Indian J Gastroenterol (November 2012) 31(Suppl 1):A128–A138 DOI 10.1007/s12664-012-0263-4

ABSTRACTS

Society of Gastrointestinal Endoscopy of India

Published online: 18 October 2012 # Indian Society of Gastroenterology 2012

Oral Presentation 01 Endoscopic band ligation for treatment of nonvariceal upper gastrointestinal bleeding in a tertiary care bleed centre Arunkumar Krishnan, Vimalraj Velayutham, Jeswanth Satyanesan, Surendran Rajagopal Department of Gastroenterology and Hepatology, Stanley Medical College Hospital, Chennai 600 001, India Background and Aim: Acute nonvariceal upper gastrointestinal bleeding (NVUGIB) is a challenging emergency condition. Early endoscopic therapy has recommended as the first-line treatment for upper gastrointestinal bleeding as it has been shown to reduce recurrent bleeding. Aims: To determine the various causes of nonvariceal gastrointestinal hemorrhage and discuss the role of band ligation. Patients and Methods: Between November 2007 and December 2010, 74 patients were treated with endoscopic band ligation (EBL) who had NVUGIB were included for the study. Bleeding lesions included Dieulafoy’s ulcer, Mallory-Weiss tear, duodenal ulcer, post surgical anastomosis bleed and gastric ulcer after polypectomy. After basic life support was provided, all patients underwent emergent and elective endoscopy. Results: These comprised 49 (66.2 %) males and 25 (33.8 %) females. The mean age was 48.2±6.4 years for males and 40.6 ± 2.2 years for females. MalloryWeiss tear and Dieulafoy’s lesion constituted the majority of bleeding lesions 26 and 17 respectively requiring EBL. Other causes were: pre-pyloric ulcer 11; duodenal

ulcer 9; ulcers in antrum 5; post polypectomy bleed 3; anastomosis bleed 1; malignant lesions 2. Bleeding stopped after endoscopic therapy in 96.5 % of patients. The single failure was in bleeding from a pre-pylori lesion. Injection sclerotherapy with 1:10,000 adrenaline solution and EBL was not successful. Conclusion: EBL provided safe and effective modality for hemostasis in NVUGIB. EBL could be considered as a primary or alternative method of choice for treatment of endoscopic hemostasis in patients with NVGIB.

02 Endoscopic ultrasound vs. endoscopic retrograde cholangiography in patients with moderate risk of common bile duct stones Rajesh Puri, Rajesh Sharma, Randhir Sud, Ragesh Babu Thandassery Medanta Institute of Digestive and Hepatobiliary Sciences, Medanta, Gurgaon Haryana 122 001, and Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Endoscopic ultrasound (EUS) prior to endoscopic retrograde cholangiography (ERC) can avoid unnecessary ERC and related complications. Aims: To evaluate the efficacy of EUS in suspected common bile duct (CBD) stone and its impact on subsequent need of ERC in moderate risk groups. Materials and Methods: One hundred patients with history of gallstone disease and moderate risk for CBD stones [CBD size >7 mm, any level of bilirubin, >2 times elevated alanine transaminase and alkaline phosphatase] were

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randomized into 2 groups; group 1 (underwent EUS and ERCP, n050) and group 2 (EUS with/without ERC, n050) were evaluated prospectively over 1 year, for occurrence of CBD stones and efficacy of EUS and procedure related complications. Results: In Group 1, 24/50 patients had CBD stone on EUS which were removed by ERC. EUS detected CBD stone in 2 patients, which were missed on ERC. Also 26 (52 %) patients underwent unnecessary ERC in this group. Four of fifty patients developed mild complications during ERC (mild pancreatis and mild sphincterotomy site bleed in 2 each). In group 2, ERC was performed only if stone was present in CBD (n028) and rest had uneventful follow up. Two patients had mild post ERC pancreatitis. Thus in 22 patients (44 %) unnecessary ERCP could be prevented. Overall rate of complications was higher in ERC (6 out of 78) than EUS (none out of 100), p00.001. Conclusions: EUS is an accurate, safe and cost effective method to diagnose CBD stones in patients with moderate risk for CBD stones.

03 New technique of railroading procedure for transnasal placement of devices following transoral endoscopy Yalaka Rami Reddy, Surinder S Rana, Chalapathi Rao, Deepak K Bhasin Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Traditional procedures of railroading cause discomfort to the patient with chances of trauma to posterior pharyngeal wall, as well as accidental bite injury to technician/endoscopist. Aim: To describe a novel technique of railroading, in which there is decreased discomfort to the patient and no need to use any instrument or transoral finger manipulations by technician/endoscopist. Methods: The patient is explained clearly about the whole procedure with special emphasis not to swallow the Ryle’s tube when it enters into the oral cavity after insertion through anterior snares. Insert the Ryle’s tube through anterior snares up to a length equal to distance between anterior snares and tragus of ear on the corresponding side. Instruct the patient not to swallow the Ryle’s tube while applying gentle pressure over cricoid cartilage with the assistance of a second person. On further advancement, the Ryle’s tube comes into the oral cavity with or without loop formation. Thus, there is no need of any instrument or transoral manipulation with fingers.

