Indian J Gastroenterol (November 2013) 32(Suppl 1):A142–A146 DOI 10.1007/s12664-013-0415-1

ABSTRACTS

Society of Gastrointestinal Endoscopy of India

Received: 20 September 2013 / Accepted: 20 September 2013 / Published online: 13 October 2013 # Indian Society of Gastroenterology 2013

Oral presentation O-1 Clinical, endoscopic and endoscopic ultrasound features of duodenal varices: A report of ten cases Surinder S Rana, Deepak K Bhasin, Vishal Sharma, Vanita Chaudhary, Ravi Sharma Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Duodenal varices (DV) are an uncommon but important cause of gastrointestinal (GI) bleeding because of the severe nature of the bleed and associated adverse outcome. Patients and Methods: We retrospectively evaluated clinical, endoscopic and endoscopic ultrasound (EUS) features in patients with DV seen at our institution over the past 4 years. Results: Ten patients (nine males; mean age 35.8±7.6 years) with DV were studied. Five patients had underlying cirrhosis, and five had noncirrhotic portal hypertension (four patients had extrahepatic portal venous obstruction and one patient had noncirrhotic portal fibrosis). Five patients presented with upper GI bleed, whereas in the remaining five patients, DV were detected on endoscopy performed for evaluation of portal hypertension. Endoscopy revealed submucosal lesion in nine patients, whereas in one patient, initial endoscopic diagnosis of Dieulafoy lesion was made. EUS could identify DV in all patients. All patients with acute upper GI bleed were initially treated with intravenous terlipressin followed by glue (n-butyl cyanoacrylate) injection in 4/5 patients with one patient refusing further endoscopic therapy. The variceal obliteration was documented by EUS in all these four patients, and there has been no recurrence of bleed in these four patients over a follow up period of 4–46 months. The five nonbleeding DV were already on beta-blockers and the same were continued. Conclusion: EUS is a useful investigational modality for evaluating patients with DV, and endoscopic injection of glue is an effective therapy for controlling and preventing recurrence of bleed from DV.

O-2 Can narrow band imaging predict duodenal histology in celiac disease? A prospective double-blind pilot study Saroj Kant Sinha, Jahangeer Basha, Kim Vaiphei, Sreekanth Appasani, Pradeep Siddappa, Kartar Singh, Rakesh Kochhar Departments of Gastroenterology and Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim: To compare the diagnostic accuracy of narrow band imaging (NBI) with histopathology in predicting the duodenal villous morphology in celiac disease (CD).

Methods: Of 50 subjects (mean age 28.17±12.7 years, 29 females), 34 were suspected to have CD (serology positive), 4 were follow up patients of CD on gluten-free diet and 12 had dyspepsia with no evidence of CD on complete evaluation. CD was diagnosed on the basis of modified ESPGHAN criteria. They underwent esophagogastroduodenoscopy along with NBI using an Olympus GIF-180 gastroscope to evaluate the villous pattern of duodenal mucosa. Digitally recorded images were analyzed by two experienced endoscopists and biopsy specimen by an experienced pathologist all of whom were blinded to clinical details and serological investigations. Villous patterns on NBI were classified into normal-villous pattern (NVP), blunted-villous pattern (DVP) and absentvillous pattern (AVP) and were correlated with histopathology. Results: Overall, NBI revealed AVP in 14, DVP in 13 and NVP in 23 patients. In the study group (CD, n =34), 14 had AVP, 13 had DVP and 7 had NVP on NBI, while on histopathology, 11 had total villous atrophy, 11 had partial villous atrophy and 12 had no villous atrophy. CD patients on gluten-free diet (n =4) and 12 dyspepsia patients (control group) had normal villous pattern on both NBI and histopathology. Significant correlation was observed between NBI and histopathology (p <0.001). The overall sensitivity and specificity of NBI for delineating villous pattern were 100 % and 82.1 %, and the positive and negative predictive values were 81.4 % and 100 %, respectively. Conclusion: NBI can predict villous atrophy with high sensitivity and negative predictive value in CD.

O-3 Intramuscular diclofenac prevents post-ERCP pancreatitis Sandip Shah , Ajit Kumar, Nayana Joshi , B Sukanya , Chintan Kansagra, Nikhil Shirole, Kunal Vyawahare Department of Gastroenterology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad 500 082, India Background: Post-ERCP pancreatitis (PEP) is common and drugs like NSAIDs are found to be useful in preventing it. Aim: (1) To assess the efficacy of intramuscular diclofenac in prevention of PEP and (2) to study the factors likely to cause PEP. Methods: Fifty consecutive patients undergoing ERCP were randomized to group A: diclofenac 75 mg IM 30 min before procedure (n =25) and group B: no intervention (n =25). Clinical assessment and serum amylase were measured pre-ERCP and 18– 24 h post-ERCP. Patients with acute or chronic pancreatitis and those who had contraindication for diclofenac were excluded. Factors like difficult cannulation, number of attempts to cannulate, amount of contrast injected, opacification of PD and acinarisation and interventions performed were noted. Results: The baseline characteristics were comparable in both groups. Overall, ten (20 %) patients, three (12 %) in group A and seven (28 %) in group B (p = 0.005) developed pancreatitis. Asymptomatic hyperamylasemia was seen in 14 % group A vs. 28 % group B (p =

Indian J Gastroenterol (November 2013) 32(Suppl 1):A142–A146

0.015). The number of attempts to cannulate (difficult vs. easy) (OR= 4.95 %, CI 0.64–31.37) and age more than 50 years (OR=3.27, 95 % CI 0.529–25.67) were shown to be significant risk factors, while PD cannulation was not significant. Moderate to severe pancreatitis was seen only in non-intervention group. Conclusion: Intramuscular diclofenac lowered the rate and severity of pancreatitis as well as asymptomatic hyperamylasemia. Difficult cannulation and age more than 50 years were significant risk factors of PEP in our study.

O-4 A new fully covered large bore wide flare metal stent or drainage of pancreatic fluid collections: Results of a single center study Amol Bapaye, Nachiket Dubale Department of Digestive Diseases and Endoscopy, Deenanath Mangeshkar Hospital and Research Center, Erandawne, Pune 411 004, India Introduction: Endoscopic ultrasonography guided transmural drainage (EUTMD) of pancreatic fluid collections (PFC) is currently the standard treatment modality. Multiple double pigtail plastic stents have limitations of adequate drainage. Aims and Methods : A new specially designed large bore wide flare FCSEMS has been recently developed (Nagi stent, Niti-S, Taewoong Medical, South Korea) to accomplish this purpose with fewer disadvantages. This study aimed to evaluate the efficacy of this FCSEMS for PFC drainage. Assessment parameters included resolution of symptoms and resolution of PFC on imaging, ability to perform necrosectomy, and complications. Results: Duration 13 months, 19 patients with 21 PFCs AFC 1, PPC 8, infected PPC 1, and WOPN 11. Mean longest PFC diameter 107 (46– 206) mm. Puncture site esophagus 1, stomach 18, and duodenum 2. Access-19 G FNA needle. Track dilatation 4 mm, additional double pigtail stent 10, and nasocystic drain 7. Necrosectomy 7. Technical success 100 % (symptom relief) and clinical success 95 % (PFC resolution on imaging @ 72 h). Successful stent removal 14/21. Complications stent migration 1 and delayed bleeding (stent erosion) 1. Conclusion: The Nagi stent is effective and safe for EUTMD of PFC including infected PPC and WOPN. Necrosectomy can be successfully performed, and stent removal is easily possible and safe. Further prospective randomized controlled trials comparing this stent to multiple plastic stents is recommended.

O-5 Stress reduction by listening to Indian classical instrumental music during gastroscopy M R Kotwal, Chewang Zangmo Rinchhen, Susrutha Kotwal, Shunyata STNM Hospital, Tibet Road, Gangtok, Sikkim, India Introduction: Many patients fear GI endoscopy. Natural anxiety may be aggravated by horror stories from friends or inappropriate remarks by endoscopy staff. Music serves on familiar conjunctures, such as in waiting rooms. However, music is not for everyone at all times. We evaluated scientific and therapeutic possibilities. Method: Study was conducted on 110 consecutive patients undergoing GI endoscopy for various reasons. Patients were randomly assigned to two groups regardless of age, sex or underlying disease. One group of 55 patients listened to the recorded instrumental music, while the other group of 55 did not. Blood pressure, heart rate and respiration were recorded at the beginning and end of endoscopic procedure. The group assigned to music listened music for 10 min before and throughout the procedure,

A143

while control waited. No sedation or topical anesthesia was used in any group. Results: Using paired t test in both the groups of patients, no statistically significant difference in the four parameters, ie. BP-S (systolic), BP-D (diastolic), heart and respiratory rate. However, on analysis of the data between two groups was compared. There was statistically significant difference in three parameters, ie. BP-S, BP-D and respiratory-rate. We also evaluated the perception of procedure using a five-point attitude scale. More patients accepted procedure in the experimental group. Conclusion: Results indicate that the selective instrumental music is efficacious in reducing psychological distress during gastroscopic examination. We suggest that back ground music could be applied to other medical situations as well.

Poster Presentation P-1 Gastrointestinal stromal tumor with extensive involvement of the small bowel: A rare presentation H P Nandeesh, Deepak Suvarna, H R Jeevan, H S Darshan Kumar, R Suchismitha, C P Madhu, G V Manjunath Departments of Gastroenterology, Medicine, Surgery and Pathology Background: A rare case of gastrointestinal stromal tumor with extensive involvement of the small bowel surviving with imatinib even after 4 years. Case Report: We describe a 28-year-old man who presented with melena since 2 years. Clinical examination did not reveal significant findings. CT abdomen showed few swellings (2–5 cm) on mesenteric border of small intestine. Radionuclide scan suggested distal ileum as probable bleeding site. Push enteroscopy showed multiple polypoidal and sessile rectangular lesions in jejunum. During laparotomy, multiple globular swellings were seen on the serosal surface of the jejunum and ileum. As tumor was unresectable due to extensive involvement of small bowel, portion of small bowel with swellings was sent for HPE. HPE revealed features of malignant GIST confirmed by immunohistochemistry CD-117 (KIT protein). The patient was treated with imatinib. Follow up PET scan was done which showed regression of small bowel lesions. Patient improved symptomatically. Conclusion: Thus, this case report offers an important contribution to a better understanding of rare presentation.

P-2 Consequences of long-term indwelling transmural stents in patients with walled off pancreatic necrosis and disconnected pancreatic duct syndrome Surinder S Rana, Deepak K Bhasin, Chalapathi Rao, Ravi Sharma, Rajesh Gupta Departments of Gastroenterology and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: There is limited data on the long-term consequences and safety profile of long-term indwelling transmural stents after successful treatment of walled off pancreatic necrosis (WOPN). Aim: To retrospectively evaluate consequences of long-term indwelling transmural stents in patients with WOPN. Methods: The records of patients who underwent endoscopic transmural drainage of WOPN and had disconnected pancreatic duct syndrome (DPDS) were analyzed.

A144

Results: Thirty patients (26 M; mean age 37.1±7.8 years) with long-term indwelling transmural stents and DPDS were followed up for a mean of 20.4±12.2 (range 3-38) months. The etiology of acute necrotizing pancreatitis was alcohol in 21, gallstones in 7 and idiopathic in 2 patients. In all patients, 2 or 2 and 7 (17 patients) or 10 Fr (13 patients) 5 cm double pigtail stents were placed. ERCP revealed disconnected PD at the pancreatic head, body and tail region in 22, 7, and 1 patient, respectively. Five patients (16.6 %) had spontaneous migration of stents (both the stents in four patients and one stent in one patient; 7 Fr in 4 and 10 Fr in one patient, respectively). Stent migration led to recurrence of pancreatic fluid collection (PFC) in one patient, whereas in the remaining four patients, it did not cause any symptoms. There was no recurrence of symptomatic PFC in remaining 25 patients. Conclusion: Long-term indwelling transmural stents in patients with WOPN and DPDS seem to be safe and also appear to decrease the risk of PFC recurrence.

P-3 Percutaneous transgastrostomal placement of jejunal feeding tube Avnish Seth, Pawan Rawal, Deepak Jha, Mandeep Singh, Gourdas Choudhuri Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon 122 002, India Percutaneous gastrostomy feeding may be associated with gastroesophageal reflux and aspiration, especially in patients with impaired gastric emptying. Conversion of percutaneous endoscopic gastrostomy (PEG) to PEGjejunostomy can be done using commercially available kits. We present the technique of percutaneous transgastrostomal placement of jejunal feeding tubes with an ultrathin endoscope through the already existing opening of PEG without the need of sedation. Case: 65-year-old male, a known diabetic for 10 years, was diagnosed with carcinoma larynx stage 3. He underwent total laryngectomy with bilateral neck dissection along with feeding gastrosotomy with placement of 20 F Foley catheter for feeding. Post-op, he developed pharyngocutaneous fistula. When feeding gastrosotomy was used, there was significant reflux of feed through pharyngocutaneous fistula due to possible diabetic gastroparesis necessitating discontinuation of feeds and starting parenteral nutrition. Conversion of feeding gastrosotomy to jejunostomy was planned. At 2 weeks post-op, allowing for tract maturation, a J-tipped Terumo guidewire was negotiated into stomach through the sideholes of Foley catheter. The Foley catheter was removed and guide-wire exchanged to 0.035 super stiff Jagwire. Ultrathin endoscope (Olympus GIF XP180N, outer diameter 5.5 mm) was passed over the guide-wire into the stomach, duodenum and into the proximal jejunum. Freka nasogastric tube was then placed over the guide-wire into proximal jejunum and the position was confirmed fluoroscopically. Conclusions: Ultrathin endoscope can be used to place jejunal feeding tubes by transgastrostomal route by a simple, quick, and safe procedure without the need of any sedation.

P-4 Treatment of diabetic gastroparesis with endoscopic intrapyloric Botox injection Avnish Seth , Pawan Rawal , Ishita B Sen , Vineet Pant , Gourdas Choudhuri Department of Gastroenterology and Hepatobiliary Sciences, Fortis Memorial Research Institute, Gurgaon 122 002, India

Indian J Gastroenterol (November 2013) 32(Suppl 1):A142–A146

Injection of Botulinum toxin A has been used as a therapy for various spastic disorders. We describe a patient where intrapyloric injection of Botulinum toxin was used successfully for treatment of diabetic gastroparesis refractory to prokinetics. Case: 43-yearold male with type 2 diabetes mellitus with neuropathy, retinopathy and nephropathy presented with recurrent vomiting for 8 months. Upper GI endoscopy was normal. He required repeated hospitalization due to inability to retain solids or liquids despite high dose of prokinetics, proton pump inhibitors and good glycemic control. Solid gastric emptying study with 15 mCi of sulphur colloid showed evidence of gastroparesis with 93 % retention at 1 h and 64 % at 2 h despite ondansetron 8 mg thrice daily and levosulpiride 25 mg thrice daily. One hundred units of Botulinum toxin was injected at pylorus, 25 U into each quadrant, by using 23 G sclerotherapy needle with needle length of 5 mm. Care was taken to inject deep and avoid submucosal injection. The procedure was well tolerated. Oral feed were resumed 4 h after the procedure and prokinetics were continued. There was marked clinical improvement with no recurrence of vomiting. The patient was discharged the following day. Repeat solid gastric emptying study at 2 weeks showed significant improvement in the transit of the radioactive meal from the stomach into the proximal bowel. The patient continues to do well at 10 weeks follow up. Conclusion: Endoscopic intrapyloric Botulinum toxin injection may be an effective treatment modality for treatment of gastroparesis refractory to medical management.

P-5 Comparative utility of CT and EUS in evaluation of pancreatic fluid collections following acute pancreatitis Sreekanth Appasani, Jahangeer Basha, Naveen Kalra, Saroj Kant Sinha, Vikas Gupta, Thakur Deen Yadav, Kartar Singh, Rakesh Kochhar Departments of Gastroenterology, Radiodiagnosis and General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim: To evaluate the role of CT and endoscopic ultrasound (EUS) in patients with acute pancreatitis (AP) having fluid collections. Methods: Twenty-five patients (age 41.84±11.7 years, 22 males) with AP-associated fluid collection(s) underwent CT and EUS when the nature of collection(s) (based on 2012 Atlanta criteria) and presence of solid debris [SD; minimal (50 %)] were recorded and the two modalities compared. Results: Of 29 fluid collections in 25 patients (mean size 10.7± 5.14 cm), four were distant (demonstrated only on CT) and 25 were peripancreatic (demonstrated on both CT and EUS). Of the latter 25, 6 (24 %) were classified as acute necrotic collections (ANC), 16 (64 %) as walled off necrosis (WON) and 3 (12 %) as pseudocysts. SD was detected on CT in 6/25 and on EUS in 24/ 25. All the ANCs labelled on CT had profound SD while pseudocysts labelled on CT had minimal SD; all of whom were managed conservatively. Amongst WONs labelled on CT, four (24 %) had minimal SD which could be managed conservatively, nine (57 %) had moderate SD, five of whom were managed conservatively and three (18 %) had profound SD; all of whom required intervention. Conclusion: EUS is a better modality than CT to classify fluid collections in AP. EUS quantification of solid debris can be used as a guide for selection of treatment modality. Solid debris significantly decreases with time as the fluid collections evolve from ANC into WON making EUS as a better modality for follow up of fluid collections.

Indian J Gastroenterol (November 2013) 32(Suppl 1):A142–A146

P-6 Evaluation of quality and patient satisfaction during endoscopic procedures Rajiv Baijal, K H R Praveen, Deepak Gupta, Nimish Shah, Sandeep Kulkarni, Soham Doshi, Deepak Amarapurkar Jagjivan Ram Railway Hospital, Maratha Mandir Marg, Behind Maratha Mandir Cinema, Mumbai Central, Mumbai 400 008, India Objectives: There are limited published studies on patient satisfaction and quality in endoscopy from Asia. We performed a survey to study patient satisfaction and quality of endoscopy. Methods: This was a prospective cross-sectional study of consecutive patients undergoing endoscopy in the Department of Gastroenterology, Jagjivan Ram Hospital from January 1, 2013 to February 28, 2013 for patient satisfaction. All endoscopic procedures were done without sedation. Patients were given modified Group Health Association of America9 (mGHAA-9) questionnaire. Quality assessment was done according to the guidelines of the American Society of Gastroenterology. All patients who had undergone diagnostic and therapeutic gastroscopies and colonoscopies were included. Results: Three hundred patients were assessed and interviewed after the procedure. Mean age of patients was 43±14.36 years. Out of all the procedures, 236 (78.66 %) were gastroscopies while 64 (21.33 %) were colonoscopies. Mean score of patients regarding satisfaction on mGHAA-9 questionnaire was 30±3.965. Waiting times for endoscopy and discomfort during procedure accounted for 90 % of unfavorable responses. Problem rate of our study was 8.71 %. Ninety percent of patients were ready to undergo endoscopy again by the same physician. Ninety-six patients were ready for endoscopy at the same centre. The success rate of gastroscopy and colonoscopy was more than 95 %. There were no complications. Conclusion: Waiting time and discomfort during endoscopy were the main causes for patient dissatisfaction. Quality of endoscopic procedures at our centre is at par with international standards with acceptable complication rate and good patient satisfaction.

P-7 Comparative evaluation of structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis Surinder S Rana, Deepak K Bhasin, Chalapathi Rao, Ravi Sharma, Vishal Sharma, Rajesh Gupta Departments of Gastroenterology and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: Patients of acute necrotizing pancreatitis may develop pancreatic insufficiency, and this is more commonly seen in patients who have undergone surgery for pancreatic necrosis. There is paucity of data on structural and functional changes in pancreas after endoscopic management of pancreatic necrosis. Aim: Retrospectively evaluate structural and functional changes in pancreas after endoscopic and surgical management of pancreatic necrosis. Methods: The records of patients who underwent endoscopic transmural drainage of WOPN over the last 3 years and completed at least 6 months of follow up after recovery were analyzed. The structural and functional changes in these patients were compared with 25 historical surgical controls. Results: Twenty-six patients (21 M; mean age 35.4±8.1 years) who underwent endoscopic drainage for WOPN were followed up for 22.3± 8.6 months. On follow up, five (19.2 %) patients developed diabetes with

A145

three patients requiring insulin and one patient had steatorrhea that required pancreatic enzyme supplementation. The pancreatic fluid collection (PFC) recurred in one patient whose stents spontaneously migrated out. In surgery group, two (8 %) patients developed steatorrhea and 11 (44 %) developed diabetes on follow up. Five (20 %) of these patients had recurrence of PFC. On comparison of follow up results of endoscopic drainage with surgery, recurrence rates as well as frequency of endocrine and exocrine insufficiency was lower in the endoscopic group but difference was not statistically significant. Conclusions: Structural and functional impairment of pancreas is seen less frequently in patients of pancreatic necrosis treated endoscopically compared to patients undergoing surgical drainage.

P-8 Role of endoscopic ultrasonography in patients with first episode of idiopathic acute pancreatitis Anurag Govil, Mahendra Kumar Agarwal, Dinesh Agrawal, Harsh Udawat Department of Gastroenterology, Santokba Durlabhji Memorial Hospital, Jaipur 302 015, India Background/Aims: Acute pancreatitis (AP) evades an etiological diagnosis in up to 10 % to 30 % patients. This group, ie. idiopathic acute pancreatitis (IAP) is prone to a high recurrence (up to 70 %). Endoscopic ultrasound (EUS) is promising, but has been scarcely studied for elucidating the cause of IAP. This observational study is the first of its kind to study the role of EUS in elucidating the etiology after the first episode of IAP. Methods: All patients diagnosed to have first episode of IAP were included in the study and taken up for EUS examination after 6 weeks. Patients with conditions known to predispose or precipitate AP, like alcohol binge, drugs, metabolic or autoimmune conditions or even a positive family history were excluded from the study. Results: A total of 51 patients were included. EUS established the etiology in 29 (56.86 %) patients. It included CBD calculus in 5 (9.8 %), CBD sludge in 4 (7.8 %), gallbladder calculus in 2 (3.92 %), gallbladder sludge in 2 (3.92 %) and chronic pancreatitis (CP) in 16 (31.37 %) patients. Fourteen patients had a normal study and 8 patients had indeterminate CP. Conclusions: EUS is safe and has a high diagnostic yield in patients with first episode of IAP. CP and biliary lithiasis are the most frequent etiologies identified. EUS should be included in the diagnostic protocol after the first episode of IAP rather than waiting for recurrent episodes.

P-9 Balloon dilatation for gastric outlet obstruction due to gastroduodenal tuberculosis Saroj Kant Sinha, Rakesh Kochhar, Jahangeer Basha, Anupam Lal, Kim Vaiphei, Pradeep Siddappa, Kartar Singh Departments of Gastroenterology, Radiodiagnosis, and Histology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: Gastroduodenal tuberculosis is an uncommon cause of gastric outlet obstruction (GOO). Balloon dilatation is an emerging modality for definitive therapy of gastrointestinal strictures. Methods: The study included patients with symptomatic GOO due to gastroduodenal tuberculosis seen over 5 years. Diagnosis of tuberculosis was based on characteristic histopathological findings or typical radiological finding and response to antitubercular treatment (ATT). All

A146

patients received ATT and proton pump inhibitor. Balloon dilatation was done using CRE balloon at 2–4 weeks interval till a diameter of >15 mm was achieved. Results: The study included nine patients (four females). Age ranged from 18 to 58 (37.4+14.7) years. Presenting symptoms included vomiting (100 %), pain abdomen (100 %) and fever (22.2 %). Site of obstruction was antrum in five, duodenum in three and gastrojejunostomy site in one patient. Biopsy and aspiration cytology showed non-caseating granulomas in eight, caseating granulomas in one and acid fast bacilli in two patients. The initial size of CRE balloon used was 10 mm in three, 12 mm in three and 15 mm in three patients. Final balloon size was 15 mm in eight and 18 mm in one patient. All patients improved symptomatically. One patient is still on dilatation programme. No serious complication like significant bleeding or perforation was noted. Two patients had transient exacerbation of pain. Conclusions: Balloon dilatation, along with ATT, is an effective and safe therapy for gastric outlet obstruction due to gastroduodenal tuberculosis.

P-10 Fully covered metal stent for treatment of pancreatic pseudocyst: Initial experience Praveer Rai, Sachin Munjal, Manohar Lal Sharma, V A Saraswat Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India Background: Endoscopic ultrasound guided drainage is the mainstay of treatment for symptomatic pseudocyst. Plastic stents used for endoscopic cystogastrostomy are prone to blockage because of narrow calibre and lead to incomplete drainage and infection. Moreover, multiple stents may be needed; placement of which is labor intensive. Biliary and esophageal stents have been used for endoscopic cystogastrostomy; however, these stents have high chances of migration and bleeding. Aim: To evaluate role of novel fully covered self-expanding metal stent with flared ends (NAGI stent) for endoscopic cystogastrostomy. Design: A consecutive case series. Setting: Tertiary-care academic medical centre. Patients : Five consecutive patients with symptomatic pancreatic pseudocyst. All patients had symptoms in form of pain, fever or vomiting. All patients were either poor surgical candidates due to underlying significant comorbidities or declined surgical treatment. Intervention: All patients underwent EUS guided stent deployment for pseudocyst drainage. Main outcome measurement: Technical and clinical success rate and stent related complication and removability. Results: Technical success achieved in all cases (5/5, 100 %). Clinical success in five out five of five cases (100 %). One patient had procedure related pneumoperitoneum, which was managed conservatively. No late complication observed. Follow up period ranges from 60 to 143 (93) days. Stents were removed without any complications in all patients after 6–7 weeks. Conclusion : Use of fully covered self-expanding metal stent for pseudocyst drainage is feasible and safe.

P-11 Endoscopic therapy for pain relief in tropical chronic pancreatitis: A prospective follow up study Praveer Rai, Manohar Lal Sharma, Sachin Munjal, V A Saraswat Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India

Indian J Gastroenterol (November 2013) 32(Suppl 1):A142–A146

Background: Pancreatic endotherapy is an established modality for pain in chronic pancreatitis. However, there are only few reports of long-term follow up studies from India. Aim: To assess the response of endoscopic therapy in pain relief as assessed by visual analogue scale in patients with chronic pancreatitis. Patients and Methods: We prospectively followed up 30 patients with chronic pancreatitis in whom endotherapy was done. Pain was assessed on visual analogue scale from 0 to 10. Extracorporeal shockwave lithotripsy (ESWL) was done prior to endotherapy in patients with stone size more than 5 mm. Results : Etiology was idiopathic in 25 (83 %) and alcohol in five. Average pain duration was 48 months before endotherapy. Pancreatic head stones were present in 26 (87 %) patients. Eleven (37 %) patients had stone disease, 15 (50 %) had both stone and stricture and three patients had stricture alone. In 18 (60 %) patients, ESWL was done and complete and partial fragmentation was achieved in 11 (61 %) and seven (49 %) patients, respectively. Seven patients underwent one session, eight patients underwent two sessions, two patients underwent three sessions and one patient underwent four sessions of ESWL. Pain relief was achieved in 28 (93 %) patients, complete in 21 (70 %) and partial in seven (23 %). Mean duration of follow up was 15.8 months. Complications of mild pancreatitis and stent block occurred in five patients. Conclusion: Pancreatic endotherapy along with ESWL is a good first line treatment modality for pain relief in tropical chronic pancreatitis.

P-12 Stress reduction in Shavasan yogic posture (corpse position) during upper gastrointestinal endoscopy Raj Kotwal, C Z Rinchen Health and Home Departments, Government of Sikkim, Shunyata, Gangtok, Sikkim Introduction: The study was to examine the effects of Shavasan on elevated state of anxiety during upper gastrointestinal (GI) endoscopy. A GI endoscopy service requires suitable ambient environment. Natural anxiety may be aggravated by horror stories from friends or inappropriate remarks by endoscopy staff. Yogic techniques in general and Shavasan in particular are known to improve psychosomatic health and enhance one's ability to combat stressful situations. Methods: Many patients become stressed and anxious during diagnostic procedures. The study was conducted on 63 consecutive patients undergoing endoscopy for various reasons. Patients were randomly assigned to two groups regardless of sex, age and underlying disease. One group of 32 patients relaxed in Shavasan before the procedure. Control group had 31 patients. Blood pressure, heart rate and respiratory rate were recorded at the beginning and end of procedure. Perception of procedure using a 5point attitude scale was assessed. Results: Results indicate that relaxation in Shavasan is effective in reducing psychological stress during gastroscopic examination and any other medical situation as well, which tend to generate undue stress and anxiety. Statistically significant difference in systolic blood pressure, heart and respiratory rate were recorded in subjects; no change in parameters in control. Acceptance of procedure using a 5-point scale was recorded. Conclusion: Preliminary study to see the effects in anxiety and stress in upper GI endoscopy subjects. Useful in many other medical and day to day situations that generate anxiety and stress. Relaxation in Shavasan leads to physical and mental relaxation. Repeated practice is essential.