (2 %) each. Conclusion: Keeping in view the high incidence of GI malignancies in this group of patients, a low threshold for GI screening as well as mass screening for IDA is required. S-18 Long-term outcome of combination therapy of antituberculosis therapy and endoscopic management for gastroduodenal tuberculosis

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Conclusion: Combination therapy of dilatation and antitubercular therapy is an effective alternative to surgery and should be the SOC. There was no recurrence of symptoms during the follow up period of 12 months following completion of ATT treatment. S-19 Gastric POEM (endoscopic per-oral pyloromyotomy): Can it be the answer to postoperative and idiopathic gastroparesis?

Amol Bapaye, Nachiket Dubale, Rajendra Pujari, Amol Kulkarni, Rucha Jajoo, Jay Bapaye, Vinay Thorat, M Mahadik, V Vyas Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Near Mhatre Bridge, Erandawne, Pune 411 004, India Background: Resistant gastroparesis unresponsive to standard therapy has limited treatment options. G-POEM was recently suggested as a possible alternative. We present three cases of resistant gastroparesis successfully treated by endoscopic pyloromyotomy. Patients and Methods: Case I: 32-year-old male, recurrent achalasia cardia (post Heller myotomy) on EGD, HRM, and barium swallow. EGD— significant gastric food residue. Gastric scintigraphy studies—grade II gastroparesis. G-POEM and POEM performed in two stages 4 days apart. Case II: 56-year-old male, operated esophagogastrectomy for cardia cancer 18 months ago. C/o recurrent postprandial regurgitation. Case III: 68year-old male, operated total laryngopharyngectomy and total esophagectomy with gastric pull 6 months ago. Cases II and III: OGD scopy— significant food residue despite 12 h of fasting but no pyloric stenosis. Barium meal—contrast hold up at pylorus. PET-CT—no recurrence. GPOEM performed in both. Steps of procedure similar to POEM. Mucosal entry through the gastric antrum 7 cm proximal to the pylorus. Submucosal tunnel by sharp dissection up to and beyond pylorus. Pyloric ring and duodenal mucosa identified by distinctive appearance and duodenal submucosa seen prolapsing proximally. Pyloric muscle divided vertically for 3 cm and mucosal defect closed using clips. Results: Average procedure time 85 min. Postprocedure NPO 24 h. Oral contrast study to exclude leak. Oral diet resumed. Patient discharged within 72 h. Significant symptom relief at 1 month follow up in all. Conclusion: This case series emphasizes a possible role of pylorospasm in gastroparesis and a novel endoscopic treatment to provide short-term symptom relief.

Ashok Dalal, Sanjeev Sachdeva, Puja Sakhuja, A S Puri Department of Gastroenterology, GIPMER, New Delhi, India S-20

Background/Aim: Gastroduodenal tuberculosis (GDT) is an uncommon disease in which surgery has been considered as the SOC for both diagnosis and management. The aim of our study was to evaluate the efficacy of combination therapy of anti tuberculosis therapy (ATT) with endoscopic dilatation as alternative treatment. Methods: Data of consecutive cases presenting to us with features of GOO due to tuberculosis over the last 5 years was analyzed. Patients were treated with 6–9 months of ATT and endoscopic dilatation and followed up for 1 year post therapy for endoscopic, radiological, and symptomatic improvement. Results: The mean age of the 44 patients was 27.5 years (68 %). The most common presenting symptoms were vomiting and weight loss. The most common site of involvement was the junction of D1 and D2. Tissue diagnosis was available in 36 (81.8 %) patients. Granulomas on biopsy were present in 29 (65.9 %). EMR for diagnosis was done in 10 patients, 7 of which had granuloma and 1 patient has AFB positivity. Extra gastroduodenal involvement was seen in 18 (40.5 %) patients. Median dilatation sessions required was 2. Only one patient required surgery. Follow up data was available for 15 patients after 12 months and all were asymptomatic. Eleven patients had stricture >15 mm and 4 patients had stricture between 10 and 15 mm. Barium study showed critical residual stricture in most patients.

Rapid and ultra-rapid metabolizers with CYP2C19*17 polymorphism do not respond to standard proton pump inhibitor therapy

Neha Deshpande, V Sharanya, V V Ravikanth, H V V Murthy, M Sasikala, Rupa Banerjee, Manu Tandon, Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Polymorphisms in genes coding for drug-metabolizing enzymes may lead to varied enzyme activity and inter-individual variability in drug efficacy and/or toxicity. CYP2C19 is an important drugmetabolizing enzyme involved in metabolizing a wide variety of drugs including proton pump inhibitors. Aim: This study aims to identify frequencies of different polymorphisms in the CYP2C19 gene and study their impact on drug metabolism in healthy individuals. Methods: Healthy subjects (n=600 including 100 tribals) were genotyped for 11 SNPs in the CYP2C19 gene. Individuals were categorized into different phenotypes based on their genotype. Volunteers from each group

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were given 40 mg of PPIs once daily (esomeprazole and pantoprazole), and the pharmacokinetics and pharmacodynamics were studied. Results: Of the 11 SNPs studied, only variants *2, *3, and *17 were observed in the CYP2C19 gene with minor allele frequencies of 0.41, 0.01, and 0.17, respectively. There were a significantly (p=0.0003) higher number of poor metabolizers in the tribal individuals as compared to the urban. Pantoprazole was found to be most effective in poor metabolizers in terms of AUCt and Tmax. In rapid and ultra-rapid metabolizers, no significant difference was observed in the intra-gastric pH at baseline and day 6. Conclusion: Our study has demonstrated that 20.7 % of our subjects are carriers of the CYP2C19*17 allele who did not respond to the standard dose of proton pump inhibitors. Screening and identification of subjects carrying variant alleles is necessary for personalization of dosage. Also, this study can serve as a basis to study the impact of these polymorphisms on other drugs metabolized by CYP2C19. S-21 Endothelial nitric oxide synthase promoter polymorphism rs2070744 is associated with gastric cancer

Krishnaveni Devulapalli, Amar Chand Bhayal, Shravan Kumar Porika, Uma Devi Malladi, Ramanna Macherla, Jyothy Akka, Pratibha Nallari, Venkateshwari Ananthapur Institute of Genetics and Hospital for Genetic Diseases, Osmania University, Begumpet, Hyderabad 500 016, India; Department of Gastroenterology, Gandhi Hospital, Secunderabad 500 003, India; Department of Genetics, Osmania University, Hyderabad 500 007, India Gastric cancer is a multifactorial disorder resulting from various genetic and environmental factors. A single nucleotide polymorphism, rs2070744, due to transition of thymine to cytosine at −786 in the promoter region of the endothelial nitric oxide synthase (eNOS) gene was reported to play an important role in various diseases and cancers, but the results are still contradictory. Hence, the present study is aimed to investigate the role of eNOS −786 T>C polymorphism in development of gastric cancer. Methods: The present study included a total of 165 GC patients and 165 control subjects. Genotype analysis of the rs2070744 polymorphism was performed by allele-specific polymerase chain reaction method. Odds ratios (OR) and corresponding 95 % confidence intervals were determined using java stat online software. Results: We found a significant difference in the distribution of the C allele (C vs. T; p=0.000, OR=4.9) in patients compared to the control subjects exhibiting a five-fold increased risk for gastric cancer. The T/T and C/C genotypes were compared and revealed an enhanced gastric cancer risk for individuals with the C/C genotype (T/T vs. C/C; p= 0.000). Patients with smoking and alcoholism developed cancer even in the heterozygous (T/C) condition indicating the presence of a single C allele is enough to cause the disease phenotype (smoking: p=<0.05 and alcoholism: p=<0.01). Conclusion: The present study reveals the first molecular epidemiological evidence from a South Indian cohort for the significant association of the C allele and CC genotype of the eNOS −786 T>C polymorphism with an elevated risk to gastric cancer. Small intestine SI-1 Spectrum of chronic small-bowel diarrhea with malabsorption in India: Is the trend really changing?

Nirav Pipaliya, Chetan Rathi, Dattatray Solanke, Prateik Poddar, Meghraj Ingle, Prabha Sawant

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Background: With improving living standards and hygienic conditions in developing countries like India, reports of rising incidence of noninfectious causes of chronic diarrhea with malabsorption like celiac disease and falling incidence of infectious causes of malabsorption are emerging. Aim: This study was undertaken to document the recent etiological spectrum of chronic diarrhea with malabsorption. The study also aimed to compare various features that differentiate tropical sprue from parasitic infections, the two most common etiologies of malabsorption in the tropics. Methods: We analyzed the clinical presentation, laboratory parameters, and endoscopic and histological features of 203 consecutive patients with malabsorption. The etiological spectrum was determined and factors that differentiate tropical sprue and parasitic infections were analyzed. Results: The most common etiology was tropical sprue (n=98, 48.3 %) followed by parasitic infections (25, 12.3 %) and tuberculosis (22, 10.8 %). Other causes were immunodeficiency (15, 7.3 %; 12 HIV and 3 hypogammaglobulinemia), celiac disease (11, 5.4 %), Crohn’s disease (11, 5.4 %), small-intestinal bacterial overgrowth (11, 5.4 %), hyperthyroidism (4, 1.9 %), diabetic diarrhea (4, 1.9 %), systemic lupus erythematosus (3, 1.4 %), metastatic carcinoid (1, 0.5 %), and Burkitt’s lymphoma (1, 0.5 %). On multivariate analysis, features that best differentiated tropical sprue from parasitic infections were larger stool volume (p= 0.009), severe weight loss (p=0.02), knuckle hyperpigmentation (p= 0.008), low serum B12 levels (p=0.05), high MCV (p=0.003), reduced height/scalloping of duodenal folds on endoscopy (p=0.003), and villous atrophy on histology (p=0.04). The presence of upper GI symptoms like bloating, nausea, and vomiting predicted parasitic infections (p=0.01). Conclusion: Tropical sprue and parasitic infections still dominate the spectrum of malabsorption in India. Severe symptoms and florid malabsorption indicate tropical sprue while the presence of upper GI symptoms indicates parasitic infections.

SI-2 Non-celiac gluten sensitivity: exploring the new entity

Vinay Zanwar, Sunil Pawar, Pravir Gambhire, Samit Jain, Ravindra Surude, Qais Contractor, Vinaya Shah, Pravin Rathi Departments of Gastroenterology and Pathology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr. A L Nair Road, Mumbai 400 008, India Background: The spectrum of gluten-related disorders got a new entity, represented by gluten sensitivity. The clinical picture is a combination of IBS symptoms and of systemic manifestations. No strict criteria for the diagnosis of NCGS exist, and the prevalence was claimed to be 6 %. Aims and Objectives: The purpose was to study the effect of gluten on gastrointestinal symptoms in IBS-D. Material and Method: One hundred and fourteen patients between 18 and 65 years meeting the Rome III criteria for IBS were included. Celiac disease and wheat allergy were excluded appropriately. A double-blind, randomized placebo-controlled rechallenge trial was undertaken in IBS-D patients. Ninety patients commenced on gluten-free diet for up to 4 weeks. Their symptoms were evaluated with visual analogue scale (VAS) at baseline and then weekly for 4 weeks. In the second phase, participants whose symptoms improved on VAS to an acceptable level were randomized to receive either gluten powder (40 cases) or placebo (44 cases) with glutenfree diet for 4 weeks. Results: A total 84 patients completed the study. Adherence to diet was good. Overall, the symptomatic improvement was statistically

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different in the gluten-containing group as compared to placebo. On a visual analogue scale, patients with gluten diet were significantly worse for pain, bloating, satisfaction with stool consistency, and overall symptoms. Conclusions: Our data identifies a patient population with IBS who are sensitive to gluten. Hence, they may be suffering from non-celiac gluten sensitivity. SI-3 Clinical profile of patients presenting with Crohn’s disease—A tertiary center study from a country where TB is endemic

M Ramu, Deni Joseph, K Srijith, Ponny, Bincy, Gopu, Krishna Das, K R Vinaya Kumar Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Patients with Crohn’s disease diagnosed between January 2009 and December 2014 were included in the study. Results: Over the period, 82 patients (56 males, 26 females) were diagnosed with Crohn’s disease in our hospital. Mean age at diagnosis was 33 years and median duration of disease was 49 months. Ileocolonic disease was found in 42.68 % of patients, ileal disease in 37 % of patients and colonic disease in 19.31 % of patients. Most patients had nonstricturing, nonpenetrating disease (65.85 %) than stricturing (23.17 %) or penetrating disease (10.97 %). Abdominal pain (82 %), diarrhea (66 %) and weight loss (46.8 %) were the most common manifestations. Twenty percent of patients received ATT in the past. Perianal disease occurred in 19.5 % of patients. Extraintestinal manifestations were found in 22 % of patients. Thirty-two percent of the patients took oral 5-aminosalicylates as maintenance treatment, 47 % were taking longterm azathioprine and 38 % received steroids. Eleven patients received anti-tumor necrosis factor, and eight responded. At diagnosis, 34 % had mild disease, 42 % had moderate disease and 24 % had severe disease. Twenty-six percent had undergone surgery for diagnosis or complications. Four patients had died. Seventeen (20.73 %) patients presented as acute emergencies, nine with intestinal obstruction, four with ileal perforation, three with active lower intestinal bleeding and one with septicemia. No patient had developed colorectal cancer. Conclusions: Most patients with CD in our study were young and male predominant. There is considerable delay in diagnosis of disease in our part of the region where TB is endemic. Abdominal pain, diarrhea and weight loss were predominant symptoms. Intestinal obstruction and perforation were the most common complications. Most were diagnosed following a nonresponse or relapse after a trial of ATT. Extraintestinal, upper GIT manifestations were less common in our study. SI-4 Differentiating small-intestinal Crohn’s disease from intestinal tuberculosis: Can capsule endoscopy help?

Surinder S Rana, Vishal Sharma, Puneet Chhabra, Ravi Sharma, Deepak K Bhasin Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Background: Differentiation of intestinal tuberculosis (ITB) from Crohn’s disease (CD) is an important challenge. Objective: The goal of this study is to prospectively evaluate the utility of capsule endoscopy (CE) in differentiating CD from ITB. Methods: Patients with suspected ITB or CD with terminal ileal involvement on ileocolonoscopy were prospectively enrolled. After confirming the patency of the gastrointestinal tract by ingestion and subsequent

passage of patency capsule or by barium enteroclysis or CT enterography, the patients underwent CE. Results: Thirty-two patients (20 M; age range 18–42 years) with ITB and 20 patients (14 M; age range 20–54 years) with CD were studied. Sixteen patients with ITB had tight stricture on radiological evaluation and 4 patients had confirmatory histopathology with presence of AFB, and CE was not done. CE was done in 18 patients with CD and 8 patients with ITB. All patients with ITB had terminal ileal involvement along with involvement of the ileocecal area. Six patients had large ulcers and two had aphthous ulcers. All patients with CD also had terminal ileal involvement, but ileocecal area involvement was seen in 5 (27.7 %) patients. Jejunal involvement as aphthous ulcers and nodularity was seen in 4 (22 %) and 1 (5 %) patients, respectively. On comparison with CD, patients with ITB had increased frequency of ileocecal valve involvement (p=0.001) and lesser frequency of aphthous ulcers (p=0.007). Asymptomatic involvement of other segments of the small bowel was observed in one third of patients with CD in contrast to none with ITB. Conclusion: Ileocecal valve involvement is more common in ITB, and aphthous ulcers as well as multi-segment involvement of the small bowel are more frequent in CD. SI-5 Selective M1 macrophage polarization in Crohn’s disease, in comparison to intestinal tuberculosis: A novel observation

Prasenjit Das, Sucharita Pilli, Tarun Kumar, Ritika Rampal, Imtiaz Khan Ahmed, Sudhir Chauhan, Dhiraj Kumar, Vineet Ahuja Departments of Pathology, Gastroenterology, and Mammalian Biology, All India Institute of Medical Sciences and ICGEB, Ansari Nagar, New Delhi 110 029, India Introduction: Crohn’s disease (CD) is a dysregulated immune response to commensal intestinal microflora. In this study, we aimed at determining the M1 and M2 macrophage (φ) polarization pattern in CD and intestinal tuberculosis (iTB), which possibly involve different pathogeneses. Patients and Methods: Intestinal biopsies from 29 patients with iTB [19 with granulomas (Gr) and 10 without] and 50 CD [Gr in 8, no Gr in 42] and 19 controls were included. Dual immunohistochemistry was performed for iNOS/CD68 (a marker of M1φ) and CD163/CD68 (a marker of M2φ). The ratio of iNOS and CD163-positive φ was assessed in comparison to the CD68 positive φ and was compared amongst the biopsies of iTB, CD, and controls. Results: M1φ polarization was more prominent in biopsies of CD (p 0.002) than in iTB (p 0.2) and controls. M2φ density was not significantly different in CD, iTB, and control biopsies. In all biopsies with granulomas, including those in CD, the M1φ infiltrate was significantly dense (p 0.001). In iTB, the densities of M1φ did not differ between biopsies showing the presence or absence of granulomas (p 0.1). Conclusions: M1φ polarization is quite significant in biopsies of CD, in comparison to iTB, which is further prominent in the presence of granulomas. In CD, macrophages are mostly activated via a classical macrophage activation pathway, which is different from φ activation in iTB. SI-6 Disease behavior and treatment outcomes in Crohn’s disease and intestinal tuberculosis patients with or without map infection

A Surendernath, Imteyaz Ahmad Khan, Sucharita Pilli, Sudhir Kumar Chauhan, Veena Tiwari, Ritika Rampal, Saurabh Kedia, Venigalla Pratap Mouli, Prasenjit Das, Govind Makharia, Vineet Ahuja Departments of Gastroenterology and Human Nutrition, and Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

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Background/Aim: Mycobacterium avium subspecies paratuberculosis (MAP) has been long debated to associate with Crohn’s disease (CD). In this study, we attempted to investigate the influence of MAP positivity on the clinical course of patients with CD or intestinal tuberculosis (ITB). Methods: Patients with a definite diagnosis of ITB (n=24) were given 6– 9 months of anti-tubercular therapy (ATT) trial. Patients with a definite diagnosis of CD (n=43) were treated with corticosteroids and 5-ASA. In patients (n=38) where there was a diagnostic dilemma between ITB and CD, a definitive diagnosis was made based on the 6–9-month response to ATT and 6-month follow up post-ATT trial. The patients were stratified according to the criteria of the Montreal classification system and other characteristics. The patients were tested for MAP positivity by Taqmanbased qPCR of the MAP-specific IS900 gene using DNA from intestinal biopsies. Results: All patients with a definite ITB diagnosis showed complete response after 6 months of the ATT trial. In patients with diagnostic dilemma of CD and ITB, 8 patients showed complete response post-ATT trial and were considered to be ITB patients. Twenty-six patients had no/partial/worsening response to ATT and were included as CD patients. The frequency of MAPspecific IS900 DNA was significantly higher in CD patients (23.2 %, p= 0.03) as compared with controls (7.3 %). However, no significant association was found between clinical characteristics and treatment outcomes with MAP positivity in CD and ITB patients. Conclusion: The presence of MAP does not affect the disease course and treatment outcomes in either CD or ITB patients.

SI-7 Perianal fistula can be the presenting clinical feature of Crohn’s disease

Gaurav Babar, Thazhath Mavali Ramachandran Department of Gastroenterology, Government Medical College, Medical College Road, Government Medical College Campus, Kozhikode 673 008, India Background: Perianal fistula can be associated with Crohn’s disease, but whether perianal fistula can be the initial and only manifestation without intestinal symptoms has not been reported much. Aims and Objectives: This study aimed to look for evidence of Crohn’s disease in patients presenting with perianal fistula. Methods: Consecutive patients presenting with perianal fistula were enrolled. Those having weight loss, abdominal pain, increased stool frequency, passage of blood or mucus per rectum, and constipation and those already diagnosed to have Crohn’s disease or ileocecal tuberculosis were excluded. Baseline blood investigations, C-reactive protein, and colonoscopy with ileoscopy were done in all patients. Biopsies were taken from the terminal ileum and colon. Selected patients underwent MR fistulogram. Results: A total of 52 patients were enrolled in the study to date. The mean age of patients was 33.12 years (ranging from 19 to 51 years). Twenty-eight (53.84 %) were male and 24 (46.15 %) were female. The mean duration of fistula was 9 months (ranging from 1–25 months). The mean hemoglobin was 11.34 g %. The mean ESR was 37.44 mm at 1 h (ranging from 5 to 86 mm at 1 h). The mean C-reactive protein was 4.56 (ranging from 0.2 to 32). A total of 6 (11.53 %) patients were diagnosed to have Crohn’s disease. Four of them had colonoscopic and histologic evidence of Crohn’s disease on index. Two patients were diagnosed to have Crohn’s disease on subsequent follow-up. Conclusion: Six (11.53 %) of the patients who presented with perianal fistula were found to have Crohn’s disease.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 SI-8 Prevalence of Mycobacterium avium subspecies paratuberculosis in patients with ulcero-constrictive ileocecal diseases

Imteyaz Ahmad Khan, Sucharita Pilli, A Surendernath, Sudhir Kumar Chauhan, Veena Tiwari, Ritika Rampal, Saurabh Kedia, Venigalla Pratap Mouli, Prasenjit Das, Govind Makharia, Vineet Ahuja Departments of Gastroenterology and Human Nutrition, and Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background/Aim: In this study, we evaluated the prevalence of Mycobacterium avium subspecies paratuberculosis (MAP) in patients with ulceroconstrictive ileocecal diseases (Crohn’s disease—CD and intestinal tuberculosis—ITB). Methods: Intestinal biopsies and blood samples were taken from 105 ulcero-constrictive ileocecal disease patients. Forty-one patients with hemorrhoidal bleed with no other symptoms served as controls. Taqman-based q-PCR targeting the MAP-specific IS900 gene was used to detect the presence of MAP DNA. q-PCR results were further validated by sequencing. Immunohistochemistry (IHC) was used to detect the presence of MAP antigen in biopsy specimens. Results: The frequency of MAP-specific IS900 DNA in biopsies by qPCR was significantly higher in CD patients (23.2 %, p=0.03) as compared with controls (7.3 %). No significant differences in intestinal MAP presence were observed between ITB patients (12.5 %, p=0.6) and controls (7.3 %). MAP-specific IS900 DNA positivity in the blood of CD patients was 10.1 % as compared to 4.9 % in controls, while no patients with ITB was found to be positive (p=0.1). Using IHC for detection of MAP antigen in intestinal biopsies, the prevalence of MAP was 2.9 % in CD, 12.5 % in ITB patients, and 2.4 % in controls. Conclusion: We identified a significantly higher prevalence of MAP in intestinal biopsies of CD patients as compared with controls. Further, we also show that q-PCR have high diagnostic value for MAP detection as compared to IHC in intestinal biopsies of CD patients. SI-9 A role of single-balloon enteroscopy in patients with suspected small-bowel disease

Kiran D Shinde, Dawood, K Anil, K Prashant, Manjunath, M Praveen, D Sreenivasa, K Praveen Vydehi Institute of Medical Sciences and Research Centre, 82, EPIPArea, Nallurahalli, Whitefield, Bengaluru 560 066, India Background: Single-balloon enteroscopy is a useful technique both as a diagnostic as well as a therapeutic tool in diseases involving the small bowel. Aim: The purpose is to study the role of single-balloon enteroscopy in patients with suspected small-bowel disease. Material and Methods: Eighteen consecutive patients with suspected small-bowel pathology were studied from August 2014 up to July 2015. Method: Mean age of patients was 40±20 years (male—12, female—6). Indications were pain in the abdomen (8), obscure overt GI bleed (6), recurrent vomiting (2), and chronic diarrhea (2). Results: In patients with pain in the abdomen, 5 of the 8 patients had an identifiable pathology. Two patients had intestinal strictures for which CRE dilatations were done. In patients with obscure GI bleed, 3 out of 6 had an identifiable pathology. In patients with recurrent vomiting, 1 of the 2 patients had an identifiable pathology. In patients with chronic diarrhea, 1 of the 2 patients had an identifiable pathology. Endoscopic therapy in the form of CRE dilatation was done in 2 of the 18 patients. Therapeutic success was 100 %. Biopsies were taken in 15 out of 18

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patients. Four were Crohn’s disease, 4 were malignant, 4 were inconclusive, 3 were tuberculosis, and 3 were normal. No complications were observed. Conclusion: Single-balloon enteroscopy had a diagnostic yield of 61 % and 100 % therapeutic efficacy.

tuberculosis and Crohn’s disease was done. Diarrhea was the only factor which predicted the diagnosis of Crohn’s disease (OR 6.50, CI 1.10– 38.25; p 0.038). Conclusion: Malignancy can be present in around 15 % of patients who present with small-bowel strictures without any mass. We recommend a low threshold for surgery in these patients.

SI-10 SI-12 Eosinophilic gastroenteritis

Sushant Kumar Sethi Senior Consultant Gastroenterologist Introduction: Eosinophilic gastroenteritis is a rare condition involving the GI tract causing mucosal, muscular layer, or serosal involvement. A case was found who presented like subacute intestinal obstruction and was diagnosed only after surgery. Case Summary: A 23-year-old male presented with pain in the abdomen, colicky in nature involving the whole abdomen associated with distension and vomiting for 10 days. He was treated elsewhere conservatively for the same and referred here upon non-improvement. He underwent appendectomy for a similar complaint 7 months back. There was no history of fever/altered bowel habit/anorexia/weight loss, etc. On evaluation, he was found to have features of subacute intestinal obstruction. Blood investigations were normal (Hb 13.2 g %, TLC 7400 mm3, P 80 %, L 14 %, E 2 %, M 4 %, normal LFT, KFT, etc.). Erect abdominal X-ray showed multiple air fluid levels, and CECT of the abdomen revealed dilated fluidfilled distal jejunum and ileal loop with focal narrowing/transition zone in the distal ileum without any mass lesion. Diagnostic laparoscopy followed by exploratory laparotomy and resection anastomosis was done. The resected specimen showed lamina propria, submucosa, muscularis propria, and serosa edematous with dense infiltration of eosinophilia ranging 40–100/high power. Field serum IgE was done which was elevated. The case was treated in the line of eosinophilic gastroenteritis. Discharged and follow up visits were uneventful. Conclusion: Eosinophilic gastroenteritis, though a rare condition, can be a cause of subacute intestinal obstruction in a patient otherwise not having any other obvious causes. SI-11 Etiology of small-bowel strictures without any mass lesion

Ujjwal Sonika, Sujeet Saha, N R Dash, Sujoy Pal, Vineet Ahuja, Peush Sahni Departments of Gastroenterology and GI Surgery, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Introduction: Patients presenting with small-bowel strictures can have varied etiologies. Globally, no data is available on demographic profile and etiology of small-bowel strictures. Methods: This is a retrospective study conducted at a tertiary care center in North India. We analyzed case records of all patients who were operated from January 2000 to October 2014. Patients with small-bowel strictures without any mass lesion and who remained undiagnosed after imaging and endoscopic studies were included. Demographic parameters, imaging, endoscopic findings, and histological diagnosis were noted. Statistical analyses were performed using STRATA software version 12.1. Results: Eighty-nine patients were included. The most common site of strictures was the proximal small intestine (41.5 %). The histological diagnoses of small-bowel strictures were tuberculosis (27 %), Crohn’s disease (23.5 %), non-specific strictures (20 %), ischemic strictures (10 %), adenocarcinoma (9 %), lymphoma (4.4 %), and others (5.5 %). Multivariate analysis to identify the distinguishing factors between

Efficacy of Bacillus clausii strain in the treatment of patients with acute diarrhea

S Sakthi Dasan, T Ramesh, S S Sakthi Gnanavel, N Dinakaran Departments of Biochemistry and Medicine, C R R I, Department of Gastroenterology, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu 603 319, India Introduction: Numerous health benefits of probiotic bacteria have been proposed. We choose to evaluate the use of Bacillus clausii strain in the treatment of patients suffering from acute diarrhea to study safety and efficacy. Aim: The purpose of the study was to evaluate the anti-diarrhea activity of B. clausii strain in patients suffering from acute diarrhea. Methodology: A total of 35 patients with age ranging from 18 to 54 years, with a mean age of 30.4±9.8 years, with acute diarrhea were included in a prospective, phase II clinical study after informed consent and ethical committee approval. The criterion included for all subjects was >3 loose stool motions in 24 h and for more than 5 days. All patients were assigned to receive a capsule of B. clausii strain (contains 2 billion CFU/mL) two times a day for a period of 7 days. Efficacy assessment of duration of diarrhea, frequency of defecation, abdominal pain, and stool consistency was tested on days 1, 3, 5, and 7 along with vital signs monitoring. Results: The results of this study showed that the mean duration of diarrhea decreased from 94.2±6.4 to 5.8±5.2 min per day and the frequency of defecation decreased from 4.2±1.3 to 1.4±0.9 times per day. Abdominal pain decreased from 4.5±1.5 to 0.56±0.42 and stool consistency improved from 2.7±0.8 (watery) to 1.6±0.7 (soft). No significant side effects were observed during treatment. Conclusion: This study shows the B. clausii strain is potentially effective in reducing symptoms of diarrhea without adverse side effects.

Large intestine LI-1 Does age of onset influence outcome of ulcerative colitis?

Alok Sangam, A S Puri G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Introduction: Data on the impact of age on the natural history of ulcerative colitis (UC) is controversial. The Montreal classification takes cognizance of this fact and classifies the disease into three categories based on the age of onset: A1<16 years, A2 between 17 and 40 years, and A3 after the age of 40 years. Whereas some studies have suggested that late-onset UC is more aggressive with a higher rate of complications and mortality, the contrarian view has been expressed in other studies. Methods: Patients were classified into E1, E2, and E3 for clinical outcome and characteristics like extent of disease, duration of disease, presence of extraintestinal manifestation (EIM), and need for an immunomodulator or biological and colectomy. Results: Data of 237 patients with UC was analyzed. Duration of the disease in the three groups was 46.8, 59.2, and 47.9 months in A1, A2,

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and A3, respectively. E3 disease was documented in 12, 77, and 31 patients in A1, A2, and A3, respectively. EIM were present in 2, 34, and 7 patients in A1, A2, and A3, respectively. Azathioprine was used in 8, 75, and 22 patients in A1, A2, and A3, respectively. Biologicals were used in 1, 11, and 3 patients in A1, A2, and A3, respectively. Total colectomy with IPAA was required in 2, 7, and 2 patients in A1, A2, and A3, respectively. None of the parameters analyzed showed any statistically significant difference between the three groups. Conclusion: Age of onset of UC does not have any statistical effect on the severity and outcome of disease. LI-2 Site-specific miRNA expression in ulcerative colitis

Raju Ranjha, Vineet Ahuja, Jaishree Paul School of Life Sciences, Jawaharlal Nehru University, New Mehrauli Road, New Delhi 110 067, India, and All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Ulcerative colitis (UC), a type of inflammatory bowel disease (IBD), is an important disease of the gastrointestinal tract having a huge impact on the health of a patient. Prolonged inflammation of the colon in a UC patient increases the risk of developing colorectal cancer. MiRNA is reported as a connecting link between inflammation and cancer. Differential miRNA expression is reported in Crohn’s disease (CD) patients involving different parts of the gastrointestinal tract. This study was performed to find out site-specific miRNA expression in the colon of UC patients. Data of UC turned CRC patients was collected and analyzed for sites of cancer in UC. miRNA expression was compared from different regions of the gastrointestinal tract, rectosigmoid area (RS) vs. ascending colon (AS). Differential expression was assessed using a microarray platform and finally validated by real-time PCR. We found that the site of CRC was the rectosigmoid colon in most of the cases. Expression of six RS of UC patients compared to AC. Expression of two miRNAs was increased in RS of UC patients compared to AC. miRNA downregulated in RS was reported to be a tumor suppressor in various cancers including CRC. This is the first study to show the differential expression of miRNA at different sites in the colon. Based on our data and previous reports, we propose that differential miRNA might be an important reason for the development of CRC in RS areas in UC patients. LI-3 Study of histologic, endoscopic, clinical, and biochemical parameters in ulcerative colitis

Bubun Kumar Patel, Ajit Kumar, B Sukanya, N Joshi, Y Raghavendra, S U Megha, V Kunal, S Nikhil, M Rohit, J Rishabh, R Gaurav Departments of Gastroenterology and Pathology, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Background: Historically, a poor correlation has been reported between histologic findings and activity scores for ulcerative colitis (UC). Aim: The aim was to study the correlation between histological grading with endoscopic, clinical, and biochemical features in UC. Methodology: Forty-three patients of UC underwent colonoscopy with biopsy along with relevant biochemical parameters. Severity was graded as per Truelove (clinical), Mayo (endoscopic), and Geboes and Rilley (histopathology scores). Results: Forty-three patients (29 M:14 F) with age 18–63 (37.8 ± 12.3) were included. Misclassification between Geboes and Mayo were 33.3 %, 77.7 %, 85 %, and 9 % and between Rilley and Mayo

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were 33.3 %, 100 %, 75 %, and 27 % for grades 0, 1, 2, and 3, respectively. There was a statistically significant correlation between Geboes and Mayo (r = 0.8004, p < 0.0001) and Rilley and Mayo (r = 0.4421, p < 0.003) and between Truelove and Mayo (r = 0.4568, p <0.0021), Truelove and Geboes (r = 0.5673, p <0.0001), and Truelove and Rilley (r = 0.5968, p < 0.0001). Platelets (p < 0.0009), ESR (p < 0.048), protein (p < 0.026), and albumin (p <0.032) values were significantly different between active and inactive UC patients according to Mayo subscore, while platelets (p <0.0048), ESR (p <0.0021), and protein (p < 0.0286) values were significantly different between active and inactive UC patients according to Geboes and Rilley score. Conclusion: Extremes of the histologic and endoscopic activity scores correlate well, but misclassifications exist for mild to moderate disease. Histology may detect more severe disease than endoscopy which may impact the clinical follow up. Histologic score in addition to endoscopy may be better when scoring disease activity for clinical trials. Platelets, ESR, protein, and albumin too can differentiate active from inactive disease. LI-4 Study of osteodystrophy in inflammatory bowel disease at a tertiary care center

Rajiv Baijal, Naveen Totla, Sandeep Kulkarni, Soham Doshi, Deepak Amarapurkar Department of Gastroenterology, Jagjivanram Railway Hospital, M M Marg, Mumbai Central, Mumbai 400 008, India Aim: The goal of this research was to study bone mineral density (BMD), vitamin D status and bone mineral parameters in subjects with inflammatory bowel disease. Methods: All patients with inflammatory bowel disease diagnosed by clinical, endoscopy and histopathology were studied. All confounding factors were excluded. Patients were categorized according to T score: normal >−1.0, osteopenia −1.0 to −2.4 and osteoporosis <−2.5 Results: Out of 42 patients, 23 were male and 19 were female. The average age of patients was 45.9 years. Among the 42 patients studied, 29 had ulcerative colitis and 13 had Crohn’s disease. Osteoporosis was seen in 5 (40 %) patients, osteopenia in 17 (32 %) and normal BMD in 20 (28 %). Serum calcium was low in 24 (40 %) patients in both groups. The average T score in ulcerative colitis was −1.05 and in Crohn’s disease was −1.15. Vitamin D deficiency was seen in 39 of the patients. Average vitamin D3 level was 18.13. The average T score in males was −1.11 and in females −1.13. No statistical correlation was found between gender and osteodystrophy. Conclusion: The prevalence of osteoporosis and osteopenia is significantly high in inflammatory bowel disease and requires early diagnosis and treatment. The prevalence of osteoporosis was related to duration of disease but not to gender.

LI-5 Inflammatory bowel disease: A prospective analysis of prevalence in a tertiary referral center in the state of Telangana

Asha Subbalakshmi Musunuri, Abdul Wadood Ahmed, Sushmita Kota, Vijaya Radhika Department of Gastroenterology and Hepatology, Maxcure Hospitals, Behind Cyber Towers, Hitech City, Madhapur, Hyderabad 500 081, India Aim: The purpose was to study the prevalence of IBD in a tertiary referral care center in Hitech city in the state of Telangana, India.

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Materials and Methods: Using an Olympus Evis Exera-III CVL 190 series colonoscope, colonoscopies were performed for 400 patients suffering from lower GI symptoms from November 2014 to May 2015. Prospective Analysis: Patients with findings suggestive of inflammatory bowel disease like erosions and ulcers were selected. Biopsies of various sections of the rectum, colon and terminal ileum were taken and sent for histopathological examination. Results: A total of 400 colonoscopies were performed. Occupation distribution was as follows: 180 software employees, 100 students, 32 bank employees, 30 housewives, 20 chefs, 20 hotel employees, 10 nurses, 6 dentists and 2 doctors. The patients presented with symptoms such as bleeding per rectum (102), diarrhea (162), anemia (78), malabsorption (24) and perianal disease (34); 160 patients (40 %; 78 male and 82 female, male/ female ratio 0.95:1) had colonoscopic findings suggestive of inflammatory bowel disease. Out of the 160 patients with positive findings, 60 (37.5 %) were biopsy proven to be inflammatory bowel disease. Most of them were found to be ulcerative colitis than Crohn’s. Patients proven to be ulcerative colitis were 38 (63 %), right colitis 8, left colitis 10, pancolitis 12 and proctitis 8, and of the 60 IBD patients, 22 (37 %) were Crohn’s of which 6 patients also had CT findings of small-bowel strictures with SAIO. Conclusion: (1) UC is the commoner IBD (63 % of all IBD) in our study with pancolitis (31.5 %) being the commonest, and (2) the incidence of Crohn’s in our study is more than the overall incidence of 7.3/105/year.

LI-6 Factors affecting medication adherence in ulcerative colitis

P Sarwal, S Mallik, N Dhaka, Y Rami Reddy, H S Dhaliwal, S K Sinha, R Kochhar Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Background: Non-adherence to medications is a known challenge in the management of ulcerative colitis (UC). We studied variables affecting adherence among UC patients. Methods: One hundred outpatients (54 females; mean age 37.6 years) with UC were assessed using a questionnaire. Demographics, disease activity, and prescribed medications were recorded. Ratio of monthly expenditure incurred to expected expenditure was calculated, with 0.90 indicating complete adherence, 0.70–0.89 partial adherence, and <0.70 non-adherence. Results: Fifty-eight patients had active disease, 30 quiescent, and 12 chronic low-grade activity. All patients were on oral 5-ASA, 40 on rectal 5-ASA, 19 on oral steroids, 18 on azathioprine, 15 on antibiotics, and one on biological therapy. Average monthly income was Rs 16,260 and expected expenditure Rs 2874. Expenditure incurred ranged from Rs 500 to 20,000. Sixty-seven percent were found to be fully adherent, 19 % partially, and 14 % non-adherent. Causes of non-adherence included cost of treatment (36.4 %), unwillingness or forgetfulness (18.2 %), medication side effects including discomfort with rectal therapy (15.2 %), alternate homeopathic treatment (15.2 %), and undisclosed reasons (24.2 %). Non-adherence to rectal therapy (42.5 %) was greater than that to oral (26.7 %). Complete adherence was reported by 72.2 % of females vs. 60.9 % of males (p>0.05), 73.5 % of urban vs. 60.8 % of rural patients (p 0.05), and 80 % with quiescent disease vs. 58.6 % with active disease (p>0.05). No patients in the non-adherent group had college education. Conclusions: Treatment cost in UC is a major impediment to adherence. Females, urban patients, higher education, and those on oral therapy may be more likely to adhere to treatment.

A21 LI-7 Prevalence of blood-borne viral infections in patients with inflammatory bowel disease

Parnita Harsh, Vipin Gupta, Sucharita Pilli, Surendranath, Sawan Bopanna, Govind K Makharia, Vineet Ahuja University of Illinois at Urbana, Champaign, USA, and Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 1100 029, India Background: Patients with inflammatory bowel disease (IBD) often require immunosuppressive therapy and blood transfusions and hence may be a high-risk group for blood-borne viral infections. The study assessed prevalence of hepatitis B (HBV), hepatitis C (HCV), and human immunodeficiency virus (HIV) in IBD patients. Methods: This retrospective study included 908 consecutive IBD patients (ulcerative colitis (UC) 581; Crohn’s disease (CD) 327) and 95 patients with intestinal TB (ITB) as disease controls. Prospectively maintained patient databases were reviewed for viral markers: HBsAg, anti-HCV, and HIV (ELISA method). HCV RNA was done in all anti-HCV-positive patients. The data was compared with available data on community prevalence of these infections in India (HBV 3.7 %, HCV 1 %, HIV 0.3 %). Results: The prevalence of HBsAg, HCV, and HIV was 2.4 %, 1.4 %, and 0.1 % respectively in IBD patients. In 581 UC patients, the prevalence of HBsAg was 2.2 % (12/541), HCV was 1.74 % (9/517), and HIV was 0.2 % (1/499). In 327 CD patients, the prevalence of HBsAg was 2.8 % (8/288), HCV was 0.7 % (2/273), and HIV was 0 % (0/277). ITB patients had presence of HBsAg in 6 % (4/67), HCV in 1.8 % (1/57), and HIV in 1.2 % (1/84). One patient had coinfection of HBV and HCV. Conclusion: Prevalence of HBV (2.4 %), HCV (1.4 %), and HIV (0.1 %) in North Indian IBD patients is similar to the community prevalence. However, if undetected, the high risk of flare after immunosuppressive therapy mandates routine screening of IBD patients for HBV, HCV, and HIV. LI-8 Successful stool transplantation for severe ulcerative colitis: First report from India

Avnish Kumar Seth, Pawan Rawal, Ruchika Bagga Fortis Memorial Research Institute, Sector 44, Opposite HUDA City Centre, Gurgaon, Haryana 122 002, India Background: Fecal microbiota transplantation (FMT) is approved for treatment of refractory Clostridium difficile colitis. We report the first successful use of FMT in severe ulcerative colitis (UC) in India. Case Report: A 44-year-old male with ulcerative proctosigmoiditis for 11 years reported frequent relapse despite daily sulfasalazine 4 g, azathioprine 125 mg, and rectal 5-ASA. Repeated use of corticosteroids led to cataract. At enrolment, he was passing stools eight times a day with blood with a Mayo score of 9 (3+1+3+2). Stool was negative for ova/cysts/ AFB and C. difficile toxin assay. Rectal biopsy showed cryptitis, crypt abscess, and crypt distortion with no inclusion bodies and CMVDNAwas negative. Following informed consent and approval from IEC, three sessions of FMT were performed at intervals of 2 weeks. The donor was 34 years relative with no history of GI illness, no use of antibiotics over 3 months, and free from transmissible disease as per standard protocol. At colonoscopy, 350 mL of blended and filtered donor stool, drawn into seven syringes of 50 cm3, was instilled from the terminal ileum to the sigmoid. Follow up sigmoidoscopy and rectal biopsy were done monthly for 6 months. There was symptomatic, colonoscopic, and histopathological improvement with Mayo scores of 4, 1, and 0 at 4, 8, and 12 weeks

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post FMT. Azathioprine and sulfasalazine were tapered sequentially between months 4 and 6 of FMT. He remains in clinical and endoscopic remission 8 months after FMT and 2 months after withdrawal of all medication. Conclusion: FMT may be effective in inducing drug-free remission in patients with severe UC. LI-9 Association of DNA repair gene polymorphisms and risk of ulcerative colitis

Avinash Bardia, Sandeep Kumar Vishwakarma, N Raju, Chandrakala Lakki Reddy, Pratibha Nallari, Md. Aejaz Habeeb, Aleem Ahmed Khan Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500 058, India, and Department of Genetics, Osmania University, Hyderabad 500 007, India Introduction: Ulcerative colitis (UC) is an inflammatory destructive disease of the large intestine characterized by motility and secretion disorders. The inter-individual variation is partly due to the genetic polymorphisms in genes involved in DNA repair mechanisms which may modulate the functions of the encoded proteins. Genetic polymorphisms in XPD and XRCC3 genes have been reported to increase the susceptibility to various cancers; however, their precise role in UC still remains elusive. The present study was designed to examine the polymorphisms in XPD and XRCC3 in the risk of UC. Methods: Blood samples from 142 unrelated subjects (60—UC, 82— healthy controls) were obtained for the study from the Centre for Liver Research and Diagnostics. Genomic DNAwas isolated and genotyped for XPDLys751Gln and XRCC3 Thr241Met using ARMS PCR. Results: The frequency of genotype Lys/Gln at codon 751 of the XPD gene did not show a significant difference in UC compared to the controls (95 % CI 0.98–2.23, p=0.06). The genotypic frequency of XRCC3 Thr/ Met at codon 241 showed a statistically significant difference among UC subjects than the controls (95 % CI 1.15–2.65, p=0.008). Conclusion: Polymorphisms in XRCC3 significantly increased the risk of UC in our population, but XPD polymorphisms do not. LI-10 Macrophage migration inhibitory factor levels in the serum of patients with ulcerative colitis

Manish Kumar Tripathi, J K Choudhary, A Ranjan, PAsati, S K Shukla, V K Dixit, A K Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background: Ulcerative colitis (UC) is an inflammatory disease of the colonic mucosa and seems to result from a complex series of interactions. Macrophage migration inhibitory factor is an important proinflammatory cytokine and plays a critical role in immune and inflammatory responses. MIF levels may be related to the pathogenesis and induction of inflammatory cytokines in UC. Aim: The aim of the present study is to evaluate the serum concentration of MIF in patients with ulcerative colitis, irritable bowel syndrome (IBS), and healthy controls. Method and Materials: A total of 247 subjects (59 UC, 127 IBS, and 61 healthy controls) fulfilling inclusion and exclusion criteria were enrolled for the study. Blood samples were obtained after informed consent for serum separation. Enzyme-linked immunosorbent assay (ELISA) was performed using a Bioassay Technology laboratory kit for human macrophage migration inhibitory factor. A p value of less than 0.05 was

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considered significant. Statistical analysis was conducted by using SPSS 16.0 (SPSS, Chicago, USA). Results: The MIF level in UC was found to be significantly high (p‚ 0.0003) having a mean SD of 3.55±1.3 when compared with healthy controls having a mean SD of 0.89±0.48, whereas in IBS patients, the MIF level was also found significantly elevated (p‚ 0.0006) having a mean SD of 3.96±1.39 when compared to healthy controls. Conclusion: Results show the MIF concentration was significantly elevated in UC and IBS in respect to control subjects. High level of MIF supports the claim that inflammation could be an effective factor in the pathogenesis of disease. LI-11 Clinical profile of ulcerative colitis at a tertiary care center in central India

Niraj R Sawalakhe, Sudhir Gupta, Bhumit R Patel, Nitin R Gaikwad, Tushar H Sankalecha Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Aim: The aim was to study the clinical profile of ulcerative colitis at a tertiary care center in central India. Material and Methods: This retrospective study was conducted from January 2001 to June 2015. Patients having symptoms of chronic and bloody diarrhea were screened for ulcerative colitis with colonoscopy. Those patients having endoscopic and histopathological evidence of ulcerative colitis according to ECCO guidelines were included in the study. Patients having infective colitis were excluded. All patients underwent colonoscopy and biopsy for confirmation of diagnosis. Patients received treatment according to standards of care. Results: There were 203 patients with diagnosed ulcerative colitis. Gender distribution was predominantly male (n=121) making up about 59.6 % of total patients with the remaining 82 (40.04 %) being females. Mean age was 37.65 years with a range of 9–70 years. Diarrhea (100 %) was the most common symptom followed by bleeding (95 %) and pain in the abdomen (97 %). The average time from onset to diagnosis was 3.5 months. Around 76 patients (37.43 %) had left-sided pancolitis. The remaining 51 patients (25.12 %) had proctitis. Overall, 36 (18 %) patients had severe colitis at presentation with the remaining 97 and 85 patients presenting as mild (48 %) and moderate (42 %) colitis, respectively. Sixteen patients (8 %) underwent colectomy due to severe presentation refractory to conventional therapy. Four patients (2 %) who died had severe pancolitis and toxic megacolon with one having perforation. Conclusion: Ulcerative colitis is not so uncommon in central India. In our study, there was male preponderance. Mild severity was the most common presentation. Left-sided colitis and pancolitis were the most common distribution of the disease. Mortality was low (2 %) and severe pancolitis and toxic megacolon were the factors determining poor prognosis. LI-12 Epidemiology and clinical profile of inflammatory bowel disease in South India

Nilesh Namdeo Toke, P Ramaswamy, M George, R Thomas, C Panackel, B Sebastian, S K Mathai Department of Gastroenterology, Medical Trust Hospital, M G Road, Kochi 682 016, India Background: Inflammatory bowel disease (IBD), traditionally uncommon in India, is increasing in its incidence and prevalence.

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Aims: This study aimed to describe the clinical profile of IBD in South India. Methods: IBD patients including both ulcerative colitis (UC) and Crohn’s disease (CD) were interviewed. Their medical records were reviewed for endoscopic, radiological, laboratory, and histopathological findings and treatment details. Results: Of 110 patients, 56 (51 %) had UC and 54 (49 %) had CD. The male to female ratio was 1.6 in UC and that in CD was 1.7. CD patients were younger (34.8 vs. 51, p<0.01) than UC patients. Bloody diarrhea was more common in UC, while abdominal pain was more frequent in CD. Left-sided colitis (55 %) and combined involvement of both large and small intestines (52 %) were the commonest disease phenotypes in UC and CD, respectively. Strictures were noted in 31 % and 21 % of CD patients had perianal manifestations. Sixty-five percent of UC patients had disease with intermittent flares. Eighty-five percent of CD patients had granuloma and focally enhanced gastritis (FEG) was seen in 52 %. 5.6 % of UC and 25 % of CD patients underwent surgical intervention. Of all IBD patients, 94.4 % of UC and 92.9 % of CD patients are continuing treatment. Conclusions: The present study provides a reasonable picture of demographic features and clinical profile of inflammatory bowel disease in the southern part of India.

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Aim: The purpose of this study was to assess the efficacy of salvage colonoscopy in patients with poor bowel preparation. Study Design: This is an observational study conducted at Osmania Medical College and Hospital from January to June 2015. Patients and Methods: Twenty-two patients (12 males and 10 females) with a mean age of 58.3 years who reported for colonoscopy after taking a split-dose regimen of polyethylene glycol but had a score of 0 or 1 according to the Boston bowel preparation score were included in the study and were administered 500 mL of polyethylene glycol enema through the accessory channel of the scope at the hepatic flexure. The patients were reassessed for adequacy of bowel preparation. Results: Out of the 22 patients, 11 (92 %) male and 9 (90 %) female patients achieved a Boston bowel preparation score of >8 and the cecum could be reached following salvage regimen and the other 2 patients achieved a score <5. There was no significant difference between the two sexes. Conclusions: Salvage regimen of 500 mL of polyethylene glycol solution enema is a safe and effective method in patients with a poor bowel preparation. It saves significant time and money for patients who otherwise would have to be rescheduled. LI-15

LI-13 Altered level of γ-aminobutyric acid-producing bacteria in ulcerative colitis patients

Endocuff-assisted colonoscopy in assessing polyp detection rate in patients undergoing colorectal screening colonoscopy—A pilot study

Surbhi Aggarwal, Vineet Ahuja, Jaishree Paul School of Life Sciences, Jawaharlal Nehru University, New Delhi, and All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India

N Sudhan, K Muthukumaran, G Ramkumar, R Balamurali, T Rajkumar Solomon, A Murali, P Ganesh Department of Digestive Health and Diseases, Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India

Inflammation in ulcerative colitis (UC) is characterized by alteration in the enteric nervous system (ENS) either at the level of the structural morphology of the system or at the level of enteric transmitters released by neurons and glial cells. The chemical neuromediators of ENS were initially thought to be limited to neurotransmitters such as acetylcholine and serotonin. Subsequently, purines, such as ATP; amino acids, such as γ-aminobutyric acid (GABA); and peptides, such as vasoactive intestinal polypeptide (VIP) and neuropeptide Y (NPY), were identified. Changes in various enteric transmitters have been associated with UC. GABA and its receptor have been detected throughout the gut in the ENS, muscle, and epithelial layers as well as in endocrine-like cells. In addition to the ENS and endocrine-like sources of GABA, commensal bacteria in the human intestine also produce GABA. Lactobacillus brevis and Bifidobacterium dentium are the most efficient GABA producers in the intestine (Barett et al. 2012). In order to find whether the level of GABAproducing bacteria (GPB) and gut inflammation during UC are somehow correlated or not, quantification of GPB in UC patients needs to be monitored. Our aim of this study was to quantify GPB in UC patients and controls. Fecal specimens were collected from both the groups. For quantification of GPB, FISH-flow cytometry and qPCR techniques were employed. The level of GPB in UC patients significantly reduced as compared to that in controls. So, elucidating the dysbiosis of GPB in UC patients may be of further importance in the study of disease pathophysiology.

Aim: The goal of the study was to assess whether polyp detection rate (PDR) increases with endocuff-assisted colonoscopy (EAC) in comparison with standard colonoscopy (SC). Materials and Methods: This is a randomized control trial. Patients willing to undergo colon cancer screening colonoscopy were included in the study conducted between May and June 2015. Those unwilling to give consent or those with a family history of colorectal cancer were excluded from the study. Bowel preparation was done with polyethylene glycol. The Boston bowel preparation scale was used to assess bowel preparation in each patient. EAC was performed on Tuesday, Thursday, and Saturday. SC was done on other days. Results: Thirty patients were included in the study, 15 in the study group and 15 in the control group. The mean ages of patients in the study and control groups are 62.3 and 60.7 years. Polyp detection rate, that is, the number of patients in whom at least one polyp was detected, is found to be 40 % (6 patients) in the study group and 26.67 % (4 patients) in the control group (p<0.05). The total number of polyps detected in the study group is 17, and that in the control group is 7. The number of polyps per patient in EAC vs. SC is 2.83 vs. 1.75 (p<0.05). There is no significant difference on bowel cleansing, cecal intubation rate, intubation time, and extubation time. There was no significant adverse event in both groups. Conclusion: Endocuff-assisted colonoscopy seems to be promising for increasing the detection of the number of polyps per patient and polyp detection rate.

LI-14 LI-16 Role of salvage colonoscopy in patients with a poor bowel preparation in a tertiary hospital

D Rahul, K Panduranga Rao, B Prabhakar, B Ramesh Kumar, L Sahithya, Mohd Saad Azmi, P Vivek Osmania Medical College and General Hospital, Hyderabad, India

Comparison of three colonoscopy preparation regimens in the Indian population—A prospective and randomized study

Sharad Kumar Jha, Amarendra Kumar, V M Dayal, S K Jha, A K Jha, Avinash, Uday, Burraque

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Indira Gandhi Institute of Medical Sciences, Bailey Road, Shiekhpura, Patna 800 014, India Background: A variability in the efficacy of various colonic preparation regimens has been reported. Aim: This study aimed to know the rate of adequacy of colon preparations and side effects and tolerability of various preparation regimens. Method: Adults (>18 years) who were scheduled for a colonoscopy procedure were prospectively recruited. The patients who were allergic to the medication used in the protocols or having metabolic or renal diseases were excluded. Three PEG protocols for a 4-l split dose of polyethylene glycol (A), a 3-l split dose of polyethylene glycol with ascorbate (B), and a 2-l single dose with dietary modifications on previous day (C) were randomly prescribed. A questionnaire describing the volume of PEG consumed, clinical data, and side effects was recorded. Colon preparation was graded by two observers according to Boston score and Aronchik scale. Result: Total enrolled patients (n=117) in the 2-, 3-, and 4-l groups were 46.22 and 49, respectively. The Aronchik scale results were as follows: excellent, good, fair, and poor preparations in the 2-l regimen were 7 (15.1 %), 20 (43.4 %), 11 (23.9 %), and 3 (6.5 %); in the 3-l regimen 5 (22.72 %), 10 (45.45 %), 4 (18.18 %), and 2 (9.09 %); and in the 4-l regimen 15 (30.61 %), 25 (51.02 %), 3 (6.1 %), and 2 (4.08 %), respectively. The Boston score results were the following: left colon (LC), transverse colon (TC), and right colon (RC) score 3 in the 2-l regimen were 11 (23.91 %), 20 (43.47 %), and 18 (39.13 %); in the 3-l regimen were 10 (45.45 %), 12 (54.54 %), and 11 (50.00 %); and in the 4-l regimen were 30 (61.22 %), 30 (61.22 %), and 25 (51.02 %), respectively. The numbers of patients having score 3 in the LC, TC, and RC in the 2-, 3-, and 4-l regimens were 6 (13.04 %), 5 (22.72 %), and 14 (28.57 %), respectively. No adverse effects of the 2-, 3-, and 4-l preparation regimens were seen (29 (63.04 %), 18 (81.81 %), and 23 (46.93 %), respectively). Conclusion: If we consider excellent and good preparations, the 4-l regimen was better than the 2- and 3-l regimens; however, if we analyzed the data of poor preparations, all regimens appear to be equal.

LI-17 Randomized controlled trial of magnesium sulfate versus polyethylene glycol solution for bowel cleansing prior to colonoscopy

Lokesh Locheruvapalli Venkateshappa, Amol Patil, Avinash Bhat Balekuduru, Umesh Jalihal, Satyaprakash Bonthala Subbaraj MSR College Road, MSR Nagar, MSRIT Post, Mathikere, Bengaluru 560 054, India Aims: Bowel cleansing is generally regarded as an unpleasant experience. Various studies have anecdotally reported that 1-day preparation is effective. The purpose of this study was to compare two regimens of magnesium sulfate (Epsom salt—ES) versus polyethylene glycol (PEG) solution for bowel preparation. Methods: A single-center, prospective, investigator-blinded, randomized controlled pilot study was done with patients undergoing elective colonoscopy. A total of 120 subjects were randomly assigned to two groups (ES vs. PEG). Subjects with known electrolyte disturbances, dehydration, or metabolic or renal disease were excluded. Subjects reported bloating, taste, cramping, and onset of stool activity, stool frequency, tolerability, and side effects via a questionnaire. Effectiveness of the bowel preparation was assessed using the Boston bowel preparation scale (BBPS) during colonoscopy. Results: A total of 120 patients were randomly assigned to undergo precolonoscopic bowel preparation with either ES (n=60) or PEG (n=60). Both the groups were similar in age, gender, body weight, and occurrence of vomiting and cramps after the preparation. Taste was not tolerable in the ES group than in the PEG group (p <0.05), and bloating was

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significantly more in the PEG group (p not significant). Overall, BBPS scores were similar in both the groups throughout the colon (p not significant). Conclusions: The ES solution as a bowel preparation method revealed a higher patient’s compliance and was as effective as the standard PEG solution. When the patient dislikes volume and bloating of the standard PEG solution, the ES solution will be a good alternative method except for the taste. LI-18 Clinical profile and risk factors for colonic polyps in the Indian population

Ankit Dalal, Pravin Borasadia, Satish Nayak, Shankar Jhanwar, Ubal Dhus, P Piramanayagam, A T Mohan, M Hariharan, Sarojini Parmeshwaran, Usha Srinivas, K R Palaniswamy Department of Gastroenterology, Apollo Hospital, 134, Mint Street, Owcarpet, Chennai 600 079, India Introduction: Polyps are commonly noted during colonoscopic evaluation and there is limited literature available from India. Aim: This study aimed to determine the profile of colorectal polyps in Indian patients and to assess the risk factors associated with their development. Methods: All patients undergoing colonoscopy in the Department of Gastroenterology at Apollo Hospital, Chennai, between 1 April 2013 and 28 February 2015 were included. Patients with incomplete colonoscopies, preexisting IBD, and colorectal malignancy were excluded. Location, size, morphology, number, and histopathology of polyps were studied. Risk factors like age, gender, obesity, diabetes mellitus, hypertension, smoking, alcohol consumption, and family history of colorectal polyps/ malignancy were assessed. Results: Two hundred and ninety-one patients with colorectal polyps were identified (mean age 48.92 + 10.07 years, 185—M, 106—F, mean BMI 26.19+2.89 kg/m2). Hematochezia was the most common presenting complaint. Two hundred and forty (82.4 %) patients had adenomatous polyps, while 43 (14.8 %) and 8 (2.7 %) patients had hyperplastic and juvenile polyps, respectively. 75.25 % polyps were seen in the left colon. Majority of the polyps were solitary and <1 cm in size. Tubular adenomas (68.3 %) were the most common variant among adenomatous polyps. Majority of the tubular adenomas were <1 cm in size, whereas the villous adenomas were >2 cm in size. Low-grade dysplasia was seen in 176 (72.9 %) patients. High-grade dysplasia was associated with villous polyps, larger size (>2 cm), pedunculated morphology, and advancing age. Risk factors for colorectal polyps were evaluated using univariate and multivariate analyses. On univariate analysis, age >45 years, male sex, BMI>25 kg/ m2, diabetes mellitus, smoking, and alcohol consumption were associated with adenomatous polyps. On multivariate analysis, age >45 years, BMI>25 kg/m2, and alcohol consumption were independent risk factors for colorectal adenomas. For hyperplastic polyps, univariate analysis revealed male sex and smoking as risk factors. Conclusion: In the present study, colorectal polyps are not uncommon in Indian patients. High-grade dysplasia is seen in large polyps, villous polyps, pedunculated morphology, and increasing age. Age >45 years, obesity, and alcohol consumption are risk factors for adenomas. Smoking and male sex are risk factors for hyperplastic polyps. LI-19 Colonic polyps—A report from central India

Manish Tiwari, Mohd Talha Noor Sri Aurobindo Medical College and PG Institute, Indore, India

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Introduction: Colonic polyps are widely prevalent in the western population and are well known precursor lesions for the development of colorectal carcinoma. Due to changes in dietary and lifestyle pattern, their incidence is going to increase in India also. There is scarcity of colonic polyp prevalence data from India. Material and Methods: Case records of all patients, including children and adults, whose colonoscopy revealed polyps, during the period June 2011 to May 2015 were retrospectively analyzed. Clinical profile, colonoscopic findings, and histological features are noted. Polyps are categorized according to various parameters. Results: Polyps are found in 36 (2.5 %) of 1440 complete colonoscopies. The mean age of patients with polyps was 36.80(±19.23)years; 31 were male. Bleeding per rectum (56 %) and altered bowel habit (39 %) were the most common presentation. There was predominance of polyps in the left colon (75 %). They were hyperplastic in 16 (44 %), adenomatous in 9 (25 %), juvenile in 6 (17 %), and inflammatory in 5 (14 %). All adenomatous polyps were sessile and found in elderly patients. Adenomatous polyps showed mild dysplasia in 5 (56 %) and severe dysplasia in 1 (11 %) patient. Conclusion: The prevalence of colonic polyp is low in central India, similar to that in other parts of India. Majority of the polyps are located in the left colon. Children have predominantly juvenile polyps and adults have hyperplastic and adenomatous polyps.

LI-20 Clinical, endoscopic, and pathologic characteristics of colorectal polyps in Indian children and teenagers

Chetan Rathi, Nirav Pipaliya, Alisha Chaubal, Vikas Pandey, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Objectives: Colorectal polyps are among the common causes of rectal bleeding in children. We studied the clinical, colonoscopic, and histopathological features of colorectal polyps and polyposis syndrome in Indian children and teenagers. Methods: Medical records of children and teenagers with colorectal polyps and polyposis syndrome were retrospectively reviewed from 2001 to 2014 at the department of gastroenterology in a large tertiary care center in Mumbai. Results: A total of 120 patients were found to have colonic polyps during the study period. The mean age of presentation in children was 7.31±4.05 years (range 2 to 20 years), with a male-to-female ratio of 2.16:1. Rectal bleeding was the presenting symptom in 95.83 % with a mean duration of 12.6± 15 months. Majority of polyps (77.5 %) were juvenile and 97.17 % were located in the left colon. Solitary polyps were seen in 76.67 %, multiple polyps in 11.67 %, juvenile polyposis syndrome in 6.67 %, familial adenomatous polyposis in 4.17 %, and Peutz-Jeghers syndrome in 0.8 % of the children. The polyposis syndrome group had higher age at presentation (p = 0.00006), greater likelihood of anemia, abdominal pain, and diarrhea (p=0.0001, 0.0002, and 0.0051, respectively). The likelihood of adenomatous change in polyps was higher in the polyposis syndrome group (p=0.0003). Left colonic polyps were more common in the non-polyposis group, whereas pan-colonic polyps were more common in the polyposis syndrome group (p<0.00001). Conclusion: The presence of anemia, abdominal pain, diarrhea, higher age at presentation (more than 10 years), and a history of polypectomy are clinical indicators of polyposis syndrome.

A25 LI-21 Chemopreventive efficacy of ferula asafoetida oleo-gum-resin against 1,2-dimethylhydrazine-induced rat colon carcinogenesis

R Panwar, S V Rana, K K Prasad, D K Dhawan Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, and Department of Biophysics, Panjab University, Sector 14, Chandigarh 160 014, India Colon cancer is the third most common malignant neoplasm in the world, and it remains an important cause of deaths. Its etiology is known to be a combination of hereditary, environmental, and dietary factors and lack of physical activity. Chemoprevention through dietary intervention is an emerging option to reduce mortality due to colon cancer. The present study was aimed to investigate the chemopreventive potential of ferula asafoetida oleo-gum-resin extract on 1,2-dimethylhydrazine (DMH)-induced rat colon carcinogenesis by evaluating tumor incidence and tumor size. Serum total sialic acid levels as well as histoarchitecture of colons of rats subjected to various treatments were observed. Rats were randomly divided into six groups. Group I rats served as control. Group II rats received DMH (30 mg/kg b.w. subcutaneously) for 16 weeks. Group III rats received subcutaneous injections of DMH (30 mg/kg b.w) once a week for 16 weeks. Group III–V animals were administered asafoetida orally daily through intubation gavage at a dose level of 5, 10, and 20 mg/ 100 g b.w. respectively along with weekly DMH injections. Group VI rats received asafoetida (20 mg/100 g b.w. daily) for 16 weeks. Increased tumor incidence and size was observed in DMH-treated rats which decreased with asafoetida supplementation. Asafoetida at the dose of 10 mg/ 100 g b.w. showed profound beneficial effects by exhibiting decreased serum total sialic acid levels and well-preserved colon histology as compared to the other two tested doses (5 and 20 mg/100 g b.w.). These findings suggest that asafoetida can serve as a novel agent for colon cancer chemoprevention. LI-22 Fusobacterium nucleatum in fecal and dental plaque samples of patients with colorectal carcinoma

Adarsh Rajendran, Varghese Thomas Department of Gastroenterology, Government Medical College, Kozhikode, Calicut 673 008, India Introduction: Colorectal malignancy is a major cause of morbidity and mortality all over the world. Fusobacterium nucleatum is a common member of the human gut microbiome, and there is strong evidence for a causal connection between F. nucleatum and colorectal cancer. These bacteria are also commonly found in dental plaque and are frequently associated with periodontal disease. Aim: This study aimed to quantify F. nucleatum in fecal and dental plaque samples of patients with colorectal carcinoma and compare it with healthy controls. Materials and Methods: This was a case-control study. Twenty cases of colorectal carcinomas and ten age- and sex-matched healthy controls were enrolled. Fecal and dental plaque samples were collected and transported in the RTF medium. The samples were inoculated into neomycin blood agar with metronidazole disc and incubated at 37 °C in an anaerobic pack system. After 48–72 h, F. nucleatum was identified and the colony counts were assessed. Results: Among the 20 cases, 9 were males. The mean age of patients was 60.7 years (range 38–73) and that of controls was 57.2 years. There was no significant difference in the Fusobacterium colony count from dental plaque (p value=0.86) of cases (mean rank=10.87) and controls (mean rank=11.32), but there was significant difference in the Fusobacterium

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count from the fecal samples (p value=0.001) of cases (mean rank= 13.67) and controls (mean rank=4.33). Conclusion: There is significant difference in the colony count of F. nucleatum from the fecal samples of patients with colorectal carcinoma in comparison with healthy controls. LI-23 Endoscopic closure of a large colonic perforation

Suryaprakash Bhandari, Vishal Bothara, Vinay Dhir, Amit Maydeo Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr. E Borges Road, Hospital Avenue, Parel, Mumbai 400 012, India Iatrogenic perforations during gastrointestinal endoscopy, although rare, can cause significant morbidity and mortality if not detected early and managed endoscopically or surgically. We hereby present a case of an elderly female who had iatrogenic colonic perforation during diagnostic colonoscopy and was managed successfully by endoscopic closure techniques. A 65-year-old lady underwent colonoscopy for evaluation of a chronic, colicky type of central abdominal pain and alternating bowel habits. CT done was suggestive of multiple tiny sigmoid colon diverticuloses with mild wall thickening. A polyethylene glycol colonic preparation was given and colonoscopy was under conscious sedation using an Olympus CIF 190 scope. On colonoscopy, there was an acute bend noted at 20 cm from the anal verge and some difficulty to negotiate the scope across. With further manipulation of the scope with gentle force, a sudden give way was noted and a large rent was seen in the sigmoid colon. After discussing with the family, a decision was taken to attempt endoscopic closure of the colonic perforation using conventional techniques. Colonoscopy was now done using a double-channel therapeutic gastroscope under CO2 insufflation. Through one channel of the scope, a nylon endoloop (Olympus, Japan) was placed over the edges of the colonic perforation. The loop was then fixed with multiple hemoclips (Olympus, Japan) circumferentially. Once the loop was fixed on all the edges of the perforation, it was then tightened so that all the edges of the perforation get approximated. The procedure could be completed in 45 min. The patient was then managed according to surgical principles by keeping her NBM, on IVantibiotics, and with good hydration for 72 h. Post procedure, she had a drop in HB by 3 mg/dL and minimal leukocytosis. Imaging did not show any significant free fluid in the abdomen. On the 4th day, she was gradually started on orals and discharged on the 6th post procedure day. In conclusion, endoscopic closure of even a large colonic perforation looks feasible and can be attempted if detected early especially when the bowel is well prepared. LI-24 Prevalence and pattern of colonic diverticulosis in Indian patients from a tertiary-level hospital

D Viswanath Reddy, Ravi Shankar, G R Srinivas Rao, Khalid Mehmood, Hilal Ahmed Department of Gastroenterology, Yashoda Hospital, Raj Bhavan Road, Somajiguda, Hyderabad 500 082, India Background: The prevalence of colonic diverticulosis in considered to be low in India. The pattern of distribution of the diverticulae was thought to be more on the right side of the colon. This study aims to look at the prevalence and pattern of distribution of colonic diverticulosis in India whether there are any changes due to the alterations in modern lifestyle and diet. Methods: All patients who underwent a colonoscopy and were detected to have colonic diverticulosis were included in the study from December 2013 till July 2015. The indication for colonoscopy and the patients’ history and clinical examination were recorded.

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Results: Eighty-five patients were detected to have colonic diverticulosis out of 2603 colonoscopy procedures (3.2 %). Fifty-three were males and 32 were females. The mean age of them was 59.3 years. Prevalence of diverticulosis was noted to be more in the sixth and seventh decades. Most of them were of the non-vegetarian diet group and urban population. Only 3 of them (3.5 %) had presented with complications which were managed conservatively. The rest of them were incidentally detected. Majority of them (48 patients) had involvement of the right side of the colon contrary to the western population. Fourteen of the 85 patients had left-sided diverticulosis. Pancolonic involvement was noted in 23 patients. The most common site of involvement was the cecum followed by the ascending colon. Conclusions: Colonic diverticulosis is relatively less common in the Indian population. It was found more in the sixth and seventh decades. The distribution of diverticulae was predominantly on the right side with the cecum being the most common site of involvement. LI-25 Argon plasma coagulation for the treatment of hemorrhagic radiation-induced proctitis—A 2-year experience

G Thiyagarajan, R Kini, S Kani, K Prem, Pugazhendhi, Mohammed Ali Department of Medical Gastroenterology, Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India Aim: This study aims to evaluate the efficacy of argon plasma coagulation (APC), as well as patients’ tolerance of the procedure, in the treatment of rectal bleeding caused by radiation-induced proctitis attending Madras Medical College Hospital from 2013 to 2015. Materials and Methods: Patients with rectal bleeding caused by radiationinduced proctitis were included. Severity of bleeding was as graded from 0 to 4. All these patients underwent APC set at 4 l/min with an electrical power setting of 40 W. They were analyzed for mean age, sex, symptoms, various types of cancers, mean duration of development of symptom after radiotherapy, need for blood transfusion before and after APC, mean session, symptom improvement, and recurrence. Observations: The mean age was 51.7 years (range 46 to 84 years). All 17 were females and none of them were males. The most common symptom was rectal bleeding followed by tenesmus. The most common cancer producing proctitis after radiotherapy is cancer of the cervix followed by uterine cancer. The mean duration of development of symptoms after radiotherapy was 23 months (range 10 to 48 months). The mean number of transfusions required before APC was 2.4, but after treatment, none of them needed transfusion. The mean number of sessions required was 3.5. Eleven patients did not have recurrence of rectal bleeding and three had significantly reduced bleeding but occasional spotting. Three patients did not respond and underwent formalin therapy. The tolerance was good, with no complications. Conclusion: APC is an effective, safe, and well-tolerated treatment for rectal bleeding caused by chronic radiation proctitis. It should be considered as a first-line therapy. LI-26 Prevalence of colonic diverticulosis in irritable bowel syndrome patients—Our center experience

A Anand, G Ramkumar, K Muthukumaran, R Balamurali, T Rajkumar Solomon, A Murali, P Ganesh Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College, 3rd Avenue, Kilpauk, Chennai 600 040, India Introduction: Irritable bowel syndrome (IBS) is a chronic gastrointestinal disorder. Patients may suffer from abdominal discomfort, bloating, or

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significant (p<0.0001). Serum TNF-alpha levels were higher in group I: mean 7.17 IU/mL (SD −2.18) vs. mean 2.45 IU/mL in group II (SD −1.65); the difference was significant (p<0.0001). Serum 25-OH vitamin D levels were significantly lower in group I: mean 17.03 IU/mL (SD −5.23) vs. mean 24.53 IU/mL (SD 6.6), and this difference was significant (p<0.0001). When univariate analysis was done, younger age <25.7 years, male sex, E3, multiple relapses, higher mean Mayo score >9.58, low albumin levels, high ESR, high TNF-alpha value, and need for blood transfusion correlated with undergoing surgery in ulcerative colitis. Multivariate analysis and logistic regression, multiple relapses, ESR, and blood transfusion requirement correlated with the need for surgery. Significant predictors of colectomy are male sex OR (2.78, 95 % CI 0.96 to 8.76); younger age OR (6.30, 95 % CI 3.43 to 11.58); E3 disease OR (26.80, 95 % CI 7.2 to 113.08); high Mayo score OR (14.55, 95 % CI 5.89 to 35.53); raised ESR OR (26.14, 95 % CI 6.4 to 105); raised TNF-alpha level OR (25.62, 95 % CI 8.6–75.91); low 25-OH vitamin D3 level OR (6.07, 95 % CI 3.0 to 12.02); and need for blood transfusion during disease course OR (102.9, 95 % CI 42.60 to 248). We addressed two principal clinical issues in managing ulcerative colitis: how to identify at an early stage those who are likely to fail intensive medical treatment and when to start rescue medical therapy. In our study, 26 (10 %) patients required colectomy, all of whom had medical refractory disease; biological therapy was not tried due to financial constraints. Each of the 26 patients underwent total colectomy followed by IPAA in a three-stage procedure. We therefore concluded that young male patients with pancolitis and relapsing disease are at an increased risk of colectomy. Abnormalities in laboratory markers such as low albumin and vitamin D levels and raised ESR and TNFalpha levels are also predictors of colectomy.

To study the predictive factors for colectomy in ulcerative colitis in a tertiary care center in India

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pain associated with disturbed defecation. The etiology has not been clear. Colonic diverticula are mucosal outpouchings through the large bowel. Recent study demonstrated more prevalence of diverticulosis in IBS. Aim of the Study: This study aimed to determine the prevalence of diverticulosis in IBS patients and the association between diverticulosis and IBS patients. Methods and Materials: A total of 50 patients were included in the study which consisted of an IBS group (25 patients) and a control group (25 patients). The study was conducted from June 2014 to June 2015. IBS was defined by Rome III criteria. Medical history, physical examination, and colonoscopy were done. Results: The IBS group consisted of 12 males and 38 females with a mean age of 52 years. There was no significant difference in age, gender, and BMI between the IBS group and control group (p>0.05).The prevalence of colonic diverticulum of the IBS group was 24 % and that of the control group was 12 %. There was a statistically significant difference in prevalence between both groups (p value=0.03).Comparison of location of diverticulum, right-sided colon and cecum diverticula were mostly found in the IBS group and in the control group were found in the rectosigmoid region. There was no significant difference in location of diverticulum between both groups. There was no significant difference in numbers of diverticula between both groups (p value=0.09). Conclusions: Prevalence of diverticulosis in the IBS group was more than that in the control group. The pathogenesis of IBS and colonic diverticulosis may share a similar pathway and this aspect should be further studied.

Vaishali Bhardwaj, A S Puri, Sanjeev Sachdeva G B Pant Post Graduate Institute of Medical Education and Research, Jawahar Lal Nehru Marg, New Delhi 100 002, India Materials and Methods: This study included patients of ulcerative colitis presenting at the Department of Gastroenterology, G B Pant Hospital, from 2010 to 2012. N=300 patients were included. Patients were admitted and given intensive medical therapy and IV steroids, and response was assessed on day 3. If there is no response to cyclosporine, reassessment was done at day 5. If still unresponsive, the case was considered a failure in medical therapy and is referred for colectomy. Calculation was done in SPSS 15 software, and a p value <0.05 was considered significant. Univariate logistic regression was performed to identify predictors of colectomy. Characteristics significant in the univariate analysis were included in the final multivariate logistic regression model to identify independent risk factors for colectomy at p<0.05. Odds ratio was calculated. Results: The study cohort consisted of 300 patients of which 249 were included in the final analysis, of which 170 were males. Among the 249 patients, 26 underwent colectomy. Analysis was done for two groups: group I (colectomy group) and group II (nonsurgical). The mean age for group I was 25.7 years (SD 9.7) and the mean age for the nonsurgical group (group II) was 34 years (SD 15.2). Group I patients were significantly younger than group II patients (p<0.005). Males comprised 84.6 % in group I and significantly lower in group II (66.4 %, chi-square=2.78, p<0.05); 249 patients were enrolled: 38 (15.3 %) E1, 82 (32.9 %) E2, and 129 (51.8 %) E3 disease. All except one patient in group I had E3 disease. None with E1 disease underwent colectomy. Patients in group I had severe disease by Mayo score. The mean Mayo score was 9.58 (SD 0.857) vs. 5.60 (SD −2.59) in group II, and this difference was significant (p<0.0001). Albumin levels were as follows: group I mean −2.2 mg/dL (SD 0.83) vs. group II mean 2.9 mg/dL (SD 0.49); the difference was significant (p<0.0001). ESR was high in group I, i.e., mean 105.26 mm/h (SD 70.24) vs. mean 34.04 mm/h group II (SD −23.15); the difference was

Initial experience with naloxone hydrochloride for the treatment of acute intestinal pseudoobstruction in intensive care unit patients

Vijay Sharma, Suresh Bhargawa, Vaibhav Vaishnav, Richa Sharma Department of Gastroenterology, Manipal Hospital, Sector 5, Main Sikar Road, Vidhyadhar Nagar, Jaipur 302 013, India Introduction: In acute intestinal pseudoobstruction, there is dilation of the intestinal loops without mechanical obstruction; it may develop after surgery or severe illness. This condition is due to an acute imbalance of the normal extrinsic autonomic innervation of the bowel. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Studies suggest that neostigmine is an effective treatment. However, there is no reported experience with naloxone hydrochloride, an opioid antagonist, which is a synthetic congener of oxymorphone. Aims and Methods: The aim of this study was to determine the efficacy of naloxone hydrochloride in patients with intestinal pseudoobstruction managed in an intensive care unit. We studied patients admitted in an intensive care unit (ICU) fulfilling criteria of acute intestinal pseudoobstruction in the form of clinical abdominal distention and radiographic evidence of significant small-bowel and colonic dilation. Reversible and mechanical causes of abdominal distention were ruled out. When there was no response to at least 24 h of conservative treatment, we prospectively recruited patients to receive 3.0 mg of naloxone (one ampule contains 0.4 mg, so seven and half ampule inj. naloxone) given through a Ryles tube; the Ryles tube was clamped for 1 h, and the medicine was administered every 6 h. A physician who was unaware of the patients’ treatment assignments recorded clinical response defined as evacuation of flatus or stool and a reduction in abdominal distention, abdominal circumference, and measurements of the small bowel and colon on radiographs. Patients who had no response to the initial dose were eligible to receive open-label naloxone 6 h later and subsequent

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doses 6 h for 24 h; if that fails, injection of neostigmine and colonoscopic decompression were kept in the treatment protocol. Results: Prospectively, 28 patients were included in the study since April 2014; 12 patients were having pneumonia and septicemia, three patients with pyelonephritis and septicemia, three patients with cerebrovascular accident and intracranial bleed, two patients with post-complicated spinal surgery, three patients with polytrauma due to road traffic accident, one patient with CRF and septicemia, one patient with subacute bacterial endocarditis and septicemia, one patient with post-cardiac surgery, and two patients with liver cirrhosis. Twenty-three patients who received naloxone had early intestinal decompression in the form of passage of flatus, passage of motion, significant (more than 2 in.) decrease in abdominal girth, significant decrease in bowel diameter on X-ray flat plate abdomen (equal or more than 1 cm), and improvement in clinical parameters especially respiratory rate and oxygen saturation. In two patients, colonoscopic decompression and also injection of neostigmine 2 mg were required. In two patients, neostigmine was contraindicated so only colonoscopic decompression was done. In one patient with spinal injury, there was significant symptomatic improvement, but X-ray of the abdomen revealed persistently dilated bowel loops. The median time to response was 6 h (range, 2 to 24). Side effects of naloxone included tachycardia in three patients, rise in blood pressure, and irritability in one patient each. Conclusion: This initial observation suggests that administration of naloxone hydrochloride through the Ryles tube is beneficial and safe in the treatment of ICU-admitted patients with acute intestinal pseudoobstruction. LI-29 Prevalence of iron-deficiency anemia in ulcerative colitis during remission and its impact on quality of life

Ajay K Jain, Sandip Vare, Mayank Jain, Shohini Sircar, Amit Bundiwal, Sandeep Kaulavkar, Suresh Hirani, Rahul Agarwal Department of Gastroenterology, Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aims: The study aimed (1) to determine the prevalence of iron-deficiency anemia in ulcerative colitis during remission and (2) to compare the quality of life in patients of ulcerative colitis during remission before and after iron supplementation. Material and Method: In this prospective study, consecutive patients of ulcerative colitis on remission (old and new) were included. Activity of disease was calculated by the simple clinical colitis activity index (SCCAI). Quality of life was assessed by the Short Inflammatory Bowel Disease Questionnaire (SIBDQ). In patients with iron-deficiency anemia, oral iron supplements (ferrous ascorbate elemental iron 100 mg) were given for 3 months. Blood parameters (Hb, serum iron, TIBC, serum ferritin, % transferrin saturation), SCCAI, and SIBDQ scores were compared before and after the abovementioned intervention. Results: Out of 125 patients of ulcerative colitis seen during the study period, 69 were on remission. Thirty eight of these had anemia. Out of 38, 34 patients had iron-deficiency anemia. Prevalence of iron-deficiency anemia was 49.27 %. Postintervention mean disease activity (SCCAI scores) was not increased when oral iron supplements were given during disease remission. Mean preintervention and postintervention quality of life scores (SIBDQ) and blood parameters showed significant improvement after iron supplementation. Conclusion: Prevalence of iron-deficiency anemia in ulcerative colitis during remission was 49.27 %. Oral iron supplementation (ferrous ascorbate) improves quality of life and blood parameters in ulcerative colitis patients on remission and does not increase disease activity during remission.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 LI-30 High risk of colorectal cancer in ulcerative colitis in India

Sawan Bopanna, Prasenjit Das, S Datta Gupta, V Sreenivas, V Pratap Mouli, Saurabh Kedia, Rajan Dhingra, Rajesh Pradhan, N Suraj Kumar, Dawesh P Yadav, Govind Makharia, Vineet Ahuja All India Institute Medical Sciences, Ansari Nagar, New Delhi 110 029, India The magnitude of colorectal cancer (CRC) in ulcerative colitis (UC) in India is considered low. As a result, screening for CRC in UC although advocated may not be followed everywhere. We report our data over the last decade in UC-associated CRC and the yield of dysplasia surveillance strategy. Methods: One thousand and twelve patients with left-sided colitis or pancolitis registered at an IBD clinic were included. The study population had at least one full-length colonoscopy done at least a year after the onset of symptoms. In addition, 136 patients with high risk of developing CRC (duration of disease >10 years) underwent surveillance white light colonoscopy. A subset of these patients who had pancolitis and disease >15 years underwent dysplasia surveillance with 33 random biopsies (4 taken every 10 cm). Results: In 1012 patients (693 males), the mean age of disease onset was 31.9±11.7 years and disease duration was 6.4±6.8 years. 55.1 % had leftsided colitis and 44.9 % had pancolitis. Twenty (1.97 %) patients developed CRC. The cumulative risk of developing CRC was 1.5 %, 7.2 %, and 23.6 % in the first, second, and third decade, respectively. Of 136 high-risk UC cases, 5 (3.6 %) had CRC on screening colonoscopy. Dysplasia surveillance was done in 30 patients. Nine hundred and twentyfour biopsies were taken, and none of them revealed dysplasia. Conclusions: The cumulative risk of CRC in Indian UC patients is high and 23.6 % at 30 years. Screening colonoscopy is mandatory after 10 years of disease onset. Random biopsy sampling for dysplasia has a poor yield. LI-31 Temporal relationship of pregnancy to long-term disease course and pregnancy and fetal outcomes in inflammatory bowel disease

Rajesh Kumar Padhan, Sushil Kumar, Saurabh Kedia, Rajan Dhingra, V Pratap Mouli, Sawan Bopanna, Saurabh Shrivastav, Lalit Kurrey, Govind Makharia, Vineet Ahuja Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background and Aim: This study evaluated the effect of pregnancy on IBD course and pregnancy and fetal outcomes in IBD patients. Methods: Females with ulcerative colitis (UC) or Crohn’s disease (CD) in the 18–45-year age group attending an IBD clinic were included. Pregnancies were categorized as either before, after, or coinciding with disease onset. Pregnancy outcomes were recorded from antenatal records or individual interviews. Long-term disease course was ascertained from prospectively maintained records. Results: Seven hundred and twenty-one females were enrolled in the IBD clinic from 2004 to 2013. Five hundred and fourteen patients were in the reproductive age group (UC 429, CD 85). Eight hundred and twenty-four pregnancies occurred with available data for 655 pregnancies (UC 529, CD 126). Median follow-up was 5.9 years in UC and 6.6 years in CD. IBD course was worse in non-pregnant than in pregnant patients (UC: p=0.02, CD: p=0.4). Disease course was worse when pregnancy precipitated IBD as compared to the disease course with pregnancy prior to or after IBD onset. Caesarian sections were more in CD (20.6 %) than UC patients (4.6 %) (p=0.038). Adverse pregnancy outcomes (abortion, stillbirth, preterm, and post dated) were more in pregnancy after onset of both UC and CD and were significantly more in CD than in UC patients (p=0.003).

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Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Conclusion: Longitudinal cohort data shows that UC with pregnancy has a favorable disease course than UC without pregnancy. A novel observation was that long-term disease course was aggressive when pregnancy precipitated disease onset compared to pregnancy prior to or after disease onset. Pregnancy and fetal outcomes were worse in pregnancy after disease onset than pregnancy before disease onset.

GI Motility MO-1 Brain activation response to rectal pain stimuli in irritable bowel syndrome patients and healthy controls using functional magnetic resonance imaging

(Rome III criteria) without structural defect were enrolled after informed consent. Anorectal manometry (Trace, Australia) was performed in four positions, i.e. left lateral position; sitting with no pedal block (Western toilet); sitting with pedal block and squatting (Indian toilet). The sequence of positions was decided by computer-generated random numbers. Several variables, i.e. basal sphincter pressure, rectal pressure, squeeze pressure, squeeze duration, and rectal and sphincter pressure while straining and balloon expulsion, were assessed in each of the four positions. The gastroenterologist analyzing the readings was blinded to the positions and sequence. Parameters in various positions were analyzed by KruskalWallis test. A P value less than 0.05 was statistically significant.

Results

Arun Karyampudi, Abhai Verma, Anupam Guleria, Dinesh Kumar, Rajan Singh, Vivek A Saraswat, C L Khetrapal, Uday Chand Ghoshal Department of Gastroenterology, and Centre of Biomedical Research, Sanjay Gandhi Post-Graduate Institute of Medical Sciences, Lucknow 226 014, India Background: Though irritable bowel syndrome (IBS) is characterized by abnormally exaggerated cerebral response including emotional processing in response to visceral stimuli, particularly among females, data among the male population is scanty. Methods: Twenty male IBS patients (10 IBS-D and 10 IBS-C) and 10 male healthy controls were assessed for rectal balloon distension threshold. Blood oxygenation level-dependent functional magnetic resonance imaging (BOLD fMRI) of the brain was performed at baseline and at pain detection threshold in all subjects. Results: Baseline characteristics were comparable between IBS patients and healthy controls. Rectal pain threshold volume was lower among IBS-D patients compared to IBS-C and healthy controls (240 [180– 350] vs. 300 [240–480] vs. 420[360–480]mL, p=<0.001). Frequency of right amygdala and intensity of left hippocampus activation were higher in IBS patients compared to healthy controls (10/20 (50 %) vs. 1/10 (10 %), p=0.049, and 0 (0–5.3) vs. 0 (0–0), p=0.041, respectively). Intensity of left hippocampus activation was higher in IBS-D compared to IBS-C and healthy controls (3.8 (3.5) vs. 1.7 (2.8) vs. 0.5 (1.5), p=0.036). Frequency and intensity of activation of the insula, supra-marginal gyrus, prefrontal cortex, thalamus, anterior cingulate gyrus, and paracentral lobule were comparable between IBS patients and healthy controls. Conclusion: Patients with IBS-D and IBS-C have disturbances of emotional processing of visceral sensation as compared to healthy subjects. MO-2 Comparison of anorectal manometry in squatting, sitting, and left lateral positions in patients with defecatory disorders

Abhishek Sadalage, Akash Shukla, Megha Meshram, Amit Gupte, Tejas Modi, Rohit Dusane, Shobna Bhatia Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Parel, Mumbai 400 012, India Background: The gold standard for diagnosis of dyssynergic defecation is anorectal manometry and MR defecography. Anorectal manometry is performed in left lateral position (Sim’s position), and pressures may not reflect the actual pressures during defecation according to type of the toilet used. We therefore did prospective study of anorectal manometry in different positions used for defecation. Methods: Institutional ethics committee permission was obtained. Twelve [age 40.2 (8.2); 9 men] consecutive patients with dyssynergic defecation

Sphincter Rectal Squeeze Squeeze Rectal Basal pressure pressure pressure duration (s) pressure sphincter during (mmHg) (mmHg) during pressure straining straining (mmHg) (mmHg) (mmHg) Left lateral position Sitting with no pedal block Sitting with pedal block Squatting P value

77.77

24.67

134.92

24.49

65.47

79.56

(30.12)

(12.35)

(58.89)

(7.84)

(44.37)

(41.66)

85.52

26.99

127.48

23.58

64.35

75.62

(39.37)

(12.79)

(51.22)

(9.37)

(31.75)

(39.74)

85.02

29.99

143.44

26.33

67.93

83.32

(27.60)

(12.14)

(59.10)

(7.26)

(28.42)

(47.13)

81.81

29.81

132.30

25.08

69.77

80.58

(38.02)

(14.94)

(56.11)

(8.45)

(30.71)

(46.02)

0.889

0.732

0.884

0.896

0.791

0.993

Out of seven patients who were unable to expel the balloon in the left lateral position, three patients expelled it in other positions. Conclusion: There appears to be no difference in various manometric parameters irrespective of position in which anorectal manometry is performed in patients with dyssynergic defecation. However, the results of the balloon expulsion test in different positions may alter the diagnosis of defecatory disorders. MO-3 Prevalence of esophageal dysmotility in patients with GERD and its relationship to vitamin D deficiency

R Kodati, U Dutta, K K Prasad, S K Bhadada Departments of Gastroenterology, and Endocrinology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Esophageal dysmotility and hypotensive LES possibly play a significant role in the pathogenesis of GERD. The relationship of vitamin D deficiency (VDD) and esophageal dysmotility is not known. Aims: The aim was to study the prevalence of esophageal dysmotility and hypotensive LES in patients with GERD and it relationship to serum vitamin D levels. Methods: This is a prospective study of consecutive patients with GERD at PGIMER, Chandigarh. After informed consent, detailed clinical, laboratory, endoscopic, manometric evaluation using HRM system (MMS), QOL, and vitamin D levels were estimated. Risk factors of VDD were evaluated. Statistical analysis was performed using SPSS version 23 using appropriate tests.

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Results: Among 42 cases of GERD (mean age 40.2±10 years, 43 % males), 43 % had mild, 40 % moderate and 17 % severe GERD. HRM manometry showed high prevalence of ineffective esophageal motility (48 %), failed peristalsis (6 %), and hypotensive LES (45 %). UGIE showed lax LES in 50 %, esophagitis in 45 %, and hiatus hernia in 12 %. VDD was present in 64 %; it was severe deficiency in 26 %, moderate in 33 %, and mild in 41 %. Predictors of VDD were high alkaline phosphatase, proximal muscle weakness, and knuckle pigmentation, of which the latter was an independent predictor (p=0.04). There is no relationship of vitamin D to symptom severity, QOL, and esophageal dysmotility. Risk factor for VDD was lack of sunlight rather than fat malabsorption. Conclusion: Among patients with GERD, esophageal dysmotility and VDD are both common. There was no relationship between vitamin D levels and esophageal dysmotility.

MO-4 Classification of pelvic floor dyssynergia based on high-resolution anorectal manometry in patients with chronic constipation

Nitesh Pratap, Vishal Akude, Abhijit Bavsar, Sharath Putta, Sethu Babu, Y Nagarjuna Department of Medical Gastroenterology, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Krishna Nagar Colony, Begumpet, Secunderabad 500 003, India Background/Aims: Dyssynergic defecation is common and affects up to 25 % of patients with chronic constipation. Inability to perform coordinated movements during defecation represents the chief pathophysiologic abnormality in patients with pelvic floor dyssynergia. The aim of study was to recognize different patterns of pelvic floor dyssynergia with help of high-resolution anorectal manometry. Methods: Anorectal manometry was done in 120 patients, presenting with chronic constipation and suspected pelvic floor dyssynergia as per ROME III criteria. The patients were classified into four types based on classification given by Rao et al. Results: In our study, 120 patients who underwent anorectal manometry, 42 (35 %) patients had anorectal dyssynergia. Of these, 30 (71.4 %) were male and 12 (28.6 %) were female. Type 1 was the most common, present in 24 (57.14 %) patients, followed by type 2 in 8 (19.04 %) patients and type 4 in 6 patients (14.28 %), and type 3 was present in 4 (9.52 %) patients.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Conclusions: The most common type of pelvic floor dyssynergia in our study was type 1. There is a need for large-scale studies to evaluate the treatment responses in different types of pelvic floor dyssynergia. MO-5 Defecation frequency and stool form based on Bristol stool chart in patients with chronic constipation presenting to tertiary care hospital

Nitesh Pratap, Vishal Akude, M Sai Vaishnavi, P Mohan Krishna, K Keerthi Pragna, Parag Dashatwar Department of Medical Gastroenterology, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Krishna Nagar Colony, Begumpet, Secunderabad 500 003, India Background/Aims: The bowel habits may vary in different populations due to differences in dietary habit, fiber intake and difference in gut transit time. The definition based on western data may not apply to a non-Western population. In this prospective observational study, we evaluated stool type and frequency in patients who presented with constipation. Methods: One hundred and twenty patients presenting with chronic constipation (Rome III criteria) were included. They were evaluated for average frequency of stools they had when constipated. Using Bristol stool chart, containing pictures as well as descriptors, type of stool during constipation was evaluated. Results: In our study, out of 120 patients, 78 (65 %) were males and 42 (35 %) were females. Most of the patients were in the 30- to 60-year age group (65 % or 54.16 %). Duration of symptoms

Number

Percentage

6–12 months

53

44.16

1–6 years

53

44.16

7–12 years

9

7.05

>12 years

5

Stool freq./week <2

Number 5

4.16 Percentage 4.16

2 to 3

7

5.80

3 to 7

62

51.60

7 to 14

32

26.60

14 to 21 >21

11 3

9.10 2.50

In our study, the predominant stool type was type 3 (59, 49.16 %) followed by type 2 (31, 25.80 %), type 1 (14, 11.66 %), type 4 (13, 10.83 %), and type 5 (3, 2.5 %). Conclusions: The predominant stool form in patients with chronic constipation was Bristol type 3. Median stool frequency in the studied population of chronic constipation was 7/week (range 1 to 28/week). MO-6 Comparative study of lactulose, polyethylene glycol and milk of magnesia in management of chronic constipation

Nitesh Pratap, Vishal Akude, Santoshkumar Ambulge, Abhijit Bhavsar, Keerthi Pragna, P Mohan Krishna, M Sai Vaishnavi

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

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Department of Medical Gastroenterology, Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Krishna Nagar Colony, Begumpet, Secunderabad 500 003, India Objective: The purpose was to evaluate the efficacy of lactulose, polyethylene glycol (PEG), and milk of magnesia with liquid paraffin in patients with chronic constipation. Method: One hundred and one patients with chronic constipation based on Rome III criteria with age group between 18 and 75 years were included. Frequency of stools and stool form as per Bristol stool chart, preand post-treatment, were noted. Patients were randomized into lactulose, polyethylene glycol, and milk of magnesia with liquid paraffin groups. Response to the treatment in the form of patient satisfaction and improvement in stool frequency and form was noted after 8 weeks of follow up. Result: Ninety-one patients completed the study. Thirty patients were on lactulose of which 24 (80 %) showed good response. Thirty-two patients were on milk of magnesia with liquid paraffin where 18 (56.25 %) showed good response and 29 were on PEG of which 16 (55.17 %) responded. It was observed that there was improvement in stool form based on Bristol stool scale in all the three groups, but it was more in the lactulose group. Bristol stool form

Pre-treatment (mean) Lactulose Milk of magnesia with liquid paraffin PEG

Patient satisfaction post-treatment (%)

Post-treatment (mean) 2.54 2.74

4.24 3.77

80 56.25

2.65

3.86

55.17

Conclusion: The present study shows that lactulose was more effective than PEG and milk of magnesia with liquid paraffin in the treatment of chronic constipation. MO-7 Study of anorectal rectal manometry evaluation in patients with dyssynergic defecation

Pankaj Asati, V K Dixit, A K Jain, S K Shukla, S Budhiraja, M Behera Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background/Aims: Dyssynergic defecation (DD) is a frequently encountered problem during a anorectal manometry (ARM). The clinical features do not often correlate with ARM findings. We prospectively evaluated the ARM findings in patients with DD and their correlation to symptoms. Methods: This study was carried out in Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi, from 2014 to 2015. A total 34 patients (20 male/14 female, with mean age 38 years) were included who presented with symptoms of constipation (Rome III criteria for constipation) with normal sigmoidoscopy. ARM was performed using a water perfusion (Sandhil, USA) system. Patients were classified into type I–IV dyssynergia on ARM. Baseline and squeeze sphincter pressures, anal sphincter pressure, rectal defecatory pressure, and BET were recorded. Those patients who could not expel the balloon with 50 g weight within 1 min were considered as abnormal. Results: Mean age of women was higher (39 vs. 34.5 years). Mean sphincter pressure was 58.8 mmHg and squeeze pressure was 113.1 mmHg and mean rectal defecatory pressure 56.8 mmHg (24– 112 mmHg). BET was abnormal in 27 patients. Baseline and squeeze

pressures were highest in patients with type I DD. None of the symptoms correlated with type of DD. Conclusions: Type 1DD is the commonest type of defecatory disorder. Only 2 patients with type II were found in our study. Clinical symptoms were not useful for predicting dyssyngia defecatory disorder. MO-8 Effect of Lp299v on symptoms related to irritable bowel syndrome

S Selva Kumar, S Sakthi Dasan, S S Sakthi Gnanavel, P Arul Prakash, A Sakthi Vel C R R I, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur 603 319, India Background: Irritable bowel syndrome is the most common gastrointestinal disorder affecting to 20 to 30 % of adults. It most often affects the quality of life in the long run. Aim: The aim of this study was to assess the efficacy and safety of Lp299v, a unique probiotic strain, in patients with IBS. Methodology: The study population consisted of 40 adult patients of various forms of IBS attending an outpatient department. The male/ female ratio was 1.8:1, age ranged from 26 to 59 years with a mean symptom period of 6 months of Rome II criteria. The study period was 6 months. They are divided into two—20 patients receiving capsule Lp299v belonging to the genus Lactobacillus plantarum 20 billion cfu twice daily for 4 weeks compared to another 20 patients to receive placebo of identical appearance capsule containing placebo starch powder b.i.d for 4 weeks. At the end of the study, their efficacy and safety were analyzed. Results: The diarrhea group (71 %) has good control of diarrhea when compared to placebo 2/7 28 % has reported disappearance of diarrhea 86 %, among the constipated patient 6/7 frequency of stool was normalized compared to 1/7 15 % in placebo with regard to discomfort and bloating group. 5/6 83 % has promised symptom relief compared to 2/6 34 % among placebo group. There were no treatment-related side effects reported in the study. Conclusion: Lp299v, belonging to the species L. plantarum, has shown promising results in IBS patients.

Liver—others L-1 Do nonselective beta blockers increase the risk of acute kidney injury in decompensated cirrhosis

Kadavanoor Srijith, M Ramu, Deni Joseph, Nikhil Suraj, T S Prasanth, G Chethan, Gopu Babu, A Shanid, S Sreejaya, D Krishnadas Department of Medical Gastroenterology, Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background: Recent studies have shown that beta blockers increase the risk of HRS in decompensated cirrhosis especially with refractory ascites and after the first episode of SBP. Aims: The purpose was to study whether nonselective beta blockers (NSBB) increase the risk of acute kidney injury (AKI) in decompensated cirrhosis. Methods: We conducted a retrospective case control study of patients with decompensated cirrhosis with (group I) and without AKI (group II) in the study period from 2012 to 2014. AKI was defined according to AKIN criteria. Results: Groups I and II included 85 and 250 patients, respectively. Groups I and II included 62 and 165 patients respectively with Child C

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cirrhosis. Fifty-five (64.7 %) patients were on beta blockers in group I as compared to 147 (58.8 %) in group II (p=0.336). The mean systolic BP in group I was 99.04±6.54 and 111.46±7.59 in group II (p<0.001), and the mean dose of beta blocker was 40.73±13.588 in group I and 29.93± 8.317 in group II (p<0.001). Sixty-seven (78.8 %) patients were on diuretics in group I and 152 (60.8 %) in group II (p=0.003). SBP and sepsis were significantly associated with presence of AKI. Mean arterial pressure (MAP) was 78.60±5.70 in group I and 85.06±4.62 in group II. Patients on combined diuretics and beta blockers were also significantly associated with AKI. Conclusion: Patients with decompensated cirrhosis on NSBB should be monitored closely. It should be stopped once there is evidence of sepsis, SBP, and low MAP. L-2 Predictors and clinical profile of infections in cirrhosis in a tertiary care setting

Deni Joseph, T S Prasanth, G Chethan, K Sreejith, M Ramu, S Nikil, Ponni M Shahana, Gopu Shanid, S Srijaya, D Krishnadas Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background: Infections in patients with CLD are an important cause of morbidity and mortality among them. The pattern of infections may be different in our settings compared to the west. Objective: The objective of this study was to find predictors and clinical profile of infections in CLD. Materials and Methods: Data of all cirrhosis patients admitted in medical gastro from 2012 January to 2014 December was collected prospectively. A total of 341 patients with infections were there. A control group of 341 cirrhosis without infections was also selected. Case-control analysis was done. Results: There were a total of 341 cirrhotic patients admitted with various infections during the study period. Males constituted 72 %. The most common infection encountered was SBP (53 %) followed by cellulitis (21 %), urinary tract infection (20 %), pneumonia (12 %), and other causes (10 %). Multiple sites of infection were identified in 11 % of patients. Culture positivity was detected in 33 %. The most common organism isolated in culture was Escherichia coli. Factors which showed significance in univariate analysis were hepatic encephalopathy, platelet count, albumin level, and Model for End-Stage Liver Disease (MELD) score and hyponatremia. Using logistic regression, hepatic encephalopathy, albumin level <2.5 g/dL, Na+ <127, and MELD >16 emerged as significant factors associated with infection. Conclusions: Hypoalbuminemia, hyponatremia, and high MELD score are the risk factors for infections in cirrhosis. The most common infection leading to admission was SBP followed by cellulitis. The most prevalent organism isolated was E. coli. L-3 Occurrence of minimal hepatic encephalopathy in patients of extrahepatic portal hypertension versus cirrhosis of the liver (Child A)—A comparative study

Gaurav Babar, Varghese Thomas Department of Gastroenterology, Government Medical College, Calicut 673 008, India Aim: The aim of this study was to study the occurrence of minimal hepatic encephalopathy (MHE) in patients of extrahepatic portal venous obstruction (EHPVO) and cirrhosis of liver (Child A) with or without history of variceal bleed in the past.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Method: Consecutive patients with a diagnosis of EHPVO with age >12 years and cirrhosis of liver Child A were included in the study. All patients underwent a combination of psychometric tests including the number connection tests A and B, digit symbol test, line tracing test and circle dotting test. Critical flicker frequency (CFF) was calculated using a HEPANORM analyser. Patients were diagnosed to have MHE if two or more of the psychometric tests were positive and if CFF was below 39. Result: Ninety-nine patients of EHPVO were enrolled in the study. Among them, 77 (77.7 %) had a history of upper gastrointestinal (GI) bleed whereas 22 (22.22 %) did not have a history of upper GI bleed. Twenty-six (26.26 %) had portal biliopathy, 51 (51.51 %) had splenic hilar collaterals, 11 (11.11 %) had leinorenal collaterals, and 16 (16 %) had pericholecystic collaterals. Fifteen (15.15 %) EHPVO patients had minimal hepatic encephalopathy. One hundred and four patients with Child A cirrhosis were enrolled in the study. Etiology was alcohol in 69 (66.34 %), non-alcoholic fatty liver disease related in 12 (11.53 %), hepatitis B in 10 (9.6 %) and hepatitis C in 9 (8.6 %), and miscellaneous in 4 (3.8 %). Twenty two of the cirrhotics (21.15 %) had MHE. Conclusion: 15.15 % of patients of EHPVO and 21.15 % of patients of cirrhosis of the liver Child A had minimal hepatic encephalopathy in our study.

L-4 Relationship between NT-proBNP and cardio-renal dysfunction in patients with liver cirrhosis

A Anand, G Ramkumar, K Muthukumaran, R Balamurali, T Rajkumar Solomon, A Murali, P Ganesh Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College, 3rd Avenue, Kilpauk, Chennai 600 040, India Background and Aims: ProBNP is a sensitive marker of cardiac dysfunction. Patients with HRS have a decreased renal blood flow, glomerular filtration rate (GFR), and sodium excretion, which appear to be correlated to the decrease in systolic function. We assessed the concentration of circulating NT-proBNP in patients with liver cirrhosis in various stages of the disease and its correlation with markers of cardiac and renal dysfunctions. Methods: Eighty patients with cirrhosis of the liver were included and divided into three groups: group A—17 control patients without ascites; group B—30 non-azotemic patients with ascites; and group C—33 patients with hepatorenal syndrome. Cardiac dysfunction was evaluated by echocardiography. Renal dysfunction was evaluated by estimated glomerular filtration rate formula MDRD 6 equation for creatinine clearance. Serum NT-proBNP levels were determined. The Child-Pugh score was used to assess liver disease severity. Results: The median NT-proBNP serum levels significantly increased in patients with advanced liver cirrhosis CTP C (954.65 pg/mL) as compared to CTP A (179.38 pg/mL) and CTP B (321.58 pg/mL) (p<0.05). There was a 80 % agreement between echocardiography and serum NT pro-BNP levels (kappa coefficient 0.80). Serum NT pro-BNP had a positive predictive value of 0.83 (95 % CI 0.76 to 0.97) and a negative predictive value of 1 (95 % CI 0.24 to 0.55). NT-proBNP levels correlated with the Child-Pugh score (p<0.01), proving the link between the cardiac dysfunction and the liver disease severity. NT-proBNP concentration and the estimated GFR, had a significant negative relationship (r=0.505; p<0.01). Cardio-renal interrelation is supported by the relationship between the NT-proBNP concentration and the estimated clearances. Conclusion: The high NT-proBNP levels in patients with advanced cirrhosis indicate the presence of cardiac dysfunction, which has a role in the pathogenesis of hepatorenal syndrome.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

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L-5

L-7

Is 25-OH vitamin D universally suboptimal in cirrhosis of the liver?

Restless leg syndrome in patients with liver cirrhosis in India

Ravikant Kumar, Sri Prakash Misra, Manisha Dwivedi, Pavan Kumar, Kandarp Nath Saxena Moti Lal Nehru Medical College, George Town, Allahabad 211 002, India

Shankar Lal Jat, S Avani, Vimal Paliwal, Rakesh Aggarwal, Amit Goel Departments of Gastroenterology and Neurology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India

Background and Aim: Liver diseases interfere with production of metabolites of vitamin D required for activation, thus resulting in abnormal calcium and bone metabolism. This study was aimed to determine the status of vitamin D and calcium in patients with cirrhosis and its relationship with etiology and severity. Methods: 25-OH vitamin D assay was performed using automated chemiluminescence immunoassay (DiaSorin LIAISON). Ionized calcium was estimated by an automated analyser (9180 Electrolyte Analyzer, Roche Diagnostics). Vitamin D deficiency and insufficiency are defined as serum 25-OH vitamin D levels less than 20 and between 20 and 30 ng/mL, respectively. Levels between 30 and 100 ng/mL are considered optimal. Vitamin D levels of patients were compared with their healthy family members. Results: Forty-six percent (69/150) of normal population and 128/160 (80 %) patients with cirrhosis had 25(OH) vitamin D inadequacy. Twenty out of 160 patients (12.5 %) had severe vitamin D deficiency. Serum Ca++ was not significantly different between patients and the control group. Etiology of cirrhosis and LFTs had no relation to vitamin D levels. Prevalence of deficiency and insufficiency increases with increase in mean CTP and MELD score and age, and 95 % of CTP class C patients had suboptimal level. Conclusion: Vitamin D insufficiency/deficiency is highly prevalent in cirrhosis irrespective of etiology and is almost universal in advanced cirrhosis of liver. In view of the increasingly recognized beneficial effects of vitamin D, measurement and its replacement may be considered as part of the overall management of patients with cirrhosis.

Introduction: Restless leg syndrome (RLS) is associated with systemic illnesses. Recently, RLS has been reported to occur in patients with liver cirrhosis (LC). We studied the prevalence of RLS in patients with LC and its association with severity of liver disease. Patients and Methods: Adults with LC but no recent hospitalization, clinical deterioration, or gastrointestinal bleeding were enrolled. Patients’ relatives were enrolled as controls. Each participant was interviewed by a gastroenterologist for presence of RLS international RLS diagnostic criteria and quality-of-life (QoL) assessment using a validated Hindi version of the WHOQoL-BREF score. Persons with two or more of five criteria were re-evaluated by a neurologist, and RLS was diagnosed if all five criteria were present. Severity of RLS was assessed using a validated Hindi translation of the International RLS Study Group Rating Scale IRLS. Results: The study included 121 persons each with (males 98; age, mean ±SD 46.1±10.2 years; Child class A/B/C 59/39/23) and 12 controls (males 84; age, 42.2±12.4 years). LC patients had lower QoL scores in all four domains than controls. RLS was more common in LC patients than controls (8/121 vs. 1/121; p<0.05). In LC, RLS was not associated with gender (M/F, 7/1), Child class (A/B/C, 5/1/2) or disease etiology (ethanol 3/8, HBV 1/8, HCV 3/8, cryptogenic 1/8). RLS was usually moderately severe (moderate 5, severe 2, very severe 1). Conclusion: RLS is more common in patients with LC and is moderately severe on most occasions; its occurrence showed no relation with any particular cause or severity of LC. L-8

L-6 A study on lipid profile in chronic liver diseases Non-HFE iron overload as a predictor of disease severity in patients of liver cirrhosis: A cross sectional study from central India

Mohd Talha Noor, Manish Tiwari Sri Aurobindo Medical College and Postgraduate Institute, Indore, India

Y Jaipaul, K Muthukumaran, G Ram Kumar, R Balamurali, A Murali, T Rajkumar Solomon, P Ganesh Department of Digestive Health and Diseases, Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India

Introduction: Cirrhosis of liver is an important cause of mortality worldwide. Various modifiable and non-modifiable factors are involved in its pathogenesis. Our aim was to see the impact of iron overload in patients of liver cirrhosis and its association with HFE gene mutation. Methods: Forty-nine patients with decompensated liver cirrhosis were recruited. Serum iron indices were calculated and various clinical and laboratory parameters were compared in patients with or without iron overload. Serum ferritin and transferrin saturation was correlated with CTP and MELD score. C282Y and H63D gene mutation analysis was done in iron overloaded patients by using polymerase chain reactionrestriction fragment length polymorphism method. Results: There was a significant correlation of transferrin saturation with CTP score (R=0.705, p<0.001) and MELD score (R=0.668, p<0.001). Transferrin saturation was an independent predictor of high CTP score in multivariate analysis (p=0.031). C282Y homozygosity or C282Y/H63D compound heterozygosity was not found in any of the patients with iron overload. Conclusion: Iron overload is an important predictor of disease severity in patients with decompensated liver cirrhosis. Removal of excess iron from the body can improve survival of these patients waiting for liver transplantation. C282Y and H63D mutations are rare in Indian population.

Aim: This study aimed to determine the lipid profiles in patients with chronic liver disease (CLD) and see if it correlates with the severity of the CLD. Materials and Methods: It is a cross-sectional study conducted at our center between August 2014 and June 2015. We included 110 patients with diagnosed CLD irrespective of etiology. Serum triglycerides, total cholesterol, HDL, LDL, and VLDL were measured in fasting state. CTP and MELD score were calculated for each patient as an index for the extent of liver damage. We excluded patients suffering from concomitant diseases, which can alter the lipid profiles, like diabetes mellitus, thyroid dysfunction, HIV infection, acute pancreatitis, and patients who were on lipid-lowering drugs. Results: The four following variables—total cholesterol, LDL, VLDL, and HDL—were significantly low with the exception of serum triglyceride level. The mean values (in mg/dL) were 138, 85, 24, and 36, respectively. Triglyceride values also showed a decline in CLD patients (mean value 119 mg/dL) but it was not statistically significant. There was no significant correlation of progression of liver damage with lower lipid levels. Conclusion: Dyslipidemia exists in patients with CLD. However, no significant correlation was found between severity of CLD and low serum lipid levels.

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Related Article: 1. Varghese JS, Krishnaprasad K, Upadhuyay R, Revathy MS, Jayanthi V. Lipoprotein profile in cirrhosis of liver. Eur J Gastroenterol Hepatol. 2007;19:521–2. L-9 Prolongation of QTc interval in patients with cirrhosis

Thennarasu Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim: The aim of this study was to confirm the QTc interval prolongation in a well-defined group of patients with alcoholic and postviral liver cirrhosis and investigate the relevance of this abnormality with the severity of the disease Materials and Methods: Twenty-six patients with cirrhosis due to alcohol abuse and chronic hepatitis B or C, seen at our center from April 2015 to June 2015. Diagnosis of cirrhosis was confirmed based on either clinical, lab, or ultrasonographical criteria. Severity of cirrhosis was assessed according to the Child-Pugh score and MELD score. Patients with coronary artery disease, conduction abnormalities or arrhythmias, chronic lung disease, arterial hypertension, thyroid disease, and intrinsic renal disease were excluded from the study. Liver function tests, blood cell count, plasma electrolytes, and thyroid hormones were determined. Results: QTc was found prolonged in both groups of patients with alcoholic and postviral cirrhosis (0.47 s) and 0.461 s. In Child-Pugh C and B groups, the mean QTc was prolonged (0.489 and 0.480 s, respectively) but not in Child-Pugh A group (0.445 s). Based on MELD, the mean QTc in patients with a score above or equal to 15 was 0.490 s, and for pts below 15, the mean QTc was 0.450 s. Conclusion: In conclusion, the QTc interval is prolonged in Child-Pugh B and C and in patients with a MELD score above 14, independently of the etiology of cirrhosis. L-10 Pneumonia outcome score in cirrhotics accurately predicts mortality due to pneumonia with cirrhosis

Kapil Dev Jamwal, Amrish Sawhney, Rakhi Maiwall, Guresh Kumar, Sachin Kumar, Shiv Kumar Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction: Pneumonia in cirrhosis is known to be associated with poor outcome; however, there are no studies which have identified predictors of mortality specifically for this group of patients. This may be important to stratify cirrhotic patients getting admitted to the hospital. Patients and Methods: We developed a pneumonia outcome score in cirrhotics (POSIC) for prediction of 28-day mortality in hospitalized patients with cirrhosis (n=583) with pneumonia and subsequently validated it in another prospective cohort (n=522) of cirrhotics with pneumonia. The score was developed using multiple logistic regression analysis. Results: A total of 1105 of 3609 (31 %) patients with cirrhosis were admitted (n=296, 26 %) or developed pneumonia in hospital (n= 809, 74 %). The mortality of patients with pneumonia was significantly higher as compared to those without (617 (55.8 %) vs. 751 (30.1 %), p<0.001, respectively). Of all patients with pneumonia, only 361 (40 %) were culture positive with 85 % having gramnegative isolates (GNB), 7.5 % were gram positive with the same number of fungal isolates, and 1.5 % of isolates were viral. Mechanical ventilation was required in n=235 (26 %). Factors considered for univariate analysis included age, gender, variceal bleed, serum

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creatinine, presence of acute-on-chronic liver failure (ACLF), infection with multidrug-resistant organism (MDR), nosocomial versus community acquired pneumonia, etiology of cirrhosis, comorbidities, presence of encephalopathy, respiratory rate, PaO2/FiO2 ratio, circulatory failure and presence of multiple site infection. Factors significant on multivariate analysis (OR, 95 % CI) in the derivation cohort were presence of ACLF (2.64, 1.72–4.04), serum creatinine ≥2 mg/dL (2.85, 1.92–4.1), nosocomial pneumonia (16.1, 8.1–32.2), and infection with multidrug-resistant bacteria (3.2, 2.1–4.8). The AUROC of the POSIC score for prediction of 1-month mortality was 80.2 % (95 % CI 76.5–83.7) with a sensitivity and specificity of 72.8 % and 73.1 %, respectively. The score performed well for prediction of mortality in the validation cohort (AUROC 0.83, 95 % CI 0.78–0.86) with sensitivity and specificity of 83.9 % and 75.5 %, respectively. The prediction of mortality by POSIC was significantly better than the MELD, MELDNa, and CTP scores in both the derivation and the validation cohorts. Conclusion: One third of hospitalized patients with cirrhosis had pneumonia with a very high mortality. POSIC score can stratify cirrhotic patients with pneumonia who are likely to have worse outcomes.

L-11 Bone marrow mesenchymal stem cells from patients with decompensated liver disease show premature senescence and loss of tissue repair/regenerative potential

Dhananjay Kumar, Sheetalnath Rooge, Smriti Shubham, Lovkesh Anand, Sujata Mohanty, Chhagan Bihari, Anupam Kumar, Shiv K Sarin Departments of Research, Hepatology, and Pathology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi, Delhi 110070, and All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background: Use of autologous bone marrow MSCs in chronic liver disease has shown varied clinical response ranging from mild change in MELD or CTP to no clinical benefit. Weather BM-MSCs form CLD patients are functionally efficient for its tissue repair and regenerative potential is not known. Aim: The aim was to study the functional efficacy of decompensated liver disease (DLD) patients’ BM-MSCs. Patients and Methods: MSCs were isolated from DLD (n=10) patients and age-matched healthy BM donor (n=8) and characterized by studying the surface marker expression (using FACS) in vitro differentiation to adipocytes and osteocytes. Tissue repair and regenerative property were analyzed by studying the level of various trophical and paracrine factors (using RT-PCR and cytokine bead array), angiogenic property (in vitro tube formation assay) and immunomodulatory function (studying the effect MSCs on proliferation of CD4 and CD8 T cells). Population doubling time, colonyforming unit (CFU), and SA-βGal staining were used to study the aging and senescence in these cells. Results: All MSCs fulfilled the minimal criteria for mesenchymal stromal cells: plastic adherence, spindle-shaped morphology, inducible osteo- and adipogenesis, and specific surface expression patterns. Functional analysis shows DLD-MSC are defective in production of growth factors, angiogenic support and immune-modulation (Fig. 1a), suggesting the loss of tissue repair/regenerative function. Further analysis of various cytokines, chemokines, and growth factors showed that DLD-MSCs are exhausted as production of most of the analyzed factors was downregulated. Morphologically, DLD-MSCs showed more flattened morphology, poor CFU, loss of proliferating capacity, X-gal positivity, and increased p21 and CDKN2 expression, suggesting ageing and premature senescence of DLD-MSCs.

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Conclusions: Bone marrow mesenchymal stem cells from patient with decompensated liver disease are functionally defective in their tissue repair and regenerative potential because of premature senescence and are not good candidate for MSCs transplantation.

evidence of portal hypertension and concurrent renal involvement. In the presence of portal hypertension, there is significant short-term mortality.

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The burden and trend of chronic liver disease and its complications: A large hospital-based study

Prevalence of hypothyroidism in patients with decompensated liver cirrhosis

J L Joeimon, K Muthukumaran, G Ramkumar, R Balamurali, A Murali, T Rajkumar Solomon, P Ganesh Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim: The purpose of this study was to identify the prevalence of hypothyroidism in patients with decompensated chronic liver disease. Materials and Methods: Early-morning fasting serum thyroid-stimulating hormone (TSH) was measured by radioimmunoassays in 53 patients with decompensated liver cirrhosis (DCLD) who were not having any known thyroid dysfunction during January 2015 to June 2015, of which 18 belonged to CTP A, 23 belonged to CTP B, and 12 belonged to CTP C. In those who had TSH increase, serum total free thyroxine (FT4) and free triiodothyronine (FT3) were measured. Results: Serum TSH was significantly increased in 6 out of 53 patients (11 %). Subclinical hypothyroidism was seen in 2 patients (3.5 %), while FT3 and FT4 were decreased in 4 patients out of 53 patients (7.5 %). Of the 6 patients having hypothyroidism, 1 belonged to CTP A out of 18 (5.5 %), 3 belonged to CTP B out of 23 (13 %), and 2 belonged to CTP C out of 12 (16.6 %). Conclusion: Although most patients with decompensated liver disease were clinically euthyroid, some abnormalities in circulating thyroid hormone concentrations are noted. It may be associated with more advanced liver pathology.

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Priyanka Jain, Guresh Kumar, Ashok Choudhury, Shiv Sarin Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims: Cirrhosis of the liver is one of the major causes of morbidity and mortality in the community. The aim of the present study was to assess the impact of cirrhosis-related complications on mortality as well as the trend over a period of 5 years. Methods: This is a retrospective hospital-based study in which all medical records of cirrhotic and noncirrhotic patients from 2010 to 2014 were included. The time trend of incident risk ratio for inpatient mortality on year of discharge, length of stay (LOS), diagnosis, and demographic parameters were analyzed using Poisson regression method. Results: A total of 12,547 were hospitalized from 2010 to 2014 with 7102 being cirrhotics; the discharge rate is 81.09 % with total deaths of 18.9 %. Ascites was present in 75.8 %, followed by sepsis in 43.2 %. The association of all-cause mortality was seen with ascites (87.5 %) and sepsis (77.7 %). The proportion of deaths in the hospital was increased significantly over the years among cirrhotics than noncirrhotics (p < 2 days (IRR 13.9, 95 % CI 11.92–16.40) and admission through emergency (IRR 3.718, 95 % CI 3.28– 4.19) associated with mortality. Conclusion: Inpatient mortality increased steadily among cirrhotics, mainly those having ascites, sepsis, and with alcohol intake during the period 2010–2014. A timely approach for diagnosis, prevention of complications, and early referral for liver transplantation may be considered to increase the survival.

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L-15

Cirrhosis in untreated sickle cell disease: protein profile and outcomes

Organ failures associated with acute kidney injury in critically ill cirrhotics have an influence on disease progression and outcomes—A prospective ICU-based study

Hanish Sharma, Hrishikesh Mishra, Nilesh Gupta Bhartiyam Centre for Gastroenterology, Background: Sickle cell disease has a significant prevalence in central India (homozygous=0.6 %). There is little data about chronic liver disease apart from episodes of jaundice with cholestasis and hepatic sequestration. Study Design: Profiled consecutive patients of sickle cell disease with jaundice and ascites were studied. Results: Between June 2014 and June 2015, 87 patients (62 males/15 females) presented with jaundice and ascites. Mean age was 41.2±4 years (range 14–56 years). There was evidence of significant proteinuria (>300 mg/day). All had prior episodes of jaundice. Palpable left lobe of the liver with esophageal varices was seen in 58. Radiologically, features of cirrhosis were seen in 71. Splenic atrophy was seen in all. The reason for jaundice was HEV in 15 and hemolytic crisis in 48. Eight patients had prolonged cholestasis. There was evidence of spontaneous bacterial peritonitis in 7 patients. Three patients developed altered sensorium initially suspected as encephalopathy; however, there was rapid deterioration and one documented brain stem stroke. All patients were homozygous for sickle cell traits. Mortality at 1 month was significantly high in those with varices (31/58 vs. 3/29). No variceal bleed was encountered. Conclusion: Chronic liver disease in Indian patients with sickle cell disease (in the absence of hemosiderosis) has distinct characteristics with

Rakhi Maiwall, S K Sarin, Richard Moreau Institute of Liver and Biliary Science, D-1, Vasant Kunj, New Delhi 110 070, India, Inserm, U1149, Centre de Recherche sur l-Inflammation (CRI), Clichy and Paris, France; 3UMRS1149, Universit © Paris Diderot-Paris 7, Paris, France; Departement Hospitalo-Universitaire (DHU) UN Background/Aims: Currently, there are no studies evaluating acute kidney injury (AKI) in critically ill cirrhotics and its association to extra-renal organ failures (E-OFs). Patients and Methods: Consecutive patients with cirrhosis admitted to the intensive care unit were prospectively followed. Extra-renal organ failures were defined according to the CLIF-SOFA score. Results: A total of 189 patients with cirrhosis, aged 48.8±11 years, 85 % males, with a mean MELD of 29±8, were included, of which only 43 (22.8 %) were alive at 1 month. AKI at admission was present in 143 (75.6 %); 152 patients (80.2 %) had at least one E-OF. At day 7, 53 % of all patients with no AKI at admission developed new AKI, while 59 % with AKI had progression of AKI. The presence of any E-OF was strongly associated with both development of new AKI (p=0.004, OR 6.7, 95 % CI 1.86–24.1) and progression of AKI (p=0.04, OR 2.28, 95 % CI 1.01–5.1). This risk further increased with increase in the number of EOFs (p=0.001, OR 1.41, 95 % CI 1.2–1.7). Further, AKI at admission

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alone was not associated with mortality but predicted mortality together with any E-OF (p<0.001, OR 5.5, 95 % CI 2.1–14.8). On multivariate analysis, the presence of any E-OF (p=0.03, OR 2.8, 95 % CI 1.05–7.6), AKI progression (p=0.02, OR 2.5, 95 % CI 1.1–5.7), arterial lactate (p= 0.02, OR 1.27, 95 % CI 1.02–1.58), and leucocyte count (p=0.003, OR 1.01, 95 % CI 1.03–1.17) were independent predictors of 1-month mortality. Conclusion: E-OFs are commonly associated with AKI in critically ill cirrhotics, which determine both development and progression of AKI as well as mortality. The presence of AKI alone is not associated with worse outcome in critically ill cirrhotics. L-16 Clinical significance of von Willebrand factor levels in patients with cirrhosis

Vaibhav Somani, Deepak Amarapurkar Department of Gastroenterology, Bombay Hospital and Medical Research Center, 12, Marine Lines, Mumbai 400 020, India Objective: von Willebrand factor (vWF) is a surrogate marker of endothelial dysfunction and is increased in patients with cirrhosis, but its clinical significance is unclear. vWF antigen (Ag) plays an important role in primary hemostasis and development of thrombotic vascular obliteration is discussed as a possible mechanism leading to portal hypertension and their possible clinical prognostic value. In this study, we evaluated the association of serum vWF Ag level with the severity of cirrhosis (according to the Child-Pugh classification), its correlation with patients having thrombosis and size of esophageal varices in cirrhotics. Materials and Methods: We included 81 cirrhotic patients (male 59, mean age 59+11) in the study. Diagnosis of cirrhosis was made on the basis of biopsy, clinical, laboratory, and imaging parameters. vWF Ag level was done using a vWF Ag 96-microwell test kit from Helena Biosciences Europe. The stage of cirrhosis was defined by using the Child-Pugh classification and MELD score. Data were analyzed by using Statistical Package for the Social Sciences (SPSS) 10.0 software program. Results: We observed there was no statistically significant difference in the vWF Ag levels with the increasing stages of cirrhosis according to Child-Pugh score, in patients with thrombosis and no thrombosis and size of esophageal varices. Conclusion: Our study does not show any correlation of increase in serum vWF Ag levels with increased severity of cirrhosis as shown in previous studies. L-17 Outcome of anticoagulation in patients with cirrhosis and portal vein thrombosis

Kadavanoor Srijith, Deni Joseph, M Ramu, G Chethan, T S Prasanth, Nikhil Suraj, Gopu, S Sreejaya, Krishna Das Department of Medical Gastroenterology, Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background and Aims: Portal vein thrombosis is a frequent event seen in patients with cirrhosis and can be treated with anticoagulants. There are limited data regarding its safety in patients with cirrhosis. We retrospectively analyzed this treatment approach in patients with cirrhosis and portal vein thrombosis. Methods: We analyzed data of 45 patients with cirrhosis and portal vein thrombosis diagnosed in between the period January 2011 to December 2014 who presented to our Department of Medical

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Gastroenterology, Govt. Medical College, Thiruvananthapuram. Portal vein thrombosis was diagnosed and recanalization was evaluated by using Doppler ultrasound and CECT abdomen (hepatic protocol). Results: Partial or complete recanalization was achieved in 22 patients (48.88 %). The factor significantly associated with recanalization was early initiation of anticoagulation. Patients with recanalization had less frequent complications such as portal hypertension related bleeding, ascites and hepatic encephalopathy during the follow up period. Four patients developed bleeding complications. The patients who developed bleeding complications were Child C and had had a platelet count less than 50,000. Two deaths were reported related to bleeding complications related to anticoagulation therapy. Conclusions: Anticoagulation is a relatively safe treatment that leads to partial or complete recanalization of the portal vein in about 49 % of patients with cirrhosis and PVT. Bleeding complications though infrequent may be related to low platelet count.

L-18 Plasma brain-type natriuretic peptide levels: Predictor of mortality in cirrhotics

Satyarth Chaudhary, Mohd.Talha Noor, Sunil Jain, Siddhant Jain, Mahendra Tilkar Sri Aurobindo Medical College and Postgraduate Institute, Indore, India Introduction: India comprises almost one fifth of global liver mortality by cirrhosis of liver. Brain-type natriuretic peptide (BNP) is elevated in cardiovascular and extracardiac conditions including liver cirrhosis. Materials and Methods: Prospective observational case control study of 40 patients (age 18–75 years) admitted and diagnosed liver cirrhosis in our center from May 2013 to December 2014. Detailed history, physical examination, complete hemogram, LFT, KFT, HIV, HBsAg, anti-HCV, plasma BNP, ultrasonography and endoscopy were performed on all patients. Pulmonary, cardiovascular, endocrine diseases, renal failure and inflammatory diseases were excluded. Forty healthy controls were also included. Primary end point was death and patients were followed up to 12 months. Results: Mean age was 46.65±10.14 years and male to female ratio was 29:11. Alcohol (50 %) was most common etiology followed by HBV (25 %), HCV (7.5 %) and dual etiology (alcohol + HBV) 2 patients (5 %). Mean BNP level in cirrhotics vs. controls were 405.95 ± 294.81 vs. 21.38 ± 14.21 pg/mL; p < 0.0001. Plasma BNP levels were more increased in alcoholics as compared to other etiologies (552.55± 314.82 vs. 226.78±123.11 pg/mL; p<0.0001). Plasma BNP levels were significantly raised in ascites (472.63±306.30 vs. 205.90±122.57 pg/mL; p=0.011), jaundice (572.89± 326.82 vs. 269.36±177.53 pg/mL; p=0.001), coagulopathy (445.16±247.04 vs. 340.60 ± 360.81 pg/mL; p = 0.006) and hepatic encephalopathy (587.36±368.17 vs. 308.27±191.70 pg/mL; p=0.003) as compared to controls but does not correlate with variceal bleed, tachycardia, SBP and renal dysfunction. BNP levels were elevated according to severity of disease (Child A vs. Child B vs. Child C: 107.6±59.53 vs. 302.88± 160.97 vs. 586.17 ±320.91 pg/mL; p <0.0001. BNP levels significantly correlate with the grade of esophageal varices (grade 1 vs. grade 2 vs. grade 3: 248.57±197.21 vs. 328.87±200.4 vs. 531.39 ± 347.12 pg/mL; p = 0.039). Mortality was seen in 11 patients (27.5 %). BNP levels were significantly elevated in patients who died as compared to those who survived (752 ± 309.21 vs. 274.69 ± 148.40 pg/mL; p<0.0001). Conclusion: BNP is an independent predictor of medium term survival in cirrhotic patients.

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Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 L-19 How common is Clostridium difficile in hospitalized patients with cirrhosis in India?

T J Vadivukkarasi, K G Sajith, Uday Zachariah, Ashish Goel, Shalini Anandan, V Balaji, C E Eapen Division of Gastrointestinal Sciences, and Department of Microbiology, Christian Medical College, Vellore 632 004, India Background: Etiology and impact of acute diarrhea, especially Clostridium difficile infection, in patients with cirrhosis in India, is unclear. This study was conducted for the same, in a tertiary liver care unit in India. Material and Methods: From December 2014 to July 2015, all hospitalized adult consecutive patients with cirrhosis and its complications, who also had acute diarrhea at the time of admission were included in the study with informed consent. All patients’ stool samples were processed for a novel, rapid (1 h) diagnostic test (Illumigene) for toxigenic C. difficile using loop-mediated isothermal amplification technology (98 % sensitivity and specificity). Besides routine evaluation, stool tests for culture, parasite microscopy were done. Results: Among 36 patients studied, there were 28 males, age 51± 16 years, mean± SD; Child’s class A:B:C (4:16:16); MELD score 19 ±8. Alcohol (17 patients) was the most common etiology of liver disease. Use of proton pump inhibitors (81 %), recent hospitalization (78 %), recent antibiotic use (69 %) and ongoing steroids/ immunosuppressants (17 %) were observed in these patients. Identified etiology of acute diarrhea were toxigenic C. difficile in 2 patients, besides Aeromonas (5), non-01/0139 Vibrio cholerae (1) in stools. Eight patients had SBP which could have presented as diarrhea. Three patients (1 each) had parasite infestation by S. stercoralis, G. lamblia, and E. vermicularis. Of the 3 (8 %) patients expired during hospital stay, one had C. difficile infection. Conclusion: C. difficile was identified etiology of acute diarrheal illness in 6 % of hospitalized patients with cirrhosis, in India. L-20 Functional assessment of a genetic variant of TNF-α±rs361525 (−238G/A) to determine its contribution to the development of alcoholic liver disease

Debanjali Dasgupta, Neelanjana Roy, Nitai P Bhattacharya, Simanti Datta, Abhijit Chowdhury, Soma Banerjee Centre for Liver Research, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, 244, A J C Bose Road, Kolkata 700 020, India, and Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India TNF-α±, a pleiotropic cytokine, plays an important role in pathophysiology of alcoholic liver diseases (ALD). Recently in a case-control association study, A allele at rs361525 (−238) loci of TNF-α±promoter has been found to be significantly associated with ALD in Eastern Indian Bengali population. This study aimed to characterize the functional significance of this SNP in ALD development. In accordance to the previous data, significantly higher luciferase activity was noted with AA-genotype positive TNF-α±promoter construct compared to GG in presence or absence of lipopolysaccharide. Furthermore, bioinformatics analysis and subsequent luciferase assay revealed that NF was the putative transcription factor, for which this subtle change in nucleotide sequence altered its binding to the TNF-α±promoter construct in a time and dose dependent manner. Higher level of TNF-α±expression was also found in ALD

patients. In vitro overexpression of TNF-α±in hepatocyte displayed enhanced level of downstream pro-inflammatory cytokine IL-1 and chemokine IL-8, followed by increased hepatocyte apoptosis. Enhanced migration of leukocytes was observed through endothelial barrier in transwell assay upon overexpression of TNF-α±in endothelial cells (ECS). Conversely, loss of function analysis of TNF-α±by over expression of miR124, verified by 3 UTR luciferase assay and protein level, showed lesser amount of apoptotic hepatocyte and reduced level of leukocyte migration through endothelial barrier. Thus, this study highlights that genotypespecific binding of NF to promoter of TNF-α± leads to overexpression of this cytokine which causes activation of the inflammatory cascade and leukocyte infiltration in the development of alcohol-mediated liver diseases. L-21 Role of serum procalcitonin levels in patients with alcoholic hepatitis in predicting infection

Santosh Kumar Yadav, Chethan Govindaraju, Prasanth Thyalill Sudeedhandran, Arun Ayer, Goerge Peter, Devdas Krishnadas Department of Medical Gastroenterology Superspeciality Block (SSB-3), Ulloor Road, Thiruvananthapuram 695 011, India Background and Aims: Procalcitonin, a propeptide of calcitonin, is an early marker of infection. Sepsis in alcoholic hepatitis carries a very high mortality risk. So early diagnosis of sepsis in alcoholic hepatitis is important for optimal management. There is no data to suggest whether serum procalcitonin is an early marker of sepsis in alcoholic hepatitis. Methods: All patients admitted with alcoholic hepatitis underwent procalcitonin measurement on admission. Patients were classified into two groups: group I—alcoholic hepatitis with infection and group II—alcoholic hepatitis without infection. Receiver operating curve (ROC) was plotted to obtain cutoff of procalcitonin to compare between two groups. Results: This study included a total of 80 patients; group I had 50 patients and group II had 30 patients. All were males (mean age 44, range 33– 63 years). Age, biochemical parameters, Child-Turcotte-Pugh score (CTP), discriminant function (DF), end-stage liver disease, and procalcitonin were analyzed. On multivariate analysis DF, serum albumin, prothrombin time, urea, total leukocyte count (TLC), and procalcitonin were statistically significant. Procalcitonin was elevated from usual baseline cutoff in both the groups. But, procalcitonin was significantly elevated in group I compared to group II which was statistically significant. ROC was plotted, area under curve (AUC) was 0.94 (95 % CI 0.89-1.003). A cutoff of 0.54 μg/L was obtained to distinguish between the two groups. Conclusions: Serum procalcitonin is a very useful marker to diagnose infection in patients with alcoholic hepatitis. Procalcitonin >0.54 μg/L implies presence of sepsis. L-22 A validation of prognostic scores to predict mortality in alcoholic hepatitis

Nikhil Suraj, Chethan Govindraju, Prasanth Thayyil Sudheendran, Deni Joseph, Srijith Kadavanoor, Ramu M Pillai, Bincy, Devadas Krishnadas, Srijaya S Sreesh, Prasanth K Sobhan, Shanid A Sathar Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Aim: Assessment of mortality risk is an important factor in the clinical management in patients with alcoholic hepatitis. There are a number of scoring systems to assess the prognosis and mortality in alcoholic hepatitis. We aimed to evaluate and compare the

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predictive performances of the Child-Turcotte-Pugh score (CTP), discriminant function (DF), Glasgow alcoholic hepatitis score (GAHS), the model of end-stage liver disease (MELD), the MELD-Na, and the age, bilirubin, international normalized ratio, and creatinine (ABIC) score in patients admitted with alcoholic hepatitis. Material and Methods: The study was conducted as a retrospective observational study. The clinical and biochemical parameters were used to calculate the scores. We applied the scoring systems to all 240 patients hospitalized and diagnosed to have alcoholic hepatitis. The ability of each score to predict mortality was evaluated using receiver operating characteristics curves, and the area under the receiver operating characteristics curves (AUROCs) was used to compare the scores. Results: The 30- and 90-day mortality were 14 and 22 %, respectively. All the scores except CTP had similar predictive properties with AUROC= 0.73–0.8 for 30-day mortality and 0.73–0.79 for 90-day mortality. There were no statistically significant differences between the models performances (p L-23 Evaluation of autonomic function tests in chronic alcoholic liver disease

S Shankar, K Muthukumaran, G Ramkumar, R Balamurali, P Ganesh, T Rajkumar Solomon, A Murali Department of Digestive Health and Diseases, Kilpauk Medical College and Peripheral Hospital, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aims and Objects: The aims of the present study were (1) to study the prevalence of autonomic dysfunction in patients with chronic alcoholic liver disease and (2) to determine the degree of severity of alcoholic liver disease by Child-Turcotte-Pugh scoring and its correlation with autonomic profile. Methods: The study was a cross-sectional study from July 2014 to May 2015 done in a sample of 40 patients with chronic alcoholic liver disease, diagnosed on the basis of history, clinical examination and relevant laboratory investigations. Autonomic function tests included (parasympathetic) heart rate variation to deep and slow breathing (E:I), heart rate response to Valsalva maneuver (VR), heart rate response to standing (30:15), and (sympathetic) blood pressure response to standing and to sustained handgrip. Results: Out of 40 patients, autonomic dysfunction was seen in 75 % of patients. All were having parasympathetic dysfunction whereas sympathetic function was affected in 30 %. 30:15 was the most common altered test (65 %). Seventy-five percent had fatty liver. Ninety percent had hepatitis and 85 % of cirrhosis patients had autonomic neuropathy. Weakness (75 %), dizziness (70 %), vasomotor symptoms (65 %), and palpitations (56 %) were the most common complaints. Low platelet count (90 %), Child-Pugh score more than 7 (80 %), portal hypertension in ultrasound scan (68 %), and varices on endoscopy (80 %) were significantly associated with the occurrence of autonomic neuropathy among alcoholic liver disease patients. L-24 Clinical profile of chronic alcoholic liver disease

Parag G Deshmukh, R P Mundle, Sanchita Rao Objective: The purpose was to study the clinical profile of chronic alcoholic liver disease (ALD) and factors effecting severity of the liver disease.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Materials and Methods: One hundred and fifteen chronic alcoholics were screened for symptoms and signs of ALD. They were compared on the basis of clinical findings and investigations. Results: Majority of the patients were in the age group 30–49 years. Only one female patient was reported. 80.87 % (n=93) patients presented classical symptoms of ALD. Country liquor was predominantly consumed (59.13 %). Most of the patients (85.21 %) consumed more than 120 g of alcohol per day. 62.61 % of patients had consumed alcohol for more than 10 years. Food intake after alcohol consumption showed significant effect on occurrence of cirrhosis. Abdominal distension was the commonest presentation (39.1 %) and the commonest clinical finding was icterus (61.73 %). Liver function test was deranged in 72.17 % of patients. Mean serum bilirubin was 5.02±5.12. SGOT:SGPT ratio was reversed in 17.39 % of patients. Hypoalbuminemia was found in 53.04 % of patients. Liver cirrhosis was the commonest finding (46.96 %). Amount (p=0.2472) and duration (p=0.3266) of alcohol consumption was not related to type of ALD. Esophageal varices were present in 32.17 % of patients. The findings of liver biopsy correlated to those of ultrasonography. Conclusion: The study presents the spectrum of ALD in chronic alcoholics. Many patients are asymptomatic so all heavy drinkers should be targeted for early investigation. The SGOT/SGPT ratio is not generally applicable in the staging of ALD. Ultrasonography is a reliable noninvasive tool for diagnosis of type of ALD.

L-25 Alcohol is the cause for most of liver-related deaths: An audit of liver mortality from a tertiary care center in north India

Varun Gupta, Ashish Kumar, Praveen Sharma, Naresh Bansal, Vikas Singla, Anil Arora Institute of Liver, Gastroenterology, and Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Background: Alcohol, hepatotropic viruses, and non-alcoholic steatohepatitis (NASH) are the most important causes of liver-related deaths. The distribution of these causes among Indian patients dying of liver disease is unknown. This information will help in prioritizing healthcare efforts in preventing liver-related deaths in India. Methods: Records of all consecutive patients who had died due to liver-related causes in the Gastroenterology Department of Sir Ganga Ram Hospital, New Delhi, India, from November 2010 to October 2014 were analyzed. Patients dying due to non-hepatic cancers metastasizing to liver were excluded. Clinical presentation and immediate etiological causes of death were analyzed. In patients with multiple factors, the most immediate etiology was taken as the cause of death. Results: Records of 401 consecutive patients were analyzed. Nine patients were excluded who had died of liver metastasis from non-hepatic cancers; hence 392 patients were included in the study (median age 50 [range 14– 87] years, males 80 %). Underlying chronic liver disease (CLD) was present in 86 % (335/392) while in 14 % (57/392) there was no underlying CLD. In CLD group most patients (71 %, 237/335) had presented with complications of cirrhosis (such as end-stage liver disease, portal hypertension, sepsis, etc.). Acute-on-chronic liver failure was the presentation in 29 % (98/335) of CLD patients. Among patients without underlying CLD, the most common presentation was with acute liver failure (68 %, 39/57). Overall, the most common cause of liver-related death was alcohol, responsible for 30 % (118/392) of deaths, followed by NASH/ cryptogenic in 23 % (91/392), hepatotropic viruses in 19 % (73/392), bacterial/other infections in 12 % (45/392), and drug-induced liver injury in 6 % (24/392). In 5 % of cases, the cause was some unidentified acute hepatic insult. The distribution of causes of death in various presentations is shown in Table.

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Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Conclusions: Alcohol is the most important cause of liver-related deaths in India and NASH/cryptogenic cirrhosis is the second important cause. Since, both these causes are preventable by increasing public awareness and implementing life-style measures, urgent attention should be paid towards these measures. L-26 Corticosteroids versus pentoxyphylline in severe alcoholic hepatitis: Experience from a tertiary care hospital in north India

Anurag Kumar Tiwari, Sunit Kumar Shukla, Manish Kumar Bhaskar, Sanchit Budhiraja, Vinod Kumar Dixit, Ashok Kumar Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction: Severe alcoholic hepatitis (SAH) continues to be a significant cause of mortality and morbidity. Treatment of SAH remains largely elusive. We retrospectively compare the role of corticosteroids versus pentoxyphylline in SAH (DF score 32 or more). Methods: Data was collected retrospectively from medical record section of patients admitted in Sir Sunder Lal Hospital, Department of Gastroenterology, Banaras Hindu University, over a period of three years from August 2012 to June 2015. Sixty-one patients with SAH were included. Twenty patients received corticosteroids (group A) and 41 received pentoxyphylline (group B). Patients with gastrointestinal (GI) bleed, acute kidney injury or sepsis received pentoxyphylline. Primary outcome was mortality in 28 days. Results: In group B, 39 % of patients had hepatic encephalopathy (HE), compared to 35 % in group A. In group B, 29 % had renal dysfunction including hepatorenal syndrome (HRS), 53 % had infection and 31.7 % had GI bleed. Twenty-five percent patients in group A and 39 % in group B died within 7 days of start of treatment. Survival beyond 28 days was 70 % in group A and 43.9 % in group B. Conclusion: SAH has high overall short-term mortality (47.5 %). Though group A patients appear to have less short-term mortality in SAH, patients in group B had severe comorbidity leading to high mortality in this group. L-27 Hand grip dynamometry as a predictor of short-term mortality in alcoholic liver disease

Nitin R Gaikwad, Sudhir Gupta, Amol R Samarth, Niraj R Sawalakhe, Sonal Gattewar Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Introduction: Malnutrition rate varies in cirrhotics from 20 % in compensated cirrhosis to 60 % in decompensated cirrhosis. Our aim was to analyze utility of hand grip dynamometry to predict the short-term mortality in alcoholic cirrhotics. Material and Method: It was a prospective study of 3 months duration at our institute from April 2015 to June 2015. All patients with alcoholic liver disease aged more than 18 years were evaluated for the nutritional status using standard nutritional tools and hand grip dynamometer (CAMREY). Short-term prognosis was assessed by 3-month mortality and complications of cirrhosis. Results: Total patients were 82. The male/female ratio was 40:1. Mean age of the patients was 43.42±10.13 years. Average alcohol intake was 48.89±14.17 g/day for 8.7±3.88 years. Mean hand grip strength was strongest in CTP A (30.91±4.83 kg), than in CTP B (24.21±5.24 kg)

and CTP C (19.44±4.19 kg) (p<0.05). 24.39 % of patients were well nourished (SGA A), 64.63 % were mild to moderately nourished (SGA B) and 10.97 %were severely malnourished (SGA C). Patients with severe malnutrition (SGA C) were more likely to have the higher CTP score than SGA A and B. Complications of the cirrhosis (spontaneous bacterial peritonitis/hepatic encephalopathy/hepatorenal syndrome) were more in SGA C (66.66 %) than SGA B (22.64 %) and SGA A (10 %). Short-term mortality is also more in SGA C (55.55 %) than SGA B (11.32 %), and SGA A (0 %). Mean hand grip strength was strongest in survivors 24.30± 5.75 kg than nonsurvivors 18±4.59 kg (p<0.05). Conclusion: Malnutrition causes significant morbidity and mortality in cirrhotics which can be predicted by hand grip dynamometry which is a simple inexpensive and effective method. L-28 Resistivity index-an early predictor of renal dysfunction in alcoholic liver cirrhosis

M I Abhilash, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, 6-1-34, Bhoiguda Road, Musheerabad, Secunderabad 500 025, India Aim: The aim of the present study was to describe the alcoholic liver cirrhosis patients in relation to Child-Pugh score, MELD score and their correlation with MDRD eGFR and resistivity index by renal Doppler study. Materials and Methods: Thirty patients of alcoholic liver cirrhosis were subjected to LFT, RFT, ultrasound abdomen and renal Doppler studies. Hepatic parameters like Child-Pugh score, MELD score, DF score were calculated according to standard formulas. MDRI eGFR was estimated and resistivity index assessed by renal Doppler study. Both hepatic and renal parameters were correlated and statistical analysis done. Results: There were 25 male patients and 5 female patients. Three patients were falling into Child-Pugh class A, 6 patients into class B, 21 patients into class C. Mean values for MELD score was 19.3±18.54, MDRD eGFR was 71.79±−62.85, DF score was 124.35±77, resistivity index was 0.77±0.27. We observed that MELD and DF scores were increasing from class A to class C. There was inverse relation between MDRD Egfr and resistivity index in all classes. Pearson’s correlation between MELD score and MDRD eGFR was −0.71, which was statistically significant with p value of 0.00001. Pearson’s correlation between MELD score and RI was +0.55 which was statistically significant with p value of 0.001. Conclusion: Our results show simple, non-invasive renal Doppler parameter resistivity correlate with severity and complications of alcoholic liver cirrhosis, which can predict the patients with risk of developing kidney dysfunction and hepatorenal syndrome. L-29 Study on the clinical profile of portal vein thrombosis in patients of alcoholic cirrhosis

Tushar H Sankalecha, Sudhir Gupta, Amol R Samarth, Niraj R Sawalakhe, Dharmesh K Shah Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Introduction: Discrepancies exist in the prevalence of portal vein thrombosis (PVT), and its clinical characteristics and sites of occurrence need to be elucidated. The aim of this study was to determine the prevalence, clinical characteristics, and sites of PVT in alcoholic cirrhotic patients attending our hospital.

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Materials and Methods: It was a retrospective analytical study for duration of two year from July 2013 to June 2015. PVT was detected by both Doppler ultrasonography and contrast enhanced computed tomography. Results: Total patients were 250 (male/female=62.5:1. 32 (12.8 %) patients had PVT. Most common site of PVT was main trunk (MT) in 19 (59.37 %), right and/or left branch thrombosis in 5 (15.62 %), MT+SMV thrombosis in 4 (12.5 %), MT+SV thrombosis in 3 (9.3 %) and in MT+ SMV+SV in 1 (3.1 %) patients. Ascites was the most common clinical feature (71.87 % PVT vs. 35.77 % non-PVT) followed by pedal edema (50 % PVT vs. 22.47 % non-PVT) and jaundice (40.62 % PVT vs. 15.13 % non-PVT). In the PVT group, 31.25 % of patients had HRS, 18.75 % had SBP, and 9.3 % had HE. In the non-PVT group, 25.68 % of patients had HRS, 14.67 % of patients had SBP, and 9.17 % of patients had HE. PVT was more common in CTP class B (50 %) and C (37.5 %) cirrhotics than in CTP-A (12.5 %). Conclusion: Occurrence of PVT was 12.8 % in alcoholic liver cirrhosis patients. PVT occurred mainly in portal vein trunk and presented most commonly with ascites. L-30 Is serum ferritin a predictor of the severity of alcoholic hepatitis?

Prasanth Thayyil Sudheendran, Chethan Govindaraju, Nikhil Suraj Deni, Joseph, M Ramu, Pillai, Sreejith Kadavanoor, Santosh Yadav, Premaletha, Narayanan Kattoor, Ramakrishnan, Vinayakumar Devang, Tank Shanid, A Sathar, S Srijaya, Sreesh Devadas Krishnadas Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background and Aims: Heavy alcohol consumption is associated with iron overload and elevated serum ferritin levels and lead to liver injury and alcoholic liver disease. The severity of alcoholic hepatitis (AH) measured using discriminant function DF (DF<32 or DF>32). But, very few studies attempted to correlate the serum ferritin level and severity of AH. Hence, we try to find out if serum ferritin correlate with severity of AH based on DF and find cutoff value to diagnose severe AH. Methods: All patients were admitted with AH over an 18-month period (cross-sectional study). They were divided into two groups depending on DF <32 (group I) and DF>32 (group II). Univariate and multivariate analyses were done using DF as the independent factor. The ability of serum ferritin to predict the severity of AH was evaluated using receiver operating characteristics (ROC) curve to find area under curve (AUC) and to derive a cutoff level. Results: The study included 160 patients (100 % males mean age 44.7 years) with 24 patients in group I and 136 patients in group II. Univariate analysis showed that age, CTP, CHILD, MELD, bilirubin, PT INR, albumin, sodium, ferritin, infection were statistically significant. In multivariate analysis age, CTP, ferritin, albumin and infection came out as independent predictors. We plotted ROC curve taking serum ferritin level and DF and got AUC 0.917 {95 % CI (0.87–0.966)} with p=0.000. A ferritin cutoff level of 212.0 or above (sensitivity 82.6 %, specificity 84.3 %) clearly shows severe AH. However we compared serum ferritin level with and without infection and found that even without infection ferritin levels are higher (697.0 vs. 576.0, p = 0.115) but was not significant. Conclusion: Serum ferritin can be used as a marker to assess the severity of AH. L-31 C-reactive protein predicts short-term mortality in patients with alcoholic hepatitis

Gopu R Babu, Ponni Krishnan, K Srijith, K D Krishnadas

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Background and Aims: We aimed at improving prediction of short-term mortality in alcoholic hepatitis in patients by evaluating C-reactive protein (CRP) as a surrogate marker of systemic inflammatory response syndrome (SIRS). To assess the utility quantitative CRP values for predicting short-term (30 and 90 days) mortality in patients with alcoholic hepatitis. This study aimed to compare quantitative CRP values with different published scoring systems in predicting short-term (30 and 90 days) mortality in patients with AH and to predict the severity. Methods: One hundred and eight consecutive patients with alcoholic hepatitis and without hepatocellular carcinoma were prospectively included and followed for 90 days. Quantitative CRP values were obtained at admission from these cases. The other published scoring systems in alcoholic hepatitis in these patients were calculated. The primary end-point was 3-month survival. Other exclusion criteria were as follows: patients with severe other systemic infections, patients with concurrent other viral hepatitis, DILI, autoimmune hepatitis. Results: CRP increased significantly with the severity of acute alcoholic hepatitis (p<0.001). Total bilirubin (OR=1.03, 95 % CI 1.01–1.06, p= 0.04) and CRP (OR=1.1, 95 % CI 1.02–1.19, p=0.01) were independent factors for predicting severity of alcoholic hepatitis. CRP is an accurate marker of alcoholic hepatitis CRP range was 1–240 mg/L (median 26 mg/ L); Forty-two patients died within the first 6 months of follow up. Shortterm mortality was associated with high MELD score, renal failure, and high baseline CRP levels (best cutoff value at 32 mg/L). Among patients with baseline CRP ≥32 mg/L, 32 still had CRP ≥32 mg/L at day 15. Multivariate analysis (Cox) adjusted for age identified three predictors of mortality: high MELD score, extrahepatic comorbidities and CRP level. Conclusions: In alcoholic hepatitis patients, CRP levels ≥32 mg/L predicted short-term mortality independently of age and MELD, and other comorbidities.

L-32 Is acute kidney injury a significant predictor of short-term mortality in patients with severe alcoholic hepatitis?

Arun Iyer, C Govindaraju, G Peter, D Krishnadas Department of Medical Gastroenterology, Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Background: Given the conspicuous short-term mortality, there is a stringent necessity for early recognition of patients who suffer from severe alcoholic hepatitis (AH) to select the appropriate management. We studied effects of acute kidney injury (AKI) on survival of patients with AH. Methods: We retrospectively analyzed data from 103 patients with AH. AKI was defined as an abrupt reduction (within 48 h) in kidney function that resulted in an absolute increase of at least 0.3 mg/dL (or a 50 % increase) in serum levels of creatinine from baseline [AKIN criteria]. Results: Twenty-nine patients (28 %) developed AKI during hospitalization, with a median time to diagnosis of 3 days. Overall 90-day mortality was 23 %, which was significantly higher among patients with AKI than those without (65 % vs. 7 %; p<0.0001). The age, bilirubin, international normalized ratio, and creatinine score (p<0.0001) and development of AKI (p<0.0001) were the most accurate independent predictors of 90-day mortality. The presence of systemic inflammatory response syndrome (p<0.0001), serum bilirubin (p=0.01), and international normalized ratio at admission (p=0.03) were the most accurate predictors of AKI. Importantly, the AKIN criteria were more accurate than traditional criteria for renal failure (serum creatinine >1.5 mg/dL) in predicting 90-day mortality (area under the receiver operating characteristic, 0.83 vs. 0.70, respectively; p=0.02). Conclusions: Development of AKI reduces survival of patients with AH, in the short-term. Strategies to prevent AKI therefore should be considered in the management of patients with AH.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 L-33 Cardiac dysfunction in nonalcoholic cirrhotic patients

V Vamsidhar Reddy, S Venkata Reddy, K R Thankappan, M G Srinivas, M Harsha, Y Harish Kumar, S Rahul Department of Medical Gastroenterology, Narayana Medical College, Chinthareddipalem, Nellore 524 002, India Background: Cirrhotic cardiomyopathy is defined as a chronic cardiac dysfunction in patients with cirrhosis, characterized by blunted contractile responsiveness to stress, and/or altered diastolic relaxation with electrophysiological abnormalities, in the absence of known cardiac disease. Cardiac failure is an important cause of mortality after liver transplantation. Aims: The objective was to study the cardiac dysfunction and conduction disturbances in nonalcoholic cirrhosis of liver and to assess the relationship between the severity of cirrhosis and the presence of cirrhotic cardiomyopathy. Methodology: All the patients attending the Department of Gastroenterology from January 2012–14, in Narayana Medical College with nonalcoholic cirrhosis were included in the study. Patients with alcoholic history, diabetes, hypertension, coronary artery disease, risk factors for cardiomyopathy other than alcohol, severe ascites, severe anemia, gastrointestinal bleed were excluded. For all patients Hemogram, LFT, ultrasound abdomen, viral markers, ascitic fluid analysis, electrocardiography, and echocardiography were done. Results: Thirty patients with nonalcoholic cirrhosis were included in the study, out of which HBV (30 %), HCV (13 %), cryptogenic (57 %). In this study, QTc was prolonged in 56.2 % of CTP class B cirrhotics, 100 % in CTP class C cirrhotics, which is statistically significant (p<0.001). Conclusions: Cirrhotic patients with nonalcoholic etiology do have evidence of cirrhotic cardiomyopathy. The presence of cirrhotic cardiomyopathy was independent of the etiology. Prolongation of QTc interval correlates with severity of cirrhosis. Ventricular end diastolic volume, end systolic volume, diastolic dysfunction and ejection fraction do not correlate with severity of cirrhosis.

L-34 Clinical profile of nonalcoholic fatty liver disease in overweight and obese children: A population based study

Sunil Pawar, Vinay Zanwar, Ajay Choksey, Ashok Mohite, Pravir Gambhire, Samit Jain, Ravindra Surude, Pravin Rathi, Quas Contractor, Prema Varthakavi, Ravi Verma, Sunita Tibrewala Departments of Gastroenterology, Endocrinology, and Radiology, Topiwala National Medical College and BYL Nair Charitable Hospital, Dr. A L Nair Road, Mumbai 400 008, India Introduction: Nonalcoholic fatty liver disease (NAFLD) is hepatic manifestation of metabolic syndrome. It is the most common cause of chronic liver disease in western countries in pediatric population. There is paucity of studies from the India the exact prevalence is not known. Methodology: We have done a school based cross sectional study with screening for NAFLD in overweight and obese children in age group 11 to 15 years. The overweight and obesity categorized by Indian specific Khadilkar as well international Cole et al. criteria. The investigations used for defining NAFLD are ultrasonography, transaminases and fibroscan. The dietary habits over a last 1 week, blood pressure, serum lipid profile, HOMA IR were studied. The relation of Fib4, APRI, PNFI with the fibroscan was evaluated. Results: We evaluated 616 student out of which 198 (32.14 %) were overweight and obese. One hundred students were included after consent. The prevalence of NAFLD was found to be 62 % in overweight and

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obesity. On ultrasound, fatty liver was found in 50 % students, liver stiffness value ≥6.1 kPa was found in 23 % students, raised ALT was seen in 30 % students. The hypertension was detected in 6 % students. 4.8 % of students were detected by only fibroscan. Hypertriglyceridemia, hypercholesterolemia, diabetes mellitus, hyperinsulinemia, and insulin resistance were seen in 14 %, 4 %, 2 %, 38 %, and 66 % students respectively. The waist circumference, serum triglyceride, hemoglobin, white cell count, APRI value, days of chocolate eating per week were significantly different in NAFLD group as compared with the nonNAFLD group. On binary logistic regression, only systolic hypertension was a independent factor for NAFLD. Fibroscan is correlated with APRI, Fib 4, and PNFI. Conclusion: NAFLD is very common in our population in asymptomatic overweight and obese children. Fibroscan should not be used for screening. Systolic hypertension is the effect of NAFLD in students. We recommend screening for NAFLD in this high-risk group with SGPT and ultrasonography. L-35 Clinical profile of patients of nonalcoholic fatty liver disease and its association with metabolic syndrome

K Saikrishna, P Shravan Kumar, M Umadevi, Ramanna Department of Gastroenterology, Gandhi Hospital, Secunderabad 500 025, India Background: Nonalcoholic fatty liver disease (NAFLD) is increasingly being recognized as a major cause of liver-related morbidity and mortality. It is associated with various metabolic abnormalities. Aim: The purpose was to study the clinical profile of patients of NAFLD with varying grades of severity and to study the correlation between the NAFLD and metabolic syndrome along with its individual components. Material and Methods: The study was an observational and analytical study of patients diagnosed as NAFLD. Seventy patients diagnosed as NAFLD evaluated for metabolic syndrome according to NCEP ATP 3 Criteria and a relationship between NAFLD and metabolic syndrome studied. Results: A total of 70 cases, 47.15 % (33), 42.85 % (30), and 10 % (7), had grade I, II, and III fatty liver respectively. Mean age in males 49.06 years, in females 49.20 years. The male/female ratio was 3:4. Thirty-three (47.15 %) of total patients were diabetics, and majority of grade III fatty liver patients had diabetes, i.e. 4 (57.14 %), while 12 (40 %) of grade II and 7 (21.21 %) of grade I patients were diabetics; 25 (35.72 %) of total patients were hypertensive. Hypertriglyceridemia was seen in 67.14 % of patients. Low HDL levels found in 63.34 % and 85.71 % of grade II and III fatty liver respectively. 51.4 % of NAFLD patients had metabolic syndrome. 61.1 % of patients of NAFLD with metabolic syndrome had grade II fatty liver whereas in those without metabolic syndrome 73.5 % had grade I fatty liver. Conclusions: Higher prevalence of all the components of metabolic syndrome in cases of NAFLD was observed. Therefore, whenever these parameters are encountered in the clinical setting, patients must be evaluated for the presence of NAFLD by abdominal ultrasonography and its early detection will help in modifying the disease course, delaying complications like NASH, COL, HCC. L-36 Metabolic syndrome as a predictor of severe non alcoholic fatty liver disease

Gaurav Babbar, Preeja Prabhakar, T M Ramachandran, V R Rajendran Departments of Physiology, Gastroenterology, and Radiodiagnosis,

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Background and Aim: Non alcoholic fatty liver disease (NAFLD) is one of the commonest causes of chronic liver disease worldwide. The prevalence of NAFLD and metabolic syndrome (MetS) is rising alarmingly. This study aims to characterize the relationship between NAFLD and MetS. Methods: A cross-sectional comparative study was conducted among 120 patients of 25–65 years of age with NAFLD, as detected by USGabdomen after applying exclusion criteria. Their anthropometry, BP, FBS, lipid-profile were recorded. Hepatic steatosis was diagnosed and severity was graded by a single experienced radiologist by USG-abdomen. MetS as defined by NCEP-ATP III criteria was used to identify and group patients into those with and without MetS. ANOVA and chi-square were applied. Results: Prevalence of MetS among NAFLD patients in this study was 39.2 %. At least one component of MetS was present in 90 % of NAFLD subjects. Central obesity was found in 82 (68.3 %) subjects, hypertension, increased FBS, low HDL and high triglycerides in 34 (28.3 %), 63 (52.5 %), 33 (27.5 %) and 69 (57.5 %) patients respectively. NAFLD patients with MetS had 3.8 times more risk (95 % CI 1.3–9.3) to develop severe (grade III) fatty liver. Higher grades of fatty liver were significantly associated with higher mean values of individual MetS components except for HDL which was lower. Conclusion: In this study, two fifths of patients with NAFLD were found to have MetS. MetS components were significantly associated with increasing severity of NAFLD. NAFLD may be considered as the hepatic manifestation of MetS. Screening of NAFLD patients for MetS and its components may aid in adopting early lifestyle changes and pharmacotherapies which may improve their long-term prognosis.

L-37 Increasing serum uric acid is associated with nonalcoholic fatty liver disease

Gaurav Babbar, Preeja Prabhakar, T M Ramachandran, V R Rajendran Departments of Physiology, Gastroenterology, and Radiodiagnosis, Department of Gastroenterology, Government Medical College, Kozhikode 673 008, India Background and Aim: Nonalcoholic fatty liver disease (NAFLD) has emerged as a global health concern with high prevalence among Asians. BARD score is a clinical tool to assess fibrosis risk in NAFLD patients. This study aims to determine the relationship of serum uric acid (SUA) levels with the severity and fibrosis risk in NAFLD. Methods: Cross-sectional study on 90 male patients, 25–65 years of age with NAFLD, as detected by ultrasonography of abdomen and excluding other causes of fatty liver. Their anthropometry, BP, SUA, FBS, LFT, and lipid profile were recorded. For study purpose, SUA levels were categorized into the following quartiles: 3.0, 3.0–4.9, 5.0–6.4, and 6.5–7.0 mg/dL. Diagnosis and severity grading of fatty liver were done by a single experienced radiologist by abdominal ultrasonography. BARD score was calculated using three variables—BMI, AST/ALT ratio (AAR), and the presence of diabetes into a weighted sum (BMI 28—1, AAR of 0.8—2, DM—1), to generate a score from 0 to 4. Data analysis was done using ANOVA, chi-square, and logistic regression. Results: 73.34 % of NAFLD patients had SUA in higher quartiles (SUA 5 mg/dL). SUA 5 mg/dL was found to be an independent risk factor to develop severe NAFLD. The adjusted odds ratio to have severe (grade III) fatty liver in higher SUA quartiles was 7.4 (95 % CI 0.9–4.2). They were also at 2.8 times higher risk (95 % CI 0.7–8.3) for progression to hepatic fibrosis (BARD score 2–4). Conclusion: Increasing SUA was independently associated with severe NAFLD. SUA may be an additional measure to assess severity and fibrosis risk progression in NAFLD.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 L-38 Evaluation of nitric oxide, cytokines, and oxidants in the hepatic and systemic circulations of nonalcoholic fatty liver disease patients

Baibaswata Nayak, Suraj Kumar Nongthombam, Hem Kumar, Anand Kumar, Priyanka Moga, Neeti Nadda, Neelanjana Roy, Shalimar, Subrat K Acharya Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Introduction: Progression of NAFLD from steatosis to NASH (nonalcoholic steatohepatitis) is a multi-hit process. Obesity, insulin resistance, oxidative stress, cytokines, and small intestinal bacterial growth (SIBO) are considered main risk factors for NAFLD progression. Elevated endotoxin/LPS level due to SIBO and increased intestinal permeability activate monocyte and macrophages to release of pro-inflammatory cytokines and nitric oxide. Endotoxin released to systemic circulation or delivered directly to liver through hepatic portal vein may modulate liver macrophage or other tissue macrophage differently. The present study was undertaken to evaluate changes in level of cytokines, nitric oxide and oxidative stress in hepatovenous and systemic circulations of NAFLD patients and its role in the liver pathogenesis. Methodology: Liver biopsy, peripheral and hepatic venous blood sampling in NAFLD patients (n=54) and disease control CHB patients (n=25) was carried out after obtaining consent from patients and IEC approval. Total nitric oxide (NOx = NO 2 + NO 3 ) in systemic and intrahepatic plasma sample was measured colorimetrically by using Griess regent after chemical reduction of kines, adipokines and LBP were measured by ELISA and oxidants are measured by colorimetric estimation methods. Results and Conclusion: Histopathological evaluation indicated NAFLD activity score (NAS) of <3 in 11.11 %, NAS ≥3–4 in 48.15 % and NAS≥ 5 in 40.74 % of NAFLD patient. The mean hepatic and systemic NOx, LBP, cytokines and adipokine; and oxidants and antioxidants concentration were mentioned in below table I along with statistical significance. We observed higher hepatic nitric oxide than systemic circulation in both NAFLD patient and CHB disease controls. In both circulations, NO level is higher in NAFLD than in CHB patients. This corroborated with increased hepatic LBP and cytokine. Lipid peroxidation product (MDA) level is more in systemic than hepatovenous circulation. There are no significant changes in antioxidant levels in both hepatic and systemic circulations.

L-39 Association between hyperammonemia and infection in acute liver failure

Shalimar, Ramesh Kumar, Hanish Sharma, Baibaswata Nayak, Sreejith Vasudevan, Arti Kapil, Immaculata Xess, Subrat Kumar Acharya Departments of Gastroenterology, Microbiology, and Biostatistics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background: The role of elevated ammonia levels in increasing risk of infection in patients with acute liver failure (ALF) remains unknown. Aim: The aim was to evaluate whether elevated ammonia increases risk of infection in ALF. Methods: Microbiological surveillance, clinical evidence of infection and blood ammonia estimation over 5 days in consecutive ALF patients, hospitalized in an Indian tertiary referral center (2004–2013). Association of hyperammonemia and infection and influence of infection on complications/outcome were evaluated.

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Results: We prospectively evaluated 469 ALF patients (etiology: hepatitis virus(es)—94.7 %). Among these, 240 (51.2 %) had infection (culture positive 130; hematological/clinical/radiological evidence 110) over a median of 3(1–13)days. Infection was documented at admission/within 48 h in 109 (45.4 %) and after 48 h in 131 (54.6 %). Survival without and with infection was 59.8 % (137/229) and 31.7 % (76/240) respectively (P128.5¼mol/L); 58.2 % of them had infection, in comparison to 44 % of patients with ammonia 128.5¼mol/L (p=0.03). On day 3 as well as day 5, proportion of patients with ammonia >128.5¼mol/L was higher in infected than in noninfected groups (day 3 58.8 % vs. 29.3 %, P128.5¼ mol/L, OR 2.04, elevated creatinine OR 5.61, ventilation OR 5.61, and seizure OR 2.53. Conclusions: Elevated ammonia levels increase the risk of infection in hepatitis virus(es) induced ALF. Hyperammonemia and infection have perpetuating and synergistic effect in these patients. L-40 Reduced expression of glycine transporter 1 in cortical neurons of patients with acute liver failure

M Chopra, K Kiran, Thumburu, Rakesh K Vasishta, A Chakraborti, Navneet Sharma, Ajay Duseja, Yogesh Chawla, Radha K Dhiman Departments of Hepatology, Histopathology, Experimental Medicine and Biotechnology, and Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

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Background: Acute liver failure (ALF) is a life-threatening critical illness with onset of altered mental status and coagulopathy (INR>1.5) within 8 weeks of initial symptoms in individuals with no previous history of liver disease. Aims and Objectives: The purpose was to study the etiology of ALF in patients admitted in a tertiary care center. Material and Methods: The study was a prospective observational study carried out over duration of 18 months. All patients of age group 18 to 60 year admitted in ICU with ALF were included. Patients with chronic liver disease and post liver transplant patients were excluded. Clinical and biochemical profile will be studied every 4th day till death/discharge. In all the patients, treatment protocol was not disturbed. Results: A total of 50 patients diagnosed with ALF were recruited. Mean age of patients was 28.9 years. Number of females was 31 (60 %) of which 20 were pregnant. In the present study, the major cause of ALF was hepatitis E (40) with other causes such as hepatitis A (3), drug induced liver injury (3), non-A non-E hepatitis (2), Wilson’s disease (1), hepatitis B (1), etc. contributing only a few cases. Forty-two patients died with mortality rate of 84 %. Grade of hepatic encephalopathy remained as an important predictor of outcome. International normalized ratio (INR), liver enzymes and creatinine were significantly higher in patients who died as compared to who were discharged. Conclusions: Majority of cases were due to hepatitis E and Awith 80 % of the patients from slum areas. Thus, these causes are preventable by improving the sanitation and hygiene.

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Background: Alteration in N-methyl D-aspartate (NMDA) mediated neurotransmission has been involved in the pathogenesis of hepatic encephalopathy due to ALF. Glycine, a positive allosteric modulator required for regulation of NMDA receptor. Glycine transporter (GlyT-1) is expressed in both astrocytes as well as neurons of cerebral cortex in association with regions of high NMDA receptor expression. The present study investigated the expression of GlyT-1 in the frontal cortex of patients with ALF. Methods: We analyzed the mRNA expression of GlyT-1 in the cerebral cortex obtained at autopsy from eight patients with ALF and from seven patients with no evidence of hepatic or neurological disorders by realtime PCR, and protein expression was assessed using immunoblotting and immunohistochemistry. All ALF patients had high grades of encephalopathy at the time of death and the same has been confirmed on histopathology. Results: A significant decrease in GlyT-1 mRNA and protein levels was demonstrated in ALF patients compared to controls. The loss of GlyT-1 protein in ALF samples was post-translational in nature. The immunostaining of GlyT-1 expression was decreased in ALF cortical brains compared to control brains and the GlyT-1 immunostaining was particularly expressed in neurons and not in astrocytes. Conclusion: These findings suggest that decreased expression of the GlyT-1 transporter may cause an impairment of regulation of glycine concentration at synaptic level and contribute to an over-activation of the NMDA receptor in ALF. NMDA receptor antagonists, particularly at the glycine modulatory site, could provide novel approach towards the treatment of hepatic encephalopathy in ALF. L-41 Study of clinical and biochemical profile of patients with acute liver failure

Vinay Zanwar, Anirudha Pawar, Sunil Pawar, Samit Jain, Ravindra Surude, Rosemarie deSouza, Pravin Rathi Departments of Gastroenterology, and Medicine; Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr. A L Nair Road, Mumbai 400 008, India

Is rapid virological response significant in the present era in the treatment of hepatitis C?

Ruchir Patel, Dhaval Choksi, Nirav Pipaliya, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal Medical College, Dr. Babasaheb Ambedkar Road, Sion (West), Mumbai 400 022, India Introduction: Treatment of hepatitis C has dramatically improved over the last decade. Unlike other infections, significant number of patients can be cured. Rapid virological response (RVR) is the best predictor of response to PEGylated interferon/ribavirin. We want to find whether the same can be replicated in patients treated with sofosbuvir or not. Methods: We prospectively evaluated patients with hepatitis C taking treatment from Lokmanya Tilak Municipal General Hospital, both cirrhotic and noncirrhotic, treatment naive and exposed genotype 1 and genotype 3. Twenty-five patients were started on sofosbuvir/PEGylated interferon/ribavirin (SPR) for 12 we eks and 33 pa ti ents w ere t re ate d wi th PEG ylat ed interferon/ribavirin (PR) according to genotype. Number of patients who achieved RVR and end of treatment response (ETR) in both the treatment groups was calculated and appropriate statistical tests applied. Results: In the SPR treatment group, out of 25 patients all achieved RVR (n—25, 100 %). In the PR treatment group, RVR achievement was 75 % (n—24). Out of those who did not achieve RVR (n—8), 5 patients achieved ETR. All 25 patients in SPR treatment group achieved ETR. The possibility of getting ETR in patients who have achieved RVR was statistically significant (p—0.029, CI 95 %). RVR in SPR group is higher than PR group in GT 1 (100 % vs. 55 %) and GT 3 (100 % vs. 83 %). Conclusion: All patients who achieved ETR had cleared HCV RNA at 4 weeks in the sofosbuvir group as compared to PR group, irrespective of their genotype. Testing for HCV RNA at 4 weeks can be skipped in the new era of DAA.

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(25, 50 %) followed by mixed genotypes (12, 24 %). Most cases of cirrhosis (18/32, 56.25 %) and chronic HBV (3/8, 37.5 %) were associated with genotype D. Hepatocellular carcinoma was seen in patients with genotypes B and D and mixed with similar frequency (27.27 %). Conclusion: The most prevalent genotype in central India is genotype D followed by mixed genotypes. Genotype D was the most common genotype observed in patients with cirrhosis.

Post-transcriptional regulation of miRNA-122 as better predictor of molecular pathogenesis during hepatitis B and C virus infection

Raju Nagarapu, Sandeep K Vishwakarma, Syed Rahamathulla, Avinash Bardia, Shaik Iqbal Ahmed, Md. Aejaz Habeeb, Aleem Ahmed Khan Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Hyderabad 500 058, India

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Background: miRNA-122 is the most abundant miRNA in adult hepatocytes. It increases the abundance of hepatitis C virus (HCV) RNA during infection. It has been suggested as a potential target for the treatment of hepatitis C. However, recent evidence shows that miR-122 decreases hepatitis B virus (HBV) replication through the inhibitory effect of p53 on HBV transcription, and consequently it acts as a tumor-suppressor through both a decrease in HBV replication and by directly targeting several key pathways. Hence, we intend to investigate the role of miR-122 in molecular pathogenesis of hepatitis B and C virus infection to explain why therapeutic applications of miR-122 may differ based on the underlying disease. Methodology: Blood samples were collected from 60 subjects (20 HBV+ ve, 20 HCV+ve and 20 healthy controls). Viral load for HBV and HCV was quantified and correlated with miRNA-122 expression levels. Expression profiles of miRNA-122 in HBV, HCV, and controls were analyzed and correlated with biochemical parameters to find their disease association. Results: Differential expression profile was observed during HBV and HCV infection compared to healthy controls. miRNA122 was found highly upregulated during HCV infection whereas got significantly decreased in HBV infection. Elevated LFT parameters were observed during HCV/HBV infection having RNA/DNA positivity, whereas a normal level was observed in HbsAg/anti-HCV+ cases having negative results for DNA and RNA respectively. Conclusion: The expression of miRNA-122 is regulated differently in HBV and HCV infections at different phases. miRNA122 might be considered as a novel therapeutic target for HBV/ HCV infection.

Spontaneous reactivation of chronic hepatitis B infection

B Harriprasad, B Krishna Rao Billroth Hospitals, 52, II Main Road, R A Puram, Chennai 600 028, India A 45-year old man presented to the OP with a history of generalized weakness, yellowish discoloration of urine and vomiting. Patient had mild grade fever with no chills or rigors. Pruritus and clay colored stools were negative. History of malignancy, immuno suppressive drugs or transplantation was negative. Alcohol consumption was less than cirrhosis dose. Blood investigations revealed elevation of total bilirubin and liver enzymes. Other routine investigations were normal. Hepatitis B antigen was positive, and other viral markers were negative. Anti-HBc IgM was negative. HBeAg was negative. HBV DNA viral load was 148,000 IU/mL. Liver enzymes were eight times the upper limit of normal. Liver was normal by scan. Hence, a diagnosis of spontaneous reactivation of chronic HBV infection was made. Antiviral entecavir was started with a dose of 0.5 mg OD. On regular follow up, the patient recovered well with improvement of weakness and jaundice. He had ALT normalization and HBV DNA level was 126 IU/mL after 1 month. Discussion: Chronic hepatitis B infection is a dynamic condition and patients with inactive infection can revert spontaneously to immune active phase. It is a common pattern seen in HBeAg negative patients. These patients may resemble acute viral hepatitis and has high chance for cirrhosis. This pattern seems to be misdiagnosed and responds well to nucleoside analogs which block episodic flares of disease.

L-44 L-46 Hepatitis B viral genotypes: Pre valence and impact of HBV genotypes on the clinical outcome in patients of central India

Mohd Talha Noor, Pranav Raghuvanshi Sri Aurobindo Medical College and Postgraduate Institute, Indore, India Background and Aim: Hepatitis B virus (HBV) infection is a global health problem and studies have shown that development of various complications of HBV infection and response to interferon therapy is linked to its genotypes. To date, no data is available from central India. Methods: Case records of 50 consecutive HBV-infected patients were analyzed retrospectively, irrespective of their clinical presentation. Determination of HBV genotypes was done by using restriction fragment length polymorphism. Results: Mean age of the patient was 49.1± 14.2 years. Seventyeight percent patient were males. Clinical manifestations included cirrhosis (27, 54 %), cirrhosis with hepatocellular carcinoma (7, 14 %), chronic hepatitis (9, 18 %), hepatocellular carcinoma in the absence of cirrhosis (4, 8 %), acute liver failure (1, 2 %), and acute hepatitis (2, 4 %). The most prevalent genotype was genotype D

Study of the side effect profile of sofosbuvir/pegylated interferon/ribavirin and pegylated interferon/ribavirin-based regimens in hepatitis C: A tertiary center experience

Alisha Chaubal, Prateik Poddar, Chetan Rathi, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Medical College, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Aim: The aim was to study the side effect profile of sofosbuvir/pegylated interferon/ribavirin (group I) and pegylated interferon/ribavirin (group II)-based regimens in hepatitis C patients in a tertiary center. Methods: Group I had 23 patients (9 cirrhotics) and group II had 30 patients (14 cirrhotics). Results: The major side effect observed was anemia in 16 % of group I patients (88 % cirrhotics) and 32 % of group II patients (90 % cirrhotics). In both groups, 75 % of anemic patients were erythropoietin responsive. One patient in group II underwent splenectomy. Decompensation of liver disease was seen in 4 % of patients in group I vs. 16 % in group II. Insomnia and fatigue were predominant in group I (12 % and 16 %

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respectively), and fever and myalgia in group II (38 % and 36 %). Rare complications in group I included abscess formation (2 patients) and dyspnea (2 patients); in group II, these included interferon-induced flare of autoimmune hepatitis (1 patient). Conclusion: Side effects like anemia and decompensation were more commonly seen in group II which might be related to the duration of treatment. Symptoms like insomnia and fatigue were higher in group I with rare side effects such as bronchospasm and abscess formation.

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Introduction: Data on hepatitis C epidemiology is scarce in our country especially in northern India which is important for implementation of preventive measures. Methods: Data was collected retrospectively from Medical Record Section and Outpatient Clinic of Gastroenterology Department, Banaras Hindu University, Varanasi from July 2012 to June 2015. Results: One hundred and eighty-four patients (mean age 46, males 64.1 %) were included. Most of the patients belonged to Varanasi (26 %), Ambedakarnagar (11 %), Azamgarh (8.2 %), Chandauli (8.7 %), Jaunpur (7.1 %) and Ghajipur (5.4 %). Eighty percent patients belonged to middle class socioeconomic status. Risk factors for probable mode of transmission were history of blood transfusion (31.5 %) dental procedure (25 %), past surgery (15.8), sex (8 %), piercing (6.5 %), IDU (6 %) and unknown (6 %). Out of 142 patients genotype 3 was most common (64.8 %) followed by genotype 1 (24.6 %), 2 (5.6 %) and 4 (4.9 %). Mean HCV RNA of 128 patients was 1.6×106 (range 3.2×103–8.09×107). Of total 184 patients, 66.3 % were asymptomatic clinically and 55 % of patients had evidence of portal hypertension upon investigations. Frequency of jaundice, gastrointestinal bleed, ascites, hepatic encephalopathy and renal dysfunction including hepatorenal syndrome were 8.2 %, 20.1 %, 22.8 %, 15.2 %, and 9.2 % respectively. Conclusions: Risk factors for probable modes of transmission are known in 94 % so preventive measures can help to reduce HCV transmission to a large extent. Two thirds of patients present asymptomatically and >50 % of patients have portal hypertension. Genotype 3 is the most common followed by genotype 1.

Sofosbuvir plus ribavirin results in high SVR4 rates in patients with chronic HCV genotype 1 or 3 infection in India

Samir Shah1, Abhijit Chowdhury2, Rajiv Mehta3, Dharmesh Kapoor4, Ajay Duseja5, Abraham Koshy6, Akash Shukla7, Ajit Sood8, Kaushal Madan9, Randhir Sud10, Sandeep Nijhawan11, Rawal Pawan12, Madhura Prasad13, Kathryn Kersey14, Deyuan Jiang14, Brian Doehle14, Bittoo Kanwar14, Mani Subramanian14, S K Acharya15, Shiv Sarin16 1 Global Hospitals, 35, Dr. E Borges Road, Hospital Avenue, Parel, Mumbai 400 012, India; 2Institute of Postgraduate Medical Education and Research, 244 A J C Bose Road, Kolkata 700 020, India; 3 Nirmal Hospital Pvt Ltd, Centre Point, Ring Road, Near Kadiwala School, Surat 395 002, India; 4Global Hospitals, 8-16-1, Sagar Road, L B Nagar, Hyderabad 500 035, India; 5Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh, 160 012, India; 6 Lakeshore Hospital, P O, Nettoor, Maradu, Ernakulam, Kochi 682 040, India; 7Seth G S Medical College and K E M Hospital, Acharya Donde Marg, Parel, Mumbai 400 012, India; 8 Dayanand Medical College and Hospital, Udham Singh Nagar, Civil Lines, Ludhiana 141 001, India; 9Artemis Hospitals, Sector 51, Gurgaon 122 001, India; 10Medanta-The Medicity, CH Baktawar Singh Road, Sector 38, Near Rajiv Chowk, Gurgaon 122 001, India; 11SMS Medical College and Hospital, Jawaharlal Nehru Marg, Gangawal Park, Jaipur 302 004, India; 12Fortis Memorial Research Institute, Sector 44, Opposite HUDA City Centre, Gurgaon 122 002, India; 13V G M Hospital, 2100, Trichy Road, Singanallur, Coimbatore 641 005, India; 14Gilead Sciences, Inc., Foster City, California; 15All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India; 16Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims: This study is being conducted in India to evaluate the efficacy and safety of sofosbuvir (SOF) plus ribavirin (RBV) in patients with chronic HCV genotype (GT) 1 or GT3 infection. Methods: Treatment-naïve patients from 13 sites in India were randomized to receive SOF (400 mg daily)+RBV (1000–1200 mg daily) for 16 or 24 weeks; randomization was stratified by genotype and the presence or absence of compensated cirrhosis. Efficacy is being assessed by the proportion with sustained viral response 4 weeks post-treatment (SVR4), SVR12 (primary endpoint), and SVR24. Results: One hundred and seventeen treatment-naïve patients (58 GT1 and 59 GT3) were enrolled; 28 % had compensated cirrhosis. SVR4 rates are shown in the Table. The most common AEs reported by ≥10 % of patients were asthenia, headache, cough, fatigue, and dyspepsia; all were mild or moderate except for 2 grade 3 AEs. Two patients had serious AEs that were considered unrelated to treatment. Conclusions: In treatment-naïve genotype 1 or 3 HCV-infected Indian patients, treatment with an interferon-free regimen of SOF+ RBV for 16 and 24 weeks resulted in SVR4 rates of 90 % to 100 %. SOF+RBV was well tolerated with a safety profile consistent with use of RBV.

Epidemiological and clinical profile of patients with hepatitis C infection presenting to a tertiary care hospital in eastern Uttar Pradesh

Anurag Kumar Tiwari, Sunit Kumar Shukla, Ajay Nandmer, Pankaj Kumar Asati, Vinod Kumar Dixit, Ashok Kumar Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

L-49 Effect of diabetes mellitus and vitamin D on hepatitis C-related liver disease

Varun Gupta, Ashish Kumar, Praveen Sharma, Naresh Bansal, Vikas Singla, Anil Arora Institute of Liver, Gastroenterology, and Panceatico-Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Background: The high prevalence of Diabetes mellitus and vitamin D deficiency among HCV patients is a cause for concern. The effect of diabetes mellitus and levels of 25-hydroxy vitamin D on cirrhosis, decompensation and HCC remains unclear in HCV patients. This study in hepatitis C patients is aimed to assess the influence of diabetes mellitus and levels of 25-hydroxy vitamin D on hepatitis C related liver disease patients. Material and Methods: In this retrospective study, all patients who tested positive for anti-HCV from December 2010 to August 2014 and presented to Department of Gastroenterology and Hepatology at our center were included and were reviewed for gender, age, diabetes, genotype, level of 25-hydroxy vitamin D, and status of liver disease including HCC at inclusion. The association of diabetes and low 25-hydroxy vitamin D levels (<30 ng/mL) with liver status and Child-Pugh class (CTP) was analyzed. Results: A total of 777 patients were included in the study. At presentation, 439 (56 %) patients had cirrhosis, including 51 (7 %) with HCC and

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287 (37 %) with chronic hepatitis. 25-Hydroxy vitamin D level was available in 206 patients at baseline. Low 25-hydroxy vitamin D level was present in 126/206 (61 %) of the patients. Diabetes mellitus was present in 165/777 (21 %) of the patients. Diabetes was associated more commonly with genotypes 1 and 4 [25 % (35/139)] in comparison to genotypes 2 and 3 [18 % (59/325), p=0.056]. Patients who had associated diabetes presented more commonly with cirrhosis [122/439 (28 %)] and HCC [122/439 (29 %)] in comparison to chronic hepatitis [28/287 (10 %), p<0.01]. Lower 25-hydroxy vitamin D level (<30 ng/mL) was seen in 67 % (98/147) of patients with cirrhosis, 78 % (11/14) with HCC, and 47 % (28/59) with chronic hepatitis (p=0.012). In cirrhotic patients, vitamin D deficiency was significant in Child B [72 % (52/72)] and Child C [75 % (12/16)] patients in comparison to Child A patients [52 % (62/ 118), p=0.013]. No significant relation of diabetes with Child class was seen. Conclusion: 25-Hydroxy vitamin D deficiency was present in 61 % and diabetes mellitus co-existed in 21 % of HCV patients at presentation. Diabetes and low levels of 25-OH vitamin D at presentation was associated with higher incidence of cirrhosis and HCC. Lower 25-hydroxy vitamin D levels also leads to a higher incidence of decompensation. Improving diabetes control and correcting vitamin D deficiency can improve outcomes in hepatitis C-related liver disease.

L-50 A randomized comparative open-label trial of tenofovir monotherapy versus tenofovir plus telbivudine dual therapy in spontaneous reactivation of hepatitis B (NCT01732224)

Ankur Jindal, Manoj Kumar, Shiv kumar Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction: Spontaneous reactivation of hepatitis B is common. Some may develop jaundice and hepatic decompensation [acute-on-chronic liver failure (ACLF-B)] and are at risk of renal dysfunction and high mortality. Tenofovir improves survival by >40 % in ACLF-B but is potentially nephrotoxic. Combining telbivudine with tenofovir may negate this risk and could boost rapid viral clearance, thereby improving clinical outcomes. Methods: Consecutive patients with spontaneous reactivation of hepatitis B [(ALT >5× ULN/>3× baseline)+HBV DNA >1.8×104 IU/mL] were randomized to tenofovir (300 mg/day) monotherapy [TM] or tenofovir plus telbivudine (600 mg/day) dual therapy [DT] along with standard medical therapy. Clinical, virological, and lab parameters were evaluated at baseline, at weeks 2 and 4, and at 3 months. None had an option for liver transplantation. Primary end point was HBsAg loss. Secondary end points were serial reduction in HBV DNA, liver-related complications, therapy-related adverse effects and survival at 1 and 3 months in the subgroup with ACLF-B. Results: Of 69 patients (TM, n=35 and DT, n=34), 25 had ACLF-B (TM, n=13 and DT, n=12). Overall baseline parameters in two treatment groups were comparable with no significant differences in MELD score, bilirubin and INR at weeks 2 and 4 and 3 months of therapy. Patients with non-ACLF had rapid decline in bilirubin and ALT at 2 weeks as compared to ACLF-B, in whom the reduction was gradual. In ACLF-B patients, mean MELD score was 26.23±5.57 (TM) and 27.42±8.20 (DT) (p—0.8) but those on DT had significant improvement in MELD and bilirubin at week 4 and 3 months in comparison to baseline. Six patients had HBsAg loss at 12 weeks, all in non-ACLF group and these patients had lower HBV DNA at baseline. Only one had anti-HBs+ at 24–36 weeks. Patients with ACLF-B receiving DT showed improvement in AKI on follow up compared to those on TM (p—0.05). Among 10 deaths in ACLF-B, 8 had received TM (p—0.02). Predictors of mortality in ACLF-B were septic shock, TM, antibody positivity, and high baseline MELD score.

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Conclusions: In spontaneous reactivation of hepatitis B presenting as liver failure, a combination of telbivudine with tenofovir is potentially safe with less risk of tenofovir-related nephrotoxicity and hence improved outcomes. L-51 Clinical profile of people living with HIV/AIDS coinfected with hepatitis B or hepatitis C on HAART

R Dewan, P Kar, S Anuradha, S Garg, Shobhit Agarwal, P Ish, A Narayana Department of Medicine, Maulana Azad Medical College and Lok Nayak Hospital, Bahadur Shah Zafar Marg, New Delhi 110 002, India Background: People living with HIV/AIDS (PLHIV) coinfected with hepatitis B or hepatitis C are at increased risk for ART induced hepatotoxicity and can have accelerated progression to AIDS. Introduction of HAART has improved the outcome in these patients. Aims and Objectives: The aim was to study the clinical, biochemical and immunological profile of PLHIV coinfected with either hepatitis B or hepatitis C virus on HAART. Method: This is an observational cross-sectional study. Thirty PLHIV coinfected with either hepatitis B or hepatitis C in whom a detailed history, examination, blood investigations, ultrasonography abdomen, CD4 cell counts, HBsAg, HBV DNA load, anti HCVantibody and HCV RNA load were done. Severity of liver disease by FIB 4 score using Sterling’s formula (score <1.45—minimal or no fibrosis, >3.25—extensive fibrosis). Results: Of 30 subjects, 9 were coinfected with HCV and 21 with HBV. Mean CD4 count was 416.70±189.50 cells/mm3, and 5 (16.67 %) had CD4<200. Twenty-four of 30 (80 %) subjects were in T1 and T2 stages. Opportunistic infections were seen in only 7 subjects. Seventeen of 30 (56.67 %) had ALT>40 IU/mL. Four subjects (13.3 %) had FIB 4>3.25 and 17 (56.7 %) had FIB 4<1.45. HBV DNA was detectable in 8 of 21 subjects (viral load 4157–11,311,334 copies/mL). HCV RNA was detectable in 6 of 9 subjects (viral load 2361–29,866,705 IU/mL). Ultrasonography showed normal liver size and echotexture in all subjects. Conclusions: PLHIV coinfected with hepatitis B or hepatitis C on HAART were found to have good clinical and immune status and there was no evidence of severe liver disease in majority patients. L-52 Hepatitis B virus-associated hepatocarcinogenesis: Comparison of molecular oncogenic potential of HBV subgenotypes D1 and D3

Somenath Datta, Debanjali Dasgupta, Alip Ghosh, Amit Ghosh, Suchandrima Ghosh, Simanti Datta, Gopal Krishna Dhali, Abhijit Chowdhury, Soma Banerjee Centre for Liver Research, School of Digestive and Liver Diseases, and Department Gastroenterology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education and Research, 244 A J C Bose Road, Kolkata 700 020, India Chronic hepatitis B (CHB) is one of the major risk factors for the development of hepatocellular carcinoma (HCC) and liver cirrhosis (LC). Although the clinical significance of hepatitis B virus (HBV) genotypes/ subgenotypes has been well established, the molecular mechanism of HBV genotype, specifically subgenotype dependent liver disease progression is rarely explored. Thus, this study was designed to determine the distribution pattern of HBV genotypes/subgenotypes with progressive liver disease in eastern Indian population and to understand the molecular basis of pathogenic potential of clinically significant HBV subgenotypes. A total of 121 HBV-infected patients with different stages (CHB, LC and

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HCC) had been enrolled in this study. The phylogenetic tree analysis with full-length HBV sequences revealed that among nine HBV/D subgenotypes, the frequency of HBV/D1 was significantly increased from CHB to HCC through LC (39 %>41 %>69 %), whereas rising frequency of HBV/D3 was observed up to LC, which suddenly dropped in HCC (44 %>59 %<24 %) suggesting the association of HBV/D1 subgenotypes with HCC more than HBV/D3. In molecular analysis, compared to HBV/D3, HBV/D1 was found to exert more endoplasmic reticulum (ER) stress due to its high replication and accumulation of more unfolded proteins in ER. In addition, cellular proliferation, migration, angiogenesis and anchorage-independent growth of cells infected with HBV/D1 subgenotype was significantly higher than HBV/D3. Thus this study highlights that oncogenic potential of HBV/D1 subgenotype is more than HBV/D3 and hence disease severity, treatment response differ according to HBV subgenotype, which warrants physicians to individualize treatment. L-53 Profile of asymptomatic HBsAg-positive patients detected incidentally (IDAHS) during screening

D Rahul, K Panduranga Rao, B Prabhakar, B Ramesh Kumar, L Sahithya, Mohd Saad Azmi, P Vivek Osmania Medical College and Hospital, Turrebaz Khan Road, Koti, Hyderabad 500 095, India Aim: The aim was to study the biochemical, serological profile and significance of HBeAg in IDAHS patients. Study Design: This is an observational study conducted at Osmania General Hospital from January to December 2014. Patients and Methods: Eighty IDAHS patients who were nonethanolic, anti-HCV negative, HIV nonreactive and not on hepatotoxic drugs were included and further tested for HBeAg, HBVDNA, ALT, USG and UGIE. Results: Forty-eight (60 %) were male with a mean age of 33.58± 12.95 years, 32 (40 %) were female with mean age of 27.40±10.35 years. HBeAg was positive in 12 (15 %), HBeAb was positive in 31 (38.75 %), and HBVDNA was undetected in 38 (47.5 %). The mean HBVDNA level in HBeAg positive is 7.67 log10 IU/mL and the mean HBVDNA level in HBeAg negative with detectable DNA is 5.40 log10 IU/mL. The mean ALT in HBeAg positive was 45.75 U/mL, and the mean ALT in HBeAg negative was 25.07 U/mL. Six (7.5 %) patients were in an immunotolerant phase, and 10 (12.5 %) had altered liver echotexture. Twenty-five (31.25 %) were detected during screening during pregnancy. No risk factors were identified in 38 (47.5 %). Conclusion: Asymptomatic HBsAg positive was most commonly detected in the 21–30-year age group. HBeAg negative with high viral load was seen in 21 (26.25 %) patients, suggesting pre core mutations. Mean ALT was higher in the 51–60-year group, and altered liver echotexture was more common in 31–40 years, suggesting further evaluation and follow up.

patients, but sometimes HBsAg-negative patients can be at risk, due to occult HBV infection, and may become seropositive after therapy. Aim: The goals were to study the spectrum of malignancies, baseline characteristics and various chemotherapeutic agents responsible for reactivation of hepatitis B in previously seronegative patients and to study the clinical profile of such reactivation and the effects of treatment with antivirals. Material and Methods: Forty consecutive patients who developed chemotherapy-induced hepatitis B reactivation were studied from January 1, 2014, to December 31, 2014. Methods: Mean age of the patients was 33±22 years (males—28, females—12). Indications for chemotherapy were hematological malignancies (20), breast cancer (8), bone cancer (6) and colonic, cervical and lung cancers (2 each). All had normal liver on ultrasound at baseline. Results: The chemotherapeutic agents which were implicated for the reactivation were cyclophosphamide (22 cases), adriamycin (20 cases), vinca alkaloids (18 cases), platinum-containing drugs (8 cases), daunorubicin (12 cases), cytarabine (14 cases) and taxanes (6 cases). The mean HBV DNA level after chemotherapy was 120 crores. Of the 40 patients, 6 patients developed fatty liver and 6 patients developed cirrhosis with ascites. IgM anti-HBc was negative in 12 patients. Twenty-four patients were started on oral entacavir 0.5 mg/day, of which 18 patients had undetectable HBV DNA after 6 months. Sixteen patients were started on oral tenofovir 300 mg/day and all patients had undetectable DNA at the end of 6 months. Conclusion: HBV reactivation is commonly seen in patients receiving chemotherapy for hematological malignancies and breast cancer due a propensity for certain chemotherapeutic agents to lead to reactivation of hepatitis B. L-55 The prevalence of occult hepatitis B virus infection in chronic liver disease patients in a tertiary care hospital

K Mohanraj, G Ramkumar, K Muthukumaran, R Balamurali, T Rajkumar Solomon, P Ganesh Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim: The aim was to evaluate the prevalence of occult HBV infection in patients with chronic liver disease (CLD). Methods: Serum samples were tested for HBV DNA by RT-PCR in 66 HBsAg negative and anti Hbc (total) negative patients between August 2014 and July 2015. Results: Occult HBV infection was diagnosed in the 8 out of 132 (6.06 %) patients. Out of the eight patients, two had chronic liver disease with HCC, one had chronic liver disease with primary biliary cirrhosis and the other five had decompensated chronic liver disease. Out of eight patients, two were female and the other six were male. Conclusion: Occult infection B was detected in 6 % of chronic liver disease patients in our hospital. Occult hepatitis B is not uncommon among patients with CLD. It may be associated with more advanced liver pathology (cirrhosis) and more aggressive clinical course (decompensated cirrhosis).

L-54 L-56 Clinical profile of hepatitis B reactivation in patients undergoing chemotherapy for various malignancies

Anil Jose Kokkat Vydehi Institute of Medical Sciences and Research Centre, 82, EPIPArea, Nallurahalli, Whitefield, Bengaluru 560 066, India Background: Hepatitis B reactivation is a potentially serious complication of anticancer chemotherapy, which occurs during and after therapy. This condition affects primarily hepatitis B surface antigen (HBsAg)-positive

Side effect profile of sofosbuvir based regimen versus conventional PEGylated interferon in the treatment of hepatitis C: A tertiary center experience

Alisha Chaubal, Prateik Poddar, Chetan Rathi, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India

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Aim: The aim was to study the side effect profile of sofosbuvir/pegylated interferon/ribavirin (group I) and pegylated interferon/ribavirin (group II)-based regimens in hepatitis C patients in a tertiary center. Methods: Group I had 23 patients (9 cirrhotics) and group II had 30 patients (14 cirrhotics). Results: The major side effect observed was anemia in 16 % of group I patients (88 % cirrhotics) and 32 % of group II patients (90 % cirrhotics). In both groups, 75 % of anemic patients were erythropoietin responsive. One patient in group II underwent splenectomy. Decompensation of liver disease was seen in 4 % of patients in group I vs. 16 % in group II. Insomnia and fatigue were predominant in group I (12 % and 16 % respectively), and fever and myalgia in group II (38 % and 36 %). Rare complications in group I included abscess formation (2 patients) and dyspnea (2 patients); in group II, these included interferon-induced flare of autoimmune hepatitis (1 patient). Conclusion: Side effects like anemia and decompensation were more commonly seen in group II which might be related to the duration of treatment. Symptoms like insomnia and fatigue were higher in group I with rare side effects such as bronchospasm and abscess formation. L-57 Viral hepatitis epidemic at Cuttack, Odisha

Haribhakti Seba Das, Umesh Chandra Patra, Sushant Ku. Jena, Sanatan Behera, R P Sahoo Department of Hepatology, S C B Medical College, Dock Road, Manglabag, Cuttack 753 007, India Background: This is a study of the first large epidemic outbreak of viral hepatitis from Cuttack, Odisha. Objective: The objective was to study the viral hepatitis epidemic outbreak at Cuttack from February to April 2015. Materials and Method: After detail history and clinical examination of jaundiced patients routine hematological tests, Liver function, viral markers, USG, other tests as and when required were done. They were studied for disease outcome, morbidity and mortality. Observation: Approximately 1550 were affected from Cuttack and nearby area during the epidemic due to water contamination. Two hundred patients were included in the study out of which 90 were hospitalized. Two thirds were males (age range 5–78 years, median of 28 years). The level of serum bilirubin was 1.6–28 mg/dL. SGOT was 126–4590 IU/mL (mean 859 IU/mL) and SGPT was 230– 5678 IU/mL (mean 956 IU/mL). Four were HBSAg positive. IgM anti-HEV was positive in 70 %. IgM anti-HAV was seen in 18 %, out of which 30 % were beyond 20 years. Viral markers were negative in 12 %. One hundred and eight patients underwent USG out of which 90 % had hepatomegaly, 60 % had GB wall thickening, and 15 % had abdominal lymphadenopathy. Eight patients had ACLF, out of which 3 died. One had ARF, another acute pancreatitis. Patients with DM, old age, and chronic alcohol abuse had prolonged hepatitis. Pregnancy with AVH was seen in eight with one ACLF. Other family members were affected in 28 % of patients. Thirty-six percent received alternative modality of treatment. Conclusion: The epidemic of viral hepatitis at Cuttack was due to mainly hepatitis E. Pregnancy had no much adverse outcome. DM, old age, and alcohol abuse led to prolonged hepatitis. Water contamination was the cause of the epidemic. L-58 Clinical profile of an outbreak of viral hepatitis and its outcome at a tertiary care center in Jaipur

Neeraj Nagaich, Radha Sharma, Neha Bhatia, Sonal, Prashant Katiyar

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Department of Gastroenterology Metro MAS Hospital, Shipra Path, Mansarovar, Jaipur 302 020, and Department of Pathology, Rajasthan University of Health Sciences (RUHS), Sector-18, Kumbha Marg, Tonk Road, Pratap Nagar, Jaipur 302 033, India Introduction and Objectives: Hepatitis E virus causes acute viral hepatitis. The monsoon season is associated with a high risk of epidemics. Our study aimed to evaluate the clinical profile and predictors of severity in patients of viral hepatitis epidemic in Jaipur during May 2014 to January 2015. Cases evaluated in the study were both index cases and referred cases, from epidemic areas, for worsening of jaundice and other complications. Material and Method: This study was conducted on 64 patients presenting with acute hepatitis in Metro MAS Hospital over a period of 9 months from May 2014 to January 2015. A detailed history of each patient was recorded, including travel history, blood transfusion, and food and water intake from outside sources. The diagnosis of acute viral hepatitis was based on accepted clinical, biochemical, and serological criteria. Results: In the present study, viral hepatitis was predominantly seen in middle age. Males (81 %) were predominantly affected. Out of the female (19 %) patients, 2 were pregnant. Maximum patients presented with jaundice (90 %), followed by nausea and vomiting (60 %), fever (30 %), and abdominal pain (13 %). The most common sign was icterus followed by tender hepatomegaly (28 %). Virology study showed 40 cases positive for HEV and 3 cases for HBV, and 5 cases were positive for HAV. In 3 cases, RFT was raised above 2 mg/dL, out of which 1 required hemodialysis. Eight cases were found with deranged prothrombin time and 6 received FFP in view of active bleeding. No mortality was seen in our study. Conclusion: Our study suggests that the outbreaks in Jaipur district were due to hepatitis E virus. Jaundice was the most common presenting feature followed by vomiting, fever, and pain. Early presentation and judicious treatment can prevent mortality. Majority of cases were cured with supportive treatment. L-59 Influence of diagnostic criteria on outcome in patients with acute-on-chronic liver failure

Harneet Singh, C Ganesh Pai, Girisha Balaraju, Shiran Shetty Kasturba Medical College, SH 65, Madhav Nagar, Manipal 576 104, India Introduction: How the diagnostic criteria for acute-on-chronic liver failure (ACLF) provided by the Asia-Pacific Association for the Study of Liver (APASL) and the European Association for the study of Liver. Chronic liver failure (EASL-CLIF) consortium influence the mortality in this condition is not clear. Aim: The aim was to assess the influence of the two diagnostic criteria on the short-term outcome in patients with ACLF. Methods: Consecutive patients with chronic liver disease (CLD) with and without ACLF as per the two definitions admitted to Kasturba Hospital, Manipal, between May 2014 and March 2015 were prospectively assessed for their 28-day mortality. Results: Of the 141 (male=133) patients, 47 (33.33 %) and 45 (31.91 %) respectively had ACLF as per the APASL and EASL-CLIF criteria. Twenty-eight (43.75 %) met both criteria, 19 (40.43 %) met APASL but not EASL-CLIF criteria, and 17 (37.78 %) met EASL-CLIF but not APASL criteria. Alcohol was the most common acute insult (62.19 %) and the cause of underlying CLD (80 %). The 28-day mortality was 57.44 % and 21.28 % in those with and without ACLF as per APASL criteria respectively (p=<0.002), whereas 62.22 % and 19.79 % among those

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with and without ACLF as per EASL-CLIF criteria respectively (p= <0.002). The 28-day mortality was higher in those fulfilling both criteria (71.43 %) compared to those meeting only the APASL criteria (36.84 %; p=0.018) but not those meeting only the EASL-CLIF criteria (47.06 %; p=0.102). Conclusions: The APASL criteria appear to include a subgroup of patients with relatively lower mortality as compared to the EASL-CLIF criteria. L-60 Acute-on-chronic liver failure: clinical profile and outcome—Experience from a tertiary care center in North India

Ajay Nandmer, Anurag Kumar Tiwari, Manish Kumar Bhaskar, Sunit Kumar Shukla, Vinod Kumar Dixit, Ashok Kumar Jain Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Introduction: Acute-on-chronic liver failure (ACLF) is defined by APASL as acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease. However, data regarding clinical profile, precipitating events and factors predicting mortality from this part of the country is largely unknown. Methods: This is a retrospective study done in the Department of Gastroenterology, Varanasi from July 2012 to June 2015. Data was collected from medical record section of hospital regarding identification of acute insults, underlying chronic etiologies, presence of organ failure, and short-term survival. Institute Ethical committee clearance was taken. Results: Ninety-three patients (mean age 51 years, 61 males and 32 females) who presented with either raised bilirubin (n=82), international normalized ratio (INR) >1.5 (n=75), acute onset ascites (n=78), or hepatic encephalopathy (n=56) were included in study. Sixty-four patients died (68.8 %). Hepatic encephalopathy was significantly associated with mortality (p1 precipitating event, additional organ failure, total leukocyte count, INR, and serum creatinine were significantly higher in patients with ACLF. Conclusions: ACLF has high mortality rate. Hepatic encephalopathy was significantly associated with mortality. %). Sepsis, organ failure, total leukocyte count, INR, and serum creatinine were significantly higher in patients with ACLF. L-61 Predictors of mortality in acute-on-chronic liver failure precipitated by hepatic or extrahepatic insult

Tarana Gupta, S Rathi, A Duseja, S Taneja, Y K Chawla, R K Dhiman Department of Hepatology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Background and Aims: Acute-on-chronic liver failure (ACLF) is a clinical scenario wherein an acute insult leads to deterioration of chronic liver disease. We studied the difference in clinical course and predictors of mortality in patients of ACLF precipitated by hepatic or extrahepatic insults. Methods: Consecutive patients of cirrhosis with acute decompensation were prospectively included. ACLF was defined based on CANONIC study. Patients with acute viral hepatitis, hepatitis B flares, alcoholic hepatitis and drugs were included in hepatic-ACLF and with sepsis, upper gastrointestinal bleed and surgeries in extrahepatic-ACLF group. Results: Out of 179 patients of acute decompensation, 122 had ACLF (hepatic-insults 47, extrahepatic-insults 51). Alcohol (66 %)

was most common etiology of cirrhosis while sepsis (36 %) was most common acute insult followed by alcoholic hepatitis (24 %). Hepatic-ACLF patients had higher bilirubin, liver failure, MELD and CLIF-SOFA than extrahepatic ACLF. ACLF patients had higher 28- and 90-day mortality (55.7 % vs. 14 %, p<0.0001 and 78.7 % vs. 19 %, p < 0.0001 respectively) compared to no-ACLF group. There was no difference in mortality among hepatic- and extrahepatic-ACLF groups at 28 and 90 days (44.7 % vs. 54.9 %, p=0.31 and 66.7 % vs. 54.9 %, p=0.182 respectively). Area under the receiver operating curve (AUROC) for 28-day mortality in the extrahepatic-ACLF group was 0.788, 0.724, 0.718, 0.634, and 0.726 and in hepatic-ACLF group was 0.786, 0.625, 0.802, 0.761, and 0.648 for CLIF-SOFA, MELD, iMELD, APACHEII, and CTP scores respectively. Conclusion: There was no difference in mortality among hepatic- and extrahepatic-ACLF groups at 28 and 90 days. iMELD and CLIF-SOFA have the highest AUROC to predict 28-day mortality in hepatic- and extrahepatic-ACLF groups respectively.

L-62 Acute-on-chronic liver failure: Data from nine tertiary care centers across India

Shalimar1, Ajay Duseja2, Akash Shukla3, C E Eapen4, Gaurav Pandey5, Jayanti Venkataraman6, K Nayayansamy7, Pankaj Puri8, R K Dhiman2, Sandeep Nijhawan9, Sandeep Thareja2, Shivaram Singh10, Shobna Bhatia3, Uday Zachariah4, Ujjwal Sonika1, Varghese Thomas11, Vivek Saraswat5, Subrat Acharya1 1 All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India, 2Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India, 3Seth G S Medical College and K E M Hospital, Acharya Donde Marg, Parel, Mumbai 400 012, India, 4 Christian Medical College, Vellore 632 004, India, 5 Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India, 6 Global Hospital, 439, Cheran Nagar, Perumbakkam, Chennai 600 100, India 7Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India, 8Army Research and Referral Hospital, R&R, Vasant Vihar Gate, Rao Tula Ram Marg, South Campus, South Moti Bagh, New Delhi 110 010, India, 9S M S Medical College, Jawaharlal Nehru Marg, Gangawal Park, Jaipur 302 004, India, 10 S C B Medical College, Dock Road, Manglabag, Cuttack 753 007, India, and 11Medical College Hospital, Medical College Road, Government Medical College Campus, Kozhikode 673 008, India, Background: Acute-on-chronic liver failure (ACLF) is a recently described clinical syndrome with high mortality. Its etiology, natural course and pathogenesis may have regional differences. Information from India is scarce. Aim: The aim of the present study was to collate and analyze etiologies, clinical presentations, frequency of hepatic and extrahepatic organ failure, and mortality of ACLF at nine tertiary centers in India. Methods: In this retrospective study (2011–2014), patients satisfying the APASL definition of ACLF were included. Etiology of the acute event and of chronic liver disease (CLD), natural course, and outcomes were evaluated. Results: Nine hundred seventy-three consecutive ACLF patients were included; mean±SD for age was 43.9±12.3 years, and 796 (82 %) were males. Clinical presentation included jaundice in all, ascites in 92 % (759/ 824), and hepatic encephalopathy in 56 % (465/832). Etiology of acute precipitants included alcohol (38 %), hepatitis viruses (hepatitis A, hepatitis B, and hepatitis E) (22 %), sepsis (16.0 %), variceal bleeding (8.7 %), drugs (5.5 %), and miscellaneous causes (10.3 %). Among causes of CLD, alcohol was the most common (57.1 %), followed by hepatitis viruses (hepatitis B and C) (15.9 %), cryptogenic (9.5 %), and

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others (17.3 %). As per Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), liver failure was observed in 58.1 % (538/ 925), renal in 62 % (572/929), cerebral in 11 % (95/832), coagulation in 32.7 % (265/809), respiratory in 14.1 % (66/466), and circulatory in 14.2 % (48/338). Mean hospital stay was 10.6±9.4 days; 45 % (430/ 949) of patients died. Conclusions: Alcohol was the commonest etiology of underlying CLD, and continuous consumption was also the commonest cause of ACLF. Liver and renal failures were the most frequent organ failures. Within a mean hospital stay of around 10 days, 45 % of patients died. L-63 Thromboelastography can accurately interpret coagulation failure in patients with acute-on-chronic liver failure

Madhumita Premkumar, Priyanka Saxena, Roshni Mirza, S Sukriti, Chhagan Bihari, Ashok Choudhury, Shiv K Sarin Departments Hepatology, Hematology, Pathology, and Research, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Aim: This study aimed at determining the prevalence severity and dynamic coagulation profile changes in patients with ACLF. Methods: Consecutive nonseptic ACLF patients were assessed at days 0, 3, and 7 and followed up for disease progression, sepsis, and development of bleeding events. Coagulation parameters measured included Sonoclot and TEG. Coagulation assays for factor VIII, von Willebrand factor (vWF), protein C, and antithrombin III were performed. Results: One hundred and fourteen consecutive patients with ACLF (APASL criteria) were recruited (mean age 44.3±11.7 years, males 90 %). The predominant etiology for underlying chronic liver disease was ethanol (63.1 %). A deranged TEG at presentation was a predictor of bleeding (OR 2.1, p=0.05) and mortality (OR 3.1, p= 0.05). Platelet count and functions (as predicted by Sonoclot) were significantly lower in ACLF patients with sepsis at days 3 and 7. INR at baseline was associated with a deranged R and K component of TEG (p=0.05) and ACT of Sonoclot (p=0.02). Baseline ACT, CR, and PF, components of Sonoclot, were associated with sepsis at day 7 (p=0.012). Likewise, the R and K components of TEG (p= 0.064) were associated with sepsis. Coagulation factor assays for protein C, antithrombin III, and vWF were lower in all ACLF patients, when compared with controls. Factor 8 levels were significantly increased in all ACLF subgroups. Conclusions: Composite tests of coagulation such as thromboelastography and Sonoclot are useful adjuncts for prediction of bleeding events. Coagulation abnormalities in ACLF are associated with an increased tendency to bleed, risk of sepsis, and mortality. L-64 Soybean-based parenteral lipid emulsions are a safe nutritional source and improve nitrogen balance with preserved immunological functions in patients with acute-on-chronic liver failure

Anand Lovkesh, Y K Joshi, Benjamin Jaya, David Paul, Ashish, Pandit Vanshija, Rekha, Trehanpati Nirupama, V Bhatia, S K Sarin Departments of Hepatology, Nutrition, and Research, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background: Augmented lipid oxidation in cirrhosis and high energy concentration of lipid emulsions (LE) should promote them as ideal energy source for artificial nutrition in acute-on-chronic liver failure

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(ACLF) patients. Restricted use of LE is argued specially in patients with liver failure and high serum bilirubin. Patients and Methods: In this open-label prospective trial, 30 alcohol-related ACLF patients (mean age 39.6± 7.1 years) were transfused 250 mL of 20 % IV intralipid/day (500 kcal/day) for three consecutive days. Nitrogen (N2) balance (by 24-h urinary urea N2 estimation), biochemical, and immunological studies were done at baseline and at the end of the study (12 h after the third infusion). Results: Mean BMI (kg/m2) was 21.1±4.4, mean serum bilirubin was 22.8±2.2 mg/dL, and mean MELD score was 26.8±5.2. A >2-fold improvement in mean N2 balance was observed (−2.88±1.04 to 0.06 ±0.85; p=0.003) due to a decrease in N2 excretion (p=0.04). There was no significant increase in serum triglyceride, FFA, serum insulin, arterial ammonia, and global coagulation parameters. Urinary isoprostane and pro-inflammatory cytokines (IL-6, TNF-α±) increased while IL-10 decreased post-lipid infusion. No significant difference was observed in percentage and median fluorescence intensity of CD14+ CD16+ cells (monocytes), CD11b+ CD163+ cells (macrophages), and CD11b+ CD16+ cells (neutrophils) along with surface expression of HLA-DR, CD68, TLR, CXCR1, and CXCR2 on these cells. Conclusions: Soybean-based LE provides a positive N2 balance and safe nutritional support in patients with severe liver failure.

L-65 Comparison of post mortem liver biopsy findings in acute-on-chronic liver failure and decompensated liver disease

K Arivarasan, A K Mantri, Jatinderpal Singh, A Sangam, G Latika, K Majumdar, A Kumar, S Srivastava, S Sachdeva, B C Sharma, P Sakhuja, A S Puri Departments of Gastroenterology, and Pathology, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Aim: The acute-on-chronic liver failure (ACLF) and decompensated liver disease (DCLD) cannot be differentiated clinically always. The definite role of histopathology in differentiating ACLF and DCLD is also not clear to date. We aim to compare the histological findings of post- mortem percutaneous liver biopsy among patients with ACLF and DCLD through a retrospective study. Methods: Percutaneous post mortem liver biopsies (PMLB) of patients with clinically diagnosed ACLF and DCLD were retrospectively analyzed. The PMLB was done using 16G Bard biopsy gun after due consent from patient’s attendants. Criteria for ACLF were defined by APASL criteria (2014). Cirrhotic patients with decompensation in absence of acute insult constituted DCLD group. This study was conducted at GIPMER, New Delhi. Results: A total of 30 patients were analyzed, 15 each in ACLF and DCLD group. Bile ductular proliferation (ACLF n=12, DCLD n=5), bile duct injury (ACLF n=7, DCLD n=2), hepatocyte necrosis (ACLF n=6, DCLD n=1), hepatic parenchyma collapse (ACLF n=7, DCLD n=0), eosinophilic degeneration of hepatocytes (ACLF n=4, DCLD n=0), ductular transformation (ACLF n=10, DCLD n=0), cholestasis (ACLF n=13, DCLD n=9), ballooning (ACLF n=4, DCLD n=1), and rosetting (ACLF n=3, DCLD n=0) were the common parameters compared. A statistically significant difference was observed in the presence of bile ductular proliferation, ductular transformation, and hepatic parenchyma collapse between these groups (p=<0.05). Chronic inflammatory cell infiltrate was seen in the DCLD group, whereas in the ACLF group, mixed inflammatory infiltrate was observed. Conclusion: ACLF is clinically and pathologically distinct from DCLD. Hence, in cases where there is diagnostic dilemma, attempting liver biopsy may be useful.

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Recent epidemic of hepatitis in Odisha was the leading cause of rising acute-on-chronic liver failure with high mortality rate

Factors predicting recurrence of spontaneous bacterial peritonitis in decompensated cirrhosis patients

Sanatan Behera, A V Reddy, U C Patra, S K Jena, R P Sahoo, H S Das Department of Hepatology, S C B Medical College Hospital, Dock Road, Manglabag, Cuttack 753 007, India

M Ramu, K Sreejith, Deni Joseph, T S Prasanth, G Chethan, Nikhil Suraj, D Krishnadas Department of Medical Gastroenterology, Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, 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 CLD, prognostic outcome and the role of supportive therapies. There is paucity of literature on this issue and those available are biased studies as patients with milder form of illness were not studied, so understanding is at a very premature level. So studies are needed to understand and define the natural history, and whether any specific subgroup of CLD which have higher predilection for decompensation after such acute hepatic insult. Prospective study was carried out in the Department of Hepatology at SCBMCH. ACLF patients admitted in Hepatology ward from August 2012 to November 2014, were enrolled. Conclusion: A total of 60 patients were enrolled. Most patients were males <50 years. Most common presentation were coagulopathy, ascites, HE and GIB. Most common cause of acute insult, were viral but alcohol, drugs, GIB and sepsis also identified. Most of the cases had CTP-C and 50 % fall into EASL-CLIF consortium grade-3. Sepsis, ARF common complications and short time mortality was very high. In our study CTP, MELD and EASL-CLIF consortium grading all were correlate with mortality. However more results are needed to be reproduced in larger number of subjects multicenter level, and F/U to define long-term outcome in each ACLF L-67 Comparative study of various criteria defining acute-on-chronic liver failure in predicting the outcome

Shabir Mohammed, Varghese Thomas Department of Gastroenterology, Government Medical College, Calicut 637 008, India Aim: To compare three different criteria for acute-on-chronic liver failure (ACLF) (Chinese/APASL/CLIF-SOFA) in acutely decompensated chronic liver disease on the basis of short-term mortality and organ failure. Methods: Consecutive patients of cirrhosis with acute decompensation were prospectively included and grouped into ACLF and no ACLF as per the three criteria. Patients were followed up for 1 month. Mortality at 28 day was compared between no ACLF and ACLF groups. Prognostic scores (CLIF-SOFA/APACHE/MELD-II) were evaluated for the ability to predict mortality. Results: Of the 112 patients, 35 (31 %), 13 (12 %) and 9 (8 %) had ACLF as per CLIF-SOFA, Chinese and APASL criteria respectively. The 28-day mortality in no ACLF and ACLF groups was 2.6 % and 58.8 % (p<0.001) as per CLIF-SOFA, 18.2 % and 30.8 % as per Chinese (p=0.232) and 18.4 and 33.3 % as per APASL criteria (p=0.282). The 28-day mortality in patients with no ACLF, ACLF grade 1, ACLF grade 2 and ACLF grade 3 as per CLIF-SOFA criteria was 2.6 %, 20 %, 46.2 %, and 81.3 % (p<0.001) respectively. AUROC for 28-day mortality were 0.943, 0.882 and 0.809 for CLIF-SOFA, APACHE-2 and MELD scores respectively. On multivariate analysis, CLIF-SOFA and APACHE-2 score were found to be independent predictors of mortality (p=0.003 and p=0.013 respectively). Conclusion: CLIF-SOFA criteria is better than both APASL and Chinese criteria to classify patients into ACLF based on their prognosis. CLIFSOFA score is the best predictor of short-term mortality in ACLF.

Background: Spontaneous bacterial peritonitis (SBP) is the most common bacterial infection in patients with decompensated cirrhosis. Bacterial gut translocation is the most common mechanism of infection in cirrhosis. Our study aimed to identify factors predicting recurrence of SBP in decompensated CLD. Methods: We have conducted retrospective study of patients admitted with SBP during period between September 2013 to June 2015. Patients were divided into two groups. Patients with recurrent SBP enrolled as cases and with one episode of SBP as controls. Results: Out of 162 patients with SBP 30 % (48) patients had recurrence. Seventy-two percent (82) patients in control group and 68 % (33) patients with recurrence SBP were taking norflox prophylaxis. Thirty percent (25) patients in control group was taking long time rifagut therapy while only 10 % (5) patients with recurrence SBP were taking rifagut prophylaxis. Factors which showed significance in Univariate analysis were albumin level (p value 0.01), high MELD score, rifagut prophylaxis, recent variceal bleed, presence of cellulitis. Using logistic regression albumin level 20 (OR 2.65, CI 1.68-6.17), cellulitis (OR=2.20; 95 % CI=0.99-4.78) emerged as significant factors for recurrent SBP. Conclusions: Low albumin, high MELD score, and presence of cellulitis were significant factors for predicting recurrent SBP in decompensated CLD. Lifelong rifagut prophylaxis should be recommended in high-risk patients with SBP L-69 Spontaneous bacterial peritonitis—Clinical profile and comparison of treatment regimens

Sanchit Budhiraja, Vinod Kumar Dixit, Sunit Kumar Shukla, Ashok Kumar Jain, Pankaj Asati, Manas Behera, V B Abhilash Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Aims: Spontaneous bacterial peritonitis is a common complication in cirrhotic patients with ascites. The principal objective was to study the clinical profile of patients with SBP and to compare the efficacy of ofloxacin and cefotaxime therapy. Material and Methods: This was a prospective study conducted in the Gastroenterology Department, Sir Sunderlal Hospital, Banaras Hindu University, Varanasi from December 2013-November 2014. Patients with decompensated cirrhosis of liver with neutrocytic ascites were included. Patients with history of hypersensitivity to quinolones/cephalosporins or on antibiotics treatment already were excluded. Ascitic fluid analysis done included cell count, protein, albumin, gram’s stain and culture. Patients were randomized to receive either cefotaxime or ofloxacin. Results: Thirty-nine patients who met the inclusion criteria were randomized, 19 patients received cefotaxime and 20 patients received ofloxacin. The male to female ratio was 3.9:1. Majority of the patients were in 5th decade. The most common presenting complaints were altered mental status and fever (59 % and 54 % respectively). Resolution of infection was similar in both the groups (84 % in cefotaxime group and 80 % in ofloxacin group). Factors predictive of prognosis included hepatic encephalopathy, Child’s class, serum bilirubin, serum creatinine and ascitic PMN count.

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Conclusion: Most of the patients who presented with SBP were males, 5th decade being the most common age. The most common cause of SBP was gram negative bacteria. There was no significant difference in the two treatment groups (cefotaxime and ofloxacin) in the resolution of SBP. L-70 Effect of albumin infusion (low versus standard dose) on the nitric oxide and cytokine levels in plasma and ascitic fluid of spontaneous bacterial peritonitis patients

Bhaskar Jyoti Baruah, Baibaswata Nayak, Neeti Nadda, Hem Kumar, Anand Kumar, Shalimar, Subrat K Acharya Department of Gastroenterology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India The standard of care for spontaneous bacterial peritonitis (SBP) includes albumin infusion adjunct to treatment with antibiotics. The kinetics of changes in cytokine and nitric oxide level will be different in patient receiving recommended albumin dose or low dose (20 gm/day for 5 days) may need to be studied for SBP resolution. The SBP patients (250 PMNs/mm3 in AF) were randomized (n=40) for low or standard dose albumin. Total nitric oxide were measured by Griess regent following VCL3 reduction. Cytokines IL-1, Il-6 and TNF-α±were measured by ELISA. SBP resolution in both the groups are 57.89 % and 60 %. NOx levels in plasma on day 1 and 5 were 20.06±11.22 and 13.99±5.92 nmol/mL in standard group and in low dose group, it is 20.73±10.96 and 18.71±13.94 in plasma. The mean cytokine levels on days 1 and 5 were 1833±921.8 and 1016±438.2 pg/mL in AF; 1215±216.2 and 1042±446.4 pg/mL in plasma for standard dose. In low dose group, it was 1219±239.6 and 1226±406.6 pg/mL in AF; 1711±893.3, 1729±1629 pg/mL in plasma. At the end of treatment, there is reduction in IL-1 level in std group [97.88±61.24 (day 1) 46.34+25.9 pg/mL (day 5) in AF; 53.71±10.71 (day 1); 38.12±9.574 pg/mL (day 5)] and in low dose group, levels are as follows 66.37±39.32 (D1), 28.96±11.41 (D5); 46.39± 9.613 (D1), 54.49±14.25 (D5) pg/mL. Reduction in plasma and AF NOx and cytokine levels is more in standard group than low dose albumin group. L-71 Comparison of leukocyte esterase reagent strip test and nitrite reagent strip test for rapid diagnosis of spontaneous bacterial peritonitis and correlation with ascitic fluid lactoferrin level

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specificity of 89.3 % for diagnosis of SBP at a level of 300 ng/mL. AFLAC correlated well with PMN count (p<0.0001). LER strip tests showed sensitivity of 80 % and specificity of 94.11 % for the diagnosis of SBP at the grade 3 and grade 4 positivity. Nitrite strip test showed lower sensitivity and specificity (29.7 % and 75.64 % respectively) for the diagnosis of SBP. Conclusion: Nitrite strip test showed lower sensitivity compared to LER strip test for diagnosis of SBP. L-72 In vitro study to identify a compatible liquid medium to prevent premature solidification within the injection catheter for effective delivery of the glue solution into gastric varix

T S Chandrasekar, S Sathiamoorthy, K Raja Yogesh, B J Gokul, M S Prasad, T C Viveksandeep Medindia Hospitals, 83, Valluvar Kottam High Road, Nungambakkam, Chennai 600 034, India Background and Aim: The incidence of gastric variceal bleeding is about 10 % to 36 %. Gastric variceal bleeding tends to be massive and life threatening. Excellent immediate haemostasis rates (90 % to 100 %) were documented in various international studies with Cyanoacrylate injection. Adequate glue delivery is important to avoid torrential post puncture site bleed. Standard guidelines are still lacking regarding the ideal flushing fluid. This in vitro study is aimed at identifying the ideal fluid which can be used to prefill the injection catheter and also to drive the glue from the catheter into the varix, without causing premature solidification within the catheter. Material and Methods: This is a randomized, double-blind, in vitro study conducted in our hospital research laboratory. Two mL of randomly assigned samples of the five solutions (5 % dextrose, ½ NS, NS, distilled water and tap water) were taken in petri dishes. Aliquots of 0.5 mL NButyl-2-cyanoacrylate glue of two different manufactures (Gesika and Endocryl—available in India) were added to the different solutions to identify incompatibility (Cloudiness, precipitation, stickiness). Results: Glue polymerized early (within 10 s) with tap water forming a slimy layer. Normal saline and ½ NS showed cloudiness when observed beyond 1 min, whereas 5 % dextrose and distilled water did not show any changes. Conclusion: Five percent Dextrose and distilled water were found to be the most compatible flushing fluid. Other solutions (NS, 1/2 NS, tap water) were found incompatible. L-73

S Kumar, S K Sinha, K K Prasad, Y R Reddy, P Sarwal, R Kochhar Departments of Internal Medicine and Gastroenterology, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Introduction: Leukocyte esterase reagent (LER) and nitrite reagent strips (NRS) used to analyze urine samples could be used as a rapid screening tool for spontaneous bacterial peritonitis (SBP). Aims and Methods: To study the utility of LER and NRS for rapid diagnosis of SBP and correlate with quantitative measurement of ascitic fluid lactoferrin level (AFLAC) for diagnosis of SBP. Methods: One hundred and fifteen consecutive patients of cirrhosis with ascites were enrolled. Abdominal paracentesis samples were sent for polymorphonuclear count, BACTEC cultures, protein and sugar. In addition, LER and NRS tests were performed using Uri-Plus analyzers. Results were interpreted semiquantitatively. AFLAC was measured using double antibody sandwich ELISA. SBP was defined as manual cell count >250 polymorphs/cu mm and/or BACTEC culture positivity. Results: 88.7 % of 115 patients were males. Etiology of cirrhosis was alcohol in 67.8 %, combined alcohol and viral in 13 % and viral in 6.1 %. Thirty patients had SBP at presentation. 81.7 % of patients had CHILD C cirrhosis and the rest were CHILD B class. AFLAC showed sensitivity of 70 % and

Estimation of dead space of glue injection catheter used for treating gastric varices

T S Chandrasekar, K Raja Yogesh, B J Gokul, S Sathiamoorthy, M S Prasad, T Cviveksandeep Medindia Hospitals, 83, Valluvar Kottam High Road, Nungambakkam, Chennai 600 034, India Background and Aim: Gastric varices occur in 5 % to 33 % of patients with portal hypertension. Obturation by Cyanoacrylate glue injection is the recommended treatment modality. For optimal results, several precautionary measures need to be adopted. To drive the glue from the catheter into the varix, a volume of compatible flushing liquid equivalent to the dead-space of the catheter should be used. Earlier reports recommend a fixed volume of 0.8 mL of flushing liquid for this purpose. However, no standard Indian data are available. Hence we conducted an in vitro study to estimate the exact volume of dead-space of two commercially available needle catheters in India. Methods: Glue injection catheters (both 21-G and 175 cm) from Innovative Therapeutics and Blue Neem Medical Devices were studied. Using a 2 cc syringe, distilled water was injected slowly into the catheters until a tiny drop emerged out of the needle tip. The dead-space was estimated by

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subtracting the residual volume within the syringe after filling up the catheter, from the initial volume (2 cc). Results: The dead space was estimated to be 1.4 mL for Innovative Therapeutics and 1.6 mL for the Blue Neem needle catheter. Conclusion: Dead-space, even for catheters of the same gauge and length differs from one product to another. In Indian scenario, at least 1.4– 1.6 mL of flushing liquid is needed to deliver the glue, instead of 0.8 mL recommended in Western literature. We advocate therefore, an accurate estimation of dead-space volume for each manufacturer beforehand, to ensure optimal glue delivery to prevent post-puncture bleeding. L-74 Emergency endoscopic variceal ligation in sitting position: A prospective study

Prithvi Priyadarshini, Bhuvan Shetty, S K Ravikiran, Umesh Jalihal Department of Gastroenterology, M S Ramaiah Medical College, MSR College Road, MSR Nagar, MSRIT Post, Mathikere, Bengaluru 560 054, India Endoscopic variceal ligation is a preferred modality in controlling variceal bleed. The blood pool in esophagus and oozing of blood from varices cause hindrance for variceal ligation leading to failure of therapy. With this background, endoscopic variceal ligation of patients in sitting position was done and results were analyzed. Cirrhotics presenting with hematemesis were included in the study. Amongst them, patients having hypotension and hepatic encephalopathy were excluded. Initial endoscopic assessment was done in left lateral position, patients with isolated gastric variceal and ulcer bleed were further excluded. Fifteen patients with esophageal variceal bleed were selected for the study. During endoscopy, position was shifted from conventional left lateral position on noting flooding of field in esophagus with blood. Difficulty was overcome by assuming sitting posture as the blood moved to stomach by gravity and band ligation was done. Initial assessment during the procedure revealed: Better visibility aiding the procedure, no aspiration, duration of band ligation was comparable to that of nonbleeders and additional sclerotherapy was not required in any case. Following the procedure, failure of therapy was analyzed according to Baveno V consensus: There was no fresh hematemesis in any case, no drop in hematocrit, no development of hypovolemic shock. However there was delayed complication in one case due to sepsis and metabolic acidosis causing death. This study suggests, endoscopic variceal ligation in sitting position can be considered in acute esophageal variceal bleed, which improves visibility and aids in successful therapy. L-75 In vitro study to determine the solidification time of two different commercially available histoacryl glue preparations

T S Chandrasekar, B J Gokul, S Sathiamoorthy, K Raja Yogesh, T C Viveksandeep, M S Prasad Medindia Hospitals, 83, Valluvar Kottam High Road, Nungambakkam, Chennai 600 034, India Background and Aim: Up to 33 % of patients with portal hypertension develop gastric varices. Obturation of gastric varices with N-butyl-2cyanoacrylate is an accepted treatment modality for bleeding gastric varices. While injecting glue into the varix, premature withdrawal of the needle can result in torrential puncture site bleeding. Allowing adequate time for the glue to solidify within the varix can prevent such mishap. The following in vitro study was carried out to determine the solidification time of two commercially available histoacryl glue preparations so that

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the results can be extrapolated for guiding in vivo catheter indwelling time, as no data is available in the literature. Materials and Methods: Different quantities (0.5 mL and 1.0 mL) of two different glue formulations (Endocryl, Samarth Pharma and Gesika, Reevax Pharma), were used for this in vitro study to measure the time taken for complete polymerization (solidification of glue) when they were added to Petri dishes containing 2 mL of blood samples. Results: The solidification times with 0.5 mL and 1.0 mL of Gesika glue were 20 and 18 s and with Endocryl glue were 30 and 25 s, respectively. Conclusion: Complete solidification time varied between 18–30 s for different quantity and preparations of glue. These in vitro results may be extrapolated to determine the in vivo catheter indwelling time to avoid premature withdrawal of needle and consequent puncture site bleeding, during the glue injection procedure. L-76 Endoscopic ultrasound guided endocoiling in post-cyanoacrylate gastric variceal re-bleed

Anoop C Haridas, Roy J Mukkada, Rajesh Antony, Mathew Chooracken J, V J Francis, A P Chettupuzha, P G Mathew, P Augustine, A Koshy Departments of Gastroenterology and Radiology, Lakeshore Hospital and Research Centre, Kochi 682 304, India Background and Aim: N-butyl-cyanoacrylate injection is recommended in bleeding or recently bled gastric varices. However, it is associated with rebleed in 25 % and 50 % of cases. Endocoiling is an emerging treatment modality for bleeding gastric varices. The aim was to compare endoscopic ultrasound guided coiling combined with cyanoacrylate injection to cyanoacrylate injection alone in post-cyanoacrylate gastric variceal re-bleed. Methods: A retrospective analysis of a prospectively maintained database was performed. Fourteen patients with portal hypertension who re-bled after cyanoacrylate injection who had endocoiling of varices were included. Forty-four comparison patients had only cyanoacrylate injection and was followed up for 12 months. Endocoiling was done under endosonographic guidance. A single coil was placed in 4, two coils in each of 7 patients, 3 coils in one, 4 coils in one and 6 coils in one patient. In addition, cyanoacrylate glue injection was given in 6 patients. Five patients had repeat endocoiling 1 month later. Re-bleed and mortality were assessed. Results: In Endocoiling group none of the patients re-bled during the follow-up of 15 to 365 days. One patient died 2 months after the procedure due to spontaneous bacterial peritonitis. In cyanoacrylate group 21/44 (48 %) re-bled during follow-up of 45 to 365 days. Two out of 44 (2 %) patients died in the group. Kaplan-Meir analysis showed statistically significant difference with respect to the probability of rebleed (p=0.04), Conclusion: Endocoiling with or without cyanoacrylate injection for the obliteration of gastric varices is effective for post-cyanoacrylate gastric variceal re-bleed. L-77 Usefulness of scoring systems in predicting re-bleed and mortality in upper gastrointestinal bleed patients

Amol S Dahale, Ajay Kumar, A S Puri, Sanjeev Sachdeva, Siddhartha Srivastav, Alok Sangam G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Aim: The prognosis and rebleed prediction is important in patients admitted with upper gastrointestinal bleed (UGIB). We aim to study the usefulness of Rockall (RA), Blatchford-Glasgow (BG) and AIMS 65 scoring system in UGIB for predicting the mortality and rebleed.

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Methods: All patients presenting with UGIB from December 2014 to May 2015 admitted at G B Pant Institute of Postgraduate Medical Education and Research were prospectively included in the study. All were treated as per standard protocol and followed up till 30 days for re-bleed and outcome. The RA, BG and AIMS 65 scores were calculated at presentation. Results: Total of 91 patients with suspected UGIB were admitted, 19 were excluded after evaluation. Total 72 patients were followed, mean age of patients was 42.91 yr±17.68 yr, males (n=51) and were females (n=21). Portal hypertension (PHT) related UGIB was cause in 79.5 % (n=58) and non-PHT bleed 19.4 % (n=14) patients. The 10 patients had re-bleeding; AIMS 65 score (mean in rebleed patients (B) −2.10 vs. non-re-bleed (NB) 1.05, p=0.008), RA score (mean B-5.3, NB-4.3, p=0.17), BG score (mean B-12.50, NB-11.59, p=0.36) were higher. Total 4 patients died, 3 in PHT group and one in non-PHT group, AIMS 65 (mean-live(L)1.03, dead (D)-4.00 p=<0.005) and RA score (mean-L-4.29, D-8.00 p= 0.01) and BG (mean-L-11.57, D-14.25 p=0.07). Conclusion: AIMS 65 and RA scores predict mortality and only AIMS 65 predicts re-bleed. L-78 Nonvariceal upper gastrointestinal bleed: Clinical profile and factors affecting outcome

Sanchit Budhiraja, Vinod Kumar Dixit, Sunit Kumar Shukla, Ashok Kumar Jain, Pankaj Asati, Manas Behera, V B Abhilash Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India Background and Aims: Nonvariceal upper gastrointestinal (UGI) bleeding remains a common emergency with an annual incidence of 50 to 150 per 100,000 population. The principal objectives were to study the profile of nonvariceal UGI bleed through clinical, biochemical and endoscopic evaluation and various factors that affect its outcome. Materials and Methods: Patients admitted to Gastroenterology Department of Sir Sunderlal Hospital, Varanasi, India with nonvariceal UGI bleeding were studied from December 2013 to November 2014. Ninety-two patients were included in the study. After initial resuscitation, the patients were subjected to endoscopic examination. Within 24 h of admission, clinical, demographic, biochemical, hematological, endoscopic and radiological parameters, and outcomes were recorded. Results: The mean age was 48.97 years. Male preponderance was seen in all age groups. The commonest cause was erosive mucosal disease (34.8 %) followed by peptic ulcer and esophagitis. The commonest presentation was melena. Diclofenac was the most common NSAID associated with UGI bleed (25 %). Majority of the patients in shock had duodenal ulcer as the etiology, seventy five patients (81.5 %) of nonvariceal UGI bleed settled with conservative management. Conclusion: The parameters that were found to increase the adverse outcome were age >60 years, hematemesis, epigastric pain for <48 h, shock, postural drop in blood pressure and comorbidities like ischemic heart disease, chronic lung disease and chronic liver disease. Short hospital stay, melena, pre-endoscopic Rockall score.

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Background and Aims: Variceal band ligation (VBL), propranolol, carvedilol and nitrates are treatment options for prevention of variceal rebleeding but data regarding superiority of one over other are scarce and controversial. This randomized controlled trial compared VBL, propranolol plus isosorbide-5-mononitrate (P+I) and carvedilol in prevention of esophageal variceal rebleeding. Methods: One hundred and forty-two patients with cirrhosis, who survived from esophageal variceal bleed were randomized; 56 into VBL, 39 into P+I and 47 into carvedilol group. Baseline patient characteristics: age, 44.1 (±8.5) years; CTP score, 8.6 (±1.7), 59 % alcoholic cirrhosis; follow-up period, 16.4±5.3 months (range, 11.1–21.7 months), were comparable in the 3 groups. Results: On intention to treat analysis, variceal rebleeding rate was 26 % for VBL, 35 % for P+I, and 28 % for carvedilol group. The 2-year actuarial risks for variceal rebleed were 32 % for VBL, 42 % for P+I, and 34 % for carvedilol group. A significant number of patients reported side effects with drug treatment (45 % P+I and 28 % carvedilol vs. 2 % VBL; p<0.05). Although there were no statistically significant differences in mortality rates in the 3 groups, 8.5 % in carvedilol, 16.2 % in VBL and 20.4 % in P+I group. The trend toward survival benefit for those taking carvedilol. Conclusions: Variceal rebleeding rate was lower in VBL and carvedilol group compared to P+I but not significant. The trend toward survival benefit for patients taking carvedilol compared with others requires further exploration. The side-effect profile for pharmacotherapy was significant. L-80 Utility of post-mortem liver biopsy: myth or reality?

K Arivarasan, A K Mantri, Jatinderpal Singh, A Dalal, G Latika, K Majumdar, A Kumar, S Srivastava, S Sachdeva, B C Sharma, P Sakhuja, A S Puri Departments of Gastroenterology, and Pathology, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and aim: Post- mortem liver biopsy (PMLB) has been acknowledged as a useful source of information, capable of stumping the diagnostic skills of one of the most astute physicians. We aimed to audit the histology results of last 50 PMLB performed at our institute. Methods: We retrospectively evaluated the clinical records of last 50 PMLB performed at our institute. PMLB was conducted using 16G Bard biopsy gun after due consent from patient’s attendants. Results: Mean age of patients was 39.8 years (range 3–72 years). Males constituted 60 % of the total cases. Ante-mortem clinical diagnosis included decompensated cirrhosis in 48 %, acute-on-chronic liver failure in 30 % and others 22 % (including acute liver failure, acute febrile illness, suspected granulomatous hepatitis and others). Alcohol was the commonest cause of underlying cirrhosis followed by chronic hepatitis B. In 37 (74 %) patients PMLB correlated with ante- mortem clinical diagnosis. In 13 (26 %) of patients the PMLB did not correlate with ante- mortem clinical diagnosis. Two very unusual post- mortem diagnosis included rhabdomyosarcoma and granulomatous tuberculosis (on background of alcoholic cirrhosis). Conclusion: PMLB is a useful informative tool in both diagnosed and undiagnosed liver disease.

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Secondary prophylaxis of variceal hemorrhage: a comparative study of band ligation, carvedilol and propranolol plus isosorbide mononitrate

To compare noninvasive markers of liver fibrosis with liver biopsy in a tertiary care center

Pavan Kumar, Ravikant Kumar, K N Saxena, S P Misra, M Dwivedi Department of Gastroenterology, Motilal Nehru Medical College, George Town, Allahabad 211 002, India

Deni Joseph, T S Prasanth, G Chethan, K Sreejith, M Ramu, S Nikil, Shanid, S Srijaya, D Krishnadas Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India

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The aim was to compare noninvasive markers of liver fibrosis like APRI index, hepatic wave forms with liver biopsy in a tertiary care center back ground fibrosis is an important determinant of prognosis in liver disease. Non invasivemarkers have an important role in accessing liver fibrosis and are risk free. Method liver biopsy details done in 160 consecutive patients in medical gastro from 2013 were collected and were compared with various noninvasive markers of fibrosis result 1. Most common indication for biopsy was transaminitis 2. Commonest cause was steatohepatitis 3 various noninvasive markers like APRI, hepatic wave forms spleen size were compared to liver fibrosis and it was found that at lower level of fibrosis they were poor in predicting fibrosis 4 but at higher grade of fibrosis they showed excellent correlation with fibrosis stage assessed by liver biopsy 5 complication rate was 2 %. L-82 Pattern of biliary abnormalities in portal cavernoma associated cholangiopathy in patients with extrahepatic portal venous obstruction

Sajith Prasad, Varghese Thomas Department of Gastroenterology, Government Medical College, Calicut 673 008, India Background: Biliary abnormalities in extrahepatic portal venous obstruction (EHPVO) which is known as portal cavernoma associated cholangiopathy occur in long standing disease. However only a few are symptomatic. Aim: To study the occurrence and patterns of biliary abnormalities in patients with long standing EHPVO who had undergone endotherapy for variceal bleeding earlier. Methods: Consecutive patients above 12 years of age with a diagnosis of EHPVO were studied. Detailed history, laboratory parameters, ultrasound abdomen and MRCP were obtained from all. Results: Seventy-one EHPVO patients were studied (male 44), mean age being 37 years (20–56). Median duration after first bleed was 22 years (7– 36). Biliary abnormalities were present in 62 (87 %) patients on MRCP. The commonest biliary abnormality noted was CBD indentations (50 %) followed by intrahepatic biliary dilatation (35 %). Gallbladder calculi were present in 7 (9 %). Findings like clustering and pruning mentioned in literature was not reported in any patient. Only 13 (18 %) were symptomatic. Those with symptoms presented with jaundice in 10 (84 %), abdominal pain in 4 (30 %) and cholangitis in 4 (30 %). Two patients had pruritus as presenting complaint. The mean bilirubin in those with biliopathy was 2.4 mg/dL (0.4-22) and alkaline phosphatase was 174 IU/ L (42–658). Only 2 patients underwent surgery for portal biliopathy. Conclusions: Biliary abnormalities are common (87 %) in long standing EHPVO. Only 18 % were symptomatic and still fewer needed any kind of intervention. Most common biliary abnormalities in MRCP were CBD indentation and intrahepatic biliary dilatation. L-83 Prevalence of portal biliopathy in extrahepatic portal venous obstruction—A tertiary center experience

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studies. It includes abnormalities of both extra and intrahepatic bile ducts and varices of the gallbladder. Occasionally, these changes become significant to give rise to overt obstructive jaundice and cholangitis. Materials and Methods: Twenty consecutive patients with EHPVO attending Medical Gastroenterology, OPD, from January 2015 to August 2015 were analyzed for asymptomatic and symptomatic biliary abnormalities. They were subjected to MRC coupled with portogram and if indicated ERCP was done for them as a therapeutic measure. Results: Four patients presented with clinical manifestations of biliary disease, gallstones were present in 3 patients, common bile duct stone in 1 patient, stricture in 5 patients, corrugated appearance of bile duct, due to choledochal plexus, in 2 patients and gallbladder varices in 3 patients. ERCP was done for 5 patients. Conclusion: Portal biliopathy is often under diagnosed in clinical practice. A high index of suspicion has to be present to diagnose this early, hence prevent complications. L-84 Expression analysis of plasma apolipoproteins in hepatocellular carcinoma: A protein-based hepatocellular c arcinoma-associated study

Dipu Bharali, Premashis Kar Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110 002, India Introduction: Hepatocellular carcinoma (HCC) is the 6th cancer in incidence worldwide and the 3rd leading cause of cancer death. To identify new marker molecule of HCC using a protein based analysis. Aims and Methods: To find out differential expression of ApoA1 and ApoAIV in HCC and controls without HCC. Fifty patients with HCC and 50 chronic hepatitis and liver cirrhosis were included in the study. Proteins were depleted and precipitated followed by separation in SDS PAGE from blood plasma and the expression changes of ApoA1 and ApoA4 were confirmed by Western blotting followed by densitometric protein semiquantitation estimation along with ELISA based protein quantification. Results: Levels of Apo-AI were significantly higher in patients with HCC than in controls without HCC (0.279±0.003 vs. 0.171±0.034 and 0.199± 0.014; p<0.01). Levels of Apo-AIV were significantly lower in patients with HCC (0.208±0.07 and 0.119±0.016 vs. 0.119±0.005; p<0.01). Quantitative measurement of ApoAI, ApoAIV and AFP by ELISA revealed the same results supporting the western blotting. There was a significant increased in Apo-A1 expression level in HCC group (p= 0.0001). To define the test characteristics of ApoAI, ApoAIV and AFP for the diagnosis of HCC respectively showed AUC of 0.901±0.031 (p=0.0001, 95 % CI 0.840-0.962) with a sensitivity 86.0 % and specificity 79.0 % at a 4747.19 ng/mL cutoff; an AUC of 0.875±0.035 (p<0.01, 95 % CI 0.7580.913) with a sensitivity 76.8 % and specificity 75.2 % at a 318.55 ng/mL cutoff and an AUC of 0.673±0.055 (p=0.003, 95 % CI 0.564-0.781) with a sensitivity 66.0 % and specificity 59.0 % at a 210.72 ng/mL cutoff. Conclusion: Apolipoprotein AI could be an additional marker molecule in prediction of HCC in chronic liver diseases. It might be used as future diagnostic tool in addition to other conventional biomarkers for HCC after further analysis in large group of population.

K Senthamizh Selvan, T Pugazhendhi, Mohammed Ali Department of Medical Gastroenterology, Rajiv Gandhi Government General Hospital-Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India

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Background: Portal biliopathy refers to biliary and gallbladder abnormalities seen in patients with portal hypertension. These changes are predominantly seen in patients with extrahepatic portal vein obstruction (EHPVO). It has been reported to occur in up to 70 % to 100 % of patients in some

Manas Kumar Behera, S K Shukla, V K Dixit, A K Jain, V B Abhilash, S Budhiraja, P Asati Department of Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India

Clinical and radiological profile of hepatocellular carcinoma in north Indian patients

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Background: Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The aim of the study is to study the clinical and radiological profile of HCC. Methods: Consecutive 84 cases of HCC attending Gastroenterology Outpatient of Institute of Medical Sciences, Banaras Hindu University from August 2012 to June 2015 were included. Detailed history was taken, tests for hepatitis B virus (HBsAg, HBeAg, anti-HBe, and HBV-DNA), hepatitis C virus (anti-HCV) infection, USG of abdomen and triple phase CT scan was done in all patients. Results: Included subjects had mean age of 53.4±14.8 years and males constituted 76 % of all HCC. The etiology of HCC was: hepatitis B virus in 39 (46.4 %), hepatitis C virus in 12 (14 %), alcohol 15 (17.8 %), both hepatitis C and alcohol in 6 (7 %) patients and 12 (14 %) had unknown cause. Cirrhosis was seen in 58 (69 %) patients and 41 patients had hepatic decompensation at presentation. The most common symptoms were weakness (82 %), anorexia (74 %), pain abdomen (61 %) and hepatomegaly in (79 %) of patients. Serum AFP>400 ng/dL was found in 32 (38 %) patients. HCC commonly involved right lobe of liver (45 %), followed by bilobar (30 %) and left lobe involved in 25 % of patients. Tumor size at 5 cm was seen in 2/3 cases. Portal vein invasion was in 36 % and distant metastases in 23 % of patients. Conclusions: Most patients had advanced disease at presentation. HBV infection is the predominant factor for development of HCC in India and majority of patients have overt cirrhosis of the liver. Serum α−fetoprotein was diagnostic in around 1/3 of our patients.

L-86 Does diabetes mellitus alter the clinical and biochemical characteristics of hepatocellular carcinoma patients—A South Indian experience

Prasanth Thayyil Sudheendran, Chethan Govindaraju, Nikhil Suraj, Deni Joseph, Kadavanoor Srijith, Ramu Muraleedharan Pillai, Santosh Yadav, Premaletha Narayanan, Kattoor Ramakrishnan Vinayakumar, Devang Tank, Krishnadas Devadas Department of Medical Gastroenterology, Government Medical College, Ulloor Road, Thiruvananthapuram 69 501, India Introduction: Recent studies suggested a strong association between diabetes mellitus and hepatocellular carcinoma (HCC) in males and females independent of the geographic location, alcohol consumption, hepatitis B or C (HBV or HCV) infection. We tried to find out if diabetes mellitus alter the clinical and biochemical characteristics of HCC patients. Material and Methods: We did a retrospective study of 170 cirrhotic HCC patients attending our department from 2011 to 2015. The various clinical and biochemical factors like age, sex, etiology, serum alphafetoprotein (AFP), portal vein thrombosis (PVT) were analyzed and correlated with diabetes mellitus by univariate and multivariate analysis with p value< 0.05 taken as statistically significant. Results: We had a total of 170 patients with 152 males (89.4 %) and 18 females (10.6 %) with mean age of patients 56.4 years with a minimum age of 17 years and maximum age of 88 years. Most of the patients belong to CHILD B (38.8 %), 42.4 % belong to BCLC C status. The most common etiology was hepatitis B 25.8 %, alcohol 19.4 %, hepatitis B+ alcohol 17.6 %, NASH 12.9 % HCV alone 6.4 % and others in 17.6 % (Fig. 1). By univariate analysis and multivariate analysis age and etiology were having significant association with diabetes. Analyzing the etiology further we found that NASH related, HBV+alcohol, HCV alone were having significant association with diabetes at the time of diagnosis of HCC. Etiology of cirrhosis like alcohol alone, hepatitis B alone are having negative correlation with the presence of diabetes mellitus. Conclusion: In HCC patients, diabetes mellitus has significant association with the etiology of cirrhosis like NASH, alcohol+hepatitis B and HCV

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alone. So diabetic patients with cirrhosis etiology like NASH, hepatitis B+alcohol and hepatitis C alone should be screened for HCC at frequent intervals than their non-diabetes mellitus counterparts. L-87 Major liver resection for large hepatocellular carcinoma

Viniyendra Pamecha, Shridhar Sasturkar, Senthil Kumar, G S B Kishore, Piyush Sinha Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background: Major liver resection for large hepatocellular carcinoma remains a clinical challenge especially in patients with chronic liver disease. Methods: Prospectively collected data of patients with large HCC who underwent liver resection between March 2011 and February 2015. The perioperative morbidity, mortality, overall and disease free survival is reported. Results: Eighteen patients (14 male) with median age of 59 years (range 20 to 73 years) underwent resection. Fourteen patients were in Child’s A and four B. Four patients had segmental portal vein involvement, two patients had bilobar disease and one had biliary obstruction. Seven patients had extended resection (>5 segments). On histopathology, all eighteen patients had R0 resection, median tumor diameter was 9 cm (5–18 cm). Eight patients had cirrhosis, six patients had mild to moderate fibrosis and four patients had chronic inflammatory changes. Twelve tumors were solitary and six were multifocal. Morbidity according to Clavien-Dindo class was grade 1–11, grade 2–5, grade 3B-1, and grade 5–1. The median post operative hospital stay was 12 days (8–22 days). Five patients had tumor recurrence, two are currently receiving radiofrequency ablation. There were 3 deaths during the follow up. Overall survival was 72 % and the disease free survival was 70 % with median follow up was 26 months (6–48 months). Conclusion: In carefully selected patients, acceptable perioperative and medium term outcomes can be achieved with major liver resection for large or multinodular HCC in chronic liver disease. L-88 Hepatocellular carcinoma in autoimmune hepatitis: The Indian experience

Amey Dilip Sonavane, Deepak N Amarapurkar Bombay Hospital and Medical Research Centre, 12, Marine Lines, Mumbai 400 020, India Backgrounds and Aims: Autoimmune hepatitis (AIH) can progress to cirrhosis and primary hepatocellular carcinoma (HCC) is thus an anticipated, though unusual, consequence. The aim of this study was to determine the incidence of HCC in AIH, to identify the potential risk factors and to find out whether AIH also belongs to a high-risk group that mandates surveillance. Methods: Medical records of 242 patients diagnosed with AIH were analyzed retrospectively. Among the patients who developed HCC, demographic, clinical, biochemical, endoscopy, imaging and treatment details were analyzed. Results: Two hundred and forty-two patients were diagnosed with AIH (149 females; 93 males). One hundred and seventy-four patients (72 %) had evidence of cirrhosis of liver (100 females, 74 males). Median age at diagnosis of AIH was 44.65±1.59 years with a total follow up of 798.75 patient years. Commonest presenting symptom was jaundice (49.17 %)

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followed by ascites (34.29 %), hepatic encephalopathy (0.02 %) and gastrointestinal bleed (0.016 %). Eight patients (3 %) were identified with HCC (5 females; 3 males). The incidence of HCC equated to 1001.56 cases per 100,000 patient follow-up years. Median age at diagnosis of HCC was 58.62±1.03 years. Risk factors noticed in patients developing HCC in AIH were cirrhosis of liver, BMI above 25, age above 52 years, thrombocytopenia and presence of esophageal varices. Conclusion: AIH with cirrhosis of liver predisposes to HCC. Incidence of HCC in AIH is lower than chronic liver disease secondary to viral hepatitis B and C, alcohol or NASH. Routine screening and surveillance for early detection of HCC must be performed in all AIH patients developing cirrhosis. Further prospective studies are needed to validate this data. L-89 Etiological and clinical characteristics of hepatocellular carcinoma at presentation in tertiary care hospital in South India

Chethan Govindaraju, Prasanth Thayyil Sudheendran, Nikhil Suraj, Deni Joseph, Kadavanoor Srijith, M Ramu, Shahana S Fathima, Shanid A Sathar, Srijaya S Sreesh, Prashanth K Shobhan, Devadas Krishnadas Government Medical College, Ulloor Road, Thiruvananthapuram 695 011, India Aim: To analyze the etiology, clinical presentation and tumor characteristics of HCC presenting to tertiary care hospital. Methods: This is a observational retrospective descriptive study. All patients who were diagnosed to have HCC from 2008 to 2014 were included. HCC was diagnosis was based on European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD) guidelines. Detailed clinical presentation, etiological workup data, laboratory parameters, child status were analyzed. Barcelona clinic liver cancer (BCLC) staging was done. Results: One hundred and seventy-two patients were diagnosed to have hepatocellular carcinoma (HCC) during this period, out of which two patients were noncirrhotic. One hundred and fifty-four patients (89 %) were male, 18 (10.4 %) were females. Mean age was 56.3 years (17– 86 years). Hepatitis B alone was seen in 44 patients (25.8 %), with alcohol in 30 patients (17.6 %). Alcohol alone in 33 patients (19.4 %), nonalcoholic steatohepatitis (NASH) in 22 patients (12.9 %), HCV in 1 patients (6.4 %). HCC presenting as first presentation in nearly half the patients. AFP was >200 in 07 patients (62.9 %), while it was normal in 4 patients (8.2 %), PVT was present in 100 patients (58.8 %), about 72 (42.2 %) patients belong to BCLC C, 52 patients (30.53 %) to D. Conclusion: Hepatitis B was the most common cause of HCC followed by alcohol in our population. Almost all the patients had underlying cirrhosis. Nearly in half the patients it was first presentation. More than two third of patient present in advanced stage. L-90 Liver regeneration after right lobe donor hepatectomy: Serial changes of cytokines and growth factors

Shridhar V Sasturkar, Viniyendra Pamecha, Paul David, Shreya Sharma, Nirupama Trehanpati Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India The aim of this study was to evaluate the circulating biological markers of liver regeneration in donors undergoing right lobe donor hepatectomy (PHx) for LDLT. Twenty-five donors were enrolled. Blood samples were taken at baseline and on postoperative day (POD) 1, 3, 7, 14 and 42. Levels of hepatocytes growth factor (HGF), interleukin 6 (IL-6), tumor necrosis factor±(TNF±), thrombopoietin (TPO), transforming growth

factor Î2 1 (TGF1), interferon± (IFN±) and interferon (IFN) were monitored. The future remnant liver volume (RLV) was calculated before and 2 weeks after surgery (RgLV). The ratio of volume of RgLV to the RLV was correlated to the ratio of RLV to the body weight and was inversely proportional (p<0.0001). HGF (p=0.01) and TNF±(p=0.004) levels increased on POD 1. IL6 (p L-91 Selection and outcome of the potential live liver donor

Pamecha Viniyendra, , Mahansaria Shyam Sunder, G S Bharathy Kishore, Kumar Senthil, V Sasturkar Shridhar, Piyush Sinha  Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background: A thorough donor evaluation process is mandatory to ensure safe outcome in an otherwise healthy individual. The aim of current study was to evaluate the reasons for not proceeding to donation and the outcome of live liver donors (LLD). Methods: Prospective observational study of potential LLD undergoing donor evaluation from 1st April 2012 to 31st January 2015. Outcome of donor evaluation in a standard stepwise protocol was recorded. Perioperative complications were graded according to Clavien-Dindo (CD) classification. Results: Four hundred and sixty LLD were evaluated in a stepwise manner for 367 potential recipients. One hundred and thirty-nine (30.3 %) donors proceeded to donation. Of the 321 (69.7 %) donors not proceeding to donation, 204 (63.55 %) were for donor related and 117 (36.44 %) were for recipient related reasons. Common donor related reasons were: donor reluctance (23.52 %), negative liver attenuation index (16.17 %), anatomic variations (10.29 %), inadequate remnant liver volume (<30 %) (9.80 %), evidence of greater than 10 % macro-vesicular steatosis or steatohepatitis on liver biopsy (8.82 %), and inadequate graft recipient weight ratio (5.39 %). Majority of donors (82.84 %) were turned down early in the (step 1 and 2) evaluation process. Recipient death was the most common recipient related reason [n=51(43.58 %)]. There was no donor mortality. The overall complication rate was 19.8 % and major complication rate (grade 3 or higher) was 4.4 %. Conclusions: A stringent stepwise donor evaluation process leads to early recognition of unsuitable donors and low morbidity. Multiple counseling sessions and donor interview alone can identify donor reluctance to make sure that the process of donation is voluntary. L-92 Correlation of platelet counts and outcome after adult to adult living donor liver transplantation for end-stage liver disease

Viniyendra Pamecha, Mahansaria Shyam Sunder, G S Bharathy Kishore, Kumar Senthil, V Sasturkar Shridhar, Piyush Sinha Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction: The study was aimed to evaluate the factors contributing to post transplant thrombocytopenia and its effect on post living donor liver transplantation (LDLT) outcome. Methods: Prospective observational study of 69 consecutive elective adult LDLT at our center from January 2013 to August 2014. Univariate and multivariate analyses were performed to assess variables predictive of post transplant thrombocytopenia and its impact on outcome. Results: The median pretransplant PLT was 62,000/mm3 (IQR=42,50096,500/mm3). The lowest median PLT after LDLT were observed on POD3 (21,000/mm3 (IQR=15,000-31,000/mm3). Then platelet counts gradually rise again to exceed pretransplant levels on day 10. Pretransplant PLT, sarcopenia, variceal bleeding, intraoperative blood

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loss, intraoperative packed red cell and fresh frozen plasma transfusions, early rejection within 1 month were significant predictors of the severity of thrombocytopenia in univariate analysis. The pretransplant PLT, sarcopenia and intra-operative packed red cell transfusions were independent predictive factors for posttransplant thrombocytopenia on multivariate analysis. Patients with severe thrombocytopenia (PLT1 liter on POD 14) (65.6 % vs. 29.7 %, p=0.001). Mortality rate (10.4 % vs. 4.8 %) was higher but this difference failed to reach statistical significance. Conclusions: Pretransplant PLT, sarcopenia and intraoperative packed red cell transfusions were independent predictive factors for posttransplant thrombocytopenia. Posttransplant thrombocytopenia was a strong predictor of major postoperative complications, prolonged ascitic drainage and sepsis. The mortality rate was high in thrombocytopenia group. L-93 Deceased donor liver transplantation—Institute of Liver and Biliary Sciences experience

Viniyendra Pamecha, Senthil Kumar, G S B Kishore, Shridhar Sasturkar, Piyush Sinha, Deeplaxmi Borle Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction: Cadaveric liver transplant is uncommon in north India because of very low organ donation rate. We present our experience of deceased donor liver transplants (DDLT). Methods: Prospectively collected data of all the DDLT performed at the institute to date was analyzed for demographic data, presentation, intraoperative variables donor factors, morbidity and outcome. Results: During the study period total 240 liver transplants were performed out of which 17 were DDLT. The median age was 39 years (1– 59), 15 males, 4 pediatric. The median MELD and PELD scores were 22 (9–34) and 15 (9–22) respectively. The median donor age was 32.5 years (16 months to 77 years), 11 males. Four organs were procured from outside Delhi. Sixty-five percent of the grafts used were marginal. Mean warm and cold ischemia times were 46 min (±6.18) and 349.5 min (±161.48) respectively. Major morbidity 35 %, median hospital stay was 28 days (20–167). Overall survival is 77 %. There were three perioperative mortalities (1 primary graft nonfunction, 1 necrotizing fasciitis, 1 miliary TB) and one late death because of chronic rejection with median follow up of 8 months (2–40) Conclusion: Despite logistic difficulties and use of marginal grafts DDLT can result in good outcome. L-94 Computed tomography-assisted assessment of body composition in healthy living donors and patients with alcoholic liver disease

Jaya Benjamin, Varsha Shasthry Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background: Sarcopenia is common in patients with alcoholic liver disease (ALD), but their body composition in comparison to healthy individuals is not well characterized. Computed tomography (CT) provides a reliable and precise tool for such assessment. Aim: To determine the cutoffs for defining sarcopenia from healthy living donors who served as controls (HC) and compare with body composition in ALD. Methods: HC comprising of organ transplant donors and ALD patients were included in this retrospective observational study. Single slice CT image at 3rd lumbar vertebrae was analyzed using Slice Omatic V4.3 software. Area of 5 muscles was normalized for height and

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expressed as skeletal muscle index (SMI; cm2/m2) and that of subcutaneous (SAT) and visceral adipose tissue (VAT) was expressed in cm2. Cutoff for defining sarcopenia was established as 2 SD below the mean of HC and body composition of male HC was compared with compensated (C, Child’s A) and decompensated (DC Child’s B and C) ALD patients. Results: The derived cutoff of SMI in HC (n=230; M:109; age 33.3± 9.9 years; BMI 25.4±2.6 kg/m2) was 35.7 cm2/m2 in males and 28.1 cm2/ m2 in females. The SMI in ALD patients [n=140; C (36 %): DC (64 %); M:140; age 46.2±9.7 years; BMI 23.1±4.7 kg/m2] was significantly lower than controls. The VAT was significantly higher in the ALD patients than HC (p=0.019). Conclusion: ALD is characterised by increased adiposity and relatively preserved muscle mass in compensated state, sarcopenia and adipopenia become pronounced only with decompensation. In ALD patients, the prevalence of sarcopenia was 15.5 % based on Indian cutoff of 35.7 cm2/m2. L-95 Evaluation of quality of life of donors after hepatectomy for living donor liver transplantation: A prospective study

Piyush Kumar Sinha, G S B Kishore, S Kumar, V Pamecha Department of HPB Surgery and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Introduction/Background: Health-related quality of life measurement is an important aspect of donor recovery. There is lack of prospective data. We present a longitudinal study evaluating HRQOL of donors after hepatectomy for LDLT. Patients and Methods: This prospective study, in a teaching hospital in India, examined 52 subjects who underwent donor hepatectomy (March 2012–August 2013). We investigated the change in QOL of donors at different time points, their predictors and the willingness to undergo donation process again. Participants were administered the WHOQOL-BREF instrument and the pre-donation motivation and concern questionnaires at various time points: predonation, at 1 week and at 1, 3, 6, 12 months post donation. Postdonation they were given a questionnaire on willingness to undergo the donation process again. Prospective donors who could not undergo donation process were taken as control group. Baseline QOL, demographics and recipient etiology were comparable between the donors and controls. The donors whose recipients died were less likely to continue with the study (n=8). Physical and psychological domain scores decreased significantly after donation (1 week; 1 month; 3 months) while social relations and environment health scores increased at 3 months after donation. All scores reached baseline after 12 months (Fig. 1 and Table 1). About 36 % of donors were hesitant about undergoing the donation process again. If given an opportunity, donors of patients having alcoholic liver disease or acute liver failure (30 % recipient mortality in ALF) were significantly less willing to undergo the donation process again. Conclusion: There is transient but significant change in quality of life after donor hepatectomy with the parameters returning to baseline after 12 months. The attitude of donors to the process of donation was affected by recipient etiology and outcome. L-96 Preoperative estimation of graft weight before donor hepatectomy for living donor liver transplantation using portal vein diameter

Piyush Kumar Sinha, G S B Kishore, S Kumar, V Pamecha Department of HPB Surgery and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India

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Introduction: Accurate estimation of graft weight before donor hepatectomy is warranted for optimal donor selection as well as operative planning. Method using portal vein diameter have been found to be accurate but the results have not been validated widely. Postperfusion decrease in the weight of the graft has not been addressed uniformly in the literature. Patients and Methods: All donors undergoing right or left hepatectomy at a tertiary care center in India from, March 2012 to January 2014 were enrolled (n=69). Graft weight was estimated using right portal vein diameter (R), left portal vein diameter (L), right anterior and posterior portal vein diameter (RA, RP) according to Lee’s formula (RHLV = SLV × [R2/(R2 + L2)], LHLV = SLV × [L2/(R2 + L2)]) and modified Lee’s formula(RHLV = SLV × [(RA2 + RP2)/(RA2 + RP2 + L2)], LHLV = SLV × [(L2/(RA2 + RP2+L2)]. Standard liver volume (SLV) was calculated using 16 different formula described in the literature. Postperfusion change in graft weight was recorded and predictors of change were analyzed. Results: Seven were left hemiliver grafts and 10 patients had segmental branch draining to right portal vein so calculation of modified Lee’s formula was not possible. Ratio of right hemiliver calculated from Lee’s, modified Lee’s and CT volumetry were not different. Estimated SLV varied widely depending on the formula used and ranged from the smallest using the formula of Chan et al. (1024.2±121.1 mL) compared with the largest using the formula of Chouker et al. (1776 ±192.2 mL). Compared to actual graft volumes, the most accurate method for estimating live-donor graft volume was the Lee’s formula and substituting the SLV calculation by the method of Urata and Hashimoto. CT overestimated the graft volume by mean 54±93.6 mL which was statistically different from the actual graft volume p<0.001. Similarly when modified Lee’s formula was used substituting the SLV calculation by the method of Urata and Hashimoto gave the most accurate estimation. Estimated volume derived from Lee’s and modified Lee’s formula was not significantly different from each other. Lee and modified lee formula were valid for left lobe grafts also when SLV was calculated using Urata and Hashimoto. Conclusion: Modified Lee’s formula could not be applied in 14 % of patients. CT over estimates graft volume while Lee’ and modifies Lee’s formula give accurate results when SLV is calculated by Urata and Hashimoto formula.

L-97 Gas-producing pyogenic liver abscess

Mayank Jain, Sandip Ware, Amit Bundiwal Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Introduction: Gas-producing pyogenic liver abscess is a rare disease seen mainly in patients with underlying diabetes mellitus. If not managed urgently, it can be life threatening. We hereby report a case of gasproducing liver abscess at our center. Case report of a 50-year-old, male patient, alcohol abuser, nonsmoker presented with complaints of highgrade fever with chills and rigors for ten days, pain in right upper quadrant of abdomen for ten days and vomiting for the last five days. Complete blood count showed a hemoglobin of 11 gm % with elevated total blood counts of 17,400 (80 % neutrophils). Blood sugar levels were 364 mg/dL. Urine examination revealed ketone bodies and glycosuria. Liver function tests showed a total bilirubin 2.50 mg/dL, total protein 8 gm/dL, serum albumin 3.5 gm/dL, alanine aminotransferase 182 IU/mL, aspartate aminotransferase 152 IU/mL, alkaline phosphatase 1995 IU/mL and gammaglumatamyl transferase 266 IU/mL. Contrast enhanced computed tomography of the abdomen (Fig. 1) showed gas forming pyogenic

abscess in the segments I, IV, VII and VIII of liver and an old granulomatous lesion in segment VIII of liver, cholelithiasis and fatty changes in the liver. Serological test for hydatid disease was negative. Serological test for Entamoeba histolytica was negative. Pus culture showed growth of Klebsiella pneumoniae. Patient was given metronidazole, amikacin and human insulin to control blood sugar levels. He improved over a period of fourteen days. Conclusion: Gas-forming pyogenic liver abscess (GPLA) is rare and is associated with a high mortality rate. L-98 Profile of patients with amebic liver abscess

Mayank Jain, Ajay K Jain, Amit Bundiwal, Shohini Sircar, Sandip Ware, Sandip Kaulavkar, Suresh Hirani, Rahul Agrawal Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aim: To study the clinical profile of patients with amebic liver abscess (ALA) at a tertiary care center in Central India. Materials and Methods: This is a retrospective study. The case records of all patients admitted with ALA at our center between January 2010 to December 2012 were analyzed. Results: A total of 70 patients formed the study group. The mean age was 60.95 years and the male to female ratio was 6:1. The main clinical symptoms included-abdominal pain (58/70), fever (45/70), swelling in lower limbs (2/70), cough (4/70), diarrhea (4/70), jaundice (2/70), weight loss (2/70) and gastrointestinal bleed (1/70). Ascites was noted in two patients and pulmonary involvement in 11 patients. The major pulmonary complications included-pleural effusion (7), pneumonia (3) and hydropneumothorax (1). The predisposing factors included-alcohol consumption (23/70) and diabetes mellitus (10/70). Fifty abscesses were located in the right lobe, 13 in the left lobe and six involved both the lobes. The size of abscesses ranged from 25–2700 cc. Nine patients required drainage-pigtail (6), laparoscopic (2) and open drainage (1). All patients were given metronidazole 400 mg thrice a day for fourteen days. Patients with TLC count >14,000, positive blood culture and drainage procedure were given additional intravenous antibiotics. The mean hospital stay was 7.86 days and all patients recovered on follow up. Conclusion: ALA is common in elderly males, alcoholics and diabetic patients. Pulmonary involvement is the commonest extrahepatic manifestation. Majority of the abscesses are located in the right lobe and drainage is required in about 13 % of patients. Outcome is favorable with adequate medical management. L-99 Autoimmune hepatitis with pyoderma gangrenosum—A rare association

Mayank Jain, Sandip Kaulavkar, Suresh Hirani Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Background: The association between pyoderma gangrenosum and autoimmune hepatitis is poorly understood. We present a rare case which was managed at our hospital. Case—A 50-year-old, married lady from Rajasthan presented with yellowish discoloration of eyes and urine for 6 months. She had noted multiple, noduloulcerative lesions over lower limbs, anterior abdominal wall and genitals for last 4 months. Since the last 1 month, she had progressive abdominal distention and swelling of both legs. On examination, she was pale and icteric. She was obese and had massive ascites. Liver function tests are mentioned in the table below. All viral markers: HBsAg, anti HCV, Ig Manti HAV and HEV; were

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negative. In the autoimmune panel, ANA was strongly positive (1:300). She had hypergammaglobulinemia. Upper gastrointestinal endoscopy showed severe portal hypertensive gastropathy. Dermatology opinion was taken and a diagnosis of pyoderma gangrenosum was made. Colonoscopy showed no evidence of inflammatory bowel disease. Liver and skin biopsies could not be done in view of grossly deranged INR. She was started on prednisolone as per guidelines, diuretics, salt restricted diet and calcium. On follow up at 1 month and 6 months, there was significant improvement in liver function tests. Her ascites had reduced significantly (weight loss of 30 kg) and skin lesions have healed. A final diagnosis of autoimmune hepatitis type 1 with pyoderma gangrenosum was made.

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Results: Twenty-nine patients (22 males, age in years 51 (12–66), median (range) were studied. Conclusion: Alternate complement pathway was activated in majority (62 %) of NCIPH patients, classical pathway was activated in 60 % of cryptogenic chronic liver disease patients (60 %) while complement pathway was not activated in 81 % of HBV-related chronic liver disease. Larger number of patients are needed to explore this further. L-102 Drug-induced liver injury at a tertiary care hospital in India: Etiology, presentation and outcome

L-100 CA-125, just a tumor marker: A misnomer

Apoorva Bansal, Rohit Gupta, Archana Prakash, N S Jyala Departments of Biochemistry, and Gastroenterology, Himalayan Institute of Medical Sciences, Swami Ram Nagar, Jolly Grant, Dehradun, Uttarakhand 248 140, India Background: Cancer antigen-125 (CA-125) is a high molecular weight glycoprotein used as a marker for ovarian carcinoma. It is also known as mucin 16 or MUC 16, a protein that in human is encoded by MUC16 gene. However, its involvement is also observed in many benign conditions particularly in liver cirrhosis and ascites. Material and Method: A total of 60 patients were enrolled in the study. They were divided into two groups: group I—30 patients of chronic liver disease with ascites (the degree of ascites was graded to into mild, moderate and severe) and group II—30 patients with acute liver disease without ascites. CA-125 levels were evaluated through enzyme linked immunofluorescence assay (ELIFA) and was compared with other liver parameters and USG findings of all the patients. Result and Discussion: (30/30) chronic liver disease patients with ascites (group I) had CA-125 levels significantly elevated and it was related with the grades of ascites, whereas (28/30) patients without ascites (group II) had CA-125 levels under the normal range. However, the levels of CA125 were significantly higher in patients with ascites compared to patients without ascites. The elevation of CA-125 in liver cirrhosis is related to the amount of ascites. Therefore CA-125 may be used as a predictor of ascites in patients with liver cirrhosis. L-101 Is the alternate complement pathway activated in patients with noncirrhotic intrahepatic portal hypertension?

Tarun Bharadwaj, A Goel, K G Sajith, U Zachariah, C E Eapen, John Jude Hepatology Department, Christian Medical College, Vellore 632 004, India Background: A subset of patients labeled to have cryptogenic cirrhosis is proven to have noncirrhotic intrahepatic portal hypertension (NCIPH) after liver biopsy. NCIPH is characterized by occlusion of intrahepatic small portal venules. There is scarce data on activation of complement systems in NCIPH. Low serum C3 and C4 levels suggest activation of classical complement pathway, while low C3 levels with normal C4 levels suggest activation of alternate complement pathway. Objectives and Aims: To study serum complement protein levels in portal hypertensive patients with cryptogenic cirrhosis/NCIPH (cases) and in hepatitis B related chronic liver disease (disease controls). Methods: We retrospectively analyzed complement levels (total hemolytic activity (CH-50), C3, C4) in study subjects.

Chetan Rathi, Nirav Pipaliya, Dhaval Choksi, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Background and Objectives: Drug-induced liver injury (DILI) is rare; however, it may result in significant morbidity or death. Causes and outcome vary according to regions; acetaminophen being common in the West and complementary medicines in the Far East. We evaluated the causes, clinical features and outcome of DILI in India. Methods: Patients with suspected DILI were enrolled based on predefined criteria and followed up for at least 6 months or until normalization of liver tests. We collected data from 65 individuals diagnosed with DILI at our hospital from 2014 through 2015 (30 men; median age, 38 years). Liver tests immediately on admission or outpatient visit were measured. Causality assessment was done by applying the Roussel Uclaf Causality Assessment Method model. Results: DILI was caused by a single prescription medication in 28 %, by complementary and alternative medicine (CAM) in 9 %, and by multiple prescription agents in 63 % of cases. The most commonly implicated drugs were antitubercular drugs (ATD) (30 of 65; 46 %), antiepileptic drugs (14 %), antiretroviral drugs (9 %), methotrexate (5 %), statins (3 %), NSAIDS (3 %), antileprosy drugs (3 %) and other drugs like paracetamol, etoposide, interferon, itraconazole and thalidomide (8 %). The median duration of therapy was 31 days (range, 1–184 days). Thirtyfour patients had jaundice (52.3 %). Forty patients were hospitalized (61 %) for a median of 10 days (range, 3–50 days). Out of 30 patients with ATD induced hepatitis, 19 (63 %) received ATD empirically (14 out of 19 received ATD for abdominal tuberculosis). Overall mortality was 10.7 % (7 patients). Three patients (4.6 %) died due to liver disease. Conclusions: DILI results in significant overall mortality (10.7 %). ATD, anticonvulsants, CAM and antiretroviral drugs are leading causes of DILI in India. L-103 Endovascular management of Budd-Chiari syndrome: A tertiary care experience

Shah Harshal, Jagtap Nitin, Singh Jagadeesh, Duvvuru Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Budd-Chiari Syndrome (BCS) is an uncommon condition caused by hepatic venous outflow obstruction. We evaluated clinical features and role of intervention radiological procedures for treatment of BCS. Methods: Forty-five consecutive cases of BCS who underwent radiological intervention were included from April 2010 to July 2015. Clinical

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profile, recanalization therapeutic strategy, complications, stent patency and re-intervention were recorded. Result: There were 30 male and 15 female with median age 30 years (range 4–60 years). The most common presentation was ascites (32/45) followed by abdominal pain (19/45), upper gastrointestinal bleeding (12/ 45) and jaundice (11/45). Radiological intervention was successful in all 45 patients: Angioplasty alone (6; 1 HVand 5 IVC), angioplasty with HV stenting (10) or IVC stenting (17) and both (1). DIPSS was done in 11 patients. Median follow up time was 13 months (range 0–60 months). Immediate complications occurred in 6 patients which were hemorrhagic ascites (2 angio-embolization), right hemothorax (1 Rt 8th intercostal artery coil embolization), sepsis (2 treated successfully with antibiotics). One patient died due to renal failure. During follow up, additional 3 patients died (1 at 12 months—sepsis, 1 at 29 months—traumatic ICH and 1 at 41 months—variceal bleed). Re-intervention required in 10 patients, 5 underwent angioplasty alone and remaining 5 underwent angioplasty with stenting. Conclusion: Endovascular procedures play an important role in the management of BCS in properly selected patients, especially when stenting of hepatic veins, IVC or DIPS are possible. L-104 Serum transaminases in patients of neurocysticercosis taking albendazole

Anju Kumari, Ravikant Kumar, Ashok Sharan Indira Gandhi Institute of Medical Sciences, Bailey Road, Shiekhpura, Patna 800 014, India Background: Albendazole is medical treatment of choice for neurocysticercosis (NCC). Though its absorption is about 5 %, it undergoes extensive first pass metabolism in liver by rapid sulfoxidation (major), hydrolysis, and oxidation reaction. Data for effects of albendazole on LFTs is limited. Material and Methods: Fifty (50) patients of NCC diagnosed on the basis of Del Brutto criteria and were prescribed albendazole 400 mg bid for 28 days. Serum transaminase at baseline and at the second week and end of therapy were estimated. Results: Baseline alanine and aspartate transaminases were 23.6±7.6 and 18±6.4 (normal range 10–40 units/L). At week 2 and end of treatment, there was no significant difference in transaminase levels. Two patients’ transaminase levels elevated to 3 times of baseline value in the second week but returned to baseline value at week 4. Bilirubin remained in normal range during treatment and no patients had clinically significant hepatotoxicity to withdraw therapy. Conclusion: Mild elevation of transaminases during albendazole therapy may seen but clinically significant liver toxicity of long duration albendazole therapy in patients of NCC is rare. L105 A randomized double-blind placebo-controlled trial to study the efficacy of bromocriptine in patients with hepatic parkinsonism

Amrish Sahney, Ankur Jindal, Ankit Bhardwaj, Guresh Chibber, R M Dhamija, Shiv Kumar Sarin Departments of Hepatology, Biostatic and Clinical Research, and Neurology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aims: Parkinsonism like features can be seen in cirrhotic patients, possibly related to alterations in brain dopamine metabolism, transport and receptor integrity at level of basal ganglia. Hepatic parkinsonism [HP] is often not suspected and only ammonia reducing therapies

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are given to such patients. We investigated the efficacy and safety of bromocriptine, a dopaminergic agent, in patients with HP. Patients and Methods: Cirrhotics were screened for the presence of any 2 of 3 features (tremor, bradykinesia, and rigidity) to make a diagnosis of HP. Classical Parkinson’s disease; Wilson’s disease and atypical parkinsonism were excluded. Patients were randomized to receive placebo (Gr. A, n=22) or bromocriptine (Gr. B, n=24) for 12 weeks in a double-blind manner. Unified Parkinson’s disease rating scale (UPDRS) motor score was used to assess treatment response. Complete, partial and nonresponse were defined as 30 %, 10 % to 30 %, and <10 % reduction in baseline UPDR motor score at 12 weeks of therapy. Results: Of the 1016 cirrhotic patients screened, 50 (4.9 %) were found to have definite HP; 4 were excluded (2 on L-dopa and 2 on bromocriptine). The two groups were comparable including MELD score, arterial NH3 and frequency of portosystemic shunts. Complete and partial response was seen in none vs. 7 (29 %) and one (4.5 %) vs. 12 (50 %) patients in Gr. A and B respectively, with over all response in 1 (4.5 %) vs. 19 (79 %) patients (p<0.001). The median dose of bromocriptine administered in Child’s A, B and C was 15±1.25, 15±3.75 and 7.5±1.25 mg/day. Baseline UPDRS <42, suggestive of mild to moderate disease, predicted treatment response (OR 0.58, CI 0.344–0.991) with accuracy of 86.8 %, sensitivity of 89 % and specificity of 80 %. There were no major sideeffects between either group. Conclusions: Hepatic Parkinsonism is seen in about 5 % cirrhotics and needs to be suspected and diagnosed early. Bromocriptine was found to be effective and safe in nearly 50 % of patients, more so with mild to moderate HP. Higher dosages and combination therapies need to be evaluated to improve outcome.

L-106 Echosens fibrometer virus A non i nvasive assessment of liver fibrosis

Neeraj Nagaich, Radha Sharma, Neha Bhatia, Sonal Department of Gastroenterology, Metro MAS Hospital, Shipra Path, Mansarovar, Jaipur 302 020, and Department of Pathology, RUHS College of Medical Sciences, Sector-18, Kumbha Marg, Tonk Road, Pratap Nagar, Jaipur 302 033, India Background: Non invasive methods for liver fibrosis assessment have replaced liver particularly for monitoring viral infections such as HBV, HCV. No studies have validated this test in NAFLD patient with high risk factors. Methods: This study was done in patients presenting with chronic viral hepatitis B, chronic viral hepatitis C and NAFLD patient with high risk factors whenever the necessity of liver biopsy was apparent in deciding the appropriate treatment plan. Echosens fibrometer virus test was done to determine the stage of fibrosis and the necroinflammatory status in this cohort of in a tertiary care hospital, Metro MAS in Jaipur during September 2013 to April 2015. Results: Analysis of data from 57 patients, 24 (42 %) of which had chronic HBV infection and 7 (12 %), chronic HCV infection and NAFLD patient with high risk factors 26 (46 %) was done. The median age was 50.1±12.0 (range 19–78). The mean body mass index (BMI) was 26.6± 2.6 in the HBV group and 23.7±2.2 in the HCV group and 33.2±1.2 in the NAFLD group. The distribution of fibrometer results was: F0–F1: 9 (12.2 %), F1: 2 (3.3 %), F1–F2: 23 (41.4 %), F2: 9 (14.8 %), F2–F3: 6 (11 %), F3: 3 (5.0 %), F3–F4: 7 (12.3 %). The distribution of the necroinflammatory activity was: A0–A1: 9 (15.6 %), A1–A2: 27 (47.1 %), A2–A3: 21 (37.3 %). No statistically significant differences was seen in this study between patients with chronic viral hepatitis and NAFLD regarding mean fibrosis scores (p = 0.468) or mean necroinflammatory activity scores (p=0.72). Conclusion. Fibrometer virus results should be interpreted in clinical context and potential confounding factors should be identified on a

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case-by-case basis. Fibrometer was also reproducible in NAFLD cohort of patients. Direct comparative study of this test with liver biopsy will further validate the sensitivity and specificity of fibrometer test. L-107 Liver involvement in P. falciparum and P. vivax malaria in northern India

Omesh Goyal, Subhadra Prashar, Prerna Goyal, Sandeep Puri Dayanand Medical College and Hospital, Tagore Nagar, Ludhiana 141 001, India Background and Objectives: Hepatic dysfunction is known to occur in Plasmodium falciparum malaria with varied incidence in different regions. Recent studies report liver involvement in Plasmodium vivax infection also. It is important to know about this entity in order to recognize it early and offer prompt and specific treatment. The present study aimed to assess the incidence, pattern, severity and outcome of hepatic dysfunction in cases of P. falciparum and P. vivax malaria admitted to a tertiary care hospital in northern India. Materials and Methods: This retrospective study included all hospitalized patients diagnosed to have malaria from January 2013 to December 2013. Their clinical and biochemical parameters, complications and outcome were recorded. Results: Out of 115 patients included, 85 (73.9 %) had P. vivax infection and 30 (26.1 %) had P. falciparum infection. The mean age was 36.7±16.1 years and male/female ratio 2.7:1. Hepatic dysfunction was seen in 31.8 % (27/85) patients of P. vivax malaria and 50 % (15/30) patients of P. falciparum malaria (p=0.082). The mean bilirubin, AST and ALT in patients with hepatic dysfunction were 7.7±7.3 mg/dL, 97.1±103.3 IU/L and 72.3± 87.8 IU/L respectively. Patients with P. falciparum malaria had significantly higher levels of mean bilirubin, AST, urea and creatinine. Patients with hepatic dysfunction had higher rate of complications like renal failure, shock, acute respiratory distress syndrome, and mortality. Interpretation and Conclusion: Hepatic dysfunction was more common and more severe in patients with P. falciparum malaria compared to P. vivax malaria. Patients with hepatic dysfunction had higher rates of complications and higher mortality. L-108 Histological features of liver in patients with chronic hypertransaminasemia of unknown etiology

Prashant Y Kanni Department of Medical Gastroenterology, Vydehi Institute of Medical Sciences and Research Center, Whitefield, Bangalore 560 066, India Background: Asymptomatic persistent transaminasemia is a common finding and may alter treatment plan if correct diagnosis is made. Liver biopsy is a critical component in establishing the diagnosis of many forms of liver diseases especially atypical, subclinical diseases of obscure etiology. Aim of the Study: To determine the spectrum of liver histopathological features and probable etiology in patients with chronic hyper transaminaesemia of unknown etiology. Methods and Materials: From January 2014 to December 2015, 32 patients with persistent hyper transaminaesemia of more than 6 months with no clear diagnosis on clinical, sonological evaluation were included. Liver biopsy were done as outpatient procedure and were stained with H & E staining and later with trichrome, orcein, rubeanic acid, periodic acid Schiff and Perl stain as necessary. Fibrosis will be staged by Ishak

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method. Alcoholic, known viral hepatitis/cirrhotic and age below 13 years were excluded. Results: Total 32 patients were selected for the study. Mean age was 38 years (13–48). Conclusion: Liver biopsy is a useful investigation in patients with persistent hypertransaminasemia based on which further evaluation could pick up underlying etiology. In our study most common histopathological findings was nonalcoholic steatohepatitis. L-109 Biliovascular complications of major liver trauma Yashwant Raj Sakaray, Vikas Gupta, T D Yadav, Naveen Kalra, Virendra Singh, Kailash Kurdia

Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160 012, India Introduction: Biliovascular complications are expected in high-grade liver injury. Present study is planned to evaluate incidence, management, outcome of biliovascular complications arising as result of major hepatic trauma. Methods: Fifty-six patients with grade III or more liver injury were studied prospectively from July 2013-December 2014 at PGIMER; Chandigarh. Patients surviving over 24 h were included. Biliary and vascular complications were evaluated with CT/HIDA and CT angio respectively. Interventions required to manage complications were analyzed and patients were followed up to 6 weeks. Results: Grade 3 (n=29), grade 4 (n=17) and grade 5 (n=10). Seventeen (30.35 %) patients developed biliovascular complications. Biliary complications (n=5), intraabdominal collections (n=1), ascites (n=2), biliary peritonitis (n=1), biliary leak from intraabdominal drains left after laparotomy (n=1). ERCP with biliary stenting (n=2), surgical intervention for biliary peritonitis (n=1). ERCP failed in (n=1), later operated for biliary stricture. Arterial complications (n=8), venous complications (n=9) were seen in 14 patients. AE alone (n=5), operated for rebleed after AE (n=1), surgery for hemodynamic instability, later with AE (n=2). Venous injuries were managed conservatively. Operative intervention, grade, size of hematoma, delayed CECT, involvement of hilum and blood transfusion requirement were statistically significant in predicting biliovascular complications. Seven (12.5 %) deaths, 2 hepatic-related mortalities occurred due to uncontrolled bleed. Conclusion: High-grade liver injury will have high incidence of developing biliovascular complications which needs multimodality treatment strategies. CECT in patients with clinical evidence of biliary and vascular complications is effective screening tool. ERCP and angioembolization role in management of high-grade liver injuries is safe and effective. L-110 A study of abnormal liver function tests in pregnancy in western India

Dattatray Solanke, Nirav Pipaliya, Mallanagoud Patil, Vikas Pandey, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Aims: We carried out a study in a tertiary care hospital in western India to study the etiology, clinical profile and prognostic factors related to

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maternal health and fetal outcome in patients with altered liver function tests in pregnancy. Materials and Methods: Ninety pregnant patients with deranged LFTs were included, who presented from 2014 through 2015. Their hematological and biochemical parameters were studied prospectively till the postpartum period. Results: Pregnancy specific causes were found in 52 % of patients with abnormal liver function tests. Abnormal liver function tests were found most frequently in the third trimester (58 %), followed by first trimester (26 %) and second trimester (16 %). Hyperemesis gravidarum (56 %) and viral hepatitis (32 %) were the most common causes in first trimester. Preeclampsia (37 %), viral hepatitis (40 %), HELLP syndrome (18 %), intrahepatic cholestasis of pregnancy (4 %), acute fatty liver of pregnancy (2 %) were important causes in the third trimester. Among viral hepatitis, hepatitis E was the most common causative organism (68 %), followed by hepatitis B (22 %). Maternal mortality was significantly higher in patients presenting with encephalopathy, SIRS, coagulopathy, and ascites. Fetal outcome was poor in pre-eclampsia, HELLP syndrome, acute fatty liver of pregnancy and viral hepatitis E. Conclusions: Viral hepatitis, especially hepatitis E is the predominant cause of altered liver function tests in pregnant females in western India. Abnormal liver function tests in first two trimesters were not associated with significant maternal mortality and fetal wastage as against in the third trimester, in which frequent monitoring is needed. L-111 Initial experience with injection darbepoetin and injection pegfilgrastim in liver cirrhosis patients: A pilot project

Vijay Sharma, Mohit Chaturvedi, Vipin Jain, Richa Sharma Departments of Gastroenterology, and Internal Medicine, Soni Manipal Hospital, Sector 5, Main Sikar Road, Vidhyadhar Nagar, Jaipur 302 013, and Department of Community Medicine, Regional Institute of Health, Medicine and Research (RIHMR), Indra Colony, Bani Park, Jaipur 302 016, India Introduction: In acute intestinal pseudoobstruction there is dilation of the intestinal loops without mechanical obstruction, it may develop after surgery or severe illness. This condition is due to an acute imbalance of the normal extrinsic autonomic innervation of the bowel. Although it may resolve with conservative therapy, colonoscopic decompression is sometimes needed to prevent ischemia and perforation of the bowel. Studies suggest that neostigmine is an effective treatment. However there is no reported experience with naloxone hydrochloride, an opioid antagonist, which is a synthetic congener of oxymorphone. Aims and Methods: To study the efficacy of naloxone hydrochloride in patients with intestinal pseudoobstruction managed in intensive care unit. We studied patients admitted in Intensive care unit (ICU) fulfilling criteria of acute intestinal pseudoobstruction in the form of clinical abdominal distention and radiographic evidence of significant small bowel and colonic dilation. Reversible and mechanical causes of abdominal distension ruled out. When there was no response to at least 24 h of conservative treatment, we prospectively recruited patients to receive 3.0 mg of naloxone (one ampule contains 0.4 mg, so seven and half ampule Inj. naloxone) given through a Ryles tube, the Ryles tube clamped for 1 h, medicine administered 6 hourly. A physician who was unaware of the patients’ treatment assignments recorded clinical response defined as evacuation of flatus or stool and a reduction in abdominal distention), abdominal circumference, and measurements of the small bowel and colon on radiographs. Patients who had no response

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to the initial dose were eligible to receive open-label naloxone 6 h later and subsequent doses every 6 h for 24 h, if that fails Injection neostigmine and colonoscopic decompression were kept in treatment protocol. Results: Prospectively 28 patients were included in study since April 2014, twelve patients were having pneumonia, septicemia, three patients with pyelonephritis, septicemia, three patient with cerebrovascular accident, intracranial bleed, two postcomplicated spinal surgery, three with polytrauma due to road traffic accident, one with CRF and septicemia, one patient with subacute bacterial endocarditis, septicemia, one post cardiac surgery and two with cirrhosis liver. Twenty-three patients who received naloxone had early intestinal decompression in the form of passage of flatus, passage of motion, significant (more than 2 inch) decrease in abdominal girth, significant decrease in bowel diameter on X-ray flat plate abdomen (equal or more than one cm), improvement in clinical parameters especially respiratory rate, oxygen saturation. In two patients, colonoscopic decompression and also injection of neostigmine 2 mg were required. Two patients neostigmine was contraindicated so only colonoscopic decompression done. In one patient with spinal injury, there was significant symptomatic improvement, but X-ray abdomen revealed persistently dilated bowel loops. The median time to response was 6 h (range, 2 to 24). Side effects of naloxone included tachycardia in three patients, rise in blood pressure, irritability in one patient each. Conclusion: This initial observation suggests that administration of naloxone hydrochloride through a Ryles tube is beneficial and safe in the treatment of ICU admitted patients with acute intestinal pseudoobstruction. L-112 Non-invasive evaluation of liver and spleen by acoustic radiation force impulse for assessment of cirrhosis and portal hypertension

Amit Kumar Bundiwal, Ajay Kumar Jain, Suchita Jain, Shohini Sircar, Mayank Jain, Sandip Vare, Sandeep Kaulavkar, Suresh Hirani, Rahul Agrwal Departments of Gastroenterology, Radiodiagnosis, and Imaging, Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aims: 1. To determine liver and spleen stiffness values by acoustic radiation force impulse (ARFI) for predicting esophageal varices (EVs). 2. Assessing whether combined liver stiffness (LS) and Spleen stiffness (SS) values are better than alone LS/SS values to predict EVs. Material and Methods: This prospective study included 120 subjects [90liver cirrhosis (case), 15 chronic hepatitis B (control) and 15, healthy volunteers]. Splenic stiffness (SS) and liver stiffness (LS) were measured by ARFI along with USG abdomen, upper gastrointestinal (UGI) endoscopy and APRI index. Results: Liver and spleen stiffness were significantly higher in cirrhotic patients compared to chronic hepatitis B and healthy volunteers (p<0.0001). The best cut-off value obtained by ROC curve for liver was 2.16 m/s and spleen was 3.04 m/s for prediction of EVs. The prediction of EVs by LS alone was 94 % positive predictive value (PPV) [81.11% accuracy] while SS alone was 94 % PPV (69 % accuracy). When both (LS+SS) combined together, accuracy of predictability increased to 92 %. We generated a regression equation for predicting esophageal varcies based on liver stiffness and spleen stiffness as follows: (0.225 LS + 0.377SS) - 0.555. If value comes>1, high chance of EVs and value is < 1, than chance of EVs are unlikely. Conclusions: 1.LS of ≥ 2.16 m/s and SS ≥ 3.04 m/s predict presence of EVs with high accuracy.

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Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

L-113

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Descriptive comparison of efficacy and safety of tenofovir disoproxil fumarate plus pegylated-interferon±−2a combination in Indians and non-Indians with chronic hepatitis B

Detection of HBsAg, HBeAg and HBV DNA load in saliva of HBV carriers

Rajiv Mehta, S K Acharya, S K Sarin, Samir Shah, A Chowdhury, V V Raj, Dharmesh Kapoor, V G M Prasad, Srikant Mukewar Surat Institute of Digestive Science, Vijay Nagar Society, Opp Gandhi College, Majura Gate, Surat 395 002; All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029; Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070; Global Hospital, 35, Dr Ernest Borges Road, Hospital Avenue, Parel, Mumbai 400 012, PGIMER, Kolkata, Manipal Hospital, 97/2, 10th Cross, Kumara Park West, Kumara Park West, Bengaluru 560 020, India Background: Differences in viral and patient characteristics between Indians and non-Indians may impact response to HBV therapy. We examined differences in between Indian and non-Indian patients enrolled in the tenofovir disoproxil fumarate (TDF) plus PEG combination study GS-US-174-0149. Methods: Seven hundred and forty CHB patients without advanced liver disease were randomized 1:1:1:1 to receive TDF+PEG ×48 weeks (Arm A); TDF+PEG ×16 weeks followed by TDF ×32 weeks (Arm B); continuous TDF (Arm C); PEG ×48 weeks (Arm D). Baseline characteristics, week 72 efficacy and overall safety were compared between Indians and non-Indians. Primary efficacy was HBsAg loss at week 72. Results: Of 30 Indian patients randomized, most were male and HBeAgpositive, and predominantly genotype (Gt)-D; while among 710 nonIndian patients, most were male, HBeAg-positive and predominantly Gt-C (Table 1). Overall, rates of HBsAg decline ≥1log10 IU/mL from baseline to week 48 were similar among Indians (28 %) vs. non-Indians (22.1 %) (p=0.468) (Table 1). Rates of HBsAg loss at week 72 were 20 %, 25 %, 0 %, and 16.7 % in Indians compared to 8.4 %, 2.3 %, 0 %, and 2.4 % in non-Indians for Arms A-D, respectively (p=0.072 for Indians vs. non-Indians). Within each treatment arm, no significant differences were observed for rates of normal ALT, HBeAg loss/ seroconversion between Indians and non-Indians at week 48. Conclusion: Although there were some demographic and clinical differences at baseline, no statistically significant differences in outcome were observed between Indians and non-Indians treated with TDF+PEG for 48 weeks.

Pabitra Sahu Maulana Azad Medical College, Bahadur Shah Zafar Marg, New Delhi 110 002, India Background/Objectives: HBV can be transmitted by parenteral exposure to human body fluids. Various studies have tried to find out HBsAg and HBV genome in different body fluids. This study is designed to test for HBsAg, HBeAg and HBV DNA load both in saliva and serum simultaneously to look for diagnostic value of saliva in HBV infection. Methods: It was a prospective observational study of 60 HBV carrier patients who were stratified according to their epidemiological profiles and risk factors. Blood and saliva samples of those 60 cases were tested simultaneously for HBsAg, HBeAg, and HBV DNA load to determine sensitivity and specificity of saliva for detection of these serological and molecular markers. Results: Mean age of the study group was (35.4±9.87) years with 71.7 % males and 28.3 % females. 11.67 % of patients had H/O blood transfusion, 20 % of patients had history suggestive of perinatal transmission, 16.7 % of patients had history of sexual transmission. 6.67 % had history of surgical procedure and 2 patients (3.33 %) were medical lab technician with possibility of occupational exposure. One patient (1.7 %) had h/o I.V. drug abuse, and 3 patients (5 %) had high-risk sexual behavior. Salivary detection of HBsAg has a sensitivity of 91.67 % and a PPV of 1000 %. Salivary detection of HBsAg found to have a sensitivity of 78.57 % and specificity of 100 %. Majority of HBV carriers (33.33 %) had serum HBV DNA level between (103.104 copies/mL) and only I patient had HBV DNA level more than 10 copies/mL. Salivary detection of HBV DNA had a sensitivity of 39.58 % and specificity of 100 % but DNA level was very less compared to serum. Mean HBV DNA load in serum was log 3.59 copies/mL and in saliva was log 3.34 copies/mL. Conclusions: Perinatal transmission, transfusion related transmission and sexual transmission are the major modes of transmission of HBV in our country. Testing of saliva for HBsAg can be a substitute of blood testing for large screening programs, as it has got a high sensitivity and specificity. Salivary detection rate of HBV DNA is not very high but there is a significant correlation between serum and salivary HBV DNA level.

Table 1 L-115 Indians (N=30)

Non-Indians (N=710)

P value Oxidation or glycosylation of circulating albumin correlates with its decreased functionality and can predict outcome in liver failure

Male N (%)

26 (86.7 %)

460 (64.8 %)

0.017

HBeAg-positive (%)

21 (70 %)

407 (57.3 %)

0.190

Viral genotypes (%)

<0.001

Gt A

7 (23.3 %)

Gt B

0 (0 %)

203 (28.6 %)

Gt C

1 (3.3 %)

313 (44.1 %)

Gt D

22 (73.3 %)

132 (18.6 %)

Other HBsAg decline >1log10 from baseline to week 48 (%) HBsAg loss at week 72 (arms A:B:C:D) (%)

0 (0 %) 7 (28.0 %)*

20:25:0:16.7

54 (7.6 %)

8 (1.1 %) 140 (22.1 %)*

8.4:2.3:0: 2.4

*Among 25 Indian and 634 non-Indians who reached week 48.

0.468

0.072

Sukanta Das, Jaswinder Singh Maras, Md. Shabir Hussain, Paul David, Kollal Gupta, Chidanand Sudarshan, Gajraj S Kushwaha, S M Shastry, Nirupama Trehanpati, Shvetank Sharma, T P Singh, P Balaram, Shiv Kumar Sarin Departments of Research, and Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, Department of MBU, Indian Institute of Sciences, and Department of Biophysics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India Background and Aims: Oxidative modification and post-translational glycosylation can affect albumin functionality. We investigated the structural and functional modifications in albumin and their association with severity and outcome. Methods: Serum of acute-on-chronic liver failure (ACLF, n=90), cirrhosis (n=60), and healthy controls, (HC, n=30) and commercial human albumin were analyzed using LC-MS/MS. Oxidation, glycosylation, ischemia modified albumin (IMA) and its ratio to albumin (IMAr), binding

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capacity (ABiC), circular dichroism were quantitated. Neutrophil activation was assessed in vitro, functional and oxidative evaluation was performed on glyco-enriched albumin fractionation. Results: The levels of HNA2 was significantly higher in ACLF, while the levels of HNA1, Cys-HNA1 was higher in ACLF, cirrhosis vs. HC [p<0.05]. Glycosylated (Glc) HMA, Cys+Glc HNA1 was significantly lower in ACLF. Reduced albumin was lowest in ACLF [p<0.05], with increased oxidative state. The ratio of (NonGlc:Glc)-HMA and (Cys:Cys+Glc)-HNA1 were higher in ACLF [p<0.05]. Advance oxidative, advance glycosylation-end products were increased in ACLF and cirrhosis [p<0.05]. IMA, IMAr, molecular ellipticity, ABiC was found to be lowest in ACLF [p<0.01]. Modified albumin also resulted in neutrophil activation and generation of oxidative stress. Mortality associated with increase in HNA2, Glc-HMA, Non Glc-HMA, Cys-HNA1, Cys+ Glc HNA1, Redox state of albumin, AOPP, molecular ellipticity. Levels of HMA, HNA1, (Cys:Cys+Glc) HNA1, ABiC were found to be lowest in non-survivors. Neutrophil activation and generation of ROS increased when treated with purified albumin from eventual non-survivors. Cutoff of 20 of redox state of albumin (AOS), 2.23 of (Cys:Cys+Glc) HNA1, 1.5 mdeg for molecular ellipticity and 16 % HNA2 significantly correlated with overall and 30-days mortality [log rank p<0.05]. Cox-regression analysis confirmed the above observation. The functional activity (IMA, IMAr, and ABiC) was significantly deranged in the glycated fraction of the purified ACLF albumin. Conclusion: Results highlight that besides having variations in structural modifications between disease types; the functionality of differently modified albumin molecules is also affected. Assessment of these modifications can be employed as potential tools for determination of early mortality in ACLF patients.

L-116 Acute kidney injury persistence at 48 h predicts mortality in patients with acute-on-chronic liver failure

Rakhi Maiwall, Guresh Kumar, Ajeet Singh Bhadoria, Shiv Kumar Sarin Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110 070, India Background and Aim: Diagnosis and management of renal dysfunction in cirrhotics has changed with advent of acute kidney injury (AKI) criteria. We evaluated the impact of AKI persistence at 48 h on in-hospital mortality in a cohort of ACLF patients (APASL definition). Methods: Consecutive patients of ACLF (n=374) were included. Results: AKI at admission was present in 167 (44.8 %) patients. At 48 h, 77.2 % of patients had persistent AKI, 22.8 % had transient AKI and 9 % developed new onset AKI. High MELD (p, OR, 95 % CI) (≥33) (<0.01, 8.3, 3.5-19.4), SIRS (0.03, 2.65, 1.1-6.3) and age (≥42 years) (0.03, 2.4, 1.06-5.69) were significant predictors of AKI persistence. Persistent AKI was associated with higher in-hospital mortality (p=0.04, HR 1.8, 95 % CI 1.4– 2.4) as compared to conventional criteria using cutoff serum creatinine ≥1.5 mg/dL (0.04, HR 1.3, 95 % CI 1.01-1.8). A lower cutoff for serum creatinine of 1.14 mg/dL at 48 h had a sensitivity of 100 % and specificity of 75.6 % against the conventional 1.5 mg/dL cutoff. The new cutoff predicted mortality with higher odds (OR 2.4, 95 % CI 1.3-4.8) as compared to the conventional cutoff (OR 2.1, 95 % CI 1.1-4.1). Further, a smaller fold change of 126 % from baseline at 48 h was associated with increased mortality (p=0.02, OR 3.3, 95 % CI 1.1–9.7) in these patients. Conclusion: AKI persistence at 48 h predicts mortality better than serum creatinine of 1.5 mg/dL in patients with ACLF. Lower threshold as well as smaller increases in serum creatinine should therefore be considered for risk stratifying patients of ACLF for additional pharmacotherapy.

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Nikhil Shirole, S Nikhi, J Nayana, K Kumar Swamy, B Sukanya, Y Raghvendra, V Kunal, M Rohit, J Rishab, Ajit Kumar Departments of Medical Gastroenterology and CP and T, Nizam’s Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Introduction: Ammonia is a well-established factor in pathogenesis of hepatic encephalopathy (HE), however other factors like nitric oxide (NO), endotoxemia are also implicated but their role is not well studied in humans. Aim: To (1) Estimate the levels of plasma NO in liver cirrhosis and healthy controls and (2) to compare plasma NO in cirrhotics with or without HE and correlate with grades of HE. Materials and Methods: A total number of 124 subjects were included. This included 25 healthy controls and 99 cirrhotic patients. Diagnosis of cirrhosis was made on clinical, radiological and laboratory findings. Plasma nitrite levels were measured using Griess reaction. Results: Ninety-nine cirrhotic patients were divided into group 1 without HE (n=54, 10 F/44 M) and group 2 with HE (n=45, 9 F/36 M). Group 3 included 25 healthy controls (13 M/12 F). The age ranged from 22 to 78 years. The mean NO levels in controls and cirrhotic group was 4.0± 1.335 and 15.34±11.65 μmol/L (p<0.001). Amongst cirrhotics the NO levels in HE group was significantly higher 20.02±11.037 than patients without HE 11.44±10.77 μmol/L (p<0.001). The patients with HE were further classified into 4 subgroups according to grades of HE. The mean NO levels increased with increasing grades of HE. The mean levels were 13.19±10.93, 16.78±9.47, 23.88±8.64 and 30.19±8.42 μmol/L in grade I, II, III, and IV respectively (p<0.002). A good positive correlation was observed in plasma NO and grades of HE (Pearson correlation coefficient +0.545). Conclusion: NO levels were significantly higher in cirrhosis with HE than in patients without HE. The NO levels correlated well with grades of hepatic encephalopathy. The study suggests that NO has an important role in pathogenesis of HE. L-118 Single-time percutaneous needle aspiration versus percutaneous catheter drainage in the management of liver abscess: Randomized clinical study of efficacy and safety

Harsh P Udawat, Kapil Gupta, Sandeep Vaishnav, Kusum Lata Gaur, Dinesh Agrawal, Anurag Govil Consultant Gastroenterologist, Santokba Durlabhji Hospital, Bhawani Singh Marg, Near Rambagh Circle, Jaipur 302 015, India Background: Percutaneous continuous catheter drainage (PCD) and single time percutaneous needle aspiration (PNA) are effective and safe methods to drain liver abscess. The comparative data of these two procedures is conflicting and guidelines/meta-analysis not available. Objective: Hypothesis tested was that PCD has equal efficacy and carries more complication than PNA. Study type: Interventional. Design: Prospective, randomized, parallel, double-blind, efficacy study. Setting: Tertiary care center. Intervention: Patients underwent ultrasound guided single time PNA or PCD. Results: Total 52 patients were randomized to two equal groups of 26. The success rate of PCD was similar to PNA (92 % vs. 69 %, p=0.07). Primary outcomes like duration to attain clinical recovery (PNA-2.5± 1.98, PCD-2.27±1.89 days, p=0.67) and 50 % reduction of abscess size at 1 month (PNA-88.4 %, PCD-100 % p=0.23) was similar in both groups. Secondary outcomes like hospital stay was similar (PNA-4.81± 3.43, PCD-6.38 ± 3.44; p = 0.159) and there were no deaths. The

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complications of PCD were higher in form of duration of procedure site pain (PCD-2.62 days, PNA-1.38 days, p<0.001) and persistent bile leak (3/26, 11.5 %). Sphincterotomy with biliary stent placement was successful in all patients with bile leak. Limitations: Multiple liver abscesses were excluded, nonuniform etiology of abscess and pus was not evaluated for tuberculosis and fungal infection. Conclusion: In patients with liver abscess requiring drainage, efficacy of PCD was similar to single time PNA. PCD also carried significantly higher complications in form of bile leak and prolonged procedure site pain.

Gallbladder GB-1 Correlation between magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography findings in hepatobiliary-pancreatic diseases at a tertiary care hospital

Nikhil Sonthalia, Ravi Jankar, Vinay Pawar, Sunil Pawar, Vinay Zanwar, Samit Jain, Ravindra Surude, Pravin M Rathi Departments of Gastroenterology, and Radiodiagnosis, Topiwala National Medical College and B Y L Nair Hospital, Dr. A L Nair Road, Mumbai 400 008, India Background: It has become common in clinical practice to obtain magnetic resonance cholangiopancreatography (MRCP) prior to endoscopic retrograde cholangiopancreatography (ERCP) to evaluate the pancreaticobiliary system. With recent improvements and non-invasive nature of MRCP, it is important to correlate the findings of these two studies. Aim: To examine the correlation between MRCP and ERCP findings in patients at a tertiary care hospital. Methods: In this ongoing study a total of 40 patients were who underwent MRCP and ERCP at TNMC, Mumbai between January 2015 and June 2015 (28 females and 12 males) were identified and analyzed. Patients’ demographic information and their laboratory values and diagnostic study outcomes prior to procedure were collected, entered into MS Access, and analyzed using SAS 10.0. Results: Baseline demographic characteristics were comparable between male and female patients. MRCP was 88.89 % sensitive and 93.55 % specific for choledocholithiasis, 87.79 % sensitive and 93.75 % specific for strictures, 81.54 % sensitive and 91.2 % specific for obstruction, and 90.5 % sensitive and 95.45 % specific for detection of periductal and periampullary masses. MRCP appeared to have more false negative results for choledocholithiasis and stricture and more false positive results for periductal mass detection compared with ERCP. Conclusions: In patients with hepatobiliary and pancreatic disease, the sensitivity and specificity of MRCP is still not close enough to that of ERCP for detection of choledocholithiasis, periductal masses, or obstruction to be used as a substitute. Thus, MRCP serves as a roadmap towards ERCP which still remains the gold standard for visualization of the hepatobiliary and pancreatic tree. GB-2 Endoscopic management of radio-opaque bile duct stones

Suryaprakash Bhandari, Vishal Bothara, Vinay Dhir, Amit Maydeo Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr E Borges Road, Hospital Avenue, Parel, Mumbai 400 012, India Background: Majority of the bile duct stones (BDS) are radiolucent (RL) and are amenable for conventional endoscopic extraction technique with high success rates. However there is no data on endoscopic management

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of radio-opaque (RO) BDS to know if their management strategy differs. Incidence of RO BDS, success of ductal clearance using conventional techniques and requirement for lithotripsy and or surgery were studied. Material and Methods: Data of patients with BDS managed endoscopically over 5 years were reviewed. Diagnosis of RO stone was done on fluoroscopy prior to obtaining a cholangiogram as routine imaging do not differentiate between RO and RL stones. ERCP was done using therapeutic duodenoscope (Olympus TJF 160, Japan). Biliary sphincterotomy was done in all patients. Stone extraction was attempted initially using conventional techniques (basket and balloon). CRE balloon sphincteroplasty or lithotripsy using Trapezoid basket and Olympus BML 3Q basket or both were done if conventional techniques failed. Spyglass holmium laser lithotripsy (LL) was done when all the above techniques failed. Biliary stenting was done if stone extraction failed or GB was still in situ. Results: A total of 12 patients were found to have RO stones in the bile duct. ERCP was successful in all patients. Stone to duct discrepancy was seen in 4 patients. Stone extraction with conventional techniques was successful in 3 patients. Successful CRE balloon sphincteroplasty or lithotripsy with ductal clearance was possible in 2 patients. Failure to crush the stone with lithotripter occurred in rest of the patients with fracture of basket in 3 patients. Spyglass LL was done in 7 patients with one patient requiring on table rescue LL due to impacted basket in the duct. Conclusions: Radio-opaque stones in the bile duct provide unique challenges for endoscopic management with success of conventional techniques/lithotripsy in only half of them. RO stone are extremely hard and difficult to crush with lithotripsy basket probably due to very high calcium content. Spyglass LL provides an excellent alternative management strategy with high success rates in our study.

GB-3 Predictors of malignancy in patients of extrahepatic biliary obstruction

Mohd Talha Noor, Piyush Manoria, Onkar Prasad Patel Sri Aurobindo Medical College and Postgraduate Institute, Ujjain State Highway, MR10, Crossing Sagar Road, Tehsil Sanwer, Indore, India Background: Etiology of extrahepatic biliary obstruction (EHBO) is often a diagnostic dilemma. To differentiate between benign and malignant causes of it is utmost important. So, we conduct a study to know the various predictors of malignancy in it. Material and Methods: One hundred and thirty-eight consecutive patients diagnosed as EHBO were included in the study. Detailed history, clinical examination and various laboratory investigations were done followed by ultrasonography, contrast enhanced computed tomography, magnetic resonance cholangiopancreatogram and endoscopic retrograde cholangiopancreatography. After that patients were divided into benign and malignant groups. Univariate and multivariate logistic regression analysis was done. Receiver operating characteristics curve was drawn to determine the optimal diagnostic cutoff value for predicting malignancy. Results: Out of 138 patients 63 were females and 75 were males. Malignant etiology was seen in 73 patients and 65 had benign etiology. Mean age of patients with malignant disease was 57.51+12.70 and of benign disease was 48.52+15.25 years. Loss of weight, cholestatic symptoms, presence of hepatomegaly and palpable gallbladder were more common in malignant disease. Mean serum bilirubin and mean serum alkaline phosphatase were significantly higher in patients with malignant etiology. Area under curve showed cutoff value for serum bilirubin of >16.5 mg/dL (sensitivity 61.9 % and specificity 84.3 %) and of serum alkaline phosphatase of >455 IU/L (sensitivity 52.4 % and specificity 82.9 %) as a predictor of malignancy.

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Conclusion: Age >45 years, serum bilirubin >16.5 mg/dL, serum alkaline phosphatase >455 IU/L and palpable gallbladder predicts malignant etiology in EHBO patients. GB-4 MUC1 and CK7 expression indicates poor survival in pancreticobiliary subtype of periampullary carcinoma

K V S R R Yesaswini, K Murali Manohar, M Sasikala, C Ramji, R Pradeep, G V Rao, D N Reddy Institute of Basic Science and Translational Research, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Introduction: Pancreaticobiliary subtype of periampullary carcinoma (PAC) has poor prognosis in comparison to intestinal subtype. We used immunohistochemistry markers to classify the subtypes and compared with the survival data to identify a marker to predict the prognosis. Methodology: PAC tumor tissues were obtained from 94 patients undergoing Whipple pancreaticoduodenectomy during 2012–2015. Paraffin embedded tissues were immunostained with CK7, MUC1, CK20, CDX2, MUC5Ac and MUC2 antibodies. The survival status of patients was obtained as follow up after 3 years of surgery. The receiver operating character curve analysis (ROC) for detecting sensitivity and specificity of markers was used. The survival data was analyzed using Kaplan-Meier survival curve. The analysis was carried out by MedCalc software. Results: Tumors were classified based on the expression of the markers into 3 groups: tumors expressing MUC1 and CK7 and lacking CK20 (pancreatobiliary type [PB-type], 67 %), tumors expressing CK20 and CDX2 and lacking MUC1 and CK7 (intestinal type [I-type], 14 %), and those expressing or lacking both CK20 and MUC1 (other type [mixedtype], 19 %). However, the markers MUC5Ac and MUC2 did not show any specificity between two subtypes. Survival analysis showed a significant relation with CK7 (0.042) and MUC1 (0.0045) (hazard ratio MUC1 2.4095 and CK7 0.1772, 95 % CI MUC1 1.3923 to 4.1699; CK7 0.001730 to 18.1568) while the other markers has not shown any significance. The median survival was calculated in terms of months; pancreaticobiliary-15, intestinal-40 and mixed-16. Conclusion: MUC1 and CK7 double positivity may predict survival in PAC patients. GB-5 Percutaneous endoscopic management of intrahepatic stones in patients with altered biliary anatomy: Study of five cases and review of literature

Suryaprakash Bhandari, Rajesh Bathini, Vishal Bothara, Vinay Dhir, Amit Maydeo Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr E Borges Road, Hospital Avenue, Parel, Mumbai 400 012, India Aims and Objectives: Incidence of primary intrahepatic stones in India is very less as compared to the Far East. However patients with altered biliary anatomy are prone for intrahepatic stone formation secondary to stricture formation. Indian data of percutaneous endoscopic management of intrahepatic stones is scare. This study was conducted to study the feasibility, success rate, no of sessions and favorable outcomes of percutaneous endoscopic management of intrahepatic stones. Materials and Methods: Between January 2012 to January 2014, five patients with intrahepatic stones were managed percutaneously. All patients had underwent roux-en-y-hepatico-jejunostomy (n=4 after excision of choledochal cyst and one after Whipple’s surgery). Symptoms at presentation were pain, fever and jaundice. All patients underwent PTBD by interventional radiologist. The tract was then serially dilated weekly using rigid

Teflon dilators till the tract size reached 16 Fr. The hepatico-jejunostomy anastomotic site was also serially dilated using CRE balloon beginning from 6 till 10 mm. Under cholangioscopy guidance the stones were then crushed using Holmium laser lithotripsy. Crushed stones were pushed across the anastomotic site using basket and balloon. PTBD catheter was left in situ for 3 months after complete ductal clearance and then removed. Results: Five patients underwent PTBD (n=4 right biliary system, n=1 left biliary system) followed by cholangioscopy guided holmium laser lithotripsy. Good stone pulverization could be achieved in all patients. Mean no of session required were 4 (range 3–7). Complete ductal clearance could be achieved in all patients. No recurrence of stones was noted at mean follow-up of 6 months (range 3–9 months). No significant complications were encountered. Conclusion: Percutaneous endoscopic management of intrahepatic stones is a valuable alternative to surgery in select group of patients especially those having dilated biliary tree with absence of intrahepatic strictures. However long-term follow up studies required to see for recurrence of stone or anastomotic re-stricturing. GB-6 Physicochemical properties of bile acids in micelle formation and correlation with cholesterol and phospholipids

Sarika Senagasetti, Ramana Ramya, V Jayanthi, Narayana Kalkura Crystal Growth Centre, Anna University, Guindy, Chennai 600 025, India Critical micelle concentration (CMC) is defined as the concentration of surfactants above which micelles form and all additional surfactants added to the system go to micelles. This study supports that the CMC is influenced by both cholesterol and phospholipids concentration. The concentrations of cholesterol, bile salts and phospholipids were analyzed in 51 bile samples. The mean groups were similar, 34 years in normal and 45 in gallstone patients. Three of the 14 normal subjects and 12 of the 37 patients with gallstones were female. The relatively small percentage of females in both groups was accounted. When the bile salts, cholesterol and phospholipid constituents were plotted on ternary plot, the clear separation of normal and abnormal bile was achieved. This separation is due to the increase in the concentration of cholesterol in abnormal bile. So, it is suggested that the bile juice physical state is determined by the composition of cholesterol, phospholipids and bile salts. It therefore may be suggested that the solubility of cholesterol in bile is determined solely by the amount of cholesterol relative to the quantities of bile salts and lecithin present. On the comparison of north and south Indian abnormal bile, there is no significant difference in the mean of cholesterol and phospholipid concentration. Analysis of gallstones based on FTIR suggests that cholesterol either singly or in combination with either calcium carbonate or bilirubin is the most predominant component of gallstones from South India. GB-7 Evaluation of gallbladder kinetics using cholescintigraphy with mebrofenin as the imaging agent in diabetics

H P Yedla, A T Mohan Apollo Hospitals, 134, Mint Street, Sowcarpet, Chennai 600 079, India Aims: To compare gallbladder ejection fraction between diabetics and nondiabetics to determine the prevalence of gallbladder dysfunction in diabetics to compare the gallbladder ejection fraction of diabetics to age and sex matched controls. Materials and Methods: This is a prospective case control study done at the Apollo Hospitals, Chennai between August 2006 and August 2009. All known diabetics and those detected de novo >18 years of age were included and those with structural gallbladder and liver diseases, history

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of cholecystectomy, pregnant, acute complications of diabetes and hemolytic disorders were excluded from the study. A standardized fatty meal is used as the stimulant and 99 mtc – mebrofenin is used as the imaging agent. Patients having GBEF <50 % were considered to have gallbladder dysfunction statistical analysis: results were analyzed using descriptive statistics, Student’s t test, chi-square test and ANOVA using SPSS v13.0 software results: total number of cases were 135 with cases and controls being 85 and 50 respectively; males—102 and females—33. The mean GBEF in controls was 66.22 % and cases 59.13 % (p value—0.026) prevalence of gallbladder dysfunction in cases and controls was 28.2 % and 14 % respectively (p value—0.043). Conclusions: Standardized fatty meal and mebrofenin have proved to be a good stimulus and imaging agents respectively GBEF in normal subjects varies between 50 % and 82 % GBEF is significantly lower in diabetics when compared to the nondiabetics gallbladder dysfunction is more prevalent in diabetics when compared to nondiabetics

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Material and Method: It was a retrospective analytical study. All the data of cirrhotic patients presented to our department in year June 2014 and July 2015 was collected and analyzed. Presence of the gallstones was confirmed by transabdominal ultrasonography. Results: Total patients were 235. Male: Female ratio was 1.37:1. Mean age of the patients was 45.04±13.46 years. Overall gallstones were present in 25/235 (10.63 %) patients. Gallstones were more common in alcoholics 11/ 85 (12.94 %) than nonalcoholics 14/150 (9.33 %). Also the prevalence was more in CTP class C 15/83 (18.07) than CTPA 4/92 (4.34 %) and CTP B 6/ 60 (10 %). Gallstones were present in 5/53 (9.4 %) and 1/9 (11.1 %) patients of cryptogenic cirrhosis and hepatitis B related CLD respectively. Conclusion: The prevalence of gallstones in cirrhotics was 10.63 % which increases with the severity of disease, i.e. more common in CTP class C. Gallstones develop in cirrhosis of all etiologies, but more frequently in alcoholic liver disease. GB-10

GB-8 Role endoscopic ultrasonography in the detection of biliary microlithiasis and missed stones—A KIMS experience

P D Dashatwar, Ambulge Santhoshkumar, Putta Sharat Reddy Department of Gastroenterology, Block III, 3rd Level, KIMS Hospital, Minister Road, Secunderabad 500 003, India Introduction: Microlithiasis and sludge can lead to whole spectrum of manifestations commonly associated with macrolithiasis including acute pancreatitis presenting a diagnostic challenge. The aim of our study was to retrospectively report our experience with endoscopic ultrasound (EUS) in investigating patients with suspected biliary pathology and normal or inconclusive conventional imaging. Method: A total of 42 patients with clinicobiochemical suspicion of biliary colic (n=3), choledocholithiasis with or without cholangitis (n=25) and biliary or idiopathic pancreatitis (n=14) were studied. Patients had at least two different (abdominal US or abdominal CT or MRCP) normal imaging studies (mean 2.28, range 2–4). EUS examination was done using a radial echoendoscope. Results: Twenty-one (50 %) of the patients had biliary tract disease (cholelithiasis in 2, gallbladder sludge in 9, choledocholithiasis in 7 and common bile duct sludge in 3 patients). Pancreas divisum was identified in one case. No underlying cause could be found in 15 (36 %) patients. Five patients had suggestive features of chronic pancreatitis (CP). Conclusion: Occult biliary pathology is the predominant cause of IAP. Half of the cases without identified etiology already had an underlying biliary tract pathology. EUS is a very important tool in evaluating IAP especially after an initial negative diagnostic work up.

Fracture of basket within the bile duct during Soehendra rescue lithotripsy, extracted after Spyglass-rescue laser lithotripsy

Suryaprakash Bhandari, Atul Sharma, Vishal Bothara, Vinay Dhir, Amit Maydeo Baldota Institute of Digestive Sciences, Global Hospitals, 35, Dr E Borges Road, Hospital Avenue, Parel, Mumbai 400 012, India An 80-year-old female patient was diagnosed with a large bile duct stone causing obstructive jaundice. She underwent endoscopic retrograde cholangiopancreatography (ERCP) and attempt at stone extraction using balloon, however the stone could not be extracted in view of relative narrowing of the lower bile duct (stone to duct discrepancy). Temporary biliary stent was inserted and she was referred to us for further management. She underwent repeat ERCP at our center after one moth of index ERCP. In view of large size of the stone, she was subjected to CRE balloon (Boston Scientific, USA) sphincteroplasty of the papilla till 12 mms. Post dilation stone extraction was attempt with stone extraction basket. However the basket got impacted in the lower CBD. Soehendra rescue lithotripter was used over the sheath of the impacted basket to crush the stone. However as the stone was getting crushed against the metal sheath the wires of the basket got fractured with partially fragmented stone and the fractured part of the basket with metal tip now lying within the bile duct. Sphincterotome and guide wire could not be negotiated across the impacted stone in the lower CBD. Spyglass cholangioscopy guided Holmium laser lithotripsy was then done and the impacted stone was fragmented. The fractured basket and the stone fragments were then extracted and the procedure could be successfully completed. The above case highlights usefulness of Spyglass cholangioscopy with laser lithotripsy for impacted bile duct stones and failed Soehendra rescue lithotripsy.

GB-9 GB-11 Prevalence of gallstones in patients of cirrhosis in Central India

Amol R Samarth, Sudhir Gupta, Dharmesh K Shah, Bhumit R Patel, Sonal Gattewar Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Introduction: The reported prevalence of gallstones in cirrhosis varies from 6.8 % to 10.2 %. Pigment gallstones are most frequent, while cholesterol stones represent about 15 % of all stones in cirrhotics. Increased biliary secretion of unconjugated bilirubin, increased hydrolysis of conjugated bilirubin, reduced secretion of bile acids and phospholipids favor pigment lithogenesis in cirrhotics. Gallbladder hypomotility also contributes to lithogenesis. Aim: To evaluate prevalence of the gallstones in the cirrhotic patients.

Management outcomes in patients with post endoscopic retrograde cholangiopancreatography perforations

Pritul D Saxena, A S Puri, B C Sharma, S Sachdeva, S Srivastava, A Kumar, A S Dahale, A Dalal, A Sangam Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Aims: Endoscopic retrograde cholangiopancreatography (ERCP) has evolved from a diagnostic tool to a primarily therapeutic procedure. Duodenal perforation occurs in 0.1 % to 1.8 % of patients after therapeutic ERCP, and is a serious complication with a high mortality rate. Management of ERCP-associated perforation remains controversial.

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Aim: The aim was to study the management outcomes of patients with post-ERCP perforations and to identify which subgroup of patients respond best to conservative management. Methods: This prospective study was conducted at GIPMER, New Delhi, between 01/09/2013 and 30/06/2015. Consecutive patients admitted with a diagnosis of post ERCP perforation after undergoing ERCP at our center were prospectively enrolled. Data relating to demography, laboratory parameters, imaging, presentation, management and outcome was analyzed. Results: Eighty-eight patients (age 47.14±14.86 years, 69 females, BMI 20.71±3.19 kg/m2) developed a perforation and were studied. Total ERCPs performed were 4531. The most frequent underlying illness was cholelithiasis with choledocholithiasis. 20.4 % had associated cholangitis. Seventy-one (80.7 %) perforations were detected on table, and 11 (12.5 %) were detected within 24 h of the procedure. Eighty-five (96.5 %) had an air nephrogram on skiagram. Seven (7.9 %) were managed with PCD (mean duration 8.6±2.3 days), 18 (20.4 %) underwent surgery whereas 63 (71.6 %) were managed conservatively. Mean hospital stay was 12.05±9.29 days. Six (6.8 %) died, 5 in surgical whereas 1 in conservative management group, of which 3 had underlying malignancy, rest 82 (93.1 %) recovered and were discharged safely. Conclusion: Most patients recover uneventfully on conservative management. Most important factor for better outcome is early detection and prompt treatment. GB-12 Endoscopic ultrasound-guided choledochoduodenostomy in malignant biliary obstruction with failed endoscopic retrograde cholangiopancreatography is feasible: A single-center experience

Ritesh Prajapati, Vikas Singla, Anil Arora Sir GangaRam Hospital, Rajinder Nagar, New Delhi 110 060, India Objectives: Endoscopic ultrasonography (EUS)-guided biliary drainage is performed for treatment of patients who have obstructive jaundice in cases of failed endoscopic retrograde cholangiopancreatography (ERCP). In the present study, we looked for the feasibility and outcome of EUSguided choledochoduodenostomy in ten patients with failed ERCP for malignant biliary obstruction. Method: Using a linear echoendoscope, a 19 G needle or a needle knife was punctured transduodenally into the bile duct under EUS visualization. Needle tract was dilated using 6 F cystotome and a fully covered self-expanding metal stent (SEMS) was inserted through the choledochoduodenostomy site into the extrahepatic bile duct. Results: All 10 patients had unresectable periampullary malignancy with duodenal tumor infiltration. In 9 of 10 cases, the obstructive jaundice rapidly improved after the procedure. In patient in whom jaundice did not regress post procedure had extensive liver metastasis. Technical and functional success rates were 100 % (10/10) and 90 % (9/10). Early complications occurred in one patient. One patient developed recurrence of jaundice due to blocked stent in whom plastic stent placement through previously placed SEMS was done. Conclusion: EUS-guided choledochoduodenostomy appears to be a safe feasible and effective alternative in patients with failed ERCP. GB-13 Comparative study of fatty meal versus drotaverine hydrochloride versus hyoscine-N-butylbromide for duodenal antimotility and ease of cannulation during endoscopic retrograde cholangiopancreatography

S Vadivel Kumaran, T Pugazhendhi, Mohammed Ali Madras Medical College, E V R, Periyar Salai, Park Town, Chennai 600 003, India

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically demanding procedure that requires considerable amount of training to be performed safely. Successful cannulation without complications usually depends on the expertise of the endoscopist. Conventionally, cannulation is facilitated with the help of hyoscine-N-butyl bromide or Drotaverine, smooth muscle relaxants to impair duodenal contractions and sphincter of Oddi relaxation. This study is to compare the effect of fatty meal (1.7 % fat containing milk of 200 mL) versus Drotaverine hydrochloride vs. hyoscine-N-butyl bromide on duodenal contraction rate, to identify the ampulla, time for cannulation, adverse events during ERCP. Sixty patients admitted for ERCP with normal appearing ampulla on endoscopy at Madras Medical College and Hospital, Chennai, fulfilling the inclusion criteria were taken up for the study. Patients were subjected randomly into the three groups. Fatty meal, 200 mL of skimmed milk (1.7 % fat) was given orally, 1 h prior to the procedure, to allow for gastric emptying. Results: The difference in duodenal motility, cannulation time and success of the procedure did not show a statistically significant p value. Whereas, the statistical analysis showed a significant p value for change in pulse rate and blood pressure variation during the procedure, which was higher with hyoscine-N-butyl bromide group. Conclusion: In the current study 1.7 % fat containing milk of 200 mL is not inferior to the conventionally used hyoscine-N-butyl bromide or its alternate Drotaverine for its anti-motility effect on the duodenum during ERCP. The cannulation time is no different within the groups. The identification of ampulla was easier with the fatty meal group. There is a possibility of higher increase in pulse rate and blood pressure in patients with ischemic heart disease with the use of hyoscine-N-butyl bromide. This shows milk can replace the conventionally used drugs during ERCP.

GB-14 Analysis of bile culture for bacteriological profile and antibiotics sensitivity pattern in patients undergoing endoscopic retrograde cholangiopancreaticography: A prospective study

Uday Kumar, Amarendra Kumar, V M Dayal, S K Jha, A K Jha, Shailesh, Avinash Kumar Indira Gandhi Institute of Medical Sciences, Bailey Road, Shiekhpura, Patna 800 014, India Background and Aim: In normal healthy person bile is sterile and obstruction leads to cholangitis. Choledocholithiasis, malignant stricture and benign biliary stricture are common predisposing factors for cholangitis and needs empirical treatment with broad spectrum antibiotics and decompression of biliary system to study bacteriological profile and sensitivity pattern in bile of patients undergoing endoscopic retrograde cholangiopancreaticography (ERCP). Method: Study conducted in Indira Gandhi Institute of Medical Sciences, Patna. Bile collected in sterile syringe using cannula and send immediately to Microbiology Department for culture and sensitivity pattern. The susceptibilities of organisms were detected using antimicrobial discs. Results: A total of 78 patients were analyzed for data collection and 36 out of these were excluded due to unavailability of bile culture report. Out of 42, 26 were female and 16 were male (61.90 % vs. 38.10 %) with median age 45.4 years (20–75 years). Among benign biliary disease, choledocholithiasis (52.30 %) and in malignant biliary disease, carcinoma gallbladder were the most common indication of ERCP. Most common organisms were E. coli (54.76 %) followed by pseudomonas (11.90 %). Most sensitive antibiotic detected was amikacin (73.80 %) followed by imipenem (52.38 %). Conclusion: 40.47 % of bile aspirates showed growth of pathological organism even absence of clinical feature of cholangitis. Therefore, preprocedure antibiotics administration may be useful to avoid postprocedure infection.

A70 GB-15 Postcholecystectomy complications requiring endotheraphy—A tertiary care experience

V Sankar, Ratnakar Kini, K Premkumar, Kani Shiek Mohammed, T Pugazhendhi, Mohammed Ali Madras Medical College, E V R, Periyar Salai, Park Town, Chennai 600 003, India Background: Significant complications like bile leak occur after open and laparoscopic cholecystectomy. These may constitute a serious and difficult problem for management. Surgical management of biliary fistulae is known to be associated with high morbidity and mortality. Biliary endoscopic procedures have become the first line of management of bile leaks and bile duct strictures following cholecystectomy injury. Materials and Methods: We conducted a prospective and retrospective analysis of data from our tertiary care hospital based on records compiled over 5 years (2011–2015). A total of 116 cases of postcholecystectomy complications requiring endotheraphy were analyzed to assess various sites of bile duct injury following cholecystectomy (both laparotomy and laparoscopic) with or without common bile duct (CBD) exploration and the feasibility of endoscopic therapy for the variety of injuries. The bile leaks, stone and stricture were confirmed by endoscopic retrograde cholangiopancreatography and the appearance of bile in percutaneous drainage of abdominal collections. Results: The mean age of our study population was 36 years with a male/ female ratio of 1:1.8 approximately. Common complications are bile leak, residual CBD stone, persistent t-tube drain, post CBD exploration leak, CBD stricture, bilio-cutaneous fistula, cystic duct calculi and complete transection. Bile leak is more common at cystic duct level. EST with DP stent placement is the most common intervention done. Conclusion: In our study complications like bile leaks, residual CBD stone and persistent t-tube drain occur most commonly. Bile leaks are common at the level of cystic duct. Most common age group affected is between 31–40 years. Laparoscopic cholecystectomy being practiced now-a-days without adequate expertise, predisposes to bile duct injury. CBD exploration with T-tube placement accounts for large number of persistent bile leaks during open-cholecystectomy. Endotherapy has a overall success rate of 75 % from our experience, for all kinds of complications. In summary, endoscopic therapy is safe and effective in the management of bile leaks and fistulae after surgery. Sphincterotomy with stenting or endoprosthesis alone is effective in the management of postoperative biliary complications.

GB-16 Cytological evaluation and outcome of patients with cholangiocarcinoma

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Results: Seventy-three patients were diagnosed with cholangiocarcinoma. Smoking is the most common risk factor identified (38 patients). Eight patients had intrahepatic-cholangiocarcinoma, forty-three patients had perihilar-cholangiocarcinoma and twenty-two patients had distal-cholangiocarcinoma. ERCP was done in 59 of the 65 patients with extrahepaticcholangiocarcinoma. Six patients declined the procedure. Stricture was identified in 55 patients. Brushings were taken in 52 patients from the stricture and were positive for malignancy in 25 patients. Biliary stenting was done in 52 patients. Forty-six patients had successful resolution of jaundice with stenting. Thirty-nine patients had stage I-II disease whereas thirty-four patients had stage III-IV disease. Forty-eight patients were followed for minimum period of 6 months. Six-month mortality of 68.75 % was observed. Conclusion: In cholangiocarcinoma, ERCP is useful in obtaining tissue for diagnosis as well as for relief of obstruction. Biliary brushings are safe and effective means for obtaining tissue and lead to a positive diagnosis of cholangiocarcinoma in nearly 50 % of the cases. Endoscopic biliary drainage represents the mainstream of palliative treatment for patients with non-resectable hilar-cholangiocarcinoma. GB-17 Bile duct strictures: 3-year experience in a tertiary care center

Ilavarasi, Mohammed Ali, T Pugazendhi Aim: To analyze the causes and management of bile duct strictures in patients presenting to The Department of Medical Gastroenterology in Madras Medical College and Hospital from July 2012-July 2015. Patients and Methods: Out of 350 patients admitted with obstructive jaundice and suspected bile duct injuries were submitted for imaging and out of which 102 patients were diagnosed with bile duct strictures. A detailed history regarding duration of symptoms, prior surgery, trauma, etc. were taken. Those who had bile duct strictures by imaging were taken up for endoscopic retrograde cholangiopancreatography (ERCP) to analyze the etiology as well as for endoscopic management. Observation and Results: A total of 102 patients were diagnosed with bile duct strictures. Sixty-five were males and 37 were females. The most common clinical presentation of the patients was obstructive jaundice, followed by cholangitis and biliary pain. Forty-five patients had malignancy (44.11 %), chronic calcific pancreatitis in 25 (24.5 %), postcholecystectomy strictures in 15 (14.7 %) patients followed by recurrent acute pancreatitis, primary sclerosing cholangitis, hiv cholangiopath. In feasible patients endoscopic sphincterotomy/stenting done. Conclusion: Males were common in the study. The most common etiology of bile duct stricture in this study was malignancy. The most common malignancy was carcinoma head of pancreas. The most common benign cause was chronic calcific pancreatitis. Type 1 stricture was the most common. Endoscopic therapy was highly successful in patients with malignant strictures and in post surgical strictures.

Chaitanya Koppolu, Murali Krishna Palakurthy, A S Sudhakar Andhra Medical College, Maharani Peta, Visakhapatnam 530 002, India

GB-18

Aim: To study the clinical profile of patients of cholangiocarcinoma, the diagnostic accuracy of various modalities and to evaluate outcome of cholangiocarcinoma. Material and Methods: It is a prospective observational study. All adult patients with suspected cholangiocarcinoma were studied after excluding other etiologies. Patients having evidence of biliary stricture on imaging with obstructive jaundice and suspected extrahepaticcholangiocarcinoma were subjected to endoscopic retrograde cholangiopancreatography (ERCP). Trans-papillary brushings were taken from the stricture and sent for cytological examination.

Ajay K Jain, Sandip Vare, Mayank Jain, Shohini Sircar, Amit Bundiwal, Sandeep Kaulavkar, Suresh Hirani, Rahul Agarwal Department of Gastroenterology, Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India

Choledochal cyst and pregnancy—A challenge to manage!

Introduction: Choledochal cyst is a rare congenital dilatation of the bile ducts. The reported incidence is 1 in 100,000 and it is commoner in females. Only few cases of choledochal cyst with pregnancy, managed conservatively, available in literature. Surgery during pregnancy is associated with high fetal and maternal risk.

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Case Reports: A 27-year-old second gravida female with 27 weeks of pregnancy presented with continuous epigastric pain, jaundice and vomiting for last 8 days. Her first pregnancy was uneventful. She had pallor, icterus, and fullness in right upper abdomen and fetal heart sounds were present. On ultrasound, hepatomegaly with dilated IHBR and a large cystic, anechoic structure of 14.2×10.6×10.6 cm was noted communicating with the hepatic confluence. Magnetic resonance cholangiopancreatography revealed a 17×10×10 cm type 1 choledochal cyst. Liver function tests showed serum bilirubin 9 mg %, GGT 102 IU/mL, alkaline phosphatase 619, ALT/AST 76/84 and INR of 1.5. The symptoms in pregnancy may be exaggerated due to hormonal effects and compression of bile duct by gravid uterus. In view of advanced pregnancy, external pigtail drainage was done for 19 weeks and patient improved significantly. She was discharged with pigtail in situ. At completion of 37 weeks of pregnancy, she delivered a 2.9 kg, healthy baby. Resection of choledochal cyst with hepaticojejunostomy was done after 2 months of delivery. Biopsy revealed fibrosis and inflammation with no evidence of malignancy. Conclusion: Management of choledochal cyst in pregnancy should be conservative and definitive treatment should be done after delivery. GB-19 Safety and efficacy of endoscopic stenting for palliation of malignant hilar strictures (bismuth type II and type III)

Rohit Sureka, Anurag Govil, Dinesh Agarwal, Harsh Udawat, Sandeep Vaishnav Santokba Durlabhji Memorial Hospital, Bhawani Singh Marg, Near Rambagh Circle, Jaipur 302 015, India Background: Conflicting results exists regarding cholangitis due to endoscopic biliary stenting in hilar strictures especially type II and type III MHS. Objective: To study technical and therapeutic success of endoscopic stenting, rate of postprocedure cholangitis, relief in pruritus in patients with type II and III MHS study type: Interventional Design: Prospective observational descriptive setting: Tertiary care intervention: Endoscopic stenting of MHS. Results: Sixty-one patients were included over 1 year. Forty-five (73.77 %) patients had Bismuth type II while 16 (26.23 %) patients had type III MHS. Etiology included carcinoma gallbladder (75.4 %), cholangiocarcinoma (22.95 %) and metastatic lymph node (1.6 %). Plastic stent was inserted in 34 (55.7 %) and SEMS in 27 (44.3 %) patients. Technical success rate for stent placement was 100 % and successful drainage achieved in 58 (95.08 %) patients. Early cholangitis (day 0–7) developed in none while late cholangitis (day 7–30) developed in 2 (3.27 %) patients. There was no procedure related mortality or morbidity. pruritus was found to decrease in statistically significant manner from 63.93 % to 3.27 % at day 30 (p<0.05). Limitations: Study is not randomized in terms of plastic stent vs. SEMS and endoscopic stenting vs. PTBD. Conclusion: Endoscopic stenting using plastic stent or SEMS is safe and effective method of palliation in patients with type II/type III MHS.

Introduction: Endoscopic retrograde cholangiopancreaticography (ERCP) has been found to be useful in the management of post-traumatic biliary and pancreatic duct injuries, but the data is limited. We did a retrospective study to evaluate the outcome after the successful ERCP in such cases. Patients and Methods: Twenty-five patients of traumatic biliary and pancreatic duct injuries were evaluated. The modes of injury, clinical presentation, modes of therapy and outcome were recorded. Results: Mean age of the patients was 22.2±11.1 years and mean time of presentation following trauma was 33.8±20.1 days. Modes of injury were motor vehicle accident (n=21), and fall from height (n=4) respectively. In patients with biliary tract injury (n=15), ERC revealed bile leak from the right hepatic duct (n=6), common hepatic duct (n=6), common bile duct (n=2), and left hepatic duct (n=1). In patients with pancreatic injury (n= 10) the ERP revealed the leak from main pancreatic duct in head (n=5), body (n=4) and tail (n=1). The therapeutic procedures done were endoscopic biliary sphincterotomy (n=3), pancreatic duct sphincterotomy (n= 6) and biliary stenting (n=11) and pancreatic duct stenting (n=3). Two patients underwent surgery. Nasobiliary drain was placed in 3 patients prior to stenting. Biliary stents and the nasobiliary drain were removed after 33.4±10.2 days and all the patients remained asymptomatic after a follow-up of 22±8 months. Conclusions: Therapeutic ERCP is an effective procedure in management of post traumatic biliary and pancreatic duct leaks. GB-21 Endoscopic gallbladder stenting for acute cholecystitis

Ramakrishna, Roy J Mukkada, J C Mathew, V F Jose, G M Pradeep, Abraham Koshy, Philip Augustine Department of Gastroenterology, Lakeshore Hospital and Research Center, Maradu, Nettoor P.O, Kochi 682 040, India Background: Endoscopic transpapillary pernasal gallbladder drainage and endoscopic gallbladder stenting (EGS) have recently been reported to be useful in patients with acute cholecystitis. Methods: We retrospectively studied 12 non-surgical patients with acute cholecystitis who were treated by EGS at Lakeshore Hospital and Research Centre, Kochi between June 2014 and June 2015. Acute cholecystitis was diagnosed by ultrasonography and computed tomography. All patients underwent EGS, with a 7-Fr double pig-tail stent being inserted into the gallbladder. Most had multiple comorbidities, most common was decompensated cirrhosis (5/12). Four out of 12 underwent cholecystectomy at a later date and one had liver transplant. Results: EGS was successful in 10 patients (83 %) with acute cholecystitis. In hospital complications include 2 deaths due to multiorgan failure, 2 had post procedure pancreatitis (self-limiting). Three out of 12 required naso gallbladder drainage. Conclusions: EGS can be effective in patients with acute cholecystitis who are poor surgical candidates and can be a bridge to surgery or even a permanent solution. GB-22 Lithogenicity of bile in North Indian and South Indian healthy population and patients with gallstones

GB-20 Endoscopic management of traumatic biliary and pancreatic duct injuries

Jatinderpal Singh, Amarender S Puri, B C Sharma, Sanjeev Sachdeva, Siddharth Srivastava, Ajay Kumar, Sudhir Maharshi, Ashok Dalal, K Arivarasan G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

Sarika Senagasettia, R Ramya, V Jayanthi, S Vijaya, Joy Varghese, M Rela, M Bhaskar Rao, M Ashok, S Narayana Kalkura Crystal Growth Centre, Anna University, Chennai 600 025, Department of Gastroenterology, Global Health City, Chennai 600 100, Shakthi Clinical Laboratory, Bheema Sena Garden Road, Mylapore, Chennai 600 004, and Department of Physics, National Institute o Gallstones in North India are predominantly cholesterol, whereas in South they are either pigmented or mixed. Lithogenic bile predisposes to

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cholesterol gallstones. What predisposes to gallstones in south India is not known.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Pancreas P-1

Aim: Aim of the study was to analyse North Indian (NI) and South Indian (SI) bile for its lithogenic properties. Methods: Bile samples from 25 south Indian (SI) (9 normal+16 GS bile), and 26 north Indian (NI) (5 normal+21 abnormal) patients were collected for bile analysis. Healthy controls were donors for liver transplant. The bile samples were analyzed and quantified for critical micelle concentration (CMC), i.e. concentration of cholesterol, phospholipid and bile salts by an enzymatic method for cholesterol and phospholipids, and HPLC with reverse column for the bile salts. Results: Cholesterol was high in healthy NI bile samples as compared to those from south. The bile salt, phospholipid and cholesterol ratio of NI healthy bile was 83:14:2 and SI bile was 77:21:1. Phospholipid was more in SI bile. In patients with gallstones, the bile sample from NI had significant increase in cholesterol compared to SI bile with gallstones (p<0.0001). The proportion of phospholipid was low in both NI and SI bile samples. The proportions were 70:7:22 and 79:8:12 respectively for north and SI bile. Conclusion: While healthy bile sample from SI was less lithogenic than NI bile, cholesterol proportion was more in SI patients with gallstones. The significance of these findings needs further exploration in large number of patients and correlated with composition of gallstones.

GB-23 Therapeutic endoscopic retrograde cholangiopancreatography during pregnancy: One of the largest experiences from Asia

Amit Soni, Sanjeev Sachdeva, Ameet Banka, J P Singh, Ashok Dalal, Ajay Kumar, Siddharth Srivastava, B C Sharma, A S Puri Department of Gastroenterology, G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Aim: Pancreato-biliary diseases during pregnancy can turn out to be lethal for both mother and fetus. We summarize our experience with therapeutic endoscopic retrograde cholangiopancreatography (ERCP) in management of pancreatobiliary diseases during pregnancy. Methods: The ERCP records from 2001 to 2015 were reviewed. Therapeutic ERCP performed during pregnancy were identified and results were analyzed. Results: Forty-one pregnant patients underwent ERCP. The median age at the time of ERCP was 30 years (range 20–40). Indications for ERCP were common bile duct (CBD) stone in 34 patients (82.9 %), biliary ascariasis in 3 (7.3 %), gallbladder cancer in 2 (4.8 %), and postcholecystectomy bile duct injury and hilar cholangiocarcinoma in 1 each. Fluoroscopy was used in 14 patients only. Median fluoroscopy time was 10 s (range 1–60). Lead shields were used in all 14 patients who were exposed to radiation. Sphincterotomy was performed in 35 patients followed by biliary plastic stent placement in 32, ascaris removal in 2 and stone removal with CBD clearance in 1. Two patients needed needle knife papillotomy for CBD access followed by biliary plastic stent placement. In one patient only biliary plastic stent was placed without any sphincterotomy due to deranged INR. Remaining 3 procedures were not successful due to failed attempts for CBD cannulation in 2 patients and gastric outlet obstruction in one patient due to malignancy. Thus technical success rate was 92.68 %. ERCP related complications included mild pancreatitis in 2 patients (4.8 %). Conclusion: Therapeutic ERCP is an effective and safe procedure during pregnancy.

Correlation of serum procalcitonin levels with severity of acute pancreatitis with special emphasis on cutoff values as a predictor of severity

Irfan A Shera, Sitendu Patel, Suneel Chakravarty, Abhishek Deo, Vivek Raj, Ashwinin Kumar Setya Department Gastroenterology, Max Superspeciality Hospital, 1, 2, Press Enclave Road, Saket, New Delhi 110 017, India Background: Acute pancreatitis (AP) is highly variable in terms of its clinical presentation and severity. Various biochemical parameters, computerized tomography and certain scoring systems are used for this purpose and to determine the need for intensive care. The ideal parameters to assess severity of pancreatitis and determining prognosis should be simple, cheap and should have a high rate of accuracy. Serum procalcitonin (PCT) a simple, practical marker to stratify severity of disease in acute pancreatitis. Aims and Methods: To determine best cutoff values of serum PCT in different degrees of severity of acute pancreatitis and compare in predicting severity to BISAP score and modified CTSI. Blood samples for PCT was collected in patient of acute pancreatitis on admission (day 0), 72 h (day 3) and repeated weekly depending upon longer stay in hospital. The serum PCT concentration was measured using a chemiluminescent immunoassay (Elecsy Brahms PCT Roche Diagnostic). Revised Atlanta classification was used as the gold standard to stratify severity of acute pancreatitis in this study. Results: Of the 70 patients of acute pancreatitis, 60 % were male, mean age of presentation was 47 yr, 50 % had biliary stones, 15.6 % had severe pancreatitis with organ failure, 18.6 % had moderately severe disease and 65.5 % had acute mild pancreatitis. Death occurred in 4.6 %. Mean value of serum PCT for mild, moderately severe and severe pancreatitis on day of admission were 0.627 ng/mL, 1.184 ng/mL and 2.67 ng/mL and at 72 h after admission were 0.225 ng/mL, 0.562 ng/mL, and 1.85 ng/mL respectively. Best cutoff value of serum PCT was 0.15 ng/mL between mild and moderately severe pancreatitis (ROC curve (AUC): 0.830 95 % CI (0.71 to 0.915) p<0.05. While best cutoff value of serum PCT was 0.8 ng/mL between moderately severe and acute severe pancreatitis (ROC curve (AUC):0.748 95 % CI (0.531 to 0.901) p=0.0261. Serum PCT had 74.2 % accuracy of determining severity of pancreatitis at admission, BISAP score >3 has 72.2 % and modified CTSI had 82.8 % accuracy of determining severity of pancreatitis after 72 h of admission. Conclusion: Serum PCT is promising simple early biomarker and had similar accuracy of BISAP score as predicting severity of acute pancreatitis. We have best cutoff values that stratify AP into mild, moderately severe and severe pancreatitis with sensitivity ranges between above 82 % and 100 % at different days of admission. P-2 Genetics of chronic and recurrent acute pancreatitis in children

Zaheer Nabi, Mohsin Aslam, Rupjyoti Talukdar, V V Ravikanth, Steffi Avanthi, Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background: Most common cause of chronic pancreatitis (CP) or recurrent acute pancreatitis (RAP) in children is idiopathic. Genetic aspects of chronic pancreatitis in children have not been well studied. In this study we aim to estimate the prevalence of genetic mutations in children with idiopathic CP or RAP.

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Methods: We analyzed the data of children aged 18 years or younger with RAP or CP diagnosed over last 1 year at our hospital. Forty-three children with RAP or CP were identified. Genetic polymorphisms for serineprotease-inhibitor (SPINK1), cationic trypsinogen (protease, serine 1PRSS1), cystic fibrosis transmembrane conductance regulator (CFTR), chymotrypsin C (CTRC), cathepsin B (CTB) and claudin2 were analyzed. Results: Among 43 children analyzed, 21 (49 %) had RAP and 22 (51 %) had CP; 46 % were female. Of these, 12 (28 %) children had pancreas divisum. Mean age of children was 12.55±3.6 years. Genetic polymorphisms predisposing to pancreatitis were identified in 35 children (81.4 %). SPINK1 mutations were found in 18 (42 %) (heterozygous13, homozygous-5), PRSS1 in 17 (39 %, all heterozygotes), CTRC in 9 (21 %, heterozygous-7, homozygous-2), CTB in 19 (44 %, heterozygous17, homozygous-2), claudin2 in 25 (58 %, heterozygous-8, homozygous17) and CFTR in 1 (2 %) children. All children with pancreas divisum and CP or RAP had at least one mutation. In children with pancreas divisum, SPINK1 mutation was found in 4 (33 %), PRSS1 in 6 (50 %, all heterozygous), CTRC in 3 (25 %), CTB in 7 (58 %), claudin2 in 8 (67 %) children. Conclusion: The prevalence of genetic polymorphisms in children with idiopathic RAP or CP is high. Further studies with large sample size and age matched controls are required to confirm our findings.

P-3 A new score to detect severe acute pancreatitis at admission, which saves time for triage

Shankar Zanwar, A T Mohan Apollo Hospital, Greams Road, Chennai 600 006, India Introduction: A well-known fact is acute pancreatitis may turn disastrous in at least 10 % to 20 % leading to severe course. A problem faced in routine practice is regarding the classification of pancreatitis on admission. Existing scores either lack sensitivity or need time of at least 48 h to fully calculate. A quick and sensitive score will make early classification and will help primary and secondary care clinician to transfer the possibly severe cases to tertiary centers. Aim: Present study was aimed to evaluate the performance of new score predicting severity of acute pancreatitis. Methods: All patients presenting with acute pancreatitis in our hospital with 48 h of onset of pain were included. Patients with evidence of prior chronic pancreatitis were excluded. Standard definitions regarding pancreatitis, severity and pancreatitis related complication as per modified Atlanta 2012 classification were followed. APACHE-II and BISAP scores were calculated based on parameters on admission. Complete Ranson’s score was calculated at 48 h after admission. And the newly devised score, BISAP+SHO, additional SHO abbreviated for oxygen saturation 1 (<90 %), hematocrit 2 (<47 %) and obesity 3 (BMI >24) at admission was calculated. Results: A total of 56 patients were enrolled in the study of which 38 (16.07 %) were mild and 9 (16.07 %) were moderate and severe each. The sensitivity, specificity, positive predictive value and negative predictive value (in %) for scores were as follows: Ranson’s—100, 82.98, 52.94 and 100; APACHE-II—77.78, 95.74, 77.78 and 95.74; BISAP—44.44, 97.87, 80 and 90.20; and BISAP-SHO—88.89, 100, 100 and 97.92 respectively. Conclusion: Though the sensitivity of Ranson’s was highest amongst the calculated scores, but it takes 2 days for complete score to calculate. New BISAP+SHO score fares better than APACHE and BISAP in all respects and comparable to Ranson’s in terms of sensitivity and better than Ranson’s in all other aspects. We recommend use of new score as routine for triage of patients with acute pancreatitis in ER.

P-4 Clinical profile and short-term and long-term outcome of acute, recurrent acute and chronic pancreatitis

Rishikesh Kalaria, Philip Abraham, Devendra Desai, Anand Joshi, Tarun Gupta P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India Background: Indian patients with acute pancreatitis may behave differently from Western patients. Aims: To study the clinical profile of acute pancreatitis, and progression to recurrent acute and chronic pancreatitis. Methods: The study was conducted in a tertiary hospital. All patients with acute, acute-on-chronic, and chronic pancreatitis during July 2013 to December 2014 were included. Details of past episodes were collected and patients were followed up till March 2015. Results: Of 151 patients (110 men), 112 presented with acute pancreatitis, 39 had chronic changes at first presentation. Among patients with acute pancreatitis (mean age 45 y), idiopathic (38 %), biliary (29 %) and alcohol (20 %) were major etiologies. One hundred and twelve patients had 144 episodes – 88 (61.1 %) mild, 44 (30.5 %) moderate, 12 (8.3 %) severe. Necrotizing pancreatitis occurred in 27 episodes (18.8 %), organ failure in 25 (17.4 %; 13 transient); 4 (2.8 %) had multi-organ failure. Mean CTSI, BISAP scores, and durations of hospitalization were progressively higher among mild, moderate and severe pancreatitis episodes. Two of 12 patients with severe pancreatitis (16.6 %) died. Recurrences after index episodes were more common in idiopathic (56 %; alcoholic 35 %, biliary 10 %) pancreatitis and with mild index episode. Progression to chronic was more common in alcoholic (33 %) and idiopathic (30 %) groups. Conclusions: Our patients with acute pancreatitis had average age a decade less than in Western studies. BISAP and organ failure are best markers to predict severity and guide management. The revised Atlanta classification defines outcome of organ failure and local complications. Recurrences were most common in idiopathic variety and with mild index episode. Progression to chronic pancreatitis was more common in alcoholic and idiopathic varieties. P-5 Interleukin 6: A biomarker for pulmonary complications and severity in acute pancreatitis

Abhishek Kathuria, Mohd. Talha Noor Sri Aurobindo Medical College and Postgraduate Institute, Indore, India Background: To assess the association of interleukin-6 (IL-6) levels with severity of disease and likelihood of pulmonary complications in acute pancreatitis. Material and Methods: Seventy-two patients of acute pancreatitis and ten healthy age and sex-matched controls were recruited from July 2013 to December 2014. Severity of pancreatitis was assessed using revised Atlanta classification. Serum IL-6 levels were measured by ELISA on day 3 of symptoms. Result: Out of 72 patients; 24 (33.3 %) had mild acute pancreatitis, 21 (29.1 %) had moderately severe acute pancreatitis and 27 (37.5 %) had severe acute pancreatitis. IL-6 levels were significantly higher in the severe group (213.8±48.4 pg/mL) as compared to controls (3.4±2.9 pg/ mL), mild (42.7±44.5 pg/mL) and moderately severe (123.8±82.7 pg/ mL) groups (p<0.0001). A cutoff of IL-6≥86.04 pg/mL on day 3 could predict severe acute pancreatitis with a sensitivity of 96.3 % and specificity of 100 %. There was a significant difference between the levels of IL-6 in patients with lung complications compared to those without lung complications (p=0.001). A cutoff level of IL-6≥44.98 pg/mL could

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predict the development of lung complications with sensitivity of 82.5 % and specificity of 73.3 %. The mean value of IL-6 in patients who died (239.3±12.7 pg/mL) was significantly higher compared to that those who survived (122.4±91.5 pg/mL) (p=0.006). Conclusion: Our study confirms that high serum IL-6 levels are associated with pulmonary complications as well as severity in patients with acute pancreatitis.

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(26 %), 4 had paraaortic lymph nodes (11 %), 1 each had peripancreatic, celiac, paracaval, interaortocaval lymph nodes (3 %). In 4 of 9 patients with suspicious mediastinal lymph nodes, FNA documented MML in 4/ 35 (11 %). Conclusions: MML is detected by EUS-FNA in 11 % of patients with pancreaticobiliary cancer. Because of its important implications, endosonographers should routinely assess for MML in patients who undergo staging EUS for pancreaticobiliary malignancy.

P-6 P-8 Urinary trypsinogen-2 test for the diagnosis of acute pancreatitis

Rohan P Reddy, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, Hyderabad 500 025, India Background: Acute pancreatitis accounts for up to 5 % of patients presenting to the emergency department. Although serum amylase and lipase historically have been used for the diagnosis of pancreatitis, neither is a definitive test for pancreatitis and levels vary independent of disease and severity. Trypsinogen-2 is present in low concentration in the urine of healthy persons. It is strongly elevated in the early stages of acute pancreatitis and, importantly, remains elevated for several days or even weeks. Aim: To assess a point-of-care urine trypsinogen-2 (UT) test for the diagnosis of acute pancreatitis. Methods: This is a prospective study of patients presenting to the emergency department with abdominal pain suggestive of acute pancreatitis. A 5-min UT-2 test (actim pancreatitis) was compared with final diagnosis of acute pancreatitis, which is based on suggestive clinical features, serum lipase and/or amylase levels and imaging. Exclusion Criteria: Patients who are known to be having chronic pancreatitis patients with renal disorder. Results: Of 40 patients included in this study, 28 patients had final diagnosis of acute pancreatitis. The sensitivity and specificity of UT were, respectively, 93.3 % (CI-77.13-99.18 %) and 70 % (34.75-93.33 %). Conclusions: The point-of-care UT test for acute pancreatitis had good sensitivity and specificity, and can be used reliably at the bedside to make a positive diagnosis. P-7 Yield of endoscopic ultrasound in patients with unexplained acute pancreatitis

Vinod Kumar, Praveer Rai Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow 226 014, India

Extra pancreatic infections in acute pancreatitis and their influence on disease outcome

Majid, Mushtaq Khan, Gul Javid, Altaf, G M Gulzar, Jaswinder Department of Gastroenterology, Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir 190 011, India Background: Pancreatic infections in acute pancreatitis is well known to increase morbidity and mortality while less data is available on prevalence of extrapancreatic infection, its influence on outcome of pancreatitis. Aims and Objectives: The aim of this study was to assess the prevalence of extrapancreatic infections in acute pancreatitis, identify risk factors and influence of extrapancreatic infections on outcome of pancreatitis. Methods: Patients of acute pancreatitis admitted from June 2013 to July 2015 were recruited in the study. The patients who developed extrapancreatic infection formed the study group while patients who did not develop infections were included in the control group. Both groups were followed and their final outcome was compared. Results: A total of 350 patients comprising of 158 cases and 192 controls were studied. Prevalence of extra pancreatic infections was found in 41.5 % with UTI (14.4 %), being highest extrapancreatic infection commonest pathogen was E. coli followed by Enterococcus faecalis and most of them sensitive to imepenam. Predisposing factors for development of extra pancreatic infections and subsequent outcome of acute pancreatitis was found to be influenced by duration of hospital stay, etiology of acute pancreatitis and comorbidities especially diabetes mellitus. Conclusions: Prevalence of extrapancreatic infections was found in 41.5 % with highest being UTI. Extrapancreatic infections increases the morbidity and mortality, early detection and proper treatment of will definitely improve outcome of acute pancreatitis with infections. P-9 Step-up approach in acute pancreatitis: A single-center experience

Background: Pancreaticobiliary malignancy needs a major surgery with significant morbidity and mortality, hence adequate preoperative staging is mandatory. CT abdomen is the primary modality to stage these tumours. However some of these patients may have malignant mediastinal lymph nodes which preclude surgical resection. Endoscopic ultrasound can detect mediastinal lymph nodes with a high sensitivity and specificity. Methods: We prospectively evaluated the presence of malignant mediastinal lymphadenopathy (MML) by EUS with or without FNA in 35 consecutive patients with a definite diagnosis of resectable pancreaticobiliary cancer (carcinoma gallbladder, carcinoma pancreas, cholangiocarcinoma, periampullary carcinoma). Patients underwent EUS-FNA by a single operator. Lymph nodes those were round, hypoechoic with regular margins and >1 cm in diameter were considered suspicious and were sampled by FNA. Results: Of the 35 patients (median age 55 years) included in this study, 16 were females. Of these, 9 patients had mediastinal lymph nodes

Shrihari Anikhindi, Vikas Singla, Ashish Kumar, Praveen Sharma, Naresh Bansal, Anil Arora Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Background: Step-up approach (SU) has replaced primary surgical necrosectomy (Sx) in management of acute pancreatitis (AP) with infected fluid collection and necrosis. We present our experience of SU in managing AP. Patients and Methods: Consecutive patients of AP admitted in SGRH from February 2012-October 2014 were analyzed. All patients were initially managed with IV fluids, early enteral nutrition and organ support if required. Antibiotics were started if local/systemic infection was suspected. Patients unresponsive to empirical antibiotics after 72 h underwent computed tomography for presence of fluid collection or necrosis. Endoscopic/ percutaneous drainage (EPD) was done if optimal window was available

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after the second week of illness, else Sx was considered. Primary outcome measures were in-hospital mortality, stay duration, local/systemic complications. Predictors of mortality were determined. Results: Three hundred and twenty-four patients [78 % male; median age 42 (12–90); alcohol 34 %, biliary 36 %; severe 31 %] were diagnosed with AP. Interventions (EPD/primary Sx) were done in 77 patients. Sixtyseven patients underwent SU with initial percutaneous (n=53) or endoscopic (n=14) drainage. Overall mortality for SU vs. primary Sx was 40.2 % vs. 70 %. Median time at intervention was 25 d (18–120) for EPD. Thirty-seven patients (55.2 %) improved with drainage. Of 30 patients having persistent symptoms, 10 died without further intervention, 2 underwent endoscopic necrosectomy and 21 underwent secondary Sx. Fifteen patients (71 %) with secondary Sx died, of which 14 had persistent organ failure(s) (POF) at time of intervention. Overall mortality in patients failing response to initial EPD was 80 %. Conclusion: Response failure to initial EPD and presence of POF at time of intervention are important predictors of mortality in management of AP. P-10 To study the etiology of recurrent acute pancreatitis

Prabhdeep Singh, M Haldar, P P Bose, A Konar Peerless Hospital, 360, Panchasayar, Kolkata 700 094, India Introduction: Recurrent acute pancreatitis is defined as more than two attacks of acute pancreatitis (the cause of the initial attack usually not apparent after basic investigations) without any evidence of underlying chronic pancreatitis on initial investigation. The causes of RAP’s need dedicated investigations to unravel. Aims and Methods: To study the etiology in patients of recurrent acute pancreatitis. In this study we investigated the patients who presented with two or more episodes of acute pancreatitis in ED/OPD of a tertiary care hospital in Kolkata between July 2011 to July 2015. Investigations like lipid profile, calcium, parathyroid, IgG4, magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), retrograde cholangiopancreatography (ERCP) when necessary and others to find out the causes of recurrent acute pancreatitis. Results: In this study we prospectively analyzed data for 80 patients (50 M, 30 F, mean age 48 years, range 7–61 years). Alcohol intake was found to be the cause in 22 (27.5 %) patients, microlithiasis was found in 11 (13.7 %) patients, hypertriglyceridemia in 6 (7.5 %) patients, autoimmune pancreatitis in 4 (5 %) patients, pancreatic divisum in 3 (3.7 %) patients, choledochocoele in 1 (1.2 %) patient, and in 18 (22.5 %) patients, no apparent cause could be identified. Fifteen (18.7 %) of our patients on follow-up developed chronic pancreatitis on (EUS follow up). Conclusion: Our results show that alcohol intake is a major cause of RAP, significant no remain idiopathic for whom genetic causes could be responsible. P-11 Can development of acute kidney injury in acute pancreatitis be predicted?

R Prasada, S K Sinha, S K Arora, R Ramachandran, S Singh, J Samanta, Y R Reddy, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Aims and Methods: To study the predictive role of inflammatory cytokines in development of acute kidney injury (AKI) in patients with AP. In this prospective study between July 2013 and December 2014 consecutive eligible patients of AP underwent complete demographic, clinical,

biochemical and radiological evaluation. Severity classification was done using revised Atlanta classification and systemic inflammatory response score (SIRS), bedside index of severity of acute pancreatitis (BISAP), CT severity index (CTSI) and APACHE II scores were calculated. Organ failure was defined according to modified Marshall core. Development of AKI was monitored in all the patients. Serum levels of interleukin (IL)6, IL-8, IL-10, IL-1b and TNF-α were measured at baseline (day 1) for all patients and on day 3 in those who had AKI. For comparative analysis patients were divided into 2 groups: with and without AKI. The AKI cohort was further subdivided into persistent AKI (P-AKI) and transient AKI (T-AKI). Statistical analysis was done using SPSS v20.0 to study the predictive value of different cytokines for development of AKI. Results: Of the 107 patients (mean age of 38.4 years, 64.5 % males, etiology: alcohol 36.4 % gallstone disease 26.2 % and others 51.4 %), AKI developed in 20 (18.7 %). T-AKI was seen in 7 (35 %) while 13 (65 %) had P-AKI. Patients with AKI had significantly higher IL-6 (p= 0.004), IL-8 (p<0.0001) and TNF-α (p=0.05) levels on day 1 when compared to non-AKI group. In the AKI group, day 3 levels of TNF-α (p=0.010) were significantly higher than day 1 levels whereas IL-10 (p= 0.04) levels were significantly lower than day 1 levels. Significant rise on day 3 of TNF-α (p=0.004) was observed in the P-AKI group. Day 1 levels of IL-6 and IL-8 had strong positive correlation with severity indices such as SIRS (p<0.001), BISAP (p<0.001) and CTSI (p<0.0001) as also with outcome measures such as need for intervention (p<0.0001), hospital stay (p<0.0001) and intensive care stay (p<0.0001). Conclusion: IL-6 and IL-8 levels at admission were significantly associated with development of AKI in AP. Rising levels of TNF-α suggested development of persistent AKI.

P-12 Does outcome of isolated extrapancreatic necrosis (EPN) in patients with acute pancreatitis differs from both pancreatic parenchymal necrosis and EPN? A single-center experience

N Dhaka, S K Sinha, J Samanta, H S Dhaliwal, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Isolated extrapancreatic necrosis (EPN) is being considered a separate entity in Revised Atlanta classification. Limited studies have shown that patients with EPN have a better prognosis than patients with pancreatic parenchymal necrosis (PPN). Aims: To compare outcome between patients of EPN with versus those with both PPN and EPN. Methods: We retrospectively analyzed data from 411 patients with AP who were managed during January 2012 to December 2014. Imaging results were reviewed by a single radiologist blinded to the clinical outcome. Patients with EPN were compared with patients with both PPN with EPN. Outcomes measures studied were persistent organ failure, infected necrosis, need for ventilator and dialysis, need for percutaneous catheter drain (PCD), surgery and mortality. Results: Necrotizing pancreatitis was seen in 337 patients, out of whom 285 (85 %) had both PPN with EPN, 40 (12 %) had only EPN and 12 (3 %) had only parenchymal necrosis. Comparison between patients with both PPN with EPN and only EPN showed that only EPN group had less multiorgan failure (7 % vs. 27 %, p<0.001), persistent organ failure (15 % vs. 43 %, p<0.001), infected necrosis (3 % vs. 32 %, p<0.001), need for PCD (20 % vs. 50 %, p<0.001), need for ventilator (0 % vs. 22 %, p<0.001), need for dialysis (0 % vs. 9 %, p<0.001), requirement for surgery (0 % vs. 14 %, p<0.01) and mortality (0 % vs. 20 %, p<0.001) as compared to patients with both PPN with EPN. Conclusion: Patients with isolated EPN have better prognosis as compared to both PPN with EPN.

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Introduction: Acute lung injury (ALI) is the commonest organ failure in patients with acute pancreatitis (AP). It is a major cause of early mortality in such patients and cytokines play a major role in its pathophysiology. Aim and Methods: To study the predictive role of inflammatory cytokines in development of ALI in patients with AP. In this prospective study between July 2013 and December 2014 consecutive eligible patients of AP underwent complete demographic, clinical, biochemical and radiological evaluation. Severity classification was done using revised Atlanta classification and also systemic inflammatory response score (SIRS) and bedside index of severity of acute pancreatitis (BISAP), CT severity index (CTSI) and APACHE II scores were used. Serial arterial blood gas (ABG) analyses were done and ALI severity defined as per Berlin classification using PaO2/FiO2 ratio. Development of ALI was monitored in all the patients. Serum levels of interleukin (IL)-6, IL-8, IL-10, IL-1b and TNF-α were measured at baseline (day 1) for all patients and on day 3 in those who had ALI. For comparative analysis patients were divided into 2 groups: with and without ALI. The ALI cohort was further subdivided into persistent ALI (P-ALI) and transient ALI (T-ALI). A subgroup of ALI patients who developed ALI later during hospital stay was defined as Blate onset^ ALI (LO-ALI) to devise a predictive model for ALI using cytokine levels. Statistical analysis was done using SPSS v22.0. Results: Of the 107 patients (mean age of 38.4 years, 64.5 % males, etiology: alcohol 36.4 % gallstone disease 26.2 % and others 51.4 %), ALI developed in 51 (47.7 %) of whom 40 (78.4 %) had ALI on admission while 11 (21.6 %) had LO-ALI. T-ALI was seen in 16 (31.4 %) while 35 (68.6 %) had P-ALI. Patients with ALI had significantly higher IL-1b (p<0.0001), IL-6 (p<0.0001), IL-8 (p<0.001) and TNF-α (p<0.0001) and lower IL-10 (p<0.0001) levels on day 1, when compared to non-ALI group. In the ALI group, day 3 levels of IL-1b (p=0.001), IL-6 (p=0.02), IL-8 (p=0.006) and TNF-α (p=0.006) were significantly higher than day 1 levels. Significant rise on day 3 of only IL-1b (p=0.04) was observed in TALI group as compared to both IL-1b (p=0.001) and TNF-α (p=0.02) in the P-ALI group. Day 1 levels of IL-6 and IL-8 had strong positive correlation with severity indices such as SIRS (p<0.001), BISAP (p<0.001) and CTSI (p<0.0001) as also with outcome measures such as need for intervention (p<0.0001), hospital stay (p<0.0001) and intensive care stay (p<0.0001). LO-ALI group had significantly higher levels of IL-6 (p<0.0001), IL-8 (p<0.0001), TNF-α (p<0.0001) and IL-1β (p<0.006). IL-6 at cutoff levels of 84.85 pg/mL (AUC=0.94, sensitivity and specificity 91 %) and IL-8 at cutoff level of 112.5 pg/mL (AUC=0.909, sensitivity 91 % specificity 94.6 %) predicted subsequent development of ALI. Conclusion: Rising levels of IL-1 and TNF-α suggest development of persistent ALI. IL-6 and IL-8 levels at admission can predict the future development of late onset ALI.

Study of lung function tests and their role in predicting development of acute lung injury in patients with acute pancreatitis

Y R Reddy, J Samanta, S K Sinha, S K Arora, A N Aggarwal, N Dhaka, S Gorka, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: The commonest organ failure in patients with acute pancreatitis (AP) is acute lung injury (ALI). Data on pulmonary function tests (PFT) in AP is limited. Aim and Methods: To study PFT in patients with AP and evaluate the role of PFTs in predicting ALI. In this prospective study between July 2013 and December 2014 consecutive patients of AP underwent complete demographic, clinical, biochemical and radiological evaluation. Severity stratification was done using revised Atlanta classification and systemic inflammatory response score (SIRS), Bedside Index of severity of acute pancreatitis (BISAP), CT severity index (CTSI) and APACHE II scores were calculated. Serial arterial blood gas (ABG) analyses were done and ALI severity defined as per Berlin classification using PaO2/FiO2 ratio. Development of ALI was monitored in all the patients. PFTs were done by spirometry as soon as possible after admission. Forced expiratory volume in first second (FEV1), forced vital capacity (FVC) and FEV1/ FVC ratio were used as basic parameters for interpretation and all measurements were expressed as a percentage of their predicted values (FVC %, FEV1 %). Patients were divided into 2 groups: with and without ALI. The ALI cohort was further subdivided into persistent ALI (P-ALI) and transient ALI (T-ALI). A subgroup of ALI group which developed ALI later during hospital stay was defined as Blate onset^ ALI (LO-ALI) to devise a predictive model for ALI with PFT parameters. Statistical analysis was done using SPSS v22.0 Results: Of the 107 patients (mean age of 38.4 years, 64.5 % males, etiology: alcohol 36.4 % gallstone disease 26.2 % and others 51.4 %), ALI developed in 51 (47.7 %) patients of whom 40 (78.4 %) had ALI on admission while 11 (21.6 %) had LO-ALI. T-ALI was seen in 16 (31.4 %) while 35 (68.6 %) had P-ALI. PFT could be performed in 87 patients (52 non-ALI, 35 ALI including 9 from LO-ALI subgroup). ALI group had significantly lower FVC % (p<0.0001) and FEV1 % (p<0.0001) signifying higher lung dysfunction compared to those without ALI. Similarly, P-ALI had lower FVC % (58.9± 14.8 vs. 69.6±17.2, p=0.06) and lower FEV1 % (p=0.04) than T-ALI. A significant correlation existed between PaO2/FiO2 ratio and FVC % (r= 0.513, p<0.0001) and FEV1 % (r=0.488, p<0.0001). Both FEV1 % and FVC % showed significant correlation with other severity parameters such as SIRS (p<0.0001), BISAP (p<0.00011), CTSI (p<0.0001) and APACHE II (p<0.002) and also with need for intervention (p=0.04), hospital stay (p<0.0001) and intensive care stay (p=0.001). LO-ALI (9) had significantly lower FVC % (p=0.02) and FEV1 % (p=0.03) as compared to those without ALI, but a predictive cutoff could not be achieved (AUC=0.257, p= 0.021) due to small numbers. Conclusion: Patients with AP who eventually develop late onset ALI have more severe lung dysfunction at baseline than those who do not, and PFTs can act as a tool to predict it. P-14 Elevated levels of IL-6 and IL-8 have predictive role in the development of respiratory failure in patients with acute pancreatitis

J Samanta, S K Sinha, S K Arora, A N Aggarwal, S Singh, R Prasada, H S Dhaliwal, A Rana, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

P-15 Comparison of revised Atlanta classification and determinant-based classification as outcome predictors in acute pancreatitis

Narendra Dhaka, S K Sinha, J Samanta, Y R Reddy, D Sharma, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Aims: To compare severity and outcome based on the revised Atlanta classification (RAC) and the determinant-based classification (DBC) in acute pancreatitis. Methods: We retrospectively analyzed data from 404 patients with AP admitted during January 2012 to December 2014. Patients were assigned to severity categories according to both RAC and DBC classification systems. Both classification systems were validated and compared in terms of outcomes measures such as hospital and ICU stay, need for ventilator and dialysis, need for percutaneous catheter drain (PCD), surgery and mortality.

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Results: Fifty-one (12.6 %), 202 (50 %), 151 (37.4 %) patients were classified as mild, moderately severe or severe AP according to RAC however when classified on basis of DBC, 62 (15.3 %), 177 (43.8 %), 105 (26.0 %), 60 (14.9 %) patients had mild, moderate, severe and critical AP. Result showed that different severity categories of both classifications system were significantly associated with prolonged hospital stay, ICU stay (AUC 0.799, 0.848; p<0.001), need for nutritional support (AUC0.798, 0.787; p < 0.001), need for ventilator (AUC-0.887, 0.893; p<0.001), need for dialysis (AUC-0.826, 0.811; p<0.001) and mortality (AUC-0.864, 0.863; p<0.001). However need for intervention and surgery were better predicted by DBC as compared to RAC (AUC-0.696 vs. 0.790; p<0.001 and AUC-0.800 vs. 0.715; p<0.001). Both the classification system showed good agreement (Kappa-0.575, p<0.001) for outcome estimation. Conclusion: The DBC and the RAC were comparable in predicting various outcome measures including mortality, although need for surgery and intervention were better predicted using DBC.

P-16 Role of ammonia PET-CT in assessing the pancreatic necrosis in patients with acute pancreatitis

Sudhanshu Budakoty, B R Mittal, N Khandelwal, S K Sinha, N Dhaka, J Samanta, N Berry, H S Dhaliwal, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 16 012, India Background: Contrast enhanced CT (CECT) is contraindicated in patients with acute pancreatitis having renal failure. Aim: To evaluate whether ammonia (13NH3) PET CT reflects the perfusion status of pancreas in patients of acute pancreatitis (AP) to detect pancreatic necrosis and to compare it with contrast enhanced CT scan (CECT). Methods: Sixty-four patients with AP were enrolled in the study. 13NH3 PET CT was done in all the patients while CECT was done in 55 patients, and 9 patients with renal failure had only 13NH3 PET CT for imaging. CECT images were interpreted and the percentage of necrosis, presence and absence of collection(s) were recorded and CTSI (CT severity index) was calculated. 13NH3 PET CT images were separately analyzed and PETCTSI was calculated along with the amount of necrosis and number of fluid collection(s). Both investigators were blinded to each other. Comparison between the two imaging techniques for detection of pancreatic necrosis was done. Results: The mean age of study population was 40.65±15.1 years. Of these 43 (67.2 %) patients were males and 21 (32.8 %) were females. Nine (14 %) patients had acute kidney injury at presentation who underwent only 13NH3 PET CT imaging for evaluation. A comparative analysis of CTSI with PETCTSI showed significant correlation between the two scores (p<0.05). The scores also showed a good agreement (Kappa-0.445, p<0.05), suggesting that the both imaging modalities were comparable for severity estimation. Necrosis on both CECT and 13NH3 PET CT was compared separately and it also showed good level of agreement between the two imaging modalities (Kappa-0.539, p<0.05). The ability of 13NH3 PET CT imaging to adequately identify collection(s) along with necrosis was separately analyzed in a subgroup of 32 patients. In 22 patients both CECT and 13NH3 PET CT diagnosed collection(s) whereas in 6 they both denied evidence of any collection(s). Out of the remaining 4 patients, collection(s) in 3 patients were identified on alone 13NH3 PET CT, while 1 identified on CECT alone. The agreement between these two imaging modalities for estimation of fluid collection(s) was also computed that showed good level of agreement between these (Kappa-0.668, p<0.05). Conclusion: Ammonia (13NH3) PET CT could be an alternative imaging modality for diagnosis of acute pancreatitis and assessing the severity of acute pancreatitis especially in patients with renal failure.

P-17 Location, size and multiplicity of fluid collection(s) determine the outcome of acute pancreatitis

Narendra Dhaka, S K Sinha, P Sarwal, J Samanta, Y R Reddy, S Malik, V Gupta, T D Yadav, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: Acute fluid collection(s) in patients of acute pancreatitis can vary in size, location and number. However the effect of these characteristics of fluid collection(s) over disease course and outcome has been not studied. Aims: To evaluate the impact of various characteristics (number, location and size) of fluid collection(s) on course and outcome of patients of acute pancreatitis (AP). Methods: One hundred and ninety-five patients with AP who had acute fluid collection(s) in and around pancreas on initial imaging were divided on the basis of collection(s) number (single vs. multiple), size (≤5 cm vs. >5 cm) and location {pancreatic (A), peripancreatic (B), both (C), peripancreatic with distant (D) and at all sites (E)}. Patients were managed as a step-up strategy. Outcome variables were hospital stay, ICU stay, need for ventilator and ICU care, need for percutaneous catheter drain (PCD), surgery and mortality. Data was recorded in excel sheet and statistical analysis was done using SPSS v22.0. Results: Thirty-eight (19.48 %) patients had single and 157 (80.52 %) patients had multiple collection(s). Patients with multiple collection(s) had significantly prolonged hospital stay and need for pigtail drainage, compared to patients with single collection(s) {22.7±20.1 days, 63 (40.12 %) and 15.1±12.4 days, 6 (15.3 %) (p=0.02 and 0.005). Surgery and mortality were exclusively seen with multiple collection(s){7(4.45 %) and 14 (8.91 %)}. Patients having collection(s) size >5 cm had significantly prolonged hospital and ICU stay {25.1±20.6 and 5.02±10 days vs. 11.71 ± 9.08 and 0.56 ± 2.01 days, (p < 0.001)}, need for ICU care {57(37.22 %) vs. 6 (10.34 %), p < 0.001} and pigtail drainage {66(48.17 %) vs. 3 (45.17 %), p<0.001}. Mortality, need for ventilator support and surgery were exclusively seen in patients with collection(s) size >5 cm. Depending on location of collection(s) we found that patients with location D and E had longer duration of hospital stay, higher need for ICU care and PCD as compared to others locations {23.65±11.51 and 21.27±19.09 days, 9 (45 %) and 41 (66 %), 14 (70 %) and 53 (85 %)}. Mortality, need for ventilator support and surgery were exclusively seen in patients with collection(s) location E. Conclusion: Patients having multiple collection(s), size >5 cm and at distant location have worse outcome and need to be identified as a separate group. P-18 Impact of the anatomical location(s) of necrosis on outcome in patients of acute pancreatitis

Narendra Dhaka, S K Sinha, V Gupta, T D Yadav, J Samanta, B Mallick, H S Dhaliwal, R Kochhar Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim: To evaluate the impact of anatomical location(s) of necrosis on outcome in patients of acute necrotizing pancreatitis (ANP). Methods: One hundred and sixty-one ANP patients were classified according to the type of necrosis [pancreatic (I), peripancreatic (II) or both (III)]. Patients with pancreatic necrosis were further divided in three groups based on anatomical location(s) of necrosis [necrosis involving only head region (A), involving body with or without tail region (B),

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involving the whole pancreas (C)] and were correlated with outcome (hospital stay, need for ICU care, need for ventilator, pigtail catheter drainage (PCD), surgery and mortality). Results: Pancreatic necrosis was seen in 115 (71.5 %) and peripancreatic necrosis alone seen in 46 (28.5 %) patients. Out of 115 patients with pancreatic necrosis, necrosis at location A was seen in 35 (30.5 %), at location B in 48 (41.7 %) and at location C in 32 (27.8 %) patients. Patients with location A and C necrosis were significantly associated with more hospital stay (38.82 ±25.8, 27.99 ± 22.1 vs. 13.04 ± 7.6 days, p<0.001), need for ICU care [n=23 (65.71 %), n=18 (56 %) vs. n=6 (12.50 %), p<0.001], requiring ventilator [n=3 (8.57 %), n=16 (50 %) vs. n=0 (0 %), p<0.001], surgery [n=3 (8.57 %), n=4 (12 %) vs. n=0 (0 %), p=0.06] and PCD requirement [n=32 (91.42 %), n=22 (68 %) vs. n=0 (0 %), p<0.001] as compared to location B necrosis (p<0.001). Outcome comparison between patients of location A and C necrosis showed that necrosis at location A was associated with more hospital stay (38.82±25.8 vs. 27.99±22 days), need for ICU [n=23 (65.71 %) vs. n= 18 (56 %)] and PCD [n=32 (91.42 %) vs. n=22 (68 %)], but it was statistically non-significant. However need for surgery [n=3 (8.57 %) vs. n=4 (12 %), p=0.067) and ventilator [n=3 (8.57 %), n=16 (50 %), p<0.001) were seen more in location C necrosis. Mortality was exclusively seen in patients with necrosis at location C [n=14 (43 %)]. Type III was the commonest type of necrosis (n=69, 42.8 %), followed by type II (n=46, 28.57 %) and type I (n=46, 28.57 %). Patients with type III necrosis had significantly increased hospital stay [34.28±24.8 vs. 13.26 ±7.4, 18.19±10.5 days, p<0.001] and need for ICU care [n=41 (59.4 %) vs. n=6 (10.86 %), n=16 (34.7), p<0.001) whereas need for ventilator (n=19, 27.5 %), PCD (n=54, 78.2 %), surgery (n=7, 10.14 %, and mortality (n=14, 20.28 %) were exclusively seen in these patients as compared to type I and II necrosis. Comparison between patients with type I and II necrosis showed that type II necrosis had significantly more hospital stay (18.19±10.5 vs. 13.26±7.4 days, p<0.05) and need for ICU care [n=16 (34.78 %) vs. n=6 (13.04 %), p<0.001) and PCD [n=15 (32.06 %) vs. n=0 (0 %), p<0.001]. Conclusion: Necrosis involving pancreatic head region had worse outcome as compared to body and tail region. Patients with necrosis involving both pancreatic and peripancreatic region had worst outcome followed by patients with only peripancreatic necrosis.

P-19 Arterial pseudoaneurysms in pancreatitis: endovascular management at a tertiary care center

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(96.5 %) cases, was not feasible in remaining three cases. Majority patients underwent coil embolization (62/87; 71 %) followed by glue embolization (16/87; 18 %). Five patients (6 %) underwent both coil and glue embolization. One patient underwent endovascular stent placement for large pseudoaneurysm. Conclusion: Endovascular management is effective for achieving haemostasis in patients with pancreatitis-related pseudoaneurysm. It should be considered as primary modality of treatment in properly selected patients. P-20 A comparative evaluation of modified ct severity index and APACHE-IV system in the prediction of severity in acute pancreatitis

A Bansal, Neel Kamal, H A Dar, S Naik, S Malhotra, R K Himthani Batra Hospital and Medical Research Centre, 1, Tughlakabad Institutional Area, Mehrauli Badarpur Road, New Delhi 110 062, India Objectives: Early identification of severe acute pancreatitis is critical for triage and treatment of patients. APACHE-IV is a newer clinical scoring system being used for assessing the critically ill patients. Aim of our study was to compare the modified CT severity index (MCTSI) and APACHE-IV for predicting the severity of acute pancreatitis. Methods: Clinical and laboratory data of 50 consecutive patients with a primary diagnosis of acute pancreatitis during a 18-month period was collected. APACHE-IV and modified CT severity index were comparatively evaluated with regards to the ability to predict the severity of acute pancreatitis. Wilcoxon signed rank test was used to test for significance difference between the two techniques and ROC curve was obtained. Results: In the study group of 50 patients, there were 33 males (66 %) and 17 females (34 %). Mean age of the patients was 47.5 years. Patients who had multiorgan failure was 16 (32 %), in which 6 had transient organ failure (37.5 %), 10 cases had persistent organ failure (62.5 %). Ten patients (20 %) required surgical intervention and 10 cases (20 %) expired. The mean APACHE-IV secure was 74.6 (patients who expired had score of >98) and mean modified CT severity index was 6. APACHE-IV co-related statistically with mortality, hospital stays, organ failure. MCTSI was statistically better for ICU stay. Conclusion: APACHE-IV score is superior to modified CT severity score in predicting the severity of acute pancreatitis.

Nitin Jagtap, Harshal Shah, Jagadeesh Singh, Manu Tandan, Rupjyoti Talukdar, Duvvuru Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India

P-21

Background: A bleeding pseudoaneurysm in patients with pancreatitis is a rare and potentially lethal complication. We evaluated clinical features and role of angiographic procedures for treatment of pancreatitis associated pseudoaneurysms. Method: The medical records of 87 patients (81 males and 6 females; age range 10–73 years) with pseudoaneurysms associated with pancreatitis between January 2010 to July 2015 were retrospectively reviewed. Result: Thirty-two (37 %) were acute necrotizing pancreatitis and 55 (63 %) were chronic pancreatitis. Fifty (57 %) patients presented as hemosuccus pancreaticus and 42 (48 %) had intra-cystic bleed. Angiography revealed splenic artery was most commonly involved in 42 cases followed by gastroduodenal artery in 22, left gastric artery, pancreaticoduodenal and superior mesenteric artery in 5 cases each, gastroepiploic artery in 2 and celiac, left hepatic artery, right hepatic artery, right gastric artery, left renal artery and left inferior phrenic artery in one case each. Angiographic intervention was successful in 84

Puneet Chhabra, Vishal Sharma, Surinder S Rana, Ravi Sharma, Deepak K Bhasin Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India

Hypocalcemic tetany: a simple bedside marker of worst outcome in acute pancreatitis

Background: Hypocalcemia is considered a marker of poor prognosis in acute pancreatitis (AP). However the prognostic significance of hypocalcemic tetany, which is not commonly observed in patients with AP, has not been described. Hence we conducted this prospective study to evaluate the role of tetany in prognosis of patients with AP. Methods: Consecutive patients of AP presenting within 7 days of onset of symptoms were included and followed up till recovery or death. The serum calcium levels were done at admission and patients were divided into two groups based on the presence (group 1) or absence of hypocalcemia (group 2). The clinical signs of hypocalcemia (Chvostek’s sign or Trousseau’s sign) were looked for in all patients with hypocalcemia and

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Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

outcome measures were compared between patients with normocalcemia, asymptomatic and symptomatic hypocalcemia (tetany). The outcome parameters assessed were POF (persistent organ failure), the need for intervention and mortality. Findings: Of the 105 patients (53 M; mean age 37.34±12.62 years) included, 37 (35.2 %) had hypocalcemia [group 1] and 68 (64.8 %) had normal corrected serum calcium levels [group 2]. Patients with hypocalcemia had significantly higher frequency of POF, mortality and need for intervention (p<0.05). Twelve of 37 (32.4 %) patients with hypocalcemia had tetany. Patients with tetany had significantly low serum corrected calcium and ionized calcium as compared to patients with asymptomatic hypocalcemia (p<0.05). Patients with tetany when compared to patients with asymptomatic hypocalcemia had significantly higher mortality (100 % vs. 32 %; p=0.000) as well as POF (100 % vs. 32 %; p= 0.000). Tetany predicted mortality with a sensitivity of 75 % and specificity of 100 %. Interpretation patients of AP with hypocalcemic tetany have a very poor prognosis and its presence can be used as a simple bedside marker of increased mortality.

P-22 A comparison of nasogastric and nasojejunal feeding in the enteral nutrition of acute pancreatitis Eswar Moparty, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Medical College, Walker town, MIGH Colony, Padmarao Nagar, Secunderabad 500 003, India

Aim of the Study: To compare nasogastric with nasojejunal mode of enteral nutrition in severe acute pancreatitis at Gandhi Hospital, Secunderabad. Material and Methods: Adult patients presenting with severe acute pancreatitis between August 2013 to July 2015 (2 years) were included in the study. Patients already on oral feeds, delayed presentation greater than 4 weeks, patients in shock, or with acute exacerbation of chronic pancreatitis excluded. Clinical evaluation along with requisite lab, imaging and nutritional parameters were noted. Patients were randomized to receive either nasogastric or nasojejunal enteral feeding with semielemental enteral formula given to both groups for 7 days. Patients monitored until endpoint of study which includes discharge from hospital, surgery or death. Results: Complications

NG group (17)

NJ group (20)

Vomiting

1

0

Pain

6

4

Refeeding pain

0

1

Acute fluid collection

1

4

Multiorgan failure

3

3

NG group 4 to 22

NJ group 6 to 28

Outcomes Days of stay ICU

4

7

Ventilatory support

3

4

Surgery

1

3

Mortality

1

2

Conclusion: Nasogastric and nasojejunal routes of enteral nutrition are comparable in terms of safety, tolerance and efficacy in the management of acute severe pancreatitis. The differences between them are statistically non-significant. Larger randomized controlled trials are needed before nasogastric enteral nutrition can be recommended for clinical practice.

P-23 A prospective study of comparative evaluation of bedside index for severity in acute pancreatitis, APACHE-II and computed tomography severity index scoring systems in the early prediction of severity in acute pancreatitis

G Swathi, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, 6-1-34, Bhoiguda Road, Musheerabad, Secunderabad 500 003, India Aim: To compare bedside index for severity in acute pancreatitis (BISAP) with acute physiology and chronic health examination (APACHE)-II, and computed tomography severity index (CTSI) in predicting severity, pancreatic necrosis (PNec), and mortality in a prospective cohort of patients with AP. Materials and Methods: Patients with AP admitted to our institution between August 2013 and June 2015 were studied prospectively with detailed history, laboratory and radiographic investigations. The BISAP and APACHE-II scores were calculated using data from the first 24 h from admission. CECT was done within 72 h. Predictive accuracy of the scoring systems was measured by the area under the receiver-operating curve (AUC). Results: Of 50 patients with AP, mean age is 37.7 (range 15–65 years) and 60 % are males. Etiology of AP is alcohol in 60 %, idiopathic in 20 %, biliary in 14 %, hypertriglyceridemia in 4 %, drugs in 2 %. Ten patients developed organ failure and were classified as severe AP (SAP 20 %). Seven developed PNec (14 %), 3 died (6 %). The number of patients with BISAP3 was 8, APACHE-II8 was 19, CTSI3 was 21. AUCs for BISAP, APACHE-II and CTSI in predicting SAP are 0.79 (CI 0.70-0.88), 0.81 (CI 0.71-0.84), and 0.82 (CI 0.75-0.87), respectively. Conclusions: BISAP score is an accurate means for risk stratification and prognostic prediction in patients with AP at 24 h. It is simple, easy to obtain and its variables are clinically relevant. P-24 Prospective analysis of economic, psychologic and nutritional burden in patients with nonalcoholic chronic calcific pancreatitis and its impact on employment status and health care experience

Pankaj Singh, Partha Sarathi Patra, G K Dhali, Kshaunish Das Department of Gastroenterology, School of Digestive and Liver Disease, Institute of Post Graduate Medical Education and Research, 244 A J C Bose Road, Kolkata 700 020, India Aim: To assess the impact of chronic pancreatitis [CP] on healthcare expenses, nutrition, psychology and employment status in a tertiary medical center in India. Methods: Two year prospective study [78 non-alcoholic chronic calcific pancreatitis and 156 healthy controls]. Validated Questionnaire [food frequency, HADS, WPAI-GH ] were used. Assessment was done at baseline and follow-up at 3 months, 6 months, and 1 year. Results: Baseline demography Table 1. Baseline assessment: Total healthcare cost in last 1 month [6.5±10.1 (INR X 103), p<0.0001]. Forty-nine percent of expenses were met by either selling assets/loans at interest/charitable donations. Patients were mostly undernourished with low BMI [19.8±3.1 kg/m2], lower calorie intake [1485.0±291.8 Kcal/d, p<0.0001]. Thirty-five percent patients had anxiety and 28 % depression [vide HADS scale]. Significant higher work-hours lost due to CP [ mean, 14.8±16.0 vs. 0.1±0.8, p<0.0001] and higher health problem affected productivity score. Follow-up data at 3 months, 6 months, and 1 year: On [medical±surgical/endotherapy] did not show any significant change over the baseline data. Conclusion: This study explores the multi-dimensional aspect of chronic pancreatitis which adversely affects the physical and mental quality of life

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(HRQL) in a developing country with profound impact on employment status hence the economic burden and nutritional status. P-25 Endotheraphy in chronic pancreatitis—A single-center experience

Bhaskar, P Muralikrishna, K Varun, L R S Girinadh Department of Gastroenterology, King George Hospital, Visakhapatnam 530 002, India Background: Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain. Our objective was to study the role of endoscopic management in chronic pancreatitis in relation to pain. Methods: A total of 50 patients with pain as the predominant symptom were included in the study. They were divided into 4 groups: group 1— CP with minimal ductal changes; group 2—CP with strictures in pancreatic head/body; group 3—CP with stones in pancreatic head/body; and group 4—CP with strictures and stones. Endotheraphy in form of sphincterotomy, stone extraction, stricture dilatation, pancreatic stenting was done. The clinical response in terms of pain reduction was evaluated at 8 weeks following endotheraphy and followed for 6 months. Results: Mean age of presentation is 32. M:F −3:2. Most common cause of chronic pancreatitis in male patients was alcohol (76.7 %) and idiopathic (55 %) in females. Technical success of endoscopic therapy was achieved in 94 % of patients. Pain response in group 1 (66.7 %), group 2 (87.5 %), group 3 (64.3 %), and group 4 (75 %) respectively. Post ERCP complications, mild pancreatitis in 8 and minor bleeding in 6 patients. Conclusions: Endotherapy is effective, offers good results and is associated with low morbidity and mortality. It is therefore advisable to offer endotherapy as the first line treatment in properly selected patients with CP. P-26 Inhibition of pancreatic stellate cell activation by Triticum aestivum for the prevention of fibrogenesis in a rat model of chronic pancreatitis

Surendra Sharma, SatyaVati Rana, Ritambhra Nada, Surinder Rana, Samir Malhotra, Deepak Kumar Bhasin Departments of Super Speciality Gastroenterology, Histopathology, and Pharmacology, Post Graduate Institute of Medical Education and Research, Sector-12, Chandigarh 160 012, India Objective: Activation of pancreatic stellate cells (PSCs) plays a central role in development of pancreatic fibrosis. Activated PSCs are the main sources of tissue inhibitor of metalloproteinase (TIMPs). TIMPs have inhibitory action on all activated tissue matrix metalloproteinases (MMPs). Therefore, this study was planned. Methods: Eighteen Wistar rats were divided in 3 groups. Group 1: Oral administration of freshly homogenized Triticum aestivum (0.8 g/kg per day) in drinking water was given to rats (n=6) two days before L-arginine injections. Group 2: L-arginine (250 mg/100 g bw/day) was administered intraperitoneally in 2 repeated doses at 1-h interval on day 1, repeated with 250 mg/100 g bw/day, on day 4,7,10,13,16 and 19 to induce CP. Group 3: Six control rats were also given drinking water orally and IP injections of normal saline. Histological examination was done by H & E and Masson’s Trichrome staining. Immunohistochemistry of ±−SMAwas done to evaluate activated PSCs. mRNA levels of TIMP-1, TIMP-2 and MMP-9, were analyzed by reverse transcription PCR.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

Results: L-arginine caused increase in ±−SMA positive PSCs and mRNA expression of TIMP-1 and TIMP-2. Oral administration of T. aestivum in pretreated L-arginine rats inhibited activity of PSCs which was characterized by significant decrease of ±−SMA. Treatment with T. aestivum increases expression of MMP-9 and decreases expression of TIMP-1 and TIMP-2. Conclusions: In animal model of CP, oral administration of T. aestivum inhibited the activity of PSCs leading to reduced expression of TIMP-1 and TIMP-2 and increase expression of MMP-9. Therefore, T. aestivum can be a novel option for alleviating pancreatic fibrotic process in CP. P-27 Profile of pancreatic cancer among patients with chronic pancreatitis in South India

Chandrashekar Sorake, G Rajesh, Suprabha Panicker, Rama P Venu, V Balakrishnan Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi 682 041, India Background: Chronic pancreatitis (CP) especially tropical pancreatitis has been reported to be a pre-malignant condition. Recent reports indicate change in profile of CP in India with identification of novel risk factors; and delayed presentation as well as delayed onset of exocrine and endocrine insufficiency. The prevalence and characteristics of pancreatic cancer in the present setting is unknown. Aim: We studied the prevalence and profile of pancreatic cancer among CP patients and associated risk factors. Results: Among 1157 patients with CP enrolled and followed up prospectively in our Pancreas clinic, there were 70 (42 males, 28 females) patients who developed pancreatic cancer. Sixty (85.7 %) had idiopathic/tropical chronic pancreatitis (ICP/TCP) while 10 (14.3 %) had alcoholic chronic pancreatitis (ACP) as underlying etiology. Mean age of ACP patients with cancer was 58.5±10.1 years as compared to 55.2±11.8 years in ICP/TCP. There were only 2 and 5 patients who developed pancreatic cancer before 35 years and before 40 years age respectively. Fourteen (20 %) were smokers while 56 (80 %) were diabetic. The tumor was located most commonly in head of pancreas among TCP/ICP (41.7 %) while it was evenly located among head, uncinate, body and tail (10 % each) in ACP. Conclusion: The prevalence of pancreatic cancer among CP was found to be 6.05 % and it was far more common in ICP/TCP as compared to ACP. Onset of pancreatic cancer in young patients with CP appears to be uncommon in ICP/TCP in the present series. Diabetes mellitus and smoking were risk factors associated with pancreatic cancer. P-28 Incidence of post ERCP pancreatitis and asymptomatic hyperamylasemia in patients undergoing ERCP: An experience from a tertiary care hospital

G Manigandan, K Muthukumaran, G Ramkumar, R Balamurali, T Rajkumar Solomon, A Murali, P Ganesh Department of Digestive Health and Diseases, Kilpauk Medical College and Hospital, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim: To measure the incidence of post ERCP pancreatitis (PEP) and asymptomatic rise in amylase levels in patients undergoing ERCP. Methods: One hundred and fifteen patients who underwent ERCP between May 2014 to April 2015 for various indications were enrolled

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104

prospectively satisfying inclusion and exclusion criteria. All the patients had pre procedure prophylaxis with rectal diclofenac suppository. CBC and amylase values were noted before the procedure and after 48 h of procedure. Patients who had high amylase levels (>3 times ULN) without signs of pancreatitis were considered as to have asymptomatic hyperamylasemia and those with high amylase values and signs of pancreatitis as PEP. Severity and grading of pancreatitis was done according to Cotton’s criteria. Results: Out of 115 patients 82 males (71 %) and 33 females (29 %). Biliary stenting was done in 90 patients (78 %) and pancreatic stenting was done in 25 patients (22 %) sphincterotomy was done in 82 patients (71 %) sphincterotomy with balloon dilatation done in 13 patients (11.3 %). Contrast injection done in 63 patients (54.7 %). PEP was diagnosed in 4 patients (3.4 %). Asymptomatic hyperamylasemia was seen in 15 patients (13 %). Conclusion: Proper patient selection along with proper technique and pre procedure prophylaxis helps in reducing the morbidity and mortality in patients undergoing ERCP. P-29 Effect of different routes of administration of diclofenac and post endoscopic retrograde cholangiopancreatography amylase and lipase levels

P N Prashanth, A J Joseph, Ebby George Simon, Amit K Dutta, Sudipta D Choudhury, Reuben T Kurien, Deepu David, Ramit Mahajan Department of Gastroenterology, Christian Medical College, Vellore 632 004, India Background and Aims: Serum amylase and lipase go up in most patients after endoscopic retrograde cholangiopancreatography (ERCP). Patients who develop post ERCP pancreatitis (PEP) have a greater degree of rise of these enzymes in the immediate postprocedure period. Rectal diclofenac is used to prevent PEP. This study compared the levels of amylase and lipase after ERCP, in two groups of patients, one that received rectal diclofenac and another that received intramuscular diclofenac. Patient and methods: Prior to May 2015, all patients undergoing ERCP in our unit received intramuscular diclofenac. Since then, all patients have received rectal indomethacin. All patients who did not have previous a sphincterotomy, and received diclofenac (rectal or IM) were included in the study. Serum amylase and lipase were measured 2 h after ERCP in all 68 patients where 16 patients received rectal diclofenac and 22 patients received intramuscular diclofenac. Other data collected included patient demographics, baseline laboratory values, details of the procedure and post procedure clinical parameters. Results: A total of 68 out of 105 patients were evaluated after excluding patients who had previous sphincterotomy. The study was further subdivided into two groups those who received parenteral diclofenac (group 1–22 patients) and those who received rectal diclofenac (group 2–16 patients) and compared the effectiveness in preventing the post ERCP pancreatitis by assessing serum amylase and lipase at 2 h post procedure. In group 1 one of 23 patients developed post ERCP pancreatitis when compared to none of 17 patients in group 2 showed rectal diclofenac is effective in preventing post ERCP pancreatitis. The mean ±SD for serum amylase at 2 h in group 1 was 60.66 and 92.59 in group 2 and for serum lipase at 2 h for group 1 was 62.24 and 149.96 in group 2. The p value was 0.57 which was not statistically significant. Conclusion: Patients who received diclofenac by the intramuscular route had elevation in amylase and lipase comparable to those who received rectal diclofenac.

A81 P-30 A study on ulinastatin in preventing post endoscopic retrograde cholangiopancreatography pancreatitis

R Vinoth Kumar, Balakrishnan Sree Balaji Medical College and Hospital, 7, CLC Works Road, Chromepet, Chennai 600 044, India Background and Aim: The most common complication of endoscopic retrograde cholangiopancreatography (ERCP) is pancreatitis. Ulinastatin, a protease inhibitor is effective in treatment of acute pancreatitis. The aim of the study is to assess the efficacy of ulinastatin for the prevention of post ERCP pancreatitis. Materials and Methods: This study was conducted in Sree Balaji Medical College, Chromepet from June 2014 to June 2015. In this single-center, randomized double-blind placebo-controlled trial, patients undergoing ERCP were randomized to receive ulinastatin 1 lakh or placebo infusions for 10 min before ERCP. Serum amylase were measured before, 4 and 24 h after the procedure. Results: A total of 46 patients were enrolled (23 in ulinastatin and 23 in placebo group). No significant differences found between 2 groups regarding baseline characteristics or endoscopic procedure. The overall incidence of pancreatitis is 10.8 %. The incidence of pancreatitis is significantly lower in ulinastatin group (4.3 %) than placebo group (17.3 %) which is statistically significant (p<0.05). The incidence of hyperamylasemia is lower in ulinastatin group (13 %) than placebo group (30.4 %). There were no severe pancreatitis in both groups. There were no side effects in ulinastatin group. Conclusion: Prophylactic use of ulinastatin reduces the incidence of post ERCP pancreatitis.

P-31 Efficacy of pancreatic endotherapy

Sudhir Gupta, Amol R Samarth, Niraj R Sawalakhe, Dharmesh K Shah, Bhumit R Patel Department of Gastroenterology, Government Medical College and Super Specialty Hospital, Behind Medical College, Hanuman Nagar, Nagpur 440 009, India Introduction: Pancreatic duct leaks can occur as a result of both acute and chronic pancreatitis or in the setting of pancreatic trauma. Pancreatic endotherapy has gained popularity in recent years. Materials and Methods: It was a retrospective analytical study for duration of one year from July 2013 to June 2015. Forty patients who underwent pancreatic endotherapy were analyzed and presented here. Results: Male/female ratio was 3:2. 24 (60 %) patients were alcoholic and 16 (40 %) were nonalcoholic. Clinically 26 (65 %) patients had pancreatic ascites, 12 (30 %) patients had pleural effusion. USG showed ascites in 29 (72.5 %) patients, dilated pancreatic duct in 26 (65 %) and MPD calculi in 13 patients (32.5 %). ERCP showed dilated PD in 28 (70 %) and PD calculus in 13 (32.5 %). All patients with ascites had pancreatic ductal leak. These leaks were seen at 33 (82.5 %) sites; most common site noted was genu 19 (57.57 %), tail 8 (24.24 %) and body 6 (18.18 %). Pancreas divisum was seen in 4 (10 %) for which minor papilla sphincterotomy with stent placement was performed. Communicating pseudocyst was seen in 4 (10 %). Thirty-six our of 40 (90 %) were benefited from the pancreatic endotherapy and 8/40 patients (20 %) required repeat endotherapy. Four out of 40 (10 %) with ascites expired due to complications.

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Conclusion: Pancreatic endotherapy is safe, effective modality of treatment in pancreatic diseases and reduces significant morbidity and mortality.

Indian J Gastroenterol (November 2015) 34(Suppl 1):A1–A104 P-34 Bridging the leak—Pancreatic endotherapy in a tertiary care center

P-32 Spectrum of congenital anomalies of pancreas managed by endotherapy—Three experiences

K Veeraraghavan, R Kini, S Kani, K Prem, T Pugazhendhi, Mohammed Ali Department of Medical Gastroenterology, Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India Aim: The use of ERCP to diagnose/treat various anatomical anomalies of pancreas among patients with recurrent acute pancreatitis (RAP) from 2012 to 2015. Methods: Patients with evidence of RAP were included. Those found to have various anatomic anomalies by imaging (CT/MRCP) underwent ERCP. PD cases underwent minor papillotomy with or without pancreatic duct (PDu) stenting. They were analyzed for mean age, sex, symptoms, various types of anomalies, subtypes, symptom improvement and recurrence of acute pancreatitis. Observations: Four hundred and twenty-five patients had clinical, biochemical and imaging evidence of RAP. Thirty patients had anatomic anomalies of pancreas by imaging. Twenty-one had PD, 4 had APBU, one had DAP, one had AP and one had MMPD. The range of age was 12 to 35 years. Eighteen were females and 09 were males. Most common symptom was pancreatic type of pain. Mean Amylase 187 IU/lit and lipase 294 IU/lit. Mean CT severity index was 6/10. MRCP was done in 29 patients. Thirty patients underwent ERCP except two who were lost to follow-up. Twenty-eight patients underwent pancreatogram except one who had PD but could not do pancreatogram as cannulation was not successful. Twenty patients diagnosed to have PD underwent minor papilla cannulation and pancreatogram. All 20 patients underwent minor papillotomy and PDu stenting was done in 17. Rest diagnosed to have other anomalies of pancreas were referred to undergo surgery. After surgery none of them had recurrence. Conclusion: Twenty patients managed to improve with only ERCP. Interestingly 7 patients had been diagnosed to have very rare cause for RAP. P-33

Thirumoorthi Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India Aim: To determine the efficacy of ERP in management of pancreatic leaks. Methods: Patients with pancreatitis (acute/recurrent acute/acute-onchronic/chronic pancreatitis) with pancreatic ductal leak (communicating pseudocyst/pancreatic ascites/pancreatico-cutaneous fistula/pancreaticopleural fistula/post trauma pancreatic duct leaks) who underwent endotherapy were included in this study. In all these patients pancreatic ductal leak/communication/fistulas has been demonstrated either by imaging or by ERP or by both. Study period from 2011 to 2014. Results: Total of 60 patients who underwent pancreatic endotherapy were included for analysis, out of which 48 were males and 12 were females. Forty patients had communicating pseudocyst-infected, 09 had pancreatic ascites, 06 had both pseudocyst and pancreatic ascites. Five patients developed pancreatic fistulas due to trauma. In 30 patients pancreatic ductal leak has been managed with pancreatic duct stenting. Sixteen patients with infected pseudocyst, who failed transpapillary drainage underwent endoscopic cystogastrostomy. Remaining 14 patients referred for surgical intervention as the endotherapy was not successful. Endotherapy was successful in 73 % of patients in our center. Conclusion: Pancreatic endotherapy was successful in 73 % of our patients. Surgical intervention can be avoided in majority of patients with pancreatic ductal leak. Proper selection of patients is very important. Better imaging modalities made ERP mainly as therapeutic intervention in pancreatic ductal leak. P-35 A case series of endoscopic drainage of pancreatic pseudocyst in a tertiary care center

S Ramakanth, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital and Medical College, Walker Town, MIGH Colony, Padmarao Nagar, Secunderabad 500 003, India

Pancreatic endotherapy—Beyond the scope for surgery

N M Aliem, Kani Shaik, Rathnakar Kini, Prem Kumar, T Pugazhendhi, Mohammed Ali Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India Background: Chronic pancreatitis (CP) is characterized by progressive pancreatic damage that eventually results in significant impairment of exocrine as well as endocrine functions of the gland. Optimal management begins with an accurate diagnosis, identifying the cause, assessing the reversibility of the cause, and then the evaluation followed by treatment of symptoms and complications. Cases: We present here a series of cases of chronic pancreatitis with its complications, which were treated successfully by endotherapy. The complications include intraductal hypertension with pancreatic pain, external pancreatic fistula, pleural effusion, pancreatic ascites, Psoas abscess and multiple pseudocysts. All the patients improved symptomatically and surgery was not needed in any of them. Conclusion: Invasive treatment for abdominal pain due to chronic pancreatitis may be either endoscopic or surgical. Due to its low degree of invasiveness, endotherapy can be offered as a first-line treatment, negating the need for surgery in most of the cases.

Aim: Study of clinical, laboratory profiles and outcomes of patients who underwent endoscopic drainage of pancreatic pseudocysts. Material and Methods: Patients admitted to the gastroenterology department with symptomatic pseudocysts and underwent endoscopic drainage of pseudocysts were included in the study. Their clinical, laboratory profile, outcomes were studied. Procedure: endoscopically cyst wall is punctured with needle-knife sphincterotome and track dilated with a 5.5-Fr dilator and an 8-Fr plastic endoprosthesis placed into cyst cavity (one step procedure). This procedure is followed by ERCP in required patients. Result: Total of 12 patients were included in this study, males-10 (83 %) females-2 (17 %). Mean age-33.75 (28–44 years). Most common etiology of pancreatitis was alcohol related-9 (75 %) and 1 patient had associated HIV infection and on ART since 2 years. Cause not identified in 3 cases (25 %) pseudocyst was a complication of acute pancreatitis in 5 (41 %) and chronic pancreatitis-7 (59 %) clinical presentation. The most common presenting symptom is abdominal pain—12 (100 %), abdominal distension—8 (66 %), jaundice—3 (25 %), fever—3 (25 %), vomiting—4 (33 %), UGI bleed—1 (8 %), dysphagia—1 (8 %). On examination: palpable lump—9 (75 %), ascites—3 (25 %), pleural effusion—2 (16 %). Investigations: Mean serum amylase—687 u/mL pseudocyst: single—6 (50 %), multiple—6 (50 %), most common location—lesser sac—6 (50 %), intra-pancreatic—4 (33 %), perisplenic—2, perihepatic—2,

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mediastinal extension—1. Median diameter of pseudocyst—38 cm procedure: cystogastrostomy was done in 10, cystoduodenostomy 1, transpapillary drainage 1 case. Complication: Hemorrhage in 1 case and underwent laparotomy, stent slippage into cyst in 1 case which was retrieved and subsequently restented. Fever developed in 4 (33 %) improved with antibiotics outcomes: Cyst size decreased in size in 12 (100 %) cases, pain abdomen decreased in 9 (75 %), mean hospital stay post procedure—6 days, no deaths noted. Conclusions: Endoscopic drainage of pancreatic pseudocysts is safe and effective strategy for management of pseudocysts.

P-36 Cystic tumors of pancreas: experience of a tertiary hospital over a period of 10 years

Sunil Pawar, Bharat Saxena, Huzefa Lokhandwala, R Singh, Rajiv Singh, Ravindra Surede, Pravin Rathi Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr. A L Nair Road, Mumbai 400 008, India Background: Cystic lesions of pancreas are accounting for less than 10 % of pancreatic neoplasm. They are increasingly recognized as imaging is frequently sought. Many of these lesions are incidental. The prevalence by CT is around 3 % and by MRI has found prevalence up to 20 %. These lesions can be benign, premalignant and malignant. Aim: The clinical profile of patients with cystic tumors of the pancreas over a 10-year period. Results: There were total 151 patients in database who underwent operation for pancreatic cysts. Most of them (122) were pseudocysts. The true cysts were 29 (19 %) and more than half (18) were diagnosed incidentally. These were diagnosed based on ultrasonography, CT, MRI and endoscopic ultrasound with aspiration. All true cysts were either surgically resected or enucleated. The histopathology showed 6 mucinous cystadenoma, 9 mucinous cystadenocarcinoma, 8 solid pseudopapillary tumors and 6 serous cystadenoma. The pre-operative diagnosis was correct 80 % of cystic lesions. The mucinous cystadenocarcinoma were found more commonly in males with M:Fratio of 7:2. In these lesions tumor markers were elevated and CT suggestive of either irregular wall with local invasion, mural nodule, egg shell calcifications. The mucinous cystadenoma and solid pseudopapillary tumors were seen exclusively in females. The serous cystadenoma were more common in female with ratio 4:1. The average largest size was 5.2 cm and it was seen in mucinous cystadenocarcinoma. All cystic tumors were surgically resected. The enucleation were performed for serous cystadenomas, majority of mucinous cystadenoma (4), solid pseudopapillary tumor (2). The mucinous cystadenocarcinoma were treated with Whipple’s operation (5). For rest of the cystic lesions distal pancreatectomy with splenectomy was done. There was no recurrence on average follow-up of 31 months. Conclusion: Most of the true cystic tumors of pancreas were diagnosed incidentally. The risk factors for malignancy were male gender, large size, high tumor markers and CT features. There was no recurrence on followup of average 31 months.

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Objective: To analyze the diagnostic utility of endoscopic ultrasound (EUS) guided fine needle aspiration cytology (FNAC) of pancreatic lesions. Methods: Retrospective review of all EUS guided FNAC of pancreatic lesions from June 2011 to June 2015. Results: A total 67 EUS guided FNACs were performed for pancreatic lesions during this period. Forty-six patients (69 %) were male with mean age was 55 years and 21/67 (31 %) were females with mean age of 52 years. Abdominal pain was the most common presenting symptom in 87 % of patients. Among all lesions, 23/67 (34 %) were cystic and 44/ 67 (66 %) were solid masses. In patients with pancreatic masses; 36/44 (82 %) patients had received a diagnosis, 3/44 (7 %) were reported to have atypical cells on cytology and required additional diagnostic procedure. Sample was inadequate in 5/44 (11 %) patients for cytology. Of the 36 patients; 29 had malignant lesions [24 (83 %) adenocarcinoma, 3 (11 %) neuroendocrine tumor, 1 (3 %) NHL, 1 (3 %) papillary Ca] and 7 had benign lesions [5(71 %) inflammatory masses, 2 (29 %) had tuberculosis]. None of our patients developed any procedure related complication. Conclusion: EUS-FNA is a useful and safe technique for the diagnosis of pancreatic lesions. It helps to avoid more invasive diagnostic procedures and complex surgeries in doubtful benign lesions. P-38 Efficacy of endoscopic ultrasound elastography in predicting the nature of pancreatic head masses

R Lunkad, A Garg, S Shrivastava, J Singh, S Mazumder, S Khanna, J C Vij, Y Batra Centre for Digestive and Liver Disease, BLK Super Specialty Hospital, 5, Pusa Road, New Delhi 110 005, India Background: Elastography is a novel tool to detect tissue hardness. Elastography data can be represented as a strain ratio, which is ratio of harness of abnormal area to the normal area. Elastographically softer areas are represented in red, yellow or green shades while harder areas are represented as blue. Malignant masses are harder and benign masses are softer. We did a study to evaluate the nature of pancreatic head masses depending elastography strain ratio. Material and Method: We studied 34 consecutive patients who presented with pancreatic head mass on CECT. Demographic, clinical and laboratory data was recorded. Each patient underwent endoscopic ultrasound (EUS), EUS elastography. A strain ratio was calculated. Final diagnosis was made depending upon available evidences. Comparison of elastographic strain ratio between benign and malignant group was made. Observations and Results: We studied 34 consecutive patients. All patients underwent a EUS elastography. The mean strain ratio in the malignant group was 73.43 and in benign group it was 14.36. Statistically significant higher strain ratio was present in malignant group as compared with benign group (p<0.001). At strain ratio value 25.5; EUS predicted malignancy with sensitivity of 91.3 % and specificity of 91 %. Conclusion: EUS-elastography is a highly sensitive and specific noninvasive method for predicting nature of pancreatic head mass lesions.

P-37

P-39

Diagnostic utility of endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic lesions

Results of endoscopic ultrasound fine needle aspiration with a 25-G needle

Nilesh Namdeo Toke, P Ramaswamy, M George, R Thomas, C Panackel, B Sebastian, S K Mathai Department of Gastroenterology and Hepatology, Medical Trust Hospital, M G Road, Kochi 682 016, India

R Lunkad, A Garg, S Srivastava, J Singh, S Mazumder, S Khanna, J C Vij, G Bahuguna, V Malholtra, Y Batra Centre for Digestive and Liver Disease, BLK Super Specialty Hospital, 5, Pusa Road, New Delhi 110 005, India

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Background: Pancreatic head masses have a diverse etiology. Patients with pancreatic head masses presents with abdominal pain, anorexia and obstructive jaundice. Though all pancreatic masses are considered to be malignant, a significant number of patients can have a benign etiology. Therefore a histological diagnosis of a lesion is important before subjecting the patient for definitive management. Material and Method: We studied 46 consecutive patients who presented with a pancreatic head mass on CECT. Demographic, clinical and laboratory data was recorded. All patients underwent endoscopic ultrasound (EUS) FNA and cyst fluid analysis if required. Final diagnosis was made depending upon available evidences. EUS FNA was done was done with Expect (Boston) needle. Observations and Results: Of the 46 patients FNAC could diagnose 42 patients correctly. Sensitivity of FNAC was 91.5 %, specificity was 100 %. In diagnosis of malignancy EUS was 96.4 % sensitive and 100 % specific and having PPV of 96.4 % and NPV was 100 %. Conclusion: EUS-FNA is a highly sensitive and specific method for tissue diagnosis of patients with pancreatic head mass lesions. P-40

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performed using curved linear echoendoscope (Olympus, Japan). A final EUS diagnosis was determined based on correlation of EUS images, CT findings and fine-needle aspiration results if available. Rapid on site evaluation (ROSE) was done by a pathologist. Patients were managed as per prevailing standard of care. Results: Twenty-six patients with cystic pancreatic lesions underwent EUS during the study period, (females-20, 76.9 %), mean age at presentation was 39.42±13.79 years. Fourteen (53.8 %) were symptomatic, commonest symptom being abdominal pain. Most lesions were located in the head body region (head 34.6 %, body 42.3 %). Mean size was 4.32 ±2.15 cm and 58.3 % were multilocular. Serous cystadenoma (34.6 %) followed by mucinous cystic neoplasm (19.2 %) and simple cyst (19.2 %) were the commonest EUS morphological diagnoses, of note two (7.6 %) patients had pancreatic hydatid cysts with cytopathological diagnosis being made on site by direct visualization of hooklets in aspirated cyst fluid. Yield of EUS-FNA was 67 %. Cytological diagnosis was conclusive in 17 patients, commonest being serous cystadenoma. Nine (34.6 %) underwent resection with good histological correlation with EUS diagnosis. There was no mortality in this series during the study period. Conclusion: EUS is a valuable diagnostic modality in the evaluation of cystic pancreatic lesions in a community hospital setting.

Etiology and clinical presentation of pancreatic head masses P-42

R Lunkad, A Garg, S Shrivastava, J Singh, S Mazumder, S Khanna, J C Vij, G Bahuguna V Malholtra, Y Batra Centre for Digestive and Liver Disease, BLK Super Specialty Hospital, 5, Pusa Road, New Delhi 110 005, India Background: Pancreatic head masses have diverse etiologies; data from India is a limited. We did a study to evaluate the etiology of pancreatic head masses. Material and Method: We studied 46 consecutive patients with a pancreatic head mass on CECT. All demographic, clinical and laboratory data was recorded. Each patient underwent endoscopic ultrasound (EUS) FNA and cyst fluid analysis if required. Results: We studied 46 patients. The mean age was 55.5 years. Out of which 33 (71.7 %) were male and 13 (27.3 %) were female. Of the total study patients 30 (65.2 %) patients were having malignant masses and 16 (34.8 %) were having benign masses. Of the 30 cases of malignant masses, 28 (60.86 %) were adenocarcinoma, 1 (2.17 %) each was neuroendocrine tumor and gastrointestinal stromal tumor. Of the 16 cases of benign masses 13 (28.26 %) were chronic pancreatitis, 2 (4.34 %) were tuberculosis, 1 (2.17 %) was a simple cyst. Ten (28 %) of the patients with malignant disease could be taken up for radical surgery. Conclusion: One third of pancreatic head masses can have benign etiologies, a histopathological diagnosis and evaluation with multiple modalities is suggested before subjecting patient to definitive treatment. P-41 Endoscopic ultrasound spectrum of pancreatic cystic lesions other than pseudocysts in the tropical region

Pancreatic tuberculosis

Nikhil Sridhar, Mallikarjun Patil, Renuka Malipatel, Pritilata Rout, Harshad Devarbhavi Departments of Gastroenterology, and Pathology. St. John’s Medical College, Sarjapur Road, Koramangala, Bengaluru 560 034, India Introduction: Pancreatic and peripancreatic tuberculosis is rare. Its clinical presentation and imaging studies often mimics like malignancy. Endoscopic ultrasound guided FNAC is an useful tool in obtaining the tissue to assist the diagnosis. Case Report: We report series of four patients of pancreatic tuberculosis. Out of four patients three were males. Mean age was 48 years. One patient was HIV positive. Two patients presented with fever, jaundice, abdominal pain and weight loss. In other two patients presentation was jaundice and weight loss. Liver function tests revealed cholestatic pattern. Contrast enhanced abdominal CT showed dilated CBD, IHBRD and solid and cystic mass in pancreatic head region measuring from 3 to 4.5 cm. All patients underwent endoscopic ultrasound guided (GF UCT 140 linear scope) FNAC by using 22 G Wilson cook needle. FNAC revealed epithelioid cell granulomas with necrosis and acid fast bacilli. All patients received antitubercular drugs. During the follow-up after completion of therapy, all patients are recovered. Conclusion: Although rare, pancreatic tuberculosis needs to be considered in the differential diagnosis of pancreatic mass lesion in endemic area like India. In the suspected cases endoscopic ultrasound guided FNAC needs to be considered for the tissue acquisition. P-43

Pritul Dishant Saxena, Siddharth Srivastava, A S Puri, B C Sharma, Sanjeev Sachdeva, Ajay Kumar Department of Gastroenterology, G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Aims: Utility of endoscopic ultrasound (EUS) in evaluation of cystic lesions of pancreas is well established but very few reports are from tropical region. We evaluated role of EUS in evaluation of cystic pancreatic lesions excluding pseudocysts. Methods: All patients undergoing EUS for cystic pancreatic neoplasms from 01/09/2013 to 31/03/2015 were reviewed retrospectively. EUS was

Endoscopic ultrasound-guided fine needle aspiration cytology of pancreatic mass lesions—A single-center experience

Nikhil Sridhar, Mallikarjun Patil, Renuka Malipatel, Pritilata Rout, Harshad Devarbhavi Departments of Gastroenterology, and Pathology. St. John’s Medical College, Sarjapur Road, Koramangala, Bengaluru 560 034, India Introduction: The utility of the endoscopic ultrasound (EUS) has become the standard of care for the diagnosis of the pancreatic mass lesion. The present study is an observational study of the patients who underwent

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endoscopic ultrasound guided fine needle aspiration cytology (FNAC) of the suspected pancreatic mass lesion. Material and Methods: EUS was performed by using GF UCT 140 linear Olympus system. After locating the lesion by EUS, FNAC was performed by using 22-G (Wilson cook) needle. Slides were prepared by the Assistant. For the cystic lesions, cyst fluid was aspirated and analyzed for the amylase and CEA along with the cytology. Results: Eighty-six patients underwent endoscopic ultrasound guided FNAC for suspected pancreatic mass lesions over 7 year period (2008– 2015). Out of 86 patients 52 were male. Sixty-four (74.41 %) patients had solid pancreatic mass and the rest 22 (25.58 %) had cystic lesion. Out of 64 patients with solid pancreatic mass lesion FNAC revealed adenocarcinoma in 26 (40.65 %) patients, chronic pancreatitis in 23 (35.93 %) patients, tuberculosis in 4 (6.25 %) patients, well differentiated neuroendocrine tumor in 3 (4.68 %) patients, solid pseudopapillary epithelial neoplasm in one (1.56 %) patient and it was inconclusive in 7 (10.93 %) patients. Out of 22 patients with cystic lesion, FNAC along with the fluid biochemistry revealed mucinous cystadenoma in 7 (31.81 %), serous cystadenoma in 5 (22.72 %) patients, IPMN in 3 (13.63 %) patients, adenocarcinoma in 2 (9.09 %) patients and it was inconclusive in 5 (22.72 %) patients. Conclusion: The diagnostic yield of EUS guided FNAC combined with fluid biochemical analysis was 86.04 %.

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urine for 7 days and reduced urination for 3 days. The patient used to consume alcohol for last ten years but his last drink was 1 month back. The patient was pale, dehydrated, icteric, had tachycardia and normal blood pressure. Asterixis was noted and hepatosplenomegaly was present. Peripheral smear and antigen test were positive for Plasmodium falciparum infection with a parasitic index of 20. Serological tests for hepatitis B virus and HIV were negative. Ultrasound abdomen showed hepatosplenomegaly with fatty changes in the liver. He was given fluids, artesunate, clarithromycin, folic acid and blood transfusion. On fifth day, he developed sudden onset, severe, epigastric pain with breathlessness. Serum amylase and lipase levels were done elevated more than five times. Serum calcium, serum triglycerides and blood sugar levels were within normal limits. Computed tomography scan of abdomen showed peripancreatic edema and fat stranding in tail region. The patient was kept nil by mouth, given oxygen and analgesics. The pain reduced over next 48 h. Conclusion: Malaria can have myriad presentations. Possibility of acute pancreatitis should be considered in patients of malaria with severe abdominal pain.

Pediatric gastroenterology PG-1

P-44 Congenital pancreatic insufficiency: Report of five cases

Nagendra Kumar, Ujjal Poddar, Surender Kumar Yachha, Anshu srivastava Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Introduction: Congenital pancreatic insufficiency is rare and to date only four cases of Shwachman-Diamond syndrome (SDS) from India and 50) droplets/high power field and 72-h fecal fat (done in 3) was 15 % (range, 13 % to 35 %). The median z score for weight was −2.94 (range, −0.8 to −4.1), for height −3.16 (range, −0.36 to −7.5). CT scan in one child showed agenesis of dorsal pancreas and in the remaining 4 generalized fatty replacement of pancreas without dilatation of duct. One child was diagnosed as SDS based on phenotypic features with neutropenia. All were started on enzyme replacement therapy and on a median follow up of 1.5 (range, 1–14) years, showed improvement in clinical features with reduction in stool fat content and improvement in weight. Conclusion: Congenital pancreatic insufficiency is rare but should be considered in children with steatorrhea. CT scan helps in differentiating them from acquired causes of insufficiency. P-45 Plasmodium falciparum malaria with acute pancreatitis—A rare presentation

Mayank Jain, Sandip Ware, Amit Bundiwal, Sandip Kaulavkar, Shohini Sircar Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Introduction: Acute pancreatitis due to malaria is uncommon. There have been a few case reports of similar presentation from other parts of India. The mechanism proposed for pancreatitis in malaria is ischemia of pancreas from microvascular occlusion and acute hemolysis. Case Report: A 32-year-old male patient presented with history of highgrade intermittent fever for 15 days, yellowish discoloration of eyes and

Low bone density and vitamin D deficiency in children with Crohn’s disease: Prevalence in children attending a tertiary care center in south India

S Shiraz, M Geetha, V P Bhanu, Chandrasekhar J Sorake, Mohan Shenoy, V Mathew, Jeffey George, G Rajesh, Rama P Venu, K H Ismail Siyad, Shine Sadasivan, Anoop K Koshy, Archana, V A Narayanan, V Balakrishnan Amrita Institute of Medical Sciences, Ponekkara, Kochi 682 041, India Background: Reduced bone mineral density (BMD) has been reported in 3 % to 77 % of patients with inflammatory bowel disease (IBD). Vitamin D deficiency is also more common in children with Crohn’s disease. The majority of these studies are cross-sectional and from tertiary referral centers outside India. The data regarding reduced BMD and vitamin D deficiency in children with Crohn’s disease in India are sparse. Aim of the study The aim of our study was to estimate the prevalence of low bone density and vitamin D deficiency in children with Crohn’s disease (CD) attending a tertiary care center in south India. Materials and Methods: Children aged between 5 and 18 years with Crohn’s disease attending Amrita Institute of Medical Sciences between January 2015 and June 2015 were investigated. BMD as measured by dual X-ray absorptiometry (DXA) of the spine (L1–L4) and serum vitamin D were measured on the first visit. Those children with Z scores less than −2.0 were considered as having low bone density and those with serum vitamin D value 20 ng/mL were considered as vitamin D deficient. Results: Male children accounted for 64 % (16) of the patients. The mean age of the study population was 14.04±3.458. Mean BMI was 17.36± 3.98. Mean serum vitamin D and Z scores values were 11.812±7.28 and −2.35±0.743 respectively. Sixty-eight percent of the children had low bone density. 58.8 % of children with low bone density used steroids or is currently on corticosteroids as part of their treatment. BMI was low in 68 % of the study population. 82.4 % of children with low bone density were currently on immunosuppressant therapy mostly azathioprine. Similarly vitamin D deficiency was seen in 61.9 % of children with Crohn’s disease on corticosteroids and 76.2 % of children with Crohn’s disease having vitamin D deficiency were on immunosuppressant therapy at some point of their treatment. Conclusion: Majority of children with Crohn’s disease have low bone density and vitamin D deficiency. The problem of low bone density and v i t am i n D i s f u r t h e r c o m p o u n d e d b y c o r t i c o s t er o i d a n d

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immunosuppressant intake as part of Crohn’s disease management. So it is imperative that all children with Crohn’s disease should have an assessment of BMD and serum vitamin D as part of their initial work up and supplement vitamin D and calcium to avoid fractures and maintain bone health. PG-2 Analyzing predisposing factors for necrotizing enterocolitis in term babies

Jenisha Jain, Swati Gupta Department of Pediatrics and Neonatology, Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Objective: To analyse the risk factors associated with necrotizing enterocolitis (NEC) in term babies. Study Design: The study was done from 1 January 2014 to 30 June 2015 at a level III NICU in Choithram Hospital and Research Centre. All data was retrieved from case files in a retrospective manner and details including patient details, antenatal history, type of feed given, surgical intervention required were recorded on a predesigned proforma. All patient with gestation age >34 weeks with diagnosis of NEC were included in the study group. Result: A total of 14 neonates formed the study group. Mean birth weight was 2232 g (1120–3860 g). Mean gestational age was 37.7 weeks (34– 40 weeks). Mean age of onset of illness was 60 h (24–168 h). Mean age at admission was 73.9 h (1–168 h). 57 % (8/14) were admitted for abdominal distension, whereas others developed necrotizing enterocolitis while being treated for other conditions. Six out of 14 (42.8 %) patients were small for gestational age (<3rd centile) with evidence of fetal distress antenatally. Five out of 14 (35.7 %) required surgical intervention. Four were diagnosed with obstructive intestinal lesions, i.e. ileal atresia 2/14 (14.2 %), jejuna atresia 1/14 (7.1 %), midgut volvulus 1/14 (7.1 %). And one had perforation peritonitis. Five (35.7 %) patients were given formula feed whereas 4 (28.5 %) were on exclusive breast feeding and 1 (7.1 %) on mixed feeding. Mean duration of the illness was 8.9 days (3–20 days) and mean duration of hospital stay was 16.8 days (7–45 days). Conclusion: NEC in term neonates is a rare entity and usually associated with predisposing factors. PG-3 Incidence and spectrum of gastrointestinal anomalies in a level III NICU in Indore

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cleft lip and palate (18 %), intestinal obstructive lesions {duodenal atresia (12.5 %), ileal atresia (6.2 %), jejuna atresia (6.2 %), midgut volvulus (6.2 %)}. Five out of 16 (31.25 %) cases were detected antenatally. Twelve cases required immediate intervention in the form of surgery and out of which 9 cases survived and were discharged in healthy condition. Conclusion: Gastrointestinal anomalies comprise quite a significant number of congenital anomalies. Timely diagnosis and intervention will go a long way in reducing the mortality and morbidity due to these anomalies. PG-4 Endoscopic ultrasound-guided drainage of pancreatic fluid collections in children

Zaheer Nabi, Jahangeer Basha, Sundeep Lakhtakia, Mohan Ramchandani, Rajesh Gupta, Rakesh Kalapala, Radhika Chavan, Jaya Agarwal, Nageshwar Reddy Gastroenterology, Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Background and Objective: Endoscopic ultrasound (EUS)-guided drainage of pancreatic fluid collections (PFCs) is well established in adults. There is limited data regarding the safety and efficacy of EUS drainage of PFCs in children. The aim of the present study was to evaluate the efficacy and safety of EUS-guided drainage of PFCs in children. Methods: The study group included children (age <18 years) who underwent EUS-guided drainage of symptomatic PFCs (pseudocysts and walled-off necrosis) at our institution. An endoscopic retrograde cholangiopancreatography (ERCP) was attempted before removing the stents to evaluate the pancreatic duct and bridge any ductal disruption. Results: A total of 42 children (male-35) with mean age 13.7±3.3 years, underwent EUS guided drainage of PFCs. The etiology was blunt abdominal trauma in 6 and idiopathic pancreatitis in rest of the children. The route of drainage was transesophageal in 4, via cardia in 7 and transgastric in rest of the children. Double pigtail stents (7 Fr) were used in 30 children and novel lumen apposing fully covered SEMS (Nagi stent) was used in 12 children. The technical success was 100 %. One patient underwent repeat EUS-guided drainage due to inadequate resolution of PFC on follow up. Four children with pancreatic duct leak on ERCP, underwent pancreatic duct stent placement. Complications included – minor bleed and stent migration in 2 children each. At a median follow up of 16 months (range 4–32 months), all of the children were doing well with no PFC recurrence. Conclusions: EUS-guided drainage of PFC in children is safe and effective in pediatric age group. PG-5

Kiran Nagdeo, Kamna Jain, Jenisha Jain Department of Neonatology and Pediatrics, Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aims and Objectives: This study was conducted to analyze the incidence and spectrum of gastrointestinal anomalies seen among neonates admitted at level III NICU of Choithram Hospital and Research Centre, Indore, in a 1-year study period. Study Design: It is an observational study, done in a one year period (1st June 2013 – 30th June 2014), during which details were noted in a predesigned performa which included antenatal, intranatal and postnatal details of the newborn and mother pair. Intervention done in neonatal intensive care unit and the outcome were recorded. Inclusion Criteria: All infants <28 days of life with major and minor gastrointestinal anomalies being admitted in our NICU during the study period. Result: This study showed that the gastrointestinal anomalies accounted for 1.5 % (16 cases) of the total admissions and included cases of Hirschsprung (12.5 %), tracheoesophageal fistula (18 %), anorectal malformations (18 %),

Autoimmune acute liver failure in children: Is it a grave end of autoimmune liver disease or not?

Vikas Jain, Anshu Srivastava, Surendra Kumar Yachha, Rachna Kathuria, Ujjal Poddar Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Rae Bareli Road, Lucknow 226 014, India Objectives: Acute liver failure (ALF) due to autoimmune liver disease (AILD) is an under diagnosed entity. This study was done to evaluate the clinical profile and outcome of AILD children presenting as ALF and compare it with non-ALF AILD. Methods: Fifty-seven AILD children were evaluated. Diagnosis was based on the simplified scoring system in non-ALF AILD. Autoimmune ALF was diagnosed in the presence of positive autoantibody, raised IgG± histology and exclusion of other etiologies. Results: Fifty-seven AILD children were divided into two groups [14 ALFAILD (Gr-A) and 43 non-ALF AILD (Gr-B)]. The median age at

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presentation [7 vs. 9 y], proportion of girls [64.3 % vs. 62.8 %], type of AILD [Type-1, 50 % vs. 70 %) and presence of ascites [71.4 % vs. 44.2 %] was similar in group A and B respectively. Group A subjects, had significantly higher INR (5.6 vs. 1.6), bilirubin (16.9 vs. 7.3 mg/dL), and leukocyte count (16,200 vs. 5800/mm3). Encephalopathy (100 vs. 16.3 %, p =0.0), and multiacinar necrosis (66.6 % vs. 0 %, p =0.0) on liver biopsy was more common in group A. However, growth failure (7.7 % vs. 35.7 %, p=0.04), hepatomegaly (21 % vs. 70 %, p =0.002), splenomegaly (7 % vs. 74.4 %, p =0.0), and raised serum globulins (3.4 vs. 4.3 g/dL, p=0.006) were less common in the ALF group. Group B patients had higher biochemical remission (56 % vs. 14 %, p=0.007) and lower mortality (7 % vs. 71 %, p=0.0). Conclusion: AILD presenting as ALF is not uncommon in children. The response to immunosuppression and outcome is poorer than the non-ALF AILD. PG-6 Celiac disease and H. pylori infection in children: Is there any association?

Manish Narang, A S Puri, Sanjeev Sachdeva, Ajay Kumar, Jatinderpal Singh, Puja Sakhuja Department of Gastroenterology, G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background and Objective: Helicobacter pylori (Hp) infection can influence the inflammatory and immune responses in small intestine and therefore, the development and evolution of gluten related enteropathy. Our objective was to assess the relationship between celiac disease and Hp infection in children. Methods: Children (1–18 years) with confirmed celiac disease (CD) (n= 324) who underwent upper gastrointestinal endoscopy with submission of gastric and duodenal biopsies were eligible for the study. Non-celiac patients referred for endoscopy were selected as controls. We studied proportion of HP prevalence in children with confirmed CD as compared to HP prevalence in reference group comprising non-celiac children referred for endoscopy. We also evaluated predictors of HP infection in children with celiac disease. Results: Of the 324 participants with CD, gastric HP was seen in 37 (11.4 %) patients. The prevalence of HP in patients without CD (50 %, p<0.001) was significantly higher. Among patients with CD, HP infection was most frequent in patients with Marsh IIIa. In the stepwise regression analysis for risk factors of HP infection in CD patients; presence of gastritis, anemia and absence of scalloping were found to be independent predictors in a multivariate set up. Conclusion: CD and gastric Hp infection have inverse relationship which raises the question whether development of HP infection confers protection against CD.

Methods: A total of 585 children (<18 years) with a diagnosis of PB disorders treated over a 9-year period. Results: The female to male ratio of 1.8:1 and a mean age of 10.2± 5.3 years. All PB diseases were more common in females except CCP. Biliary and pancreatic ascariasis (BPA) was the commonest cause of PB disorders accounting for 57.7 % of our patients followed by gallstones (14 %), oriental cholangiohepatitis (12.1 %), CCP (4.4 %), bile duct stones (3.1 %) and others. BPA presentations included biliary colic, cholangitis, cholecystitis, intractable abdominal pain, pancreatitis, pancreatitis associated with cholangitis and liver abscess. Ultrasonography was highly effective tool for diagnosis of PB disorders. Whereas 85.5 % of BPA responded to conservative treatment, 14.5 % of patients required endoscopic therapy during acute phase which was successful in 85.7 %. Surgery was required in 7 patients. Only 2 patients died. In all 125 children required ERCP for therapeutic reasons. Post-ERCP complications occurred in 9 patients and were minor which were managed conservatively. Surgery was done in 143 patients. Conclusions: PB disorders are a quite common cause of hospital admissions in pediatric age group in the Kashmir valley. BPAwas the commonest cause of HBP disorders which usually responded to conservative measures. ERCP is a safe and useful modality for managing PB disorders. PG-8 Amebic liver abscess in children—A single-center experience

Jenisha Jain, Mayank Jain, Swati Gupta, Hemang Mendpar Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Aim: To study the clinical profile of children presenting with amebic liver abscess at a tertiary referral center in Central India. Methods: Retrospective study of all children admitted with amebic liver abscess over the past three years, i.e., from January 2012 to January 2015. Results: A total of 3205 children were admitted under the Pediatric Services of our hospital during the study period. Ten children had amoebic liver abscess. The mean age was 8.2 years (range 4–14 years) and male to female ratio was 4:1. None of the children had diabetes or was on any immunosuppression. All children presented with fever and right upper abdominal pain. Shoulder pain was noted in 3 patients. Nine children had solitary right lobe abscess and one child had multiple abscesses involving both lobes. Amebic serology was positive in all cases. The complications note were rupture (2), inferior vena caval thrombosis (1) and right sided pleural effusion (3). Pigtail drainage was done in 3/10 patients. All patients were given metronidazole for 14 days and followed up for at least 1 month. All patients recovered completely after treatment. Conclusion: Amebic liver abscess presents with fever and abdominal pain predominantly. Pigtail drainage is required in case of rupture and persistent fever. Outcome is favorable. PG-9

PG-7 Pattern of pancreaticobiliary disorders in children of the Kashmir Valley: A 9-year experience from a superspecialty center

Abid Shoukat, Altaf Shah, Gul Javed, Showkat Ali Zargar Sher-I-Kashmir Institute of Medical Sciences, Soura, Srinagar, Jammu and Kashmir 190 011, India Background and Aims: Pancreaticobiliary (PB) disorders constitute an important cause of hospital admissions in the pediatric age group. Our study describes the magnitude, clinical features, diagnostic and treatment modalities and outcome of PB disorders.

Endoscopic retrograde cholangiopancreaticography in pediatric population: One of largest experience from Asia

Amol S Dahale, A S Puri, B C Sharma, Sanjeev Sachdeva, Siddhartha Srivastav, Ajay Kumar, Pritul D Saxena G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background: The pediatric endoscopic retrograde cholangiopancreaticographies (ERCP) are being performed less commonly. Pediatric ERCP is technically difficult. Very scarce data available from India in Pediatric ERCP. We aimed to audit safety, efficacy and outcome of Pediatric ERCP.

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Methods: We retrospectively analyzed ERCP records from G B Pant Institute of Postgraduate Education and Research (GIPMER) from March 2011 to May 2015. All patients between age group below 15 years whom underwent ERCP were included in study. Results: Total 158 ERCP were done in the study group of which 40 ERCP were repeat procedures. Out of 158, 87 were males (55.5 %) and 71 were females (44.5 %). The indications for ERCP was CBD stone (n=49, 31 %), chronic calcific pancreatitis (n=38, 24.1 %), main pancreatic duct injury (n=19, 12 %), CBD Injury with leak (n=12, 7.6 %), biliary ascariasis (n=7, 4.4 %), choledochal cyst (n=6, 3.8 %), cystolithiasis (n=6, 3.8 %). The success cannulation could be achieved 89.2 % (n=141); while procedural success was 87.3 % (n=138). The complication rate was 5 % (n-8), all of which were managed conservatively and there was no mortality. Conclusion: ERCP is safe and effective procedure to manage host of pancreatobiliary disorders in children. PG-10 Prevalence of gastrointestinal symptoms and celiac disease in children and adolescents with diabetes mellitus

A Srivastava, A Mathias, S Chaturvedi, P Dabadghao, S K Yachha, U Singh Departments of Pediatric Gastroenterology, Endocrinology, and Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Objectives: Patients with diabetes mellitus (DM) are at an increased risk of developing celiac disease (CD) and gastrointestinal symptoms (GIS) even without CD. This study evaluated the prevalence of CD and GIS in children and adolescents with DM. Methods: Subjects with DM were prospectively evaluated with a demographic and gastrointestinal symptom questionnaire, anthropometry and physical examination. Hemogram, serum protein, albumin, total IgA, IgA tTG (anti tissue transglutaminase) was done in all and endoscopic duodenal biopsy in serology positive cases. Results: One hundred and three [52 boys, age 12.3±4.7 years] children with DM were enrolled. IgA tTG was positive in 13.6 % (14/103) and 3.8 % (4/103) had CD [villous atrophy on histology]. Patients with DM and CD were younger (6 ±2.9 vs. 12.6 ± 4.8 years; p = 0.008), had periumbilical abdominal pain (2/4 vs. 6/89; p=0.01) and higher stool frequency of 2–3/day (3/4 vs. 38/89; p=0.004) in comparison to screen negative diabetics. Four subjects were already diagnosed with CD. Twenty-six (25 %) patients with DM had GIS, most common being epigastric pain (8.7 %), periumbilical pain (7.8 %), nausea (6.8 %) and heartburn (5 %). Patients with GIS were older (14.5 vs. 12 y), had longer disease duration (36 vs. 25 mo) and more growth failure (26.9 % vs. 19.4 %) than those without GIS, but it was not significant. The hemoglobin, albumin and HBA1c were similar in patients with and without GIS. Conclusions: 3.8 % children with DM had biopsy proven CD and 14 % had potential CD on screening. Overall, 7.4 % of cases with DM had CD. One fourth of children with DM have gastrointestinal symptoms.

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role in the evaluation of RAP, data of its role in children is sparse. The aim of the study was to assess its role and safety as a diagnostic modality in RAP in pediatric population and its consequences on the management of underlying disease. Methods: This was a single-center (Christian Medical College, Vellore) study. Case records of children (18 years) who underwent EUS between January 2005 to September 2014 for evaluation of RAP was reviewed. Recurrent acute pancreatitis was defined as two or more discrete episodes of acute pancreatitis occurring at least 2 months apart. Results: Seventy-one children underwent EUS in this study period for a provisional diagnosis of recurrent acute pancreatitis. Of them, forty two were males. Mean age of presentation was 15.3 years. Using conventional EUS criteria twenty (28.2 %) children had imaging consistent with a definite diagnosis of chronic pancreatitis, thirty one (43.6 %) had intermediate probability, and twenty (28.2 %) had normal pancreas. In the intermediate probability group, three of them had a repeat EUS within one year and one child progressed to chronic pancreatitis. Adverse event in form of desaturation was noted in one individual. EUS had clinical impact in 21 (29.6 %) children establishing diagnosis and was helpful in further management. Conclusions: EUS is an important diagnostic tool in evaluation of recurrent acute pancreatitis in pediatric population. It is generally safe and well tolerated.

Miscellaneous M-1 Endothelium-dependant brachial artery flow-mediated vasodilatation in diabetes mellitus type IIIc

Nitin Jagtap, Harshal Shah, Rupjyoti Talukdar, Duvvuru Nageshwar Reddy Asian Institute of Gastroenterology, 6-3-661, Somajiguda, Hyderabad 500 082, India Aim and Introduction: Brachia artery flow mediated dilatation is an index of nitric oxide–dependent endothelial function that is impaired in patients with type 1 and 2 diabetes. We studied whether there is endothelial dysfunction in DM type IIIc as compared to normal. Materials and Methods: We analyzed FMD in 31 patients with type IIIc DM and 33 age and sex matched controls along with history of alcohol or smoking. Results: FMD was significantly lower in patients with type IIIc DM as compared to controls (2.74±1.28 vs. 8.31±2.51; p value 0.0001). FMD was significantly lower in patients who were smokers (2.05±0.76 vs. 3.24±1.36; p value 0.0081) and who drink alcohol (1.89±0.68 vs. 3.43 ±1.25; p value 0.0003) in type IIIc DM. Conclusion: Endothelial dysfunction as assessed by FMD was significantly impaired in type IIIc DM compared to controls; also in those who continue to smoke or drink alcohol. M-2

PG-11 Endoscopic ultrasound as a diagnostic modality in pediatric patients with recurrent acute pancreatitis

Abhishek Jain, Ramit Mahajan, Reuben K Thomas, Amit K Dutta, A J Joseph, Sudipta Dhar Chowdhury, Ebby George Simon Department of Gastrointestinal Sciences, Christian Medical College, Vellore 632 004, India Background and Aims: Recurrent acute pancreatitis (RAP) is often encountered in children. While endoscopic ultrasound has an established

Yield of endoscopic ultrasound-guided fine-needle aspiration in the evaluation of mediastinal lymphadenopathy

Santoshkumar Ambulge, Parag, Manmadharao, Satish, Deepika, Sharat Reddy Putta Krishna Institute of Medical Sciences, 1-8-31/1, Minister Road, Krishna Nagar Colony, Begumpet, Secunderabad 500 003, India Background and Aims: Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is an accurate and safe technique to biopsy mediastinal lymph nodes. There is limited data about the safety and efficacy of EUS-

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FNA in the diagnosis of mediastinal lymph nodes of unknown origin, especially from the Indian subcontinent. We aimed to evaluate the yield and safety of EUS FNA in the diagnostic evaluation of mediastinal lymphadenopathy. Methods: Settings: Tertiary care Referral Center. Design: Retrospective analysis of a prospectively collected data from October 2012 to May 2015. EUS-FNA was performed with a linear echoendoscope using a 22- or 25-G needle. Tru-Cut biopsy was performed wherever feasible and sent for histopathology. Results: Sixty-eight consecutive patients with mediastinal lymphadenopathy underwent EUS-FNA. 44 (64.7 %) were men and 26 (38.2 %) women. EUS-FNA yielded tissue diagnosis in 60 (88.2 %) patients and was inconclusive in 8 (11.7 %) patients. Among the sampled lesions, 36 (36/ 68=52.9 %) patients had necrotizing granulomatous lymphadenitis, 14 (20.5 %) had neoplastic lesion (primary lung cancer-9 patients; metastatic cancer-5 patients). Four patients had NHL and 3 patients sarcoidosis. The sensitivity and specificity of EUS-FNA were 95 % and 100 % respectively. None of the patients had serious adverse events. Conclusions: We conclude that EUS FNA is a safe technique, and is a useful tool for guiding clinical management in patients with mediastinal lymphadenopathy of unknown origin. M-3 Natural-based therapies in the prevention and treatment of gastrointestinal disorders

S Selva Kumar, S S Sakthi Gnanavel, P Arul Prakash, A Sakthi Vel, N Dinakaran C R R I, Department of Gastroenterology, Melmaruvathur Adhiparasakthi Institute of Medical Sciences and Research, Melmaruvathur, Tamil Nadu 603 319, India An average life span of Bulgarian peasants was 87 years. One of the major difference in life style in comparison to the contemporary diet was large consumption of natural food and no antibiotics. Autotoxication theory of Metchnikoff 1907 suggested that human body was slowly poisoned by toxins present in the body resistance steadily weakened by proliferation of enteric pathogens, all of which were successfully prevented by consumption of natural based food and therapies. The critical role of many natural based therapies are well recognized. The protective properties of these foods have been documented in a number of disease models includes HIV, Alzheimer’s disease. Natural medicinal products have been user for hundreds of years back to treat a range of ailments and although conventional innovation neutraceutical approaches are more commonly used in modern era of science, there is still renewed interest by general public and to medical research community in natural products. The initial question what constitutes natural therapy? This is far from clear and some examples are therefore discussed. Unicellular organism’s, bacteria and yeast broadly based as probiotics, multicellular origins, essentially un modified products and partially modified natural products. M-4 Percutaneous endoscopic gastrostomy: timing, prophylactic antibiotics and peristomal infections

N Kayal Vizhi, Sagar Patil, Ismail Siyad, Rama P Venu Department of Gastroenterology, Amrita Institute of Medical Sciences, Ponekkara, Kochi 682 041, India Introduction: Percutaneous endoscopic gastrostomy (PEG) is the preferred route of feeding in patients who require long-term enteral nutrition. Peristomal infection is the most common complication following PEG.

Aim: Assess the incidence of peristomal infections (PI) following PEG and to identify risk factors. Methods: Retrospective study of 704 patients with successful PEG at a tertiary referral center (January 2010-May 2015). Medical records were reviewed for the requisite data and follow-up was obtained for a minimum of 1 month and a maximum of 3 years. Statistical analysis was done using SPSS software and significance calculated using Fisher’s exact test. Results: PI occurred in 158 patients (22.4 %). Indications included oropharyngeal malignancies (n=461), neurologic conditions – benign (n= 205) and malignant (n=38). PI were observed within 30 days in 62 % of patients. Diabetes mellitus was a risk factor in 59 % of patients (p= 0.000). Among patients with oropharyngeal malignancies, 52 % of patients with chemotherapy-prior and 23 % of patients with chemotherapypost PEG developed PI (p=0.000). Similarly, PI developed in 45 % of patients with radiotherapy-prior and 24 % of patients with radiotherapypost PEG (p=0.001). Serum albumin, systemic infections, duration of hospital stay and ICU stay did not contribute to the increased incidence of infections. No incidence of necrotizing fasciitis or 30-day mortality was noted. Organisms were Klebsiella (n=72), pseudomonas (n=63), Candida (n=44), MRSA (n=25), Enterococcus (n=18), E. coli (n=15) and Acinetobacter (n=11). Conclusion: PI is a common complication following PEG. Prophylactic antibiotics needs revision considering the increasing incidence of grampositive and fungal infections. Glycemic control should be optimized. Among patients with oropharyngeal malignancies, PEG prior to chemoradiation may decrease PI.

M-5 Palliative self-expanding metal stents in gastrointestinal malignancies: A retrospective analysis

Sabari Nathan, Kani Sheikh, Ratnakar Kini, K Premkumar, T Pugazhendhi, Mohammed Ali Department of Medical Gastroenterology, Madras Medical College and Hospital, E V R Periyar Salai, Park Town, Chennai 600 003, India Introduction: Self-expanding metal stents (SEMS) are self expandable metallic stents either covered or uncovered, is of cylindrical in shape, being devised in numerous lengths and diameters having cross-hatched, braided or interconnecting rows of metal that are assembled into a tube-like structure. SEMS are used to alleviate symptoms caused by cancers that obstruct the luminal structures and are inserted during endoscopy. Aim of the Study: To explore the indications for use and to evaluate the complications with use of SEMS in patients with GI malignancy. Methodology: Retrospective analysis done in 94 patients on palliative SEMS from August 2011 to August 2015 (5 years) for various gastrointestinal malignancies in the Department of Medical Gastroenterology in Madras Medical College and Hospital. Results: Out of 94 patients with SEMS, 63 were males and 31 females with a mean age of 55.43 years. The indications were carcinoma esophagus in 65, biliary cancers in 17 and enteral malignancies in 6. In esophageal SEMS, 28 had TEF, 4 had recurrent growth, the rest 33 had unresectable tumors, 3 had undergone telescopic SEMS for tumor in growth. Among biliary SEMS, 4 had carcinoma head of pancreas with mid CBD stricture, 2 with periampullary growth with distal CBD obstruction, 1 with ampullary growth, 2 with extrinsic compression by lymph nodes, 1 CA GB with mid CBD stricture and 7 with malignant hilar stricture. In enteral SEMS all the 6 had antropyloric growth with GOO. Conclusion: SEMS being the ultimate palliative measure for a malignant stricture or obstruction of the GIT when radiotherapy and surgery failed, thereby improving the quality of life.

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median 1 cm (range 0.5–2 cm). Success rate was 88 %. There were no complications. Median time to start oral diet was 48 h. Conclusion: OTSC is an effective as well as a feasible technique for gastrointestinal luminal defects. It provides surgery-free rapid and definitive therapy.

The profile study of use of self-expanding metal stents in gastrointestinal disorders in coastal Eastern India: A single-center experience

Prakash Chandra Dalai, Kedarnath Panda, Bijay Misra, Brundaban Nahak, Manoranjan Mohapatra, Adya Kinkar Panda Departments of Gastroenterology, Gastroenterosurgery, and Radiology, Institute of Gastro and Kidney Care Bhubaneswar, Odisha 751 015, India

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Background: Endoscopic stenting plays an indispensable role in the management of malignant and benign conditions in all segments of the gastrointestinal tract. In the present study we analyze the profile of patients in whom study of use of self-expanding metal stents (SEMS) were used. Methods: Consecutive patients attending the hospital with inoperable malignancy of the gastrointestinal (GI) tract and for GI leaks and fistulas in whom SEMS placements were done in the last one year included in the study. Result: The total numbers of patient undergone SEMS placement were 57. The mean age was 64.01±13.17, median age of 63 year and M:F ratio of 3:2. Majority cases (91 %) had malignant etiology; only 5 patients had benign etiology. The most common etiology was carcinoma gallbladder with obstructive jaundice (43.85 %) followed by cholangiocarcinoma (10.52 %), carcinoma head of pancreas (10.52 %), esophageal carcinoma (10.52 %), gastric carcinoma with outlet obstruction (7 %), duodenal malignancy (7 %) cases and colonic malignancy in one cases. Cases with benign etiology, fully covered SEMS were placed in refractory biliary stricture in two, prolong post op bile leak in one, corrosive esophageal stricture in one and tracheoesophageal fistula in one case. The median duration of survival was 5 months. Fully covered SEMS were placed second time in seven patients (6 biliary and one malignant GOO), due to tumor in growth after 6 months of initial uncovered SEMS placement. Conclusion: SEMS placement is both a safe and effective technique for inoperable gastrointestinal malignancies, GI leaks, strictures and fistula. Pancreatobiliary malignancies were the most common indication for SEMS placement in our part.

Pritul Dishant Saxena, A S Puri, B C Sharma, S Sachdeva, S Srivastava, A Kumar, A S Dahale, A Dalal, A Sangam Department of Gastroenterology, G B Pant Institute of Post Graduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

M-7 Over-the-scope-clip system for management of upper gastrointestinal defects: A pilot study

Endoscopic removal of foreign bodies from the upper gastrointestinal tract: A single-center experience

Background: Majority of foreign bodies (FBs) get lodged in the upper gastrointestinal tract accidentally. Removal of FBs is a frequent challenge for endoscopists. Aim of this study was to elicit our experience over a 5year period in removal of FBs from the upper gastrointestinal tract. Methods: All patients who underwent attempted endoscopic removal of a foreign body from the upper gastrointestinal tract, from 01/07/2010 to 31/ 06/2015, were analyzed retrospectively. Demographic data, type of FB, its anatomical location of lodgement, accessories used, and outcomes were noted. Results: A total of 184 patients underwent attempted removal of a foreign body from upper gastrointestinal tract during the study period. All endoscopies were performed in conscious sedation with midazolam or anaesthesia with ketamine or propofol as and when required. A foreign body could be visualized within the reach of the endoscope in 151 patients, who were analyzed further (males 70.86 %). Mean age was 11.4 years (range 0.58–79 years). Coins (58.3 %), button batteries (6.6 %), ornaments, food boluses apart from others, were the most frequently encountered FBs. Site of lodgement was stomach in 77 (51 %), esophagus in 64 (42.3 %), and duodenum in 10 (6.6 %). 25 (16.5 %) FBs were observed to be impacted in the underlying mucosa. Successful endoscopic retrieval could be done in 145 patients (96.02 %). Endoscopic accessories used were, rat-toothed forceps (in 56.9 %), alligator forceps (21.8 %), dormia basket (6.6 %), snare (5.2 %) and roth net (5.2 %). There was no procedure related complication or mortality. Conclusion: Endoscopic removal is a safe and effective therapy for FBs lodged in the upper gastrointestinal tract.

Amol S Dahale, Siddharth Srivastav, Pritul D Saxena, B C Sharma, Shivakumar Varakanahalli G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India

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Background and Aim: Over-the-scope-clip system (OTSC) is novel technique developed for closure of luminal gastrointestinal defects. It is simple and efficacious technique. Data on OTSC is lacking as regards safety and efficacy. We aimed to evaluate efficacy and feasibility of OTSC. Methods: We planned to use OTSC clip in consecutive patients presenting with upper gastrointestinal (GI) fistula or iatrogenic perforation less than 2.5 cm in size at G B Pant Institute of Postgraduate Medical Education and Research. Patient followed for at least 2 months. Clinical improvement with documented oral gastrograffin and endoscopic closure was taken as success. Results: Total 7 patients underwent OTSC placement with 9 clips. Median age of patients was 32 years (range 17–75 years). Females were 3, male constituted 4 patients. Six clips used for esophageal defects, 2 for GE junction and 1 for duodenal defect. Etiology of upper GI defects were tubercular esophagotracheal/pleural fistula—2 patients, iatrogenic perforations—3 patients, Boerhaave’s syndrome—1, foreign body induced esophageal perforations—1 patient (2 perforations). Defect size was

Bhuvan Shetty, Ravi Kiran, Avinash Bhat Balekuduru, Satyaprakash Bonthala Subbaraj, Umesh Jalihal Department of Gastroenterology, M S Ramaiah Hospitals, MSRIT Post, New BEL Road, Mathikere, Bangalore 560 054, India

Foreign bodies in gastrointestinal tract: A 5-year experience from a tertiary care hospital from south India

Background and Aim: Foreign bodies (FB) in gastrointestinal system (GIT) pose an emergency challenge to the treating physician. The aim of this study is to analyze the management and outcome of endoscopic FBs at our center. Methods: Records of all the patients with FB ingestion who had undergone endoscopic removal at our institution during the 5 years (2010– 2015) were retrospectively reviewed. Results: Of the 20,216 patients who underwent endoscopy during the five years, 139 (0.7 %) had FB. Most common (MC) FB was coin (43.8 %). In adults, 75 % had denture impaction. MC etiology for FB ingestion was accidental and 7 (0.05 %) were deliberate. MC symptoms were dysphagia (61 %) and throat pain (27.3 %). FBs were extracted mostly under general

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anesthesia (GA). Thirty-three (23.7 %) were adults and the remaining 103 (76.3 %) were children. Foreign bodies included 61 coins, 25 dentures, 13 batteries, 10 food impactions, 5 pins, 4 clips and bangles each, 2 anklets, keys, marbles and seeds, one of spoon, bangle pieces, blade, spanner, peanut, toe ring, nose ring, feeding bottle and a pencil. Esophagus was the MC site of trapping (85/139). There was a feeding bottle in rectum (most weird). FB removal was successful by endoscopy in 97.1 %. Four (0.03 %) cases were referred for surgical removal and no mortalities. Mild esophageal tear in 15 (10.7 %). Conclusions: Endoscopic removal of FBs is a safe procedure with well-equipped endoscopic units and support staff especially under GA. M-10 Upper gastrointestinal foreign body presentation and management in a tertiary care center

A Senthivadivu, B Karthikeyan, P Senthilkumar, B Sivasubramaniyam, M Kannan, B Caroline Selvi, A Aravnid Department of Medical Gastroenterology, Government Mohan Kumaramangalam Medical College, Steel Plant Road, Kollapatty, Salem 636 030, India Aim: To evaluate the presentation and outcome of accidently ingested upper gastrointestinal foreign bodies. Methods: Retrospective analysis of patients with gastrointestinal foreign body from 2014 to 2015, age, sex, type op object, site of object, time op presentation to hospital, associated comorbid illness, endoscopic accessory used, failed rate, negative endoscopy, complication and surgical requirement were analyzed. Observation: Total 25 patients, pediatric (7) 28 %, male 9 (36 %) and female 16 (64 %) predominating. Dentures were the common foreign body encountered 7 (28 %), sharp objects 8 (32 %), metal nail (1) one, seven denture 7 (28 %). Youngest age was one yr old male child. Oldest was 75 years old male. Large objects (1) one button battery removed under GA. Esophagus was the common site. Rat tooth foreign 15 (60 %), snare 4 (16). Endoscopic removal 19 (76 %), negative endoscopy 2 (8 %), ENT area (1) one impacted. No endoscopic complications. Surgical removal 4 (32 %). Conclusion: Most of the gastrointestinal foreign bodies were removed by flexible endoscope by using standard endoscopic accessory with relatively low failure rate and low surgical requirement. M-11 Simethicone (orally disintegrating strips) for the preparation before esophagogastroduodenoscopy—Our center experience

A Anand, G Ramkumar, K Muthukumaran, R Balamurali, T Rajkumar Solomon, A Murali, P Ganesh Department of Digestive Health and Diseases, Government Peripheral Hospital, Kilpauk Medical College, 3rd Avenue, Kilpauk, Chennai 600 040, India Introduction: Esophagogastroduodenoscopy (EGD) is one of the most common diagnostic and therapeutic methods of upper gastrointestinal diseases. One limitation of the method is the presence of air bubbles and foam in stomach and duodenum, which leads to decreased diagnostic accuracy, prolonged endoscopy time, and decreased patient’s tolerance. Currently, except fasting prior to endoscopy, no standard method has been recommended for prior EGD preparation. Simethicone is a detergent, which is a chemical mixture of dimethyl polysiloxane and silica gel and it helps in reduction of foam and air bubbles.

Materials and Methods: Candidates of elective EGD received orally disintegrating strip of simethicone 15–30 min before the EGD. Patients with upper gastrointestinal (UGI) bleed, gastric outlet obstruction, sedation, caustic ingestion, pregnancy, asthma were excluded. Patients were divided into 3 groups—group A (only 6 h fasting prior to EGD—controls); group B (6 h fasting plus 62.5 mg gasofilm); and group C (6 h fasting plus 125 mg gasofilm). Foam/air bubbles were assessed and graded on a 3-point scale—0 no air bubbles, 1 small amount of bubbles without interfering in the evaluation, 2 considerable amount of air bubbles and foam such that it was somehow difficult to evaluate, and 3 mucosal evaluation hardly possible owing to the presence of foam and air bubbles. The amount of foam and air bubbles and duration of endoscopy was recorded. Conclusion: This is the first study evaluating efficacy of orally disintegrating strip of simethicone and comparing two different doses of simethicone. Our study shows that administration of gasofilm prior to EGD reduces the amount of gastric foam and bubbles and provides better visibility for evaluating the mucosa. It also decreases the duration of endoscopy. M-12 Endoscopy on a human cadaver—A training tool

Avinash Bhat Balekuduru, Satyaprakash Bonthala Subbaraj, Umesh Jalihal, Peter Vilmann Department of Gastroenterology and Hepatology, M S Ramaiah Hospitals, Bangalore 560 054, India, and, Gastro Unit, Division of Endoscopy, Copenhagen University Hospital Her Traditional training in endoscopy takes place during the 1–2 years of a 3year fellowship in gastroenterology. However, the increasing need for training has led to the development of small courses dedicated to endoscopy. The use of simulation based training in endoscopy has been increasingly described, simulation has the potential to reduce the harm caused to patients by novices performing procedures, increase efficiency by reducing the time needed to train in the clinical environment and increase the opportunity to repeatedly practice procedures as well as allowing the assessment of performance. Cadavers can also be used to train along with simulators if preserved well as they give the trainee the feel of the normal anatomy and the maneuvers needed for completion of the procedure. Porcine cadavers were used for training as they resemble human anatomy. However use of human cadaver for training endoscopy is deficient. We performed endoscopy on human cadaver along with simulation and incorporated as a training module for first year postgraduate trainees at our center. M-13 Role of GeneXpert in peritoneal tuberculosis

Amol S Dahale, A S Puri, Sanjeev Sachdeva, Ajay Kumar, Pritul D Saxena G B Pant Institute of Postgraduate Medical Education and Research, 1, Jawaharlal Nehru Marg, New Delhi 110002, India Background and Aim: GeneXpert is recommended by WHO in pulmonary tuberculosis not evaluated properly in peritoneal tuberculosis (PTB). There is scarce data regarding its role in ascitic fluid (AF) and no data on peritoneal tissue biopsies. We aimed to evaluate role of GeneXpert in PTB. Methods: We prospectively enrolled patients of PTB. Histopathological proof of TB taken as Gold standard for diagnosis of PTB. GeneXpert done in ascitic fluid as well as peritoneal tissue sample. We compared positivity of GeneXpert with gold standard diagnostic criteria.

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Results: Total 20 patients subjected to AF GeneXpert analysis while 18 patients subjected to peritoneal tissue GeneXpert analysis. AF GeneXpert analysis showed positivity in 3/20 patients (sensitivity 15 %). Comparable AF AFB stain showed positivity in 3/20 patients. Concordance of AF AFB stain and GeneXpert positivity was seen only in 33 % (1 in 3). Tissue analysis showed 10/18 GeneXpert positivity (55 % sensitivity). Comparable tissue AFB positivity was 5/18 (sensitivity 27.27 %). Overall, 2 patients turn out to be rifampicin resistant on GeneXpert analysis (2/20—10 %). Conclusion: GeneXpert sensitivity in AF in patients with PTB is less but it is comparatively more sensitive in peritoneal tissue. In view of limited availability of rapid diagnostic tests GeneXpert can be used in PTB considering potential to detect additional cases and rapid availability of results. M-14 Evaluation of Xpert MTB/RIF assay performance in diagnosis of abdominal tuberculosis and drug resistance in North India

N Suraj Kumar, R Padhan, B Sawan, S Kedia, D Rajan, Pratap Mouli, Mikashmi Kohli, Jigyasa Chaubey, Rohini Sharma, S Datta Gupta, S K Sharma, V Ahuja Departments of Gastroenterology, Internal Medicine, and Pathology, All India Institute Of Medical Science, Ansari Nagar, New Delhi 110 029, India Background: Prospective studies describing the prevalence of MDR and utility of Xpert MTB/RIF assay in diagnosing abdominal TB are lacking. Methods: We conducted a prospective cohort study, which included 108 patients: 46 abdominal TB and two disease control groups: 43 CD and 19 IBS patients. Colonoscopy was done before starting any disease specific therapy and mucosal biopsies were taken and subjected to histopathology, AFB staining, L-J culture and Xpert MTB/RIF assay. Patients were followed up for 6 months to confirm the diagnosis and response to therapy. Composite reference standard (CRS) was used as a reference standard for diagnosis. Results: Out of 46 abdominal (intestinal and peritoneal) TB patients, Xpert MTB/RIF was positive in 8.7 %, and MDR-TB was detected in 2.7 %. In intestinal TB patients, Xpert MTB/RIF was positive in 8.1 %, but none had rifampicin resistance. In peritoneal TB, 11.1 % had both Xpert MTB/RIF positivity and rifampicin resistance. Xpert MTB/RIF was negative in all patients in both the disease control groups. Of 18 patients who were given ATT trial before eventual diagnosis as CD, Xpert MTB/RIF at end of therapy was negative in all. The sensitivity, specificity, PPV and NPVof Xpert MTB/RIF assay was 8.1 %, 100 %,100 % and 64.2 % respectively with a negative likelihood ratio of 0.91. Conclusion: Xpert MTB/RIF assay has low sensitivity and high specificity for diagnosing abdominal TB. Prevalence of MDR-TB in abdominal tuberculosis is low and our study suggests that in the event of nonresponse to ATT, likelihood of CD is much higher than MDR-TB. M-15 Evaluation of response to antituberculosis treatment in patients with abdominal tuberculosis at 6 and 9 months

A Garg, R Lunkad, S Mazumder, S Khanna, Y Batra, J C Vij Center for Digestive and Liver Disease, BLK Superspecialty Hospital, 5, Pusa Road, New Delhi 110 005, India

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(6 months) of antituberculosis treatment (ATT) in abdominal tuberculosis patients. Materials and Methods: In a prospective study, 53 patients (29 male and 24 female, mean age 35.6±13.3 years) were included. All patients were given standard ATT (HRZE×2 months followed by HR×4 months). The response was assessed by using endoscopic, radiology and histopathological criteria. The patients showing inadequate response were given HR for another 3 months. Results: In 53 prospective patients, 18 (34 %) had intestinal, 8 (15.1 %) each had nodal and ascetic variety. Nineteen 19 (35.8 %) had multiple gastrointestinal (GI) sites involved. After 6 months, 45 (90 %) patients showed resolution. Five (10 %) patients (4 with multiple sites and 1 with nodal variety) showed inadequate response. Most rapid improvement was observed in ascetic variety. Three patients (5.5 %) with intestinal tuberculosis underwent surgery (treatment failures). Using Fisher’s exact test and Mann-Whitney U test, presence of GI lymph nodes, presence of strictures, diabetes, BMI<19.5 kg/m2 and alcoholism were associated with prolongation of therapy. Conclusion: Most of the patients with abdominal tuberculosis can be treated with short course anti tuberculosis treatment for 6 months. Patients with GI lymph nodes, strictures, diabetes, low BMI<19.5 kg/m2 and alcoholism may require prolong treatment. M-16 An observational study of prevalence of ABO blood groups in cancers of the gastrointestinal tract in a tertiary care hospital

R Shanthi, K Muthukumaran, G Ramkumar, R Balamuarali, T Rajkumar Solomon, P Ganesh Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim of the study: To find out the association of ABO blood groups in different types of gastrointestinal tract (GIT) malignancies: viz; esophageal: gastric and colonic so as to assess the utility of ABO blood groups as a preclinical marker in patients with definite predisposing factors. Design of the Study: Study period—b/w August 2012 and July 2015. Total no of GIT cancer patients were 718. About 178 patients with ca esophagus: 316 patients with ca stomach and 224 patients with ca colon were enrolled. The age/sex/predisposing factors/diagnostic endoscopy/histopathological types and ABO grouping were entered with all enrolled patients. Results: In esophageal cancer group: out of the 178 patients, 108 (61 %) belonged to blood group B: 39 (22 %+ve): 28 (16 % AB+ve) and 5 (3 % O+ve) gp. In gastric cancer group: out of 316 patients about 66 % of patients blood group was A+ve in both the sexes. The remaining were found to be (21 % B+ve): ((11 % AB+ve): (1 % A-ve) (1 % O+ve). In colonic cancer group: out of 224 patients about 32 % (72 patients) belonged to AB+ve: 24 % (54 patients) to A+ve; 23 % (51 patients) to O+ve; 20 % (45 patients) to B+ve and 1 % (2 patients). Conclusions: Blood group B was found to be more common with esophageal ca; bl. Group A was more among gastric ca patients followed by blood group B and in ca colon, the ABO blood group system was randomly distributed. The increased risk in Bl.gp A has been explained by the expression of Forssman antigen in these cancers which is structurally similar to the blood group antigen A. M-17 Retrospective analysis of kidney transplant recipients with diarrhea

Background: Abdominal tuberculosis is one of common form of extra pulmonary tuberculosis, which is primarily of three types-intestinal, peritoneal and lymph nodal. Except bone and meningeal tuberculosis, most guidelines recommend 6 months of treatment for extrapulmonary tuberculosis. We conducted study to determine the efficacy of short course

Vatsal Mehta, Anand Joshi, Philip Abraham, Devendra Desai, Tarun Gupta, Jatin Kothari, Alan Almeida, R Sirsath P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India

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Background: Organ transplant recipients frequently develop diarrhea on immune suppressant therapy. Aim: To determine the frequency and cause of diarrhea in a cohort of kidney transplant recipients. Methods: Retrospective analysis of data of 85 kidney transplant recipients following up in our hospital from 1999 to 2015. Sixteen (18.8 %) of them developed diarrhea (defined as stool frequency >3/day for more than one day). Results: Major causes of diarrhea included parasitic infection (25 %), antibiotic and other non-immunosuppressive drug-related (12 %) and immunosuppressive drug-related diarrhea (12 %). Sixty-three of diarrhea episodes were self-limiting. Thirty-three percent of patients required dose adjustment of immunosuppressant. Diarrhea-related graft dysfunction was noted in 85 % of patients; all of these were reversible. Conclusion: Diarrhea causes significant morbidity and graft dysfunction in kidney transplant recipients. This is potentially reversible if the cause is identified and treated, but a third of patients may require immunosuppressive drug dose adjustment. Noninfective causes like drug-induced diarrhea should also be considered before empiric antibiotic treatment. M-18 Types and patterns of gastrointestinal polyps encountered at the Medical Gastroenterology Department, Rajiv Gandhi Government General Hospital, Chennai

M Manoj, Mohammed Ali, Pugazhendhi Madras Medical College, E V R Periyar Salai, Park Town, Chennai 600 003, India Aim: To identify the prevalence, types, and patterns of gastrointestinal (GI) polyps in a cohort of patients presenting to a tertiary care referral center-Rajiv Gandhi Government General Hospital, Chennai. Methods: Endoscopy and pathology reports of a single unit from 2014 May to 2015 July were analyzed retrospectively. Results: There were a total of 163 patients (M:F, 102–61) who had polyps encountered on colonoscopy, flexible sigmoidoscopy and esophagogastroduodenoscopy. Mean age was 56.5 years and the incidence of polyps increased with age. The majority had a single polyp. Most were seen in the stomach followed by rectum. A total of 22 patients underwent polypectomy. The histopathology of the polyps were assessed, studied and compared. Discussion and Conclusion: The incidence of GI polyps was studied and correlated with their pathology. More polyps were identified in males. Stomach was the commonest site followed closely by rectum in our study. There was no statistically significant association between age, gender, or multiplicity and malignant change in the polyps. M-19 Progressive muscle relaxation: An adjuvant therapy for managing fatigue and depression among hospitalized gastrointestinal cancer patients

Pragya Pathak, Rajender Mahal, Adarsh Kohli, Vinod Nimbran College of Nursing, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, Oswal Cancer Hospital and College of Nursing, Ludhiana, India, Department of Psychiatry, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India and, Grecian Super Specialty Hospital, Sector 69, Sahibzada Ajit Singh Nagar, Ajitgarh, Punjab 160 062, India Background and Objective: Patients with gastrointestinal (GI) cancers face a number of physiological and psychological problems,

among those fatigue and depression are the most common problems. To manage problems of cancer patients, studies now a days are even focusing on use of non-pharmacological/noninvasive adjuvant therapies as exercises, imagery, etc. Progressive muscle relaxation (PMR) exercises can be easily performed by fatigued, depressed and even nonambulatory patients. But studies on effect of PMR exercises on fatigue and depression among admitted patients are scarce. The present study aimed to evaluate the effectiveness of PMR on fatigue and depression among hospitalized GI cancer patients receiving radiotherapy. Methods: The study design was quasi-experimental Pre-test Posttest control group design. Total 80 GI cancer patients, 40 in each, PMR and control groups were included. Subjects in PMR group received four PMR exercise sessions within 4 weeks with daily practice while subjects in control group received treatment as usual with no added intervention. Their fatigue levels were assessed by cancer fatigue scale (CFS) and depression by Beck depression inventory (BDI). Results: Age and gender found to be comparable in PMR and control groups. Pre to post comparison of CFS scores (34.80±9.62 vs. 27.9± 8.74) showed significant reduction (p<0.05) in PMR group. Pre to post BDI scores (31.76±8.65 vs. 22.88±9.58) also found to be significantly reduced (p<0.05) in PMR group. However, there was no reduction in CFS and BDI scores in control group. Conclusion: PMR is effective in reducing fatigue and depression among hospitalized cancer patients receiving radiotherapy.

M-20 Gastrointestinal-liver mobile application to manage gastrointestinal and liver emergencies

U Dutta, A R Sharma, K P Srikant, A Duseja, A Aggarwal, R Dhakal Department of Gastroenterology and Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Several recent evidence-based guidelines exists for managing emergencies. But they are not easily accessible in a readable format for a busy clinician while managing emergencies. Translating them into a customized and accessible format will facilitate bringing knowledge into practice. Aim: To construct a mobile application accessible on smart phones for providing principles of diagnosis, assessment and management of common gastrointestinal (GI) and liver emergencies. Methods: Recent standard guidelines for common GI and liver emergencies from various sources were evaluated and translated into a practical format. Design and development of the app was created in close collaborations with Esperanza innovations through an iterative process using latest mobile technologies (Core Java, Javascript, HTML5/CSS3) and customized mobile frameworks. Standard scoring systems and key references are provided. The content was reviewed and approved by national experts. Results: Mobile app of 8.8 Mb size was designed for Android/i-phone platforms and launched on the PGIMER website (pgimer.edu.in). It offers evidenced-based management principles for 15 common GI and liver emergencies in an actionable format and is freely downloadable. The interface is user-friendly, intuitive, color-coded with a high degree of clarity. Validation study done among resident doctors (n=42), found that it enhanced their mean performance scores from 57 to 71 (p<0.001). Over 1000 physicians in India have downloaded it for their clinical use. Conclusions: It is feasible to provide evidence-based guidelines using a mobile app platform. It is a validated tool to enhance effectiveness and quality of patient care in emergency situations.

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P Padmanabhan, J Subadra Devi, C Rahul, J Goutham Kumar K G Hospital and R V S College of Pharmacy, Coimbatore, India

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performed on tissue obtained with snare biopsy or EMR. Diagnosis of tuberculosis was established in 11 out of 12 patients (91.6 %). EMR was not associated with any complication in any of the patients. Conclusion: EMR/snare biopsy is a useful and safe tool for definitive diagnosis of GI tuberculosis, where pinch biopsy is inconclusive. M-23

Background: Gastroesophageal reflux disease (GERD), dyspepsia and constipation are common disorders in gastrointestinal (GI) practice. These illness were underestimated and overlooked since they are benign. But these symptoms are chronic, disabling the Quality of Life (QOL) of the sufferers resulting in absence from work, loss of productivity and burden for the sufferer and the society. Aims: (1) To study the profile of patients with GERD, dyspepsia and constipation. (2) Objective assessment of QOL in those patients. Methodology: It was a cross sectional study. The patients were evaluated clinically, biochemically, radiologically and endoscopically. Rome III criteria and appropriate QOL, anxiety-depression study questionnaire were administered. Results: Sixty patients were included; 31 had dyspepsia group-A; 20 had GERD group-B; 9 had constipation group-C. male: female ratio was 15:16, 3:7, 4:5 respectively. There were considerable overlap of symptoms among groups. QOL was unaffected in 29 % in group A, 25 % in group B, and 33.3 % in group C; mildly affected in 64.5 %, 60 %, 44.4 %, severely affected in 6.4 %, 15 % and 22.2 % in respective groups. Possible psychiatric illness was noted in 61.2 %, 35 % and 55.5 % respectively; borderline psychiatric illness in 6.4 %, 30 %, 11.1 % and no psychiatric illness in 32.5 %, 35 % and 33.3 % in respective groups. Females were found to have psychiatric illness significantly. There was no association with other variables. Conclusion: The QOL is mildly affected in all groups; worst in constipation followed by GERD and dyspepsia. The high percentage of possible psychiatric illness is alarming; early and effective management including psychiatric aspects is necessary to avoid a public health problem from emerging.

Endoscopic ultrasound-guided fine-needle aspiration in undiagnosed mediastinal mass: experience from Central India

Arvind Namdeo, C C Chaubal, Sanjay Kumar, Lalit Nihal, Neetu Kumar, Sandesh Sharma, P K Pandey National Hospital, Bhopal, Gastrocare, Bhopal, Narayana Hospital, Raipur, Shivalaya GI Centre, Bhopal, India Background and Aim: Mediastinum is a site of neoplastic and nonneoplastic lesions, many of which present as mediastinal mass. Several studies have reported the performance of endoscopic ultrasound fineneedle aspiration for the diagnosis of mediastinal mass or lymphadenopathy. Herein we report our initial experience with this technique. Patients and Methods: In this retrospective study, we report the outcome of patients who underwent EUS FNA for cytology from January 2015 to June 2015. Details of the lymph nodes or mass sampled, number of passes, results of the cytological examination, and the final diagnosis of all the patients are presented. Results: Eighteen patients underwent EUS FNA. FNAC was done under conscious sedation. FNAC was done with 22-G needle. Patients aged from 22 to 71 years. Eight patients were male, 10 female. 11/18 cases were benign and 7 were malignant. Mycobacteria tuberculosis is most common cause of mediastinal lymphadenopathy. Cheesy aspirate on FNA is initial onsite clue. Among the malignant metastatic tumor was more common including small cell carcinoma, NET, lymphoma. EUS FNA yield of tissue was 100 %. Conclusions: Benign mediastinal lesions are more common than malignant lesions with tuberculosis being the most commonly diagnosed mediastinal disease on EUS FNAC.

M-22 M-24 Utility of endoscopic mucosal resection/snare biopsy in definitive diagnosis of gastrointestinal tuberculosis

A Soni, A S Puri, S Sachdeva, A Kumar, P Sakhuja, J P Singh Department of Gastroenterology, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Background/Aims: Various studies from India and elsewhere suggest that yield of endoscopic biopsy in identifying caseating or noncaseating granuloma ranges between 8.6 % and 80 %. We hypothesized that the endoscopic yield could be increased by doing endoscopic mucosal resection (EMR) or snare biopsy in suspected cases of gastrointestinal (GI) tuberculosis who had an inconclusive endoscopic pinch biopsy. Methods: A hospital based retrospective observational study was performed from 2011 to 2015. All the suspected cases of GI tuberculosis who had an inconclusive endoscopic pinch biopsy and who further underwent EMR/snare biopsy were included in the study. The diagnosis of tuberculosis was considered if the EMR specimen showed features of well formed granuloma with or without demonstration of caseation or acid fast bacilli (AFB). Results: A total of 12 patients (7 males and 5 females) were identified. The median age was 29 years (range 14–45). Ten patients had gastroduodenal involvement while the remaining two had colonic lesions. Granulomatous inflammation was documented in 9 patients (75 %) by EMR. AFB was demonstrated in two cases only. Out of 3 remaining patients with nonspecific histology, 2 had AFB positive in polymerase chain reaction (PCR)

Percutaneous endoscopic gastrostomy: 5-year experience at a tertiary care center in India

Alok Kumar Mantri, K Arivarasan, Alok Sangam, Ajay Kumar, Siddharth Srivastava, Sanjeev Sachdeva, Amarender Singh Puri Gastroenterology Department, G B Pant Hospital, 1, Jawaharlal Nehru Marg, New Delhi 110 002, India Objective: To review the experience of percutaneous endoscopic gastrostomy (PEG) tube placement at a tertiary care center in India. Methods: All patients who underwent percutaneous endoscopic gastrostomy from July 2010 to July 2015 at Gastroenterology Department, G B Pant Hospital, New Delhi were included in this study. The indications, complications and follow-up were noted from endoscopy database. The PEG insertion was done by standard pull technique in all of the cases. Results: Total of 112 persons underwent PEG, in 111/112 (99.1 %) PEG could be placed successfully. The indications of PEG were cerebrovascular accident (n=73, 65.2 %), brain tumor (n=15, 13.4 %) head injury (n=10, 9 %), motor neuron disease (n=6, 5.4 %), Parkinson’s disease (n= 5, 4.5 %) and dementia (n=3, 2.7 %) respectively. The 10 (8.9 %) complications were noted, 5 patients had mild bleeding from PEG site and 10 patients had infection at PEG insertion site. All complications were managed conservatively and there was no procedure related mortality. Median follow up was 45 days and tube dislodgement was seen in 15 (13.4 %)

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patients. The PEG tube dislodgement was treated with removal and reinsertion of PEG. Conclusion: Percutaneous endoscopic gastrostomy is effective method of providing the enteral nutrition in patients with host of neurological disorders. M-25 Optimization of erythrocyte thiopurine metabolite estimation

Suruchi Parkar, A J Dherai, Prasad Naik, Rohan Lokhande, Devendra Desai, T F Ashavaid Departments of Biochemistry, and Gastroenterology, P D Hinduja Hospital and Medical Research Centre, Veer Savarkar Marg, Mahim, Mumbai 400 016, India Background and Objective: Thiopurines are widely used in treatment of inflammatory bowel disease (IBD). Efficacy of this treatment is based on production of thiopurine metabolites 6-methyl mercaptopurine (6 MMP) and 6-thioguanine nucleotides (6 TGN). Elevated levels of these metabolites cause hepatoxicity and myelotoxicity. Thus, monitoring of these metabolites helps in optimizing thiopurine therapy. Aim: To optimize the estimation of 6 MMP and TGN from the RBCs using HPLC based assay coupled with UV detector. Methods: Calibrators and controls were prepared by spiking pooled RBCs with commercially available 6 MMP and 6 TG [1] The serial dilutions for concentration range 62.5–625 pmol/8×108 cells for 6TG and 625– 6250 pmol/8×108 cells for 6MMP were prepared and analyzed using HPLC. The separation was performed using a reverse phase C18 column with a gradient of 20 mmol KH2PO4 in 3 % acetonitrile and 100 % acetonitrile. Estimation was done at 343 nm for TG and 303 nm for 6 MMP [1]. Results: The retention time for 6 TG and 6 MMP was 2 and 4.5 min respectively. The calibration curves at different concentrations showed a regression of 0.99 for both TG and 6 MMP. The recovery experiments showed a variation of 80 % to 120 % at different concentrations. Conclusion: Results suggest that the method is optimized for estimating thiopurine metabolites and can be further used for monitoring IBD patients on thiopurine therapy. References: 1. Jharap B, de Boer N, Vos R, et al. Biotransformation of 6thioguanine in inflammatory bowel disease patients: a comparison of oral and intravenous administration of 6-thioguanine. Br J Pharmacol. 2011;163:722–31. M-26 Gastrointestinal bleeding due to visceral artery pseudoaneurysms: an LTMMC experience

Dattatray Solanke, Nirav Pipaliya, Ruchir Patel, Nilesh Pandav, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Aims and Objectives: Gastrointestinal visceral artery pseudoaneurysms are rare. This study was carried out in a tertiary health care center in Mumbai to study the patients with gastrointestinal (GI) visceral artery pseudoaneurysms presenting as (GI) bleed. Methods: The patients presenting with GI bleed due to visceral artery pseudoaneurysms were studied in this prospective study. Patients’ demographic data, symptoms at presentation, risk factors, comorbid conditions, laboratory investigations, imaging characteristics were studied. The patients underwent interventions either radiological or surgical. All patients were followed up for 3 months.

Results: Twenty-one patients had GI visceral artery pseudoaneurysms. Nine patients presented with hematemesis, fifteen patients presented with melena. Four patients had blood coming out from papilla on side viewing endoscopy. Causes of aneurysm included chronic pancreatitis (12 patients), trauma (2 patients), GI surgery (2 patients), iatrogenic cause (1 patient) and unknown cause (4 patients). Aneurysm diameter ranged from 0.3 to 4 cm (mean, 1.8 cm). Splenectomy and distal pancreatectomy were performed in 2 patients, endovascular transcatheter embolization in 18 patients. One patient with a ruptured pseudoaneurysm died before any intervention could be performed; there were no postoperative deaths. The sites identified were splenic artery (8 patients), gastroduodenal artery (6 patients), hepatic artery (3 patients), gastroepiploic artery (1 patient) and inferior phrenic artery (1 patient). Conclusions: Visceral artery pseudoaneurysm usually is a complication of pancreatitis or trauma. Repair of all GI pseudoaneurysms especially splenic and gastroduodenal artery pseudoaneurysms is recommended as the size of pseudoaneurysm does not correlate with bleeding episode. M-27 Results of endoscopic resection of subepithelial tumors: A single-center study

A Bapay, N A Dubale, K Sheth, J A Bapaye, R Jajoo, M Mahadik, Vyas Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Near Mhatre Bridge, Erandawne, Pune 411 004, India Background and Aims: En bloc resection of subepithelial tumors (SETs), i.e. tumors arising from the sub mucosa or muscularis propria is desirable. Endoscopic techniques used for these lesions include endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFTR) or submucosal tunneling endoscopic resection (STER). We present our experience of endoscopic treatment of SETs. Methods and Materials: Data of all consecutive patients undergoing endoscopic resection of SET from 2012 to 2014 was analyzed. SET was assessed by pre-procedure screening esophagogastroduodenoscopy (EGD) and radial endoscopic ultrasound (EUS). Either ESD or EFTR/ STER was performed as per layer of origin of SET. Location, origin, procedure performed, technical success, complications and their management and final histopathology with margin positivity was recorded. Results: Twenty-nine consecutive patients with SETs were analyzed. Mean age 56 years (range 29–78). ESD was performed in 23 patients, EFTR in 4 and STER in 2. SETs were located in stomach (14), colon (6), duodenum (5), esophagus (3) and rectum (1). Mean area of SETs was 14.11 cm2 (range 1–110). Histology was NET (9), lipoma (7), GIST (6), leiomyoma (5), ectopic pancreatic rest (1) and duplication cyst (1). Technical success was 100 %. Three complications: perforations—2 and bleeding—1 patient; all treated endoscopically. Histopathology of all specimens showed en bloc excision with negative tumor margins. Conclusions: Endoscopic en bloc resection using ESD, EFTR or STER is a safe and effective therapy for SETs. Pre-procedure EUS allows selection of appropriate excision procedure. M-28 A randomized control trial of antidepressants and anxiolytics in functional bowel disease

K Desai, M J Chooracken, P G Mathew, R J Mukkada, J V Francis Departments of Gastroenterology, Lakeshore Hospital and Research Centre, Kochi 682 304, India

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Aim: To assess the response to antidepressant and anxiolytics in functional bowel disease (FBD). Material and Methods: Prospective single blind placebo controlled randomized trial was conducted in patients with FBD presenting to the Department of Gastroenterology at Lakeshore Hospital over a period of 12 months. Patients were diagnosed as FBD as per ROME III criteria. They were randomized into three arms A (amitriptyline), B (flupenthixol +melitracen) and C (placebo). After 3 weeks, if no response was seen in arm A or B, either clonazepam or chlordiazepoxide+clidinium were added. If there was no response in the placebo group at the third week, re-randomization was done to one of arms-A or B. They were re-assessed at week 6 and week 12. If no response was noted at week 6 in arm A/B, sertraline was added. The final assessment was done, at end of the 12 weeks. All patients were given loperamide, simethicone and ispagulla as required for symptomatic relief. Primary end point was IBS-AR (adequate response) and secondary end point was IBS-SSS (severity scoring system). Results: At interim analysis, n=55. Arm A=26, B=17 and C=19 during first randomization and re-randomization from Arm C (placebo). At 3 weeks, IBS-AR was achieved in 13 (50 %), 7 (41 %), 7 (36 %) response in Arm A, B and C respectively. At 12 weeks, IBS-AR showed 13 (50 %), 12 (70 %) and 5 (26 %) response in Arm A, B and C respectively. IBS-AR is not statistically significant at end of 3 or 12 week (P-0.2). Drug arms (A, B) showed higher response rate than placebo at end of 12 weeks. IBS-SSS at the end of 12 weeks showed response in 18 (69 %), 13 (76 %), 5 (26 %) patients in Arm A, B and C respectively (p=0.13). In Arm A, 18 (70 %) had severe/moderate (IBS-SSS >150) disease at 0 week and 5 (19 %) had severe/moderate at 12 weeks. Mild/ relief (IBS-SSS <150) was seen in 17 (65 %) at 12 weeks. In Arm B, 11 (64 %) had severe/moderate (IBS-SSS >150) disease at 0 week and 3 (17 %) had severe/moderate at 12 weeks. Arm B showed mild/relief (IBS-SSS <150) 11 (64 %) at 12 weeks. In Arm C severe/moderate (IBS-SSS >150) disease was in 6 (31 %) at 0 week while mild/relief (IBS-SSS <150) at 12 weeks was in 4 (21 %). However, none of them were statistically significant. The estimated sample size at currently observed response rates is 220. Conclusion: Response rate for drugs compare to placebo was not significant due to small sample size.

M-29 Lactose intolerance, calcium, vitamin D and parathyroid hormone levels in type 2 diabetic patients

Satya Vati Rana, Aastha Malik, Sanjay Bhadada, Naresh Sachdeva, Rajesh Kumar Morya, Gaurav Sharma Departments of Gastroenterology, and Endocrinology, Post Graduate Institute of Medical Research and Education, Chandigarh 160 012, India Type 2 diabetes mellitus is chronic metabolic disorder. Common gastrointestinal symptoms in type 2 diabetic patients are nausea, vomiting, flatulence, constipation and/or diarrhea. Reason for these symptoms may be lactose intolerance. Lactose is rich source of calcium. Vitamin D, calcium and parathyroid hormone further regulate bone mineralization in our body. Therefore, present study was planned to measure lactose Intolerance and levels of vitamin D, calcium and parathyroid hormone in type 2 diabetic patients. One hundred and fifty diabetic patients with age range 24–72 years and 150 age and sex matched healthy controls attending Endocrinology Clinic in PGI, Chandigarh were enrolled. Lactose intolerance was measured using non-invasive lactose breath test. 25hydroxyvitamin D3 and parathyroid hormone were measured in plasma using immunoassay. Plasma calcium was measured using auto analyzer.

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T score was recorded from DEXA scan for bone mineral density measurement. Out of 150 patients, 46.6 % were males and in control group 50.6 % males. Lactose intolerance was observed in 89/150 (59.3 %) diabetic patients and 63/150 (42 %) in controls. Levels of plasma vitamin D3, calcium and parathyroid hormone were significantly less as compared to controls. Furthermore, levels of vitamin D3, calcium and parathyroid hormone were more decreased in lactose intolerant diabetic patients than lactose tolerant patients. Sixty-seven percent of diabetic patients suffered from osteoporosis and 20 % of controls. Eighty percent diabetic patients and 16 % controls suffered from lactose intolerance. Thus, it shows that osteoporosis in diabetic patients was significantly higher as compared to controls. Hence, from this study we can conclude that measurement of lactose intolerance using non-invasive lactose breath test is suggested for type 2 diabetic patients along with timely measurement of vitamin D, calcium and parathyroid hormone levels.

Case Reports CR-1 Isolated hepatic amyloidosis: A rare entity

Nikhil Sonthalia, Samit Jain, Vinay Pawar, Vinay Zanwar, Sunil Pawar, Ravindra Surude, Pravin M Rathi Department of Gastroenterology, Topiwala National Medical College and B Y L Nair Charitable Hospital, Dr A L Nair Road, Mumbai 400 008, India Amyloidosis is a pathological process that encompasses a spectrum of disease resulting from the extracellular deposition of fibrillar amyloid protein, which can involve any organ isolated or in conjunction with other organs and can do so in the form of a focal, tumor-like lesion, or an infiltrative process. Amyloidosis localized to the liver has been rarely described, although it is possible that these patients have yet to exhibit evidence of systemic disease. We describe a case of 40-year-old female presenting with pain abdomen with loss of weight and fever for 8 months. On examination she was cachectic, had pallor, with tender gross hepatomegaly (liver span 20 cm). On evaluation she had raised alkaline phosphatase of 584 IU/mL with raised gamma-glutamyltransferase (GGT) with normal transaminases. On CT imaging she had diffuse enlargement of liver with heterogenous contrast uptake in liver. Further liver biopsy was done after excluding hepatocellular carcinoma, viral infection, autoimmune disease. It depicted massive deposition of amyloid in perisinusoidal spaces which revealed apple green birefringence on congo red staining. Bone marrow biopsy was normal. Cardiac and renal evaluation was unremarkable. Abdominal fat pad and rectum biopsy was also negative for amyloid deposit. Serum free light chain assay was normal. Immunoperoxidase staining for serum amyloid Associated protein was negative from liver biopsy. IHC for hereditary variety of amyloid protein detection was not available. Patient was put on dexamethasone and colchicines with no relief of symptoms. This represents a rare case of isolated hepatic amyloidosis with diagnostic and therapeutic challenge. CR-2 A case of ankylosing spondylitis and Crohn’s disease: Case report

G Swathi, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, Musheerabad, Secunderabad 500 003, India Introduction: Six percent to 10 % of ankylosing spondylitis (AS) patients develop IBD and 70 % of patients with AS have microscopic gut

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appetite was good and he had no fever. On investigations, his hemoglobin was 9.6 gm % with low MCV, ESR of 5 mm/h and normal leukocyte counts. Stool examination showed fat cells, undigested food material and occult blood. No ova and cysts were noted. His HIV serology, thyroid profile, blood sugar and abdominal imaging were within normal limits. Upper gastrointestinal endoscopy and colonoscopy were done. Partial villous atrophy was noted in duodenal biopsies. Tissue transglutaminase antibodies were negative but he had low vitamin B12 and D levels. He was given a 4-week course of doxycycline and folic acid with no benefit. On repeat history taking, it was noted that symptoms were recurrent and used to occur when he was prescribed olmesartan to control his blood pressure. Symptoms improved after stopping the drug. Thus, a final diagnosis of olmesartan induced sprue like syndrome was made. Conclusion: Drug induced side effects, mainly diarrhea are common. They may mimic malabsorption. Prompt identification and stopping the drug may prevent unnecessary investigations.

inflammation. A 38-year-old male patient presented to us with 1 year history of diarrhea-4 episodes/day along with mucus, intermittent, colicky abdominal pain. No h/o blood, pus in stools. No h/o tenesmus, steatorrhea, fever, loss of appetite, redness of eyes. Since the past 20 years patient is having progressive involvement of axial and peripheral joints with stiffness. On examination patient had clubbing, soft abdomen, limited spinal mobility with fixation of neck, loss of lumbar lordosis, abnormal Schober’s test, fixed flexion deformity of both hip joints and reduced chest expansion. Investigations revealed normal CBP, LFT, chest X-ray. Stool examination showed pus cells with acidic pH. ESR—40 (1 h), 70 (2 h), CRP—56 mg/dL. HIV, Mantoux and FOBT-negative. X-ray spine s/o bamboo spine. HLA B27-negative. Colonoscopy showed multiple aphthous ulcers, cobblestoning, skip lesions and serpiginous ulcers with involvement of terminal ileum. Biopsy taken for HPE is suggestive of Crohn’s disease. Patient is diagnosed to have ankylosing spondylitis with moderately active Crohn’s disease (CDAI-246), Montreal class-A2L3B1 and managed with dietary modification, prednisolone, sulfasalazine, azathioprine, physiotherapy, vitamin D, calcium and folic acid.

CR-5

CR-3

A rare complication of azathioprine therapy for ulcerative colitis

Granulomatous colitis associated with Hermansky-Pudlak syndrome—A case report

Mayank Jain, Rahul Agrawal Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India

Khalid Mehmood, G R Srinivas, D Viswanath Reddy, Sandeep J Patil, Vamsi Krishna, Hilal Ahmad, B Ravi Shankar Department Of Gastroenterology, Yashoda Hospitals, Alexander Road, Secunderabad 500 003, India Background: Hermansky-Pudlak syndrome (HPS) is a rare autosomal recessive disorder. It consists of a triad of tyrosinase-positive oculocutaneous albinism (Ty-pos OCA), bleeding diathesis secondary to platelet dysfunction, and systemic complications associated with accumulation of ceroid lipofuscin within the reticuloendothelial system. HPS has been associated with gastrointestinal (GI) complications related to chronic granulomatous colitis with pathologic features suggestive of Crohn’s disease. This colitis can be severe, and has been reported to be poorly responsive to medical therapies including sulfasalazine, mesalamine, steroids, and metronidazole. Case Report: We report a patient with HPS which was complicated by inflammatory bowel disease with clinical features of ulcerative colitis and pathologic features of Crohn’s disease, refractory to antibiotics and corticosteroids. A trial of infliximab was attempted and repeated infusions produced a complete response. Conclusion: Many phenotypic and pathologic similarities exist between granulomatous enterocolitis and Crohn’s colitis in HPS. Granulomatous colitis in HPS is because of ceroid deposition or reflects the coexistence of Crohn’s disease and HPS. Given this similarity and the failure of the standard medical therapy of corticosteroids and antibiotics, our patient received infliximab with marked clinical improvement.

Case Report: A 45-year-old male patient presented fever and loose watery motions for 15 days. He had also noted reddish nodules over the lower limbs and abdomen. He was a known case of ulcerative colitis diagnosed at an outside hospital and had been taking mesacol 1.6 g/day and azathioprine 100 mg/day for last 18 years. He had not followed up with his treating doctor for the last seven years. He reported that the disease had been under control prior to this presentation. On examination, he had erythema nodosum, was febrile, pale and dehydrated. He had pancytopenia and mildly elevated ALT. HIV test, Widal and blood culture were negative. X-ray abdomen and ultrasound abdomen were normal. Stool culture showed growth of multidrug resistant E. coli and Clostridium difficile toxin assay was negative. Patient did not permit for endoscopic examination. He was given antibiotics as per sensitivity pattern. In view of pancytopenia, a bone marrow examination was done and it showed features of acute promyelocytic leukemia. Patient was explained the treatment options. He left against medical advice as he was not willing to continue treatment. Discussion: The first description of secondary AML in patients with inflammatory bowel disease was published in 1980. There are 18 case reports of AML developing in patients with inflammatory bowel diseases. Patients were treated with steroids (12 cases), sulfasalazine (8 cases), azathioprine (3 cases), 5-aminosalicylic acid (3 cases) and 6mercaptopurine (2 cases). The reported median survival was 7 months (range 3 weeks–4 years). CR-6

CR-4 An interesting case of chronic diarrhea Mayank Jain, Sandip Kaulavkar

Choithram Hospital and Research Centre, 14 Manik Bagh Road, Indore 452 014, India Introduction: Malabsorption syndrome is associated with morbidity for the patient and is a major diagnostic challenge. We report a rare cause of malabsorption. Case Report: A 68-year old, hypertensive male patient presented with history of loose, watery motions for last one year and weight loss of 15 kg. The patient reported bloating, borborygmi and greasy stools. His

A rare case of visceral leishmaniasis presenting as anemia, chronic diarrhea and duodenopathy

Vijay Sharma, Ravikant Porwal, Ankur Agarwal Soni Manipal Hospital, Jaipur, A Unit of Manipal Group of Hospitals and Institutions, Sector 5, Main Sikar Road, Vidhyadhar Nagar, Jaipur 302 013, India A 53-year-old male was admitted to Manipal Hospital, Jaipur, a tertiary care center with history of diarrhea 3 months, weight loss, feverishness, malaise, shortness of breath on exertion for 3 months increased for last 1 month. The diarrhea was small bowel type, watery, high volume, day and night time, with abdominal bloating, gurgling, and milk intolerance.

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No blood in stool, mild pain abdomen present. Diarrhea responded partially to Loperamide and antibiotics given by local primary physician. Patients condition worsened referred to our hospital for management. On admission initial supportive treatment started and work up done, report revealed Total leukocyte count 5900 cells/mm3, differential leukocyte count were neutrophil 47 %, lymphocyte 51 %, monocyte 01 % and eosinophil 01 %, hemoglobin 8.4 gram %. MCV was 82 femtoliter, MCH 29 picograms, MCHC 35 fl, RDW 17.7, platelet count was 78,000 cells/ mm3. Biochemistry tests revealed serum creatinine 1.9 mg/dL, serum potassium 3.4 mmol/L. Next day after hydration, IV fluids infusion blood urea 37 mg/dL, serum creatinine 1.3 milligram (mg)/dL, total calcium 6.4 mg/dL, serum phosphorus 3.2 mg/dL, uric acid 11.8 mg/dL, total protein 5.2 grams/deciliter (gm/dL), serum albumin 1.1 gm/dL, globulin 4.1 gm/dL, A:G ratio 0.3, sodium 136 mmol/L, potassium 2.8 mmol/L, chloride 110 mmol/L, total bilirubin 0.9 mg/dL, direct bilirubin 0.3 mg/ dL, SGOT 23 units/L (U/L) SGPT 27 U/L, alkaline phosphatase 99 U/L. Peripheral blood film revealed RBC normocytic normochromic, moderate anisopoikilocytosis with microcytes, few macrocytes, pencil cells, target cells, teardrop cells and occasional echinocytes, no NRBC seen, white blood cells reduced, DLC showed predominant neutropenia, no premature cells seen, platelet count decreases with normal morphology, hemoparasite not seen, impression pancytopenia. Ultrasound whole abdomen done revealed fatty liver, mild splenomegaly (size on longitudinal axis 13.4 cm), retroperitoneal lymphadenopathy, bilateral medical renal disease. Normal all other viscera. Upper gastrointestinal endoscopy revealed normal esophagus, Normal stomach, duodenal mucosa was abnormal, scalloped, eroded, flattened, D2 biopsy done to find out cause of duodenopathy (Fig. 1). Histopathology of duodenum second part revealed reduction in height of duodenal villi, lamina propria densely infiltrated by macrophage containing both intracellular as well as extracellular amastigote forms of Leishman-Donovan bodies, mild crypt hyperplasia with increase in intraepithelial lymphocytes, no evidence of granulomatous or neoplastic lesion seen (Fig. 2). Bone marrow examination revealed normocellular marrow, myeloid erythroid ratio 1:1, erythropoiesis was normoblastic hyperplasia, on differential count granulopoiesis myeloid series distributed normally. Blasts 1 %, promyelocytes 4 %, myelocytes 31 %, metamyelocytes 14 %, neutrophils 14 %, lymphocytes 30 %, eosinophil 3 %, plasma cells 2 %, megakaryocytes seen normally. Microscopy of bone barrow revealed macrophages 1 % with clusters of both intra and extracellular Leishman-Donovan bodies having round nucleus with kinetoplasts, final impression leishmaniasis (Fig. 3). HIV serology was positive, HIV viral load testing revealed HIV RNA quantitative below 20 copies per mL. CD45 absolute lymphocyte gated 2067/mm3, CD3 (T cell %) 72.25 %, CD3 (T cell absolute) 1493 cells/μL, CD4 (helper T cell %) 6.84 %, CD4 (helper T cell absolute) 141 cells/μL, CD8 (suppressor T cell s%) 65.41 %, (suppressor T cells absolute) 1352 cells/μL, CD4: CD8 ratio 0.10. Interferon gamma release assay negative 0.04 IU per mL. HBV, HCV serology was negative. Patient was managed with Intravenous Injection Liposomal Amphotericin–B and started recovering, discharged on antiretroviral treatment. Discussion and Conclusion: It was a rare case of visceral Leishmaniasis presenting as anaemia, chronic diarrhea and duodenopathy. This patient was found to be HIV positive with low CD4 count but viral load was also very low, there was no evidence of any opportunistic infection. Possibly patient was exposed to Leishmania during travel to eastern part of India.

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Case Report: A 4-year-old male child, product of consanguineous marriage, had failure to thrive, distension of abdomen, general weakness since the age of 1½ years, and was diagnosed to have tyrosinemia type 1. He presented with worsening of above symptoms since the past 3 months along with upper abdominal pain, loss of appetite and significant loss of weight. O/E malnourishment with rachitic features, protuberant abdomen with hepatosplenomegaly, renomegaly and motor weakness found. Patient investigated for progression to HCC. Investigations: USG abdomen: Multiple liver nodules in right lobe of liver suggestive of HCC. Triphasic CECT: Hypo to isodense lesion 36 X 28 mm in right lobe of liver with arterial enhancement and venous washout s/o HCC. Multiple isodense lesions in both lobes with venous phase enhancement s/o metastases FNAC: s/o well differentiated HCC. Investigations confirmed HCC. Patient was prescribed sodium acid phosphate, calcitriol, multivitamins, nutritional support, symptomatic treatment and nitisinone. Patient was Child A status, but performance status was 3—hence, stage BD^ HCC for which liver transplantation is not indicated. Hence only symptomatic treatment given. Conclusion: Tyrosinemia 1 can lead to liver cirrhosis and HCC—which can be prevented with nitisinone in 90 % of patients. Early disease detection, management of metabolic abnormalities and liver transplantation improves prognosis and survival in patients. CR-8 Spontaneous isolated dissection of superior mesenteric artery

Sandeep Vaishnav, Surendra Sultania, Harsh P Udawat, Dinesh Agrawal, Anurag Govil Department of Gastroenterology, Santokba Durlabhji Hospital, Bhawani Singh Marg, Near Rambagh Circle, Jaipur 302 015, India Introduction: Isolated spontaneous dissection of the superior mesenteric artery (SMA), without the involvement of the abdominal aorta, is a very rare condition. Endovascular stent placement and conservative management has been proposed recently for selected cases, which has led to good clinical results. Case Presentation: We report two cases of spontaneous dissection of the superior mesenteric artery. Both cases presented with acute epigastric pain with normal routine laboratory tests and abdominal radiography. The diagnosis of SMA dissection was made on CECT abdomen. There was no sign of bowel ischemia in both the cases. One benefited from the placement of an endovascular stent while another one treated conservatively. Both patient were asymptomatic after 2 and 3 months respectively and both were on antiplatelet drugs (Table 1). Conclusion: Conservative management and endovascular stent placement are good alternative strategy to surgery for dissection of the superior mesenteric artery. The most important prognostic indicator is adequate blood supply through the SMA to prevent bowel ischemia. In most cases, conservative treatment suffices. However, endovascular therapy should be performed early for symptomatic patients when there is suspicion of bowel ischemia. CR-9 Non-surgical management of perforated peptic ulcer: A case report

CR-7 A case of metabolic liver disease with hepatocellular carcinoma in a 4-year-old child

Kuldip Solanki, Sudhir Gangey, Kaiser Saleem, Sanjay Verma Solanki Gastro and Endo Centre, Near Ratan Pura, Kotra Talab Road, Janta Colony, Raipur, Chhattisgarh 492 001, India

Eswar Moparty, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, 6-1-34, Bhoiguda Road, Musheerabad, Secunderabad 500 003, India

Emergency laparotomy and repair is the standard modality of managing perforated peptic ulcer. We present two cases of perforation which were managed non-surgically.

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Case 1: 35/M with h/o GJ 10 years ago presented with acute abd. UGIE showed deep ulcer near GJ stroma with overlying slough with ? rent. Patient was started on NPO regimen with antibiotics and ∼75 mL. of pus was aspirated. Patient gradually improved. Case 2: 23/M presented with h/o pain abd. and distention post RTA. UGIE—2×1 cm deep ulcers in D1 with ? sinus. USG showed thick pus. Leukocytosis +. Patient was treated with NPO regimen, antibiotics and USG guided aspirations of 300 mL pus. Both patients had been doing well. Total FU is now 40 months. Conclusion: In case one, the patient had already undergone G-J and fortunately he presented early. Revision surgery would have been very tedious. Second Case had sealed DU with no element of ileus. In both cases single time aspiration of pus and broad spectrum antibiotics were adequate in tackling the peritonitis. Exploratory laparotomy and repair is the gold standard. However USG guided aspiration with antibiotics can be used as a modality to salvage high-risk patients unfit for surgery. CR-10 Ascites in a tertiary care center—Thinking beyond cirrhosis

R K Kartikayan, K Muthukumaran, G Ramkumar, R Balamurali, T Rajkumar, A Murali, P Ganesh Department of Digestive Health and Diseases, Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Ascites is a common manifestation of several conditions. Cirrhosis of liver, the most common cause of ascites can be diagnosed easily based on the imaging and ascitic fluid analysis. But ascites presenting in a patient with no evidence of cirrhosis, requires a series of investigations to establish the etiology. The present study aimed at enrolling all cases of ascites in non-cirrhotic patients and further evaluation in establishing the etiology. The study was conducted between August 2014 and June 2015. Adult patients who presented with ascites (either symptomatically or detected on imaging) with no evidence of cirrhosis (based on USG abdomen and SAAG of <1.1) were enrolled in the study. Ascitic fluid analysis was done for all patients. Patients also underwent upper and lower GI endoscopy and CT abdomen according to the clinical presentation. Relevant blood investigations (e.g., tumor markers) and other tests were done for appropriate patients 26 patients were enrolled in the study of whom 11 were male (42 %) and 15 were female (58 %). Among the patients, malignant ascites was the most common cause seen in 11 patients (42 %), followed by tuberculous ascites (n-8; 31 %), pancreatic ascites (n-5; 19 %) and ascites due to CCF (n-2; 8 %). CR-11 Intestinal hemangiomatosis—An occult case

Bhuvan Shetty, Amol Patil, B Avinash, Ravikiran, Satyaprakash, Umesh Jalihal M S Ramaiah Medical College, MSR College Road, MSR Nagar, MSRIT Post, Mathikere, Bengaluru 560 054, India An 8-year-old girl, presented with puffiness of face and easy fatigability. She had earlier hospital admissions for blood transfusion. She had no overt GI bleed, fever, hematemesis, bleeding diathesis. On examination she was noted to be pale. No organomegaly was noted on systemic examination. Her blood investigation revealed Hb of 3 gm %, microcytic hypochromic with normal LFT, PT, creatinine. Her Iron parameters were low. Endoscopy and colonoscopy under GA revealed multiple sub mucosal nodules of 0.25–0.75 cm with erythematous overlying mucosa in stomach and colon. Sclerotherapy was done for colonic lesions. Biopsy confirmed as vascular abnormality. She has no other cutaneous, CNS manifestation. She is under regular follow-up and Hb is maintained.

CR-12 Gastric antral vascular ectasia lesion associated with severe iron-deficiency anemia in a diabetic with end-stage renal disease—A rare case

Shatdal Chaudhary, Krishna K Agrawal, Niraj Jaiswal, Bickram Pradhan Gastroenterology Division, Department of Internal Medicine, Universal College of Medical Sciences, Bhairahawa, Nepal, and Gastroenterology Division, Department of Internal Medicine, B P Koirala Institute of Health Sciences, Dharan, Nepal Introduction: Gastric antral vascular ectasia (GAVE) is an uncommon cause of chronic gastrointestinal bleeding or iron-deficiency anemia. Dilated small vessels are seen in the antrum which gives watermelon like appearance of the stomach. Although it is associated with heterogeneous medical conditions, including hepatic, renal, and cardiac diseases, its pathogenesis is unknown. Objectives: We are reporting a rare case of GAVE lesion associated with severe iron-deficiency anemia in a diabetic female patient with end-stage renal disease (ESRD). Subjects and Methods: It was a 57-year-old female presented to us with generalize weakness and tired feeling. Patient also gave history of passing black colored stool in the past. She was a known diabetic since last 20 years and was also found to have CKD with ESRD 2 years back. She was on irregular hemodialysis. Patient was found to have hemoglobin of 5 gm/dL. She was transfused 5 pint of whole blood. A written informed consent was taken. Upper GI endoscopy was done under local lignocaine spray. Endoscopy Finding: It showed extensive vascular ectasias and linear patchy erythema in the distal antrum. Rapid urease test for H pylori was negative. Endoscopic biopsy of the lesions were done. Patient was sent for APC. Conclusion: GAVE syndrome is an important diagnosis to consider in older patients with severe anemia and occult or profuse gastrointestinal bleeding, especially in the setting of heart, liver, or kidney diseases. CR-13 Eruptive xanthoma and acute pancreatitis in a patient with hypertriglyceridemia—A case report

Parag G Deshmukh, Ashokananda Konar Acute pancreatitis and eruptive xanthomas are the only recognized direct complications of severe hypertriglyceridemia. We present the case of a 33-year-old male patient who presented with development of brown colored papular rash over the extensor surfaces followed by development of abdominal pain. On evaluation patient was diagnosed to have acute pancreatitis with uncontrolled diabetes and hypertriglyceridemia. Dermic eruptive xanthomatosis is a typical but rare sign of acute hypertriglyceridemia. If the skin signs of dyslipidemia can be recognized earlier the episode of pancreatitis can be avoided. CR-14 Unusual cases of gastric outlet obstruction

Tarun J George, Kani Sheik, Prem Kumar, R Kenny, T Pughazendhi, Mohammed Ali Department of Medical Gastroenterology, Madras Medical College, Rajiv Gandhi Government General Hospital, General Hospital Road, Park Town, Chennai 600 003, India

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Case 1: Diagnosis—A duodenal carcinoid 65-year-old male, chronic smoker and alcoholic presented with complaints of abdominal pain, ball rolling movement, early satiety for 1 year duration. Clinical examination and routine investigation were normal. UGI scopy done showed a large globular swelling with central umbilication in D2 causing luminal narrowing. Biopsy was taken and was found to be inconclusive. CECT abdomen showed well defined intensely enhancing lesion 1.3×1.1 cm in lumen of D2 abutting the wall. Patient was submitted to surgery and a 1.5 cm fleshy, pedunculated, polypoidal lesion arising from D2 distal to the ampulla was found intra operatively. Duodenectomy and excision of polyp was done. Histopathology revealed duodenal carcinoid. Since the size of the polyp was less than 2 cm with no metastasis, no further treatment was necessary and patient was discharged after improvement of his general condition. Case 2: Diagnosis—Pancreatic divisum/autoimmune pancreatitis with inflammatory pancreatic head mass causing obstructive jaundice and gastric outlet obstruction. A 21-year-old male who is a known case of type 1 neurofibromatosis presented with pruritis, jaundice and abdominal pain for 1 year duration. On examination, external markers of neurofibromatosis and hepatomegaly was present. Investigation revealed hyperbilirubinemia with markedly elevated alkaline phosphatase suggestive of obstructive pattern. CECT abdomen showed dilated CBD, right, left hepatic duct and IHBR. MRCP was done revealed pancreatic divisum, stricture in pancreatic head and short segment narrowing in mid CBD with back pressure changes. On UGI scopy, minor ampullary swelling seen partially obscuring the lumen. Patient was subjected to ERCP. Cholangiogram showed dilated proximal CBD, IHBR with thinned out mid and distal CBD secondary to inflammatory pancreatic head mass. IgG4 levels were suggestive of autoimmune pancreatitis. This case is a rare combination of pancreatic divisum and autoimmune pancreatitis with an inflammatory mass causing obstructive jaundice and gastric outlet obstruction. CR-15 A case report of esophageal mucormycosis secondary to gastric adenocarcinoma

Rohan P Reddy, P Shravan Kumar, M Umadevi, M Ramanna Department of Gastroenterology, Gandhi Hospital, Musheerabad, Hyderabad 500 025, India Background: Mucormycosis is a rare invasive fungal infection with high mortality. It usually affects patients with poorly controlled diabetes, immunosuppression and malignancies. Early diagnosis and prompt appropriate therapy reduces morbidity and mortality. A 34-year-old male patient, came with the chief complaints of dysphagia more to solids and liquids for 1 month. It was progressive in nature with a significant history of weight loss and loss of appetite associated with melena. There was no history of any drugs or DM. On examination, the patient had pallor and abdominal examination was unremarkable. Upper GI endoscopy revealed normal mucosa in the proximal esophagus with a whitish, ulcerative, nodular and friable growth with circumferential narrowing seen at 35 cm from the incisors. Histological work up of biopsies showed necrotic tissue with numerous fungal elements, with branching hyphae and vascular invasion consistent with mucormycosis. He was treated with broad spectrum antibiotics and antifungal liposomal amphotericin-B (5 mg/kg). After 3 weeks of the above therapy dysphagia gradually improved and a repeat upper GI endoscopy revealed regression of the mucosal lesion in

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the esophagus but there was an infiltrating mass along the lesser curvature of the stomach involving the proximal body. Multiple biopsies revealed gastric adenocarcinoma. The patient was subjected to surgery and is on follow up.

CR-16 A rare case of Budd-Chiari syndrome secondary to anti-phospholipid antibody syndrome and inherited thrombophilia

K Saikrishna, P Shravan Kumar, M Umadevi, Ramanna Department of Gastroenterology, Gandhi Hospital, Secunderabad 500 025, India Background: Budd-Chiari syndrome is a heterogenous condition characterized by hepatic venous outflow obstruction at the level of hepatic veins and/or inferior vena cava. Case Report: A 20-year-old, nonalcoholic male presented with progressive abdominal distension, hematemesis and jaundice since 4 weeks with H/O similar complaints twice in the past 1 year for which he was hospitalized and managed conservatively with medications and blood transfusions On examination pallor+, icterus+, clubbing+, absent pubic and axillary hair and testicular atrophy noted. abdomen distended, ascites present. Engorged veins noted over anterior abdominal wall and flanks with direction of flow of blood below upwards and away from umbilicus. Hepatosplenomegaly: present. Patient was evaluated for the cause of cirrhosis of liver and screened for viral markers, Wilsons disease, autoimmune hepatitis are found to be negative. Color Doppler hepatic veins revealed nonvisualization of hepatic veins. MRI abdomen with MR venogram suggested: CLD with COL, portal HTN with ascites, caudate lobe hypertrophy causing retrohepatic IVC narrowing, nonvisualization of hepatic veins S/O Budd-Chiari syndrome. Coagulation profile: serum APLA IgG: 18.24 u/mL (<10), Factor V functional 19 % (70% to 120 %), anti-thrombin III activity: 35 % (80 % to 120 %), serum homocysteine: 5.77 μmol/L (5.46–16.40), protein S functional 41 % (60 % to 140 %). Conclusion: This patient is classified as having antiphospholipid antibody syndrome as per presence of 1 lab and 1 clinical criteria. This patient is also having inherited thrombophilia along with APLA syndrome leading to the development of Budd-Chiari syndrome with COL. CR-17 Co-existence of eosinophilic enteritis and carcinoma colon-causal association or coincidence?

Rachit Agarwal, Piyush Ranjan Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi 110 060, India Eosinophilic enteritis is an uncommon disease which can involve all three layers of gastrointestinal tract and any site from esophagus to colon. Clinical features depend upon the site of involvement and layer of gastrointestinal tract involved. Persistence of inflammation can lead to stricture. There are no reports linking eosinophilic enteritis to carcinoma of colon. We report a case which links eosinophilic colitis to carcinoma of colon. This 42year-old male had presented to our hospital with discharging fecal

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fistula. He had undergone exploratory laparotomy previously for acute abdomen. He underwent CT sinogram which showed enterocutaneous fistula. Colonoscopy showed narrowing of the IC junction with multiple nodules in the cecal area. Biopsy obtained from the nodules showed features of eosinophilic enteritis. He underwent right hemicolectomy with ileotransverse anastomosis for the enterocutaneous fistula. Biopsy from surgical specimen showed well differentiated adenocarcinoma. Surveillance colonoscopy done one year later showed ulcer at anastomotic site and biopsy showed features of eosinophilic colitis. Peripheral blood showed eosinophilia and he was started on prednisolone. Subsequent colonoscopy done 3 months later showed resolution of anastomotic ulcers and there was resolution of absolute eosinophil count. Presence of features of eosinophilic colitis in preoperative colonoscopy and recurrence subsequently is a proof which links carcinoma colon to underlying eosinophilic colitis.

CR-18 A case of Henoch-Schonlein purpura presenting as gastrointestinal bleed in an adult

S N K Chenduran, P Padmanabhan, P Bibin Meenakshi Medical College Hospital and Research Institute, Enathur, Karrapettai Post, Kanchipuram, Tamil Nadu 631 552, India Background: Adult onset of Henoch-Schonlein purpura (HSP) is rare and unusual with atypical features and atypical gastrointestinal (GI) involvement. HSP is a nonthrombocytopenic palpable purpura occurring mainly in children. It is a leukocytoclastic vasculitis involving small vessel with deposition of immune IgA complexes. HSP is a characterized by tetrad of nonthrombocytopenic palpable purpura, arthritis or arthralgias, GI and renal involvement. Here we present a case of adult onset of HSP. Material and Methods: A 31-year-old man referred for evaluation of melena, hematemesis and hematochezia. He developed abdominal pain 3 weeks earlier and noticed skin eruptions, 6 days after onset of abdominal pain. He had joint pain and back pain. He underwent endoscopic evaluation and renal workup. Findings: 1. Esophagogastroduodenoscopy: Discrete circumferential erosions with central ulcerations involving the body, antrum, pylorus and duodenum. 2. Colonoscopy: Discrete erosions of varying sizes involving the anal canal up to the ileum 3. Renal biopsy: Features suggestive of IgA nephritis–HSP by immunofluorescence study.

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Discussion: The clinical presentation of HSP is more severe among adult. The involvement of body, antrum and duodenum with entire colon and ileum is rare as in this case which is unusual. Usually entire bowel involvement is rare. Here in this adult onset HSP–GI symptoms preceded skin rashes with renal involvement. The renal involvement is documented by immunofluorescence study in this patient. Conclusion: Adult onset of HSP which is rare is presented here along with immunofluorescence documentation of renal involvement which is also rare.

CR-19 Noncorrosive esophageal injury

P Senthil Kumar Saravana Hospital P. Ltd., 14, Thillai Nagar 1st Cross, Ponnammapet, Salem 636 001, India A 24-year-old male presented with history of accidental hot water ingestion by 7 am, presented to hospital by 9 am with history of pain in the oral cavity, odynophagia, burning chest pain and abdominal pain. Immediately he has undergone upper GI endoscopy which revealed severe mucosal damage, equivalent to grade IIIa–IIIb injury (Zargar’s grading of caustic injury). Fundus shows some blisters. Rest of the stomach was normal. Duodenum is normal. He has been treated with NPO, IV PPI, IV fluids, antibiotics with nasogastric tube. After about 3 days later, he has fed with liquids/ semisolid foods. He has been discharged with NG tube. After about 6 weeks later he has done upper GI endoscopy which revealed completely healed mucosa which is not possible with such a grade of caustic injury (Gr IIIa–IIIb) Hence other than caustic mucosal injury need different classification. Zargar’s grading cannot be used for these type of injuries.

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CR-20 Pregnancy and Crigler-Najjar syndrome type 2

Alisha Chaubal, Dattatray Solanke, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India We discuss a case of a female with Crigler-Najjar syndrome type II who presented to us in the third month of gestation. Unconjugated bilirubin crosses the placental barrier resulting in neurotoxicity in the newborn. Patient was treated with low dose phenobarbitone to maintain serum bilirubin levels below 10 mg/dL. Treatment protocol based on review of previous reported cases was followed and resulted in a successful outcome of a normal fetus without neurological impairment. Case Report: A 24-year-old woman presented to us in the third month of gestation. She had jaundice and a past medical history of mild icterus which started in childhood. Investigations showed unconjugated hyperbilirubinemia, normal liver enzymes and negative anti-HBc and anti-HCVantibody titers. Antinuclear antibodies, smooth muscle antibodies, antibodies to liver/kidney microsomes and serum ceruloplasmin levels were also negative ruling out an autoimmune condition. Abdominal ultrasound was also normal. A genetic study of the UDT1A1 gene revealed it to be negative for the TATA sequence ruling out Gilbert’s syndrome. Based on history of hyperbilirubinemia since childhood and response to phenobarbitone she was diagnosed to be a case of CriglerNajjar type 2. Patient was started on phenobarbitone at a dose of 20 mg/ day and her bilirubin levels were monitored. During pregnancy patient maintained bilirubin levels between 4–8 mg/dL. At delivery her bilirubin was 4.92 mg/dL with indirect bilirubin being 3.78 mg/dL. Patient had a full term normal delivery and the neonate had normal bilirubin levels not requiring any form of treatment.

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Case Description: The three females presented to us in the 3rd, 6th, 7th months of gestation respectively. All 3 had a history of mild icterus since childhood. Based on the presence of hyperbilirubinemia with near normal liver enzymes and a negative test for viral, autoimmune markers and a normal ceruloplasmin level and ultrasound abdomen a diagnosis of Crigler-Najjar syndrome was made. Response to phenobarbitone was also observed. All three patients were started on low dose phenobarbitone (60 mg once a day) and liver functions were monitored frequently. Only one patient had a n increase in liver enzymes and dose of phenobarbitone was reduced to 30 mg once a day. All three females had uncomplicated deliveries with no neurological impairment in the newborn. Conclusion: Hyperbilirubinemia in the newborn can cause neurological impairment, kernicterus and sometimes death. Pregnancy being a stressful condition can cause an increase in bilirubin levels. Crigler-Najjar being a rare condition should be considered as a diagnosis as Type II shows good response to phenobarbitone and can prevent bilirubin toxicity in the newborn. Low dose phenobarbitone is not teratogenic and can be safely used. CR-22 Uncommon cause of ascites—Enteric fever

Dhaval R Choksi, Ruchir Patel, Chetan Rathi, Prabha Sawant, Meghral Ingle Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Enteric fever is a systemic illness with varied presentation. It is a common infectious disease in tropical countries. It can result in complications in different organ systems. Complications involving multiple systems is not commonly seen. We present a case of young female who came with fever, jaundice and ascites of 3 weeks’ duration. Her evaluation did not reveal portal hypertension or chronic liver disease. Patient also had pancytopenia. During the course of illness she developed dyspnea and palpitation, needing ICU care. Dyspnea was found to be due to myocarditis. The diagnosis of enteric fever was established by high Widal titers and consecutive blood culture studies showing growth of S. typhi. She eventually responded to antibiotics, diuretics and supportive therapy, with complete recovery. A 2-week follow-up revealed normalization of liver function tests, ascites, hemogram and cardiac function. The combination of hepatitis, pancytopenia, probably secondary to infection associated hemophagocytic syndrome and myocarditis in a single patient with typhoid is extremely uncommon. The case also showed that complications of enteric fever respond well to timely treatment and has good prognosis. CR-23 Acute pancreatitis and hyperparathyroidism

CR-21 Pregnancy and Crigler-Najjar syndrome type 2

Alisha Chaubal, Ruchir Patel, Dattatray Solanke, Pathik Parikh, Meghraj Ingle, Prabha Sawant Department of Gastroenterology, Lokmanya Tilak Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Introduction: Crigler-Najjar syndrome is an autosomal recessive condition which leads to unconjugated hyperbilirubinemia. Unconjugated bilirubin crosses the placental barrier resulting in neurotoxicity in the newborn. We present three cases of Crigler-Najjar syndrome who presented to us during pregnancy and were treated with phenobarbitone.

M G Jayan Malankara Orthodox Syrian Church Medical College, Medical College Road, PO Kolencherry, Kochi 682 311, India Background: Acute pancreatitis is a common and challenging medical emergency seen in Gastroenterology practice. While alcohol, gallstone and viruses are the common causes, one also comes across cases like primary hyperparathyroidism (PHPT). It is unusual for PHPT to present with acute pancreatitis as the first event. In this case report we wish to high light the case of a young male who presented with a severe episode of acute pancreatitis which was due to PHPT caused by an adenoma in the parathyroid gland. Acute pancreatitis and hyperparathyroidism: Introduction: Acute pancreatitis is a common and serious medical emergency. The most common causes are alcohol, Gallstone, viruses and drugs.

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Methods: We present a case which was admitted in our hospital with abdominal pain. In February 2015 a young male 25-year-old came to casualty with severe abdominal pain of 2 days duration. He was admitted to the ICU. His amylase done outside was very high 2463 IU/L. His USG done outside was s/o of bulky pancreas with a small right renal stone. Clinically patient was in ileus. Results: Hemoglobin was 19.8 mg/dL PCV was 56, s/o severe hemoconcentration. Total count was 18,600/mm3. Bilirubin was 6.3 mg/dL with mild elevation of SGOT/SGPT. Amylase was 1152 U/L and lipase was 7272 U/L. Serum calcium was 14 mg/dL and magnesium was 2.4 mg/dL. USG of thyroid was done which was s/o—a well-defined lesion lying between the rt. right carotid artery and lower pole of right, lobe of thyroid s/o parathyroid adenoma with differential diagnosis of Bexophytic thyroid nodule.^ Surgical consult was taken. In view of this finding serum PTH was done and was 207.6 pg/mL normal range being 15–75 ng/dL. X-rays of skull clavicles and both hands was taken for any lesions. This was s/o mild abnormal appearance of calvarium-? Early Bpepper-pot^ appearance and doubtful loss of lamina dura of teeth. No lesions in digits or clavicles. In view of persistent high calcium dialysis was started. Calcitonin nasal spray was also given. Patient starting taking food orally. He was shifted to the room. One month later still was in hospital slowly recovering. He suddenly developed high-grade fever with chills and rigors and hypotension. He was immediately shifted to ICU and broad spectrum antibiotics was started and necessary supportive measures initiated. An emergency CT was done s/o large pseudocyst formation with significant spread of gas particles s/o infection with gas forming organisms. Pig tail catheter under CT guidance was placed into the abscess cavity by our surgery colleagues. Cinacalcet was started. This drug works by increasing the parathyroid gland chief cell calcium-sensing receptor sensitivity to extracellular calcium, thereby decreasing PTH secretion. Parathyroid scintigraphy was done with injection of 15 mCi of 99 TcMIBI and images obtained by SPECT gamma camera which was s/o of Bright lower parathyroid gland adenoma.^ Pig tail catheter site continued to drain small quantities of pus. It got dislodged spontaneously. However the site sealed off. Prior to discharge USG was done showing a large pseudo cyst. Patient was advised to undergo MRCP to delineate the pancreatic duct. He was readmitted with fever and abdominal discomfort. A repeat CT scan was s/o large pseudocysts in the abdomen. Patient was lost to follow up. Discussion: Parathyroid glands are four in number and located posterior to the thyroid gland. They produce parathyroid hormone which maintains calcium homeostasis. (1) Hyperparathyroidism is caused by adenoma or hyperplasia of the glands. In this situation feedback controls are lost. Primary hyperparathyroidism is a generalized disorder of calcium, phosphate, and bone metabolism due to an increased secretion of PTH. The elevation of circulating hormone usually leads to hypercalcemia and hypophosphatemia. There is great variation in the manifestations. Patients may present with multiple signs and symptoms, including recurrent nephrolithiasis, peptic ulcers, mental changes, and, less frequently, extensive bone resorption. More than 50 % of patients are asymptomatic. Pancreatitis has been reported in association with hyperparathyroidism, but the incidence and the mechanism are not established. (1) Hypercalcemia of any cause leading to pancreatitis is rare. (2). Primary Hyperparathyroidism accounts for less than 0.5 % of cases of pancreatitis. The incidence is between 0.4 % to 1.5 %. It is very unusual to have acute pancreatitis as the presenting feature of PHPT total incidence being 1 %. The first report of pancreatic lithiasis with PHPT (primary hyperparathyroidism) was published in 1947. Later in 1957 PHPT was accepted as a cause of acute pancreatitis. In BJS 10 cases of acute pancreatitis related to hypercalcemia were reported by Sitges Serra et al. Seven had PHPT and remaining had HPT post renal transplant. It was suggested that pancreatitis may complicate the course of hyperparathyroidism. (3) In a large study of patients with PHPT numbering 684 only 10 (1.5 %) developed acute pancreatitis. (4) Of 1435 patients operated over a period of 30 years 1224 had primary hyperparathyroidism and the remaining had renal hyperparathyroidism. A total of 3.2 % (n=40) of patients with PHPT had

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pancreatitis, which was acute in 18 cases, sub acute in 8 cases and chronic in 14 cases (5). Conclusion: This case highlights the importance of doing all routine investigations in a case of acute pancreatitis. High levels of calcium at admission should make the clinician look for all causes of hypercalcemia. CR-24 Endoscopic full-thickness resection of a large gastric GIST+closure of accidental full-thickness esophageal perforation

A Bapaye, N A Dubale, K Sheth, S Mahajani, M Mahadik, V Vyas Shivanand Desai Center for Digestive Disorders, Deenanath Mangeshkar Hospital and Research Center, Near Mhatre Bridge, Erandawne, Pune 411 004, India Introduction: Endoscopic full-thickness resection (EFTR) is a minimally invasive method for en bloc resection of gastrointestinal lesions. We present a patient undergoing EFTR for large fundic gastrointestinal stromal tumor (GIST) with an unexpected complication during per-oral tumor delivery; managed endoscopically. Methods: A 73-year-old male presented with upper GI bleed. EGD showed submucosal lesion in fundus. Endoscopic ultrasound (EUS) showed globular heterogeneous tumor (65 x 60 mm) arising from muscularis propria (MP). EFTR performed using gastroscope with transparent ESD cap, CO2 insufflation, IT-knife, Hook-knife, and Coag-grasper. EFTR steps: (1) submucosal elevation using saline with methylene blue, (2) circumferential mucosal incision and submucosal dissection around tumor, (3) Division of MP layer to complete en bloc dissection; (4) closure of MP layer defect with metallic clips; (5) Resected tumor more cellated and delivered piecemeal; during which accidental full-thickness tear in the lower esophagus encountered; closed using multiple hemoclips. Results: Total procedure time 106 min. Postprocedure chest radiograph next day showed no mediastinal/peritoneal air. No leak on oral contrast study at 48 h. Patient discharged on 4th postprocedure day. Final HPEGIST with low mitotic activity. Conclusion: EFTR is an expansion of the ESD technique that can be used to resect tumors from the outer muscle layer of the gastrointestinal tract. This video case demonstrates successful use of EFTR technique to resect a large MP layer tumor and also challenges faced during delivery of a large tumor CR-25 Two interesting cases of upper gastrointestinal bleed

Nikhil Bondade, Rajesh Bathini, Atul Sharma, Vishal Bothara, Suryaprakash Bhandari, Vinay Dhir, Amit Maydeo Baldota Institute of Digestive Sciences, Global Hospitals, Parel, Mumbai 400 012, India Background: Common causes of upper gastrointestinal (GI) bleed are peptic ulcers and varices. Here we present two interesting cases of upper GI bleed. Case 1: A 6-year-old boy presented with massive hematemesis with no hemodynamic instability. On evaluation Hb was 6.4 gm % and other routine investigations were normal. Upper GI endoscopy revealed a large clot in the fundus and active ooze below the clot from a small vessel. Lesion was consistent with Dieulafoy’s lesion. Hemoclip was applied and hemostasis was achieved. Case 2: A 51-year-old male patient had massive hematemesis and melena in hypovolemic shock. After resuscitation upper GI endoscopy showed an active spurting ulcer overlying a thickened gastric fold at the fundus. Glue injection done and hemostasis achieved. However within 48 h patient again had repeat upper GI bleed for which repeat endoscopy was done it showed spurting from the same lesion and repeat glue injection was done. Within

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24 h patient had rebleeding, CT angio of abdomen was normal and surgery was done with wedge resection of fundus using staples. Histopathology of resected specimen was consistent with Dieulafoy’s lesion. Discussion: Dieulafoy’s lesion is a persistent caliber submucosal artery. It is an uncommon cause of massive upper GI bleed. Endoscopy successfully identifies lesion in about 82 % of patients. Out of these 49 % during the first endoscopy while 33 % require more than one endoscopy and treatment. Remainder of patients are identified angiographically or intraoperatively and treated accordingly.

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of left ventricle with pulmonary hypertension, and pericardial effusion. Histology (image 8) and clinicopathologic correlation established the diagnosis of metastatic malignant melanoma possibly duodenal origin. To our knowledge, this is the first report in the English literature about gastric outlet obstruction cased by malignant melanoma.

CR-27 Post colonoscopy ischemic colitis

CR-26 Malignant melanoma of the stomach and duodenum presenting with gastric outlet obstruction: Report of a rare case

Vijay Sharma, Suresh Bhargawa, Vaibhav Vaishnav, Ravikant Porwal, Ankur Agarwal Departments of Gastroenterology, Critical Care Medicine, Medicine, and Pathology, Manipal Hospital, Jaipur 302 013, A unit of Manipal Group of Hospitals and Institutions, Jaipur, India, and Department of Gastroenterology, Regional Institute of Health, Medicine and Research, Indra Colony, Bani Park, Jaipur 302 016, India Introduction: Malignant melanoma involving gastrointestinal tract is rare, gastrointestinal melanoma (GIM) may present with abdominal pain, anemia, dysphagia, constipation, small bowel obstruction and gastrointestinal bleeding. Case Report: A 87-year-old man presented to our hospital with abdominal distention, nausea and vomiting for 15 days. On clinical examination chest had bilateral crepitations, hepatomegaly, epigastric fullness. His Ryles tube had large volume dirty aspirate, feed was not accepted, gastroscopy revealed multiple dark black flat nodules in stomach (image 1), gastric outlet was narrowed with a large ulcer involving near half of circumference the first part of duodenum (image 2), with black base and margin. Biopsy taken from stomach, patients body had black macules and nodules on trunk (image 3), large nodule at anal region (image 4) scrap taken from skin. Chest X-ray PA view (image 5), contrast enhanced compound tomography of chest and abdomen (image 6) was done which revealed diffuse metastasis of both lungs, pleura and liver with pleural effusion. 2 D echocardiography (image 7) revealed severe concentric hypertrophy

Prateik Poddar, Alisha Chaubal, Dattatray Solanke, Nilesh Pandav, Meghraj Ingle, Prabha Sawant Lokmanya Tilak Municipal Medical College and General Hospital, Dr. Babasaheb Ambedkar Road, Sion West, Mumbai 400 022, India Description: Ischemic colitis is the most common form of intestinal ischemia and is more common in the elderly and in people having risk factors for ischemia. Common conditions predisposing to colonic ischemia are major vascular occlusion, small vessel disorder, shock, certain medications, colonic obstruction and hematologic disorders. Colonoscopy is a very rare cause of ischemic colitis. Fewer than 20 cases of ischemic colitis following colonoscopy have been reported in the English literature to date. We report a case of ischemic colitis after routine colonoscopy in a 43-year-old male patient without any risk factors for colonic ischemia. This patient presented to us within hours of routine colonoscopy with rectal bleeding and lower abdominal pain. On repeat colonoscopy, the patient had mucosal edema, and ulcerations in the descending colon and sigmoid colon. Computed tomography of abdomen and biopsy of the involved segment confirmed ischemic colitis. The patient recovered with conservative management. Conclusion: Ischemic colitis is one of the most common types of intestinal ischemia representing more than 50 % of cases with gastrointestinal ischemia. It usually occurs in patients above 60 years of age. Patients present with mild crampy abdominal pain, urge to defecate, passage of bright red blood through anus usually mixed with stools, and tenderness over the affected part of the bowel. Though rarely implicated, we believe that colonoscopy itself predisposes the patient to ischemia due to pressure effect of insufflations and repeated trauma due to scope movement.