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Results: This technique was prospectively applied on 30 patients, and was successful in 28 patients. One patient was extremely uncooperative, in whom RT came over dorsum of tongue and other patient needed transoral manipulations with fingers. None had aspiration or transtracheal passage of the tube. Conclusion: We have described a new technique of railroading for placement of transnasal devices like nasojejunal tube, nasogastric tube, nasobiliary drain and nasopancreatic tube following transoral endoscopy so as to reduce discomfort.

04 Clinical presentation, radiological features and endoscopic management of mediastinal pseudocysts Deepak K Bhasin, Surinder S Rana, Chalapathi Rao, Rajesh Gupta, Mandeep Kang, Saroj K Sinha, Birinder Nagi, Kartar Singh Departments of Gastroenterology, Surgery and Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: There is paucity of data on clinical and imaging features as well as experience with endoscopic drainage in mediastinal pseudocysts. Objective: Evaluate clinical presentation and results of endoscopic drainage in 12 cases of mediastinal pseudocysts. Patients: Twelve patients with mediastinal pseudocysts (male: 10; mean age±SD: 36.1±9.8 years) were retrospectively analyzed. All patients were treated with attempted endoscopic transpapillary drainage. Results: Nine patients had chronic pancreatitis and 3 acute pancreatitis. Majority of patients (8/11; 67 %) had alcohol as etiology for underlying pancreatitis. Only 2/12 (17 %) patients had dysphagia because of compression of the esophagus by the pseudocyst. The size of pseudocysts ranged from 2 to 8 cm (median 4 cm). Endoscopic retrograde pancreatography was done in 11 patients. All patients had single partial disruption and it could be bridged in 10/11 (91 %) patients. 5 Fr stent was placed in 5 patients and 5 Fr NPD in 5 patients. In one patient, pancreatic sphincterotomy alone was performed. All the patients had marked improvement in their symptoms following endoscopic drainage and the mediastinal pseudocysts resolved within 6 weeks (median 4 weeks). There has been no recurrence of symptoms over a follow up period of 4 months to 10 years. Conclusion: Mediastinal pseudocysts infrequently cause compressive symptoms and endoscopic transpapillary drainage is a safe and effective modality for their treatment especially when there is partial ductal disruption and the disruption can be bridged by an endoprosthesis.

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O5 Biodegradable stents for caustic esophageal strictures: do they work ? Rakesh Kochhar, Gourdas Choudhuri, Sundeep Lakhtakia, Abhai Verma, Abdul Khaliq, Sreekanth Appasani, D Nageshwar Reddy Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, Department of Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, and Department of Gastroenterology, Asian Institute of Gastroenterology 6-3-661, Somajiguda, Hyderabad 500 082, India Aims: To study the response of biodegradable stents (BD) (ELLA, Czech Republic) in patients with refractory caustic esophageal strictures (CES). Material and Methods: Thirteen patients (18–72 years, 9 males) of refractory CES were subjected to placement of BD stents. Patients were followed weekly for 1 month and then monthly for 6 months with periodic endoscopies. Immediate and delayed complications were noted. Results: The BD stent was placed successfully in all 13 patients with no immediate complication of bleeding, or perforation or migration. The size of the stent was 23 mm in width in all with 80 mm of length in 12 patients and 115 mm of length in 1 patient. Pain in retrosternal area was reported by all the 13 patients postprocedure which persisted a week (n010); 2 weeks (n06) and till 8 weeks (n02). One patient had stent migration at 4 weeks. Tissue hyperplasia was noted in 6 patients at the proximal end at 3– 4 weeks. Stent disintegration completed by 12 weeks in 12 patients with stent in-situ. Nine of thirteen patients had restenosis at 3 months, 10/12 at 6 months and 11/13 at 1 year. Patients with recurrence of stricture were subjected to dilatation (n09)/surgery (n02). At esophagectomy, in one patient, no residue of the stent or tissue reaction was found. Two patients (16 %) were free of symptoms at 1 year including the one with migration of stent. Conclusions: Biodegradable stents do not provide long term relief in a majority of patients with CES. Stents with longer time to degradation may be more effective.

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Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Aim: To compare the response of benign esophageal strictures to dilatation with Savary-Gilliard (SG) bougie dilators or controlled radial expansion (CRE) balloon dilators (Boston Scientific Inc). Material and Methods: Consecutive patients with benign esophageal strictures were randomized to undergo dilatation with SG/CRE dilators until a target of 15 mm was reached. Dysphagia relief, complications, recurrences and number of dilatations required to reach 15 mm were noted. Recurrence was defined as need for dilatation 1 month after reaching end point (15 mm). On follow up dilatation frequency was calculated as dilatations per month in patients with recurrences. Results: One hundred and six patients (mean age—50.1± 17.3 years, 62 % males) were randomized to receive either CRE/SG dilatation after an informed consent. The etiology of strictures was corrosives in 32 %, peptic (17 %), anastomotic (25 %), radiation (14 %) and miscellaneous in 11 %. Ninety-one percent of patients had single stricture, 7 % had 2 and 2 % has multiple strictures. Out of 79 patients who could achieve the target of 15 mm dilatation, 38 patients underwent CRE dilatation while 41 patients underwent SG dilatation. Complete improvement was noted in 76 % of patients while 24 % still required dilatations on follow up. There was no difference in occurrence of complications in SG/CRE group. When CRE and SG dilatators were compared, number of dilatations required to reach 15 mm were similar to both groups (p00.567) but on follow up mean dilatation frequency (dilatations/month) was significantly higher in CRE group (1.4+0.7) than in SG group (0.9+0.5) (p00.002). SG group had better final outcome than CRE group (p00.011). Conclusion: While both CRE and SG dilators were equally effective in achieving end point of 15 mm patients treated with CRE dilators had more recurrences and required more dilatations on follow up.

Poster Presentation P1

06 Comparison between balloon and bougie dilators: a randomized controlled trial Rakesh Kochhar, Sreekanth Appasani, Abdul Khaliq, Mohd T Noor, Ragesh Thandassery, Usha Dutta, Kartar Singh

Effect of biliary stenting for large and multiple common bile duct pigment stones in elderly and high risk patients Arunkumar Krishnan, Ravi Ramakrishnan, Jayanthi Venkataraman Department of Gastroenterology and Hepatology, Stanley Medical College Hospital, Chennai 600 001, India

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Background: Different endoscopic modalities are available for the extraction of common bile duct (CBD) stones. The aim is to analyze the effectiveness of interim™ plastic biliary stent deployment in difficult pigment stones. Methods: Patients who had comorbid illness and elderly patients who are not fit for surgery were included. Endoscopic plastic biliary stenting was performed in 35 patients with large and/or multiple CBD stones. Bile duct drainage and endoscopic placement of 7 Fr plastic biliary stents were established in all patients. The diameters of the CBD stones were measured on the radiographs before and after stenting. Results: In this 11 patients has multiple CBD stones (>3) and 26 patients had large stones (>2 cm). Stone retrieval was possible, after a median of 24 days. All patients had reductions in the stone number and/or stone size. In 6 patients there was spontaneous clearance of the stones from the CBD. The median number and size of stones per patient was significantly reduced after biliary stenting compared with before {5 (3) vs. 2.0 (1.0) [p < 0.001]} respectively. All the stones were black and amorphous in consistency. Conclusion: Plastic biliary stenting was safe and effective in the management of difficult stones in elderly and high risk patients. It may fragment common bile duct stones and decrease stone sizes. Unlike the reports from the West, shorter period of deployment was sufficient for pigment stones, unlike the hard cholesterol stones reported from the West.

P2 Analysis of colonoscopic findings in the characteristics between intestinal tuberculosis and Crohn’s disease Arunkumar Krishnan, Jayanthi Venkataraman Department of Gastroenterology and Hepatology, Stanley Medical College, Chennai 600 001, India Introduction: Tuberculosis of the gastrointestinal tract and Crohn’s disease are chronic granulomatous disorders with similarities in clinical presentation and pathology. Aim was to identify the distinctive characteristics of ileocecal and colonic TB and Crohn’s disease (CD) at colonoscopy and to correlate the colonoscopic findings with histology. Methods: Eighty-two patients were chosen on the basis of clinical history, colonoscopic findings, diagnostic histology, response to treatment. Patients at extremes of age (<14, >61 years), known case of TB or CD on treatment and follow up, IBD radiation induced injury and diverticular disease were excluded. Results: Fifty-eight individuals fulfilled the criteria. Among the 58 cases who underwent colonoscopy, 55.2 % patients had

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features favoring TB, 11.9 % had features of CD. Colonoscopic findings of isolated ileal involvement, aphthous ulcer, cobble stoning long-segment strictures, and perianal involvement favored a diagnosis of CD (p<0.05). Histopathology confirmed intestinal tuberculosis (ITB) in 15.5 %, CD in 27.6 %, and inconclusive histology in 31 % and nonspecific colitis in 25.9 %. Colonoscopy correlated with histology in 18.8 % patients with ITB and 54.4 % with CD. Colonoscopy was only 50 % accurate with 66 % sensitivity, 47 % specificity for ITB, where as it was 84 % accurate with 37.5 % sensitivity, 84 % specificity for CD. Multi variant analysis showed the presence of mucosal nodularity predicted ITB and aphthous ulcers with isolated ileal involvement predicted CD. Conclusion: Colonoscopic findings of isolated ileal involvement, aphthous ulcer, cobble stoning long segment strictures, skip lesions than that of IBD. The accuracy, sensitivity and specificity of colonoscopy were superior in the diagnosis of Crohn’s disease than TB.

P3 Endotherapy in pancreatitis—an audit Raja Yogesh K, Ratnakar Kini, Kani Sheik, K Prem Kumar, T Pugazhendhi, Mohamed Ali Madras Medical College, Chennai 600 003, India Endotherapy is one of the effective therapeutic modalities for pancreatitis and its complications. Complications that can be managed endoscopically include pseudocysts, pancreatic-duct leaks, pancreatic strictures and concomitant biliary disease. Objective: To audit the array of endotherapies done in the management of pancreatitis and its complications. Materials and Methods: The study was done by reviewing an endoscopic database of seventy patients (56-M, 14-F; aged 12–75 years) with pancreatitis who were taken up for endotherapy between January 2008 and June 2012. Fortyeight had chronic pancreatitis, sixteen had acute pancreatitis, five had traumatic pancreatitis and one had pancreasdivisum. The most common complication associated was pseudocyst (25), followed by pancreatic ascites (12), obstructive jaundice (5), pancreatic abscess (1) and pancreatic pleural effusion (1). Out of seventy patients, ERCP was attempted in sixty-one patients and EUS in 10. Results: ERCP was successful in fifty out of sixty-one patients. Three had a normal pancreatogram. The therapeutic interventions included sphincterotomy in eleven patients, pancreatic duct stenting in sixteen, transpapillary pseudocyst drainage in two and biliary stenting in eight. EUS was required in ten. EUS guided

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aspiration of pseudocyst was done in seven patients. Three underwent EUS guided trans-mural drainage, and one patient with infected pseudocyst underwent nasocystic drainage. Three had procedural bleed—managed endoscopically, 4 had post-ERCP pancreatitis—managed conservatively, two had late bleed—managed with relook endoscopy and therapy, and 3 patients returned with stent blockage—managed with stent exchange. Conclusion: Endotherapy is a relatively safe and effective modality in the treating pancreatitis and its complications.

P4 A study on clinical profile and endoscopic findings in post gastrojejunostomy patients R Vinoth Kumar, G Ramkumar, Muthukumaran, R Balamurali, P Ganesh, S Jeevan Kumar Department of Digestive Health and Diseases, Kilpauk Medical College, Poonamallee High Road, Kilpauk, Chennai 600 010, India Aim: To study the clinical profile and endoscopy findings in post gastrojejunostomy patients. Materials and Methods: This is a retrospective study. Data was collected from endoscopic registers and case study books of postgastrojejunostomy patients who attended our department between July 2011 and June 2012. Results: Total number of patients studied was 52. The commonest surgery was gastrojejunostomy—45 (86 %) followed by subtotal gastrectomy with GJ—6 (12 %) and pyloroplasty with GJ—1 (2 %). The cause for initial surgeries included complicated peptic ulcer—31 (59 %), malignancy—13 (25 %) and corrosive injury—8 (16 %). The common symptoms for which endoscopy was done include pain abdomen— 24 (46 %), weight loss—9 (17 %), vomiting—4 (7 %), dysphagia—4 (7 %) and others (23 %). The clinical signs included anemia—29 (55 %), koilonychia—4 (7 %) and others (38 %). The commonest endoscopic findings : bile gastritis —24 (46 %), peristomal edema/ulcer/lesion—11 (21 %), reflux esophagitis—5 (9 %), peristomal carcinoma developed in 3 patients (5 %) after a mean of 18 years, esophageal stricture —4 (7 %), esophageal varices—3 (5 %), postcricoid web—3 (5 %), esophageal candidiasis—2 (3 %), growth at D1 and D2 junction—2 (3 %) and gastric polyp—2 (3 %). Conclusion: The commonest postoperative stomach seen endoscopically in our department was isolated gastrojejunostomy followed by subtotal gastrectomy with GJ. Pain abdomen was the commonest symptom whereas anemia was the commonest sign. The commonest endoscopic finding was bile gastritis, followed by reflux esophagitis. Peristomal carcinoma developed in 5.5 % of previously benign

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gastrojejunostomy patients after a mean of 18 years. Hence malignancy should always be considered and endoscopic screening should be started early while evaluating a patient with post gastrojejunostomy.

P5 Nonsurgical management of pancreatic pseudocysts associated with arterial pseudoaneurysm Deepak K Bhasin, Surinder S Rana, Vishal Sharma, Chalapathi Rao, Vivek Gupta, Rajesh Gupta, Mandeep Kan, Kartar Singh Departments of Gastroenterology, Radiodiagnosis and Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Pseudoaneurysms associated with pancreatic pseudocysts are different from simple, isolated pancreatic pseudoaneurysms and there is paucity of published data on their nonsurgical treatment. Aim: To retrospectively analyze results of combination of angioembolization or thrombin injection followed by endoscopic transpapillary drainage for management of pseudoaneurysms associated with pancreatic pseudocysts. Methods: Eight patients (all males; mean age±SD: 31.2± 6.1 years; age range: 21–38 years) underwent radiological management of the pseudoaneurysm followed by endoscopic drainage of the pseudocysts. Results: All patients had pseudocysts (median size 4 cm) with underlying chronic pancreatitis (etiology: alcohol in 5 (62.5 %) and idiopathic chronic pancreatitis in 3 (37.5 %) patients). All patients had abdominal pain on presentation and 7/8 (87.5 %) patients had presented with overt gastrointestinal bleeding. The size of the pseudoaneurysms varied from 1 to 4 cm. The location of pseudoaneurysm was in the gastroduodenal artery in three patients and splenic artery in five patients. Two patients were treated with percutaneous thrombin injection whereas six patients underwent digital subtraction angiography and angioembolization. One patient had a rebleed after percutaneous thrombin injection and required additional angioembolization. All 8 patients underwent successful endoscopic transpapillary drainage through the major (5) or minor papilla (3) and resolution of pseudocysts was noted within 6 weeks (median 4 weeks). No significant complication of the procedure was noted in any of the patients. Conclusions: Pseudoaneurysms associated with pancreatic pseudocysts could be successfully and safely treated with a combination of radiological obliteration of the pseudoaneurysm followed by endoscopic transpapillary drainage.

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P6 Retrospective analysis of ERCP procedures: seven years experience from a single centre in Odisha Chitta Ranjan Panda, Haribhakti Seba Das, Prakash Chandra Dalai, Shreejoy Pattanaik Department of Gastroenterology, S C B Medical College, Cuttack 753 007, and Shanti Hospital Pvt Ltd, Cuttack 753 001, India Background: There is no comprehensive data available till date about ERCP procedures from Odisha. For the first time, we present our data of 7 years experience in ERCP from a single centre at Cuttack. Aim: To determine the etiological profile of patients who underwent ERCP procedures from July 2005 to July 2012. Methods: All ERCP procedures were performed with either propofol administration or under GA, using Olympus video endoscopes and standard accessories. Results: A total of 1,038 cases underwent therapeutic ERCP procedures from July 2005 to July 2012, out of which 636 (61 %) were males and 402 (39 %) were females with age range between 20 and 80 years. Eight hundred forty-six (83 %) had diagnosis of malignant biliary obstruction which includes 678 (78 %) cases of CaGB with hilar obstruction, 108 (12.5 %) cases of periampulary growth, 36 (4.6 %) cases of Ca head pancreas with biliary obstruction and 42 (4.8 %) cases of cholangiocarcinoma. Benign etiology was found in 174 (17 % of total cases), out of which 138 (13 %) had bile duct stones, 11 had chronic pancreatitis (CBD obstruction—4, MPD stones/strictures—7), post cholecystectomy bile duct stricture in 19, biliary ascariasis in 4 and ruptured hydatid cyst in to CBD in 2 cases. Failure of procedure observed in 102 (9.8 %) cases. One hundred seventy-four (16.8 %) had procedure related complications comprising of cholangitis in 156 (15 %) and pancreatitis in 18 (1.7 %) cases. Conclusion: Malignant etiology far exceeded benign etiology in the ERCP procedures done in Odisha, and the failure and complication rates were within acceptable limits.

P7 Fully covered self-expanding metallic stent placement is effective for dilatation of benign refractory esophageal strictures Akash Shukla, Chirag Shah, Hardik Parikh, Tejas Modi, Shobna Bhatia Department of Gastroenterology, Seth G S Medical College and K E M Hospital, Mumbai 400012, India

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Background and Aim: Refractory benign esophageal stricture is defined as inability to dilate a stricture to a diameter of 14 mm after 5 sessions at 2-weekly intervals. Removable self-expanding metallic stent (SEMS) are a treatment option for these strictures. We retrospectively analyzed the data of patients who underwent fully-covered SEMS placement for refractory benign esophageal stricture. Methods: Four patients with refractory benign esophageal stricture (peptic 2 [length of stricture 2 and 3 cm], corrosive 2 [length 8 and 10 cm]), who did not respond to conventional dilatation protocol with Savary-Gilliard dilators and steroid injections, underwent SEMS (HV stent, ELLA) placement under fluoroscopic and endoscopic guidance. The stent was removed after 4 weeks as per manufacturer’s recommendation. All patients were monitored at onemonthly for a minimum of 6 months. Results: Stent could be placed in all patients. There was no stent migration. There was no difficulty in removing stents. One patient developed severe pain following stent placement, which could be managed with analgesics. Median follow up was 7 months (range 6–12). Both patients with peptic strictures responded well without need for dilatation till date. One patient with corrosive stricture developed recurrence of symptoms after 1 month and was referred for surgery. The second patient had recurrence of symptoms after 6 months and needed dilatation only once. There were no serious adverse events. Conclusions: Fully covered SEMS were safe and effective for refractory benign esophageal strictures, especially for short segment peptic strictures.

P8 An unusual complication of ERCP Mallikarjun Patil, Keyur Sheth, Adarsh C K, Girisha B St. John’s Medical College, Bangalore 560 034, India Introduction: Among the endoscopic procedures of upper gastrointestinal tract, ERCP has greater likelihood of procedure related complications. Extraluminal hemorrhagic complications are relatively rare in ERCP, reported in form of case reports. We present a rare complication of subcapsular hepatic hematoma with ERCP due to guide wire injury. Materials and Methods: A 50-year-old male presented to us with right upper quadrant abdominal pain, jaundice and fever associated with chills for last 4 days. He was febrile, icteric with right upper quadrant tenderness on physical examination. Laboratory data showed leukocytosis with cholestasis on liver function test. Ultrasound (US) of abdomen showed dilated common bile duct (CBD) and gallstones. ERCP showed dilated CBD containing many calculi. Endoscopic spincterotomy was performed with

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successful clearance of stones and 7 Fr double pigtail stent was placed in view of cholangitis. He was asymptomatic for next 48 h, when he suddenly complained of right upper quadrant abdominal. His serum amylase and lipase were normal. An urgent US and subsequent CT scan demonstrated 5×3 cm subcapsular hepatic hematoma on right lobe of liver which was managed with percutaneous drainage and antibiotics. Conclusion: Subcapsular hematoma is a rare post ERCP complication. It is assumed that hematoma occurs as an accident rupture of intrahepatic bile duct and small blood vessels within the liver parenchyma, causing subcapsular hematoma formation. Conservative treatment involving antibiotics and analgesics is enough in most cases. However it should be included in post ERCP complications because early recognition and conservative management is enough in most of cases.

P9 Endosonographic evaluation of pancreas in patients with alcoholic liver disease Karam Singh Romeo, Sreekanth Appasani, Jahangeer Basha, V Singh, K Singh, R Kochhar Departments of Gastroenterology and Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Introduction: Co-association of alcoholic pancreatitis and liver disease has been sparsely described. Endoscopic ultrasound (EUS) has revolutionized detection of parenchymal changes in patients with pancreatitis. However, there is no data of pancreatic changes on EUS in patients with alcoholic liver disease (ALD). Aim: To study the pancreatic changes (both ductal and parenchymal) in patients with ALD. Materials and Methods: Seventy-four patients admitted in our department with symptomatic ALD were classified as alcoholic hepatitis/cirrhosis (mean age 41.78±10.5 years, all males) and were offered EUS after an informed consent. Diagnosis of cirrhosis was based on signs of portal hypertension, ultrasonographic evidence of altered echotexture, irregularity of margins or portal vein >14 mm; and in absence of clinical characteristics of alcoholic hepatitis. Pancreatic parenchymal and ductal changes were evaluated using the Pentax echoendoscope and Rosemont’s classification was used characterizing these changes. Patients with BMI >40, hepatitis B and C, HIV, diabetes mellitus and gallstones were excluded. Results: Sixty-eight patients with ALD agreed for EUS evaluation of the pancreas. Pancreatic involvement was found in 40 % of ALD patients, 5 patients (7 %) had features

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of chronic pancreatitis, 8 (12 %) had features suggestive of CP and 14 (21 %) patients had features of indeterminate of CP. No changes in pancreas were seen in 41 (60 %) patients. Subgroup analysis amongst types of liver disease (cirrhosis and alcoholic hepatitis) showed a trend of more changes in pancreas in patients with cirrhosis than alcoholic hepatitis but it was not statistically significant (p00.44). Conclusion: Better imaging with EUS enhanced the assessment of pancreas in patients with ALD. Pancreatic changes could also worsen with liver disease progression.

P10 Endoscopic clipping for duodenal Dieulafoy’s lesion Sreekanth Appasani, Jahangeer Basha, Amit Raj, S K Sinha, Kartar Singh, Rakesh Kochhar Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Case Report: A 45-year-old male presented to our emergency services with history of painless massive hematemesis accompanied with melena. There was no history of dyspepsia nor was the patient on nonsteroidal antiinflammatory drugs (NSAID). The patient was a chronic smoker. There were no other comorbidities. His clinical examination was noncontributory except for presence of pallor. The hematological examination revealed hemoglobin of 3 g/dL with normal platelet count and coagulation profile. The renal function, liver function tests and ultrasound of the abdomen were normal. The patient was resuscitated and blood transfused. Upper gastrointestinal endoscopy revealed altered blood in stomach with fresh blood in the second part of duodenum. After washing the duodenum, a small elevated protruding lesion over the duodenal fold with no surrounding ulcer and continuous ooze was noted. Possibility of a Dieulafoy’s lesion (DL) was considered. Hemostasis was achieved by applying hemoclip (Resolution Clip, Boston Scientific Inc.). Bleed subsided completely with no further ooze. Twenty-four hours later, relook endoscopy revealed normal duodenum with clip in situ and no further bleed or ooze. The patient improved with no further bleeding and was discharged later. Conclusion: Different therapies for Dieulafoy lesion were compared in various clinical trials. Second part of duodenum forms a difficult place to deploy clips in view of torque on the scope. Placing the clip slightly beyond the tip of endoscope in antrum and then extending into duodenum followed by shortening the scope eases the deployment of clip. Recurrence of bleeding was lesser with banding or clipping (8 %) than with injection therapy (33 %).

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P11 Tuberculosis presenting as dysphagia: clinical, endoscopic, radiological and endosonographic features Surinder S Rana, Deepak K Bhasin, Chalapathi Rao, Radhika Srinivasan, Kartar Singh Departments of Gastroenterology and Cytology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Dysphagia as a presenting manifestation of tuberculosis is rare and there is paucity of data on the clinical, endoscopic and endosonographic features of these patients. Patients and Methods: A retrospective analysis of the clinical, endoscopic, radiological, endosonographic and cytological findings in 14 patients (male:10; mean age:37.7± 10.4 years) with dysphagia due to tuberculosis presenting to us over last 4 years. Results: Nine patients (64.3 %) had grade 1, 4 (28.6 %) patients had grade 2 and one patient (7.1 %) had Grade 3 dysphagia. Mid-esophagus was the commonest site of involvement. Endoscopic findings were extrinsic bulge (50 %), linear ulcers (28.6 %) and polypoidal ulcerated lesion (7.1 %). Endoscopic biopsies were inconclusive. Endoscopic ultrasound (EUS) demonstrated mediastinal lymph nodes being responsible for endoscopic bulge and their infiltration into esophageal wall leading on to ulcers. EUS guided fine needle aspiration from these nodes established diagnosis in all patients. Conclusion: Dysphagia in tuberculosis is most commonly caused by compression by the surrounding mediastinal lymph nodes. EUS is a useful investigation for assessment of these patients.

P12 Endoscopic balloon dilatation for management of benign ileal strictures Surinder S Rana, Chalapathi Rao, Deepak K Bhasin Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Benign ileal strictures can cause considerable morbidity and have been conventionally treated surgically. Aim: To report our experience of endoscopic balloon dilatation in patients with benign ileal strictures of various etiologies. Methods: Over last 8 years, 9 patients (6 males; mean age 39.7 ±13.2 years) with benign terminal ileal strictures were treated

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by endoscopic balloon dilatation. Dilatation was repeated every 2 weeks with the end point being dilation of 15 mm or surgery. Results: Five patients had Crohn’s disease and 4 patients had ileal tuberculosis. All patients with Crohn’s disease had no or partial response to steroid therapy and had no mucosal ulcerations. All patients had single stricture with length of stricture ranging from 0.6 to 1.8 cm. Endoscopic balloon dilatation was successful in all 9 patients with median number of sessions required being 2 (range: 1–5 sessions). Patients with Crohn’s disease required more endoscopic sessions as compared to patients with tuberculosis but this difference was not statistically significant (mean number of sessions being 3.0±1.58 vs. 1.75±0.5 sessions respectively; p00.1). One patient with ileal tuberculosis had enterolith proximal to stricture that was removed with dormia. There were no complications. There was no recurrence of symptoms in successfully treated patients of tuberculosis whereas 2 patients with Crohn’s disease had recurrence of stricture and symptoms. One of these patients could be successfully treated with repeat dilatation whereas other patient required surgery. Conclusion: Endoscopic balloon dilatation was an effective, safe, and minimally invasive treatment modality for benign ileal strictures.

P13 Endoscopic ultrasound guided thrombin injection in pancreatic pseudoaneurysm Abdul Khaliq, Rakesh Kochhar, Care Hospital, Hyderabad 500 034, and Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Pancreatic pseudoaneurysms are potentially fatal complications of pancreatitis which develop because of autodigestive property of pancreatic enzymes in combination with local inflammation. Endoscopic ultrasound (EUS) is a good modality to assess pancreas and has the advantage of precise injection of embolizing material; endoscopic evaluation of upper gastrointestinal tract and completion of procedure in conscious sedation. Case Report: A 45-years-old gentleman with significant history of alcohol consumption presented with history of epigastric pain and hemetemesis. After resuscitation esophagogastroduodenoscopy was done which was normal including the papillary orifice. Contrast enhanced computed tomography with angiography showed pseudocyst with splenic artery pseudoaneurysm (Figs. 1, 2). EUS evaluation of pseudoaneurysm followed by intrapseudoaneurysmal

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injection of 1,500 IU of human thrombin (Tissel Kit, Baxter AG, Vienna, Austria), was done using 22 g needle (Cook Endoscopy, Limerick, Ireland), with linear scope (Pentax EPK 1000), (Video1). Following injection of thrombin hemostasis was achieved. As a definitive measure distal pancreatectomy along with splenectomy and aneurysmectomy was done (Fig. 3). Conclusion: A case of thrombin treatment of pancreatic pseudoaneurysm is reported.

P14 Endoscopic ultrasound in diagnosing hepatopulmonary syndrome Abdul Khaliq, Rakesh Kochhar, Care Hospital, Hyderabad 500 034, and Department of Gastroenterology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Background: Hepatopulmonary syndrome (HPS) is characterized by widened alveolar–arterial oxygen gradient due to intrapulmonary microvasculature dilatation in a case of liver disease. Recognition of HPS is important because it is an MELD exception for liver transplantation and is potentially reversible after liver transplantation. Transthoracic echocardiogram is used for screening for HPS but transesophageal echocardiogram is more sensitive to diagnose HPS when there is no hypoxemia. Endoscopic ultrasound which is primarily a gastroenterologist’s tool and it can be used to diagnose HPS. In the index case we demonstrate how to diagnose HPS using endoscopic ultrasound. Case Report: A 60-year-old gentleman, known case of alcoholic cirrhosis presented with progressive dyspnea for 6 months. On examination he had clubbing, cyanosis, spiders, hepatosplenomegaly, ascites but cardiovascular and chest examination were normal. Arterial blood gas analysis showed Pao2—63.7 mmHg, PCo2— 22.8 mmHg on room air and P(A-a) O2 of 57 mmHg. HPS was considered and endoscopic ultrasound was done as an alternative to contrast echocardiogram using linear echoendoscope (Pentax EPK 1000). Agitated saline was injected and the microbubbles took 4 cardiac cycles to appear in right heart after appearance in left heart (video 1). Technetium-99m-macro aggregated albumin scan and contrast enhanced computed tomography also suggested HPS (Figs. 1, 2). Because of logistic reasons liver transplantation could not be done and was treated with pentoxyphylline and norfloxacin. Conclusion: The role of EUS in diagnosing hepatopulmonary syndrome was explored.

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P15 Double balloon enteroscopy in diagnosing common variable immunodeficiency Abdul Khaliq, Rakesh Kochhar, Kim Vaiphei Care Hospital, Hyderabad 500 034, and Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India Case Report: A 22-year-old young man presented with chronic recurrent diarrhea for 5 years each episode lasting 3–6 days. The diarrhea was large volume, watery and associated with bloating and nausea. There was no pain abdomen but he had lost 10 kg of weight. Once he had documented giardia in stool. The symptoms of diarrhea used to subside with over the counter available antibiotics. General physical examination was normal but he had mild hepatosplenomegaly. Stool examination for ova and cyst and atypical organisms was non-contributory. Esophagogastroduodenoscopy showed normal duodenal mucosa and biopsies showed nonspecific inflammation. Computed tomography of abdomen showed mild hepatosplenomegaly with small mesenteric lymphadenopathy and thickened small bowel loops (Fig. 1). Barium enteroclysis showed diffuse mucosal fold thickness of distal jejunum and ileal loops (Fig. 2). Double balloon enteroscopy showed diffusely thickened and edematous folds of distal jejunum and ileum. The biopsies showed normal villi but lamina propria had inflammation and in the lumen there were multiple giardia organisms (Fig. 3). Special stains to rule out lymphoma was negative. FNAC from mesenteric lymph nodes showed only reactive hyperplasia. As the patient had chronic diarrhea due to giardiasis, immunological work up was done which showed reduced CD3, CD19 and NK cells on flow cytometry and decreased IgG and IgA levels with normal IgM levels. A diagnosis of common variable immunodeficiency was made. He was treated with metronidazole with which his diarrhea improved. Workup for other organ involved was negative. He improved symptomatically and his hepatosplenomegaly and lymphadenopathy regressed next 3 months. Conclusion: A case of common variable immunodeficiency is described.

P16 A study of the role of platelet count/spleen diameter ratio as a predictor of esophageal varices in patients with chronic liver disease Sharma Jayesh, Gupta Abha, Aneja G K, Arya Tung Vir Singh, Singh Yogita

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Department of Medicine, Lala Lajpat Rai Memorial Medical College, Meerut 250 004, India Background and Introduction: Esophageal variceal rupture is the most common cause of upper gastrointestinal (UGI) bleeding in advanced chronic liver disease (CLD). The only method to determine the presence of esophegeal varices is UGI endoscopy. In order to reduce the burden of invasive procedure, we have tried to identify on invasive parameter to predict the presence of esophageal varices. Material and Methods: The study was conducted on 100 patient of CLD disease admitted in medicine ward of L L R M Medical College, Meerut (UP). All patients of CLD underwent a complete biochemical work up. UGI endoscopy and USG measurement of spleen bipolar diameter and platelet count/spleen diameter ratio was calculated for all patient. All patients were classified according to Child-Pugh criteria and were divided into two groups according to presence/absence of esophageal varices. Results: The actual prevalence of esophageal varices diagnosed by UGI endoscopy was 75 % and the sensitivity and specificity of the presence of esophageal varices by platelet count/spleen diameter was 93.3 % and 96 % respectively. The positive predictive value and negative predictive value of the study was 98.6 % and 96 % respectively. Mean±SD of serum albumin was lower (2.81±0.35) in a patient with ratio ≤909 than patient with ratio ≥909 (3.72±0.35). No marked difference of mean ±SD of serum bilirubin level in patient with and without ratio ≤909 and ≥909 (4.56±4.12 vs. 3.14±4.34 respectively. There also no marked difference of mean±SD of prothrombin time (PT). MEAN±SD of serum albumin was lower (2.87±0.34) with ratio ≤909 than with ratio ≥909. Conculsion: We conclude that platelet count/spleen diameter ratio is a reliable parameter which is independently associated with presence of esophageal varices. In CLD and its negative predictive value is 96 % and this ratio proved to be independent of Child-Pugh classification allowing a more confident use even in patient with compensated disease. In cost benefit analysis of screening of cirrhotic patient it is more cost effective than UGI endoscopy.

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Aims: To study role of endoscopic ultrasound (EUS) in detection of parathyroid adenomas in patients with acute pancreatitis (AP). Methods: Patients with AP from November 2011–July 2012 were evaluated after informed consent for evidence of alcohol intake, gallstones, calcium profile, trauma, drug intake and congenital anomalies. These patients were managed as per institutional protocol and followed for complications. Patients underwent EUS for evaluation of pancreatic changes (acute and chronic), gallbladder, bile duct and fluid collections. During withdrawal of echoendoscope thyroid glands were examined in neck region and carefully noted for parathyroid adenomas (nodules/cysts) at both poles of thyroid. Patients who had lesions detected on EUS were confirmed with sestamibi scan along with intact parathyroid hormone levels (iPTH) levels. Confirmed patients underwent surgery. Results: One hundred and seven consecutive AP patients (61 % males, mean age—42.8±12.4 years) were analyzed. Etiologies were alcohol (n048, 45 %), gallstones (n030, 28 %), trauma (n03, 3 %), post ERCP (n03, 3 %) and idiopathic (n016, 15 %). EUS showed evidence of chronic pancreatitis in 10/48 alcoholic patients. Parathyroid lesions were noted in 5 patients in the form of hypoechoic/cystic lesions measuring from 8 to 18 mm. Calcium ranged from 6.5 to 12.7 mg/dL and iPTH from 77.3 to 112.6 pg/mL (normal015–65 pg/mL). These five patients had no evidence of gallstones, trauma, alcohol intake or ductal anomalies. Three of five patients underwent surgery with histopathology revealing parathyroid adenomas in 2 and papillary carcinoma of thyroid in one. One patient underwent ultrasound guided alcohol ablation of the tumor. Conclusion: Five (4.6 %) of patients with first attack of AP were found to have parathyroid adenomas. Three of five were confirmed on histopathology while 1 patient had papillary carcinoma of thyroid. EUS of parathyroid could be included in the etiological work up of AP.

P18 Tuberculosis of the duodenum: clinical presentation, diagnosis and outcome

Utility of endoscopic ultrasound in etiological localization of pancreatitis

Amarender S Puri, Sanjeev Sachdeva, Ameet Banka, Puja Sakhuja Departments of Gastroenterology and Pathology, G B Pant Hospital, New Delhi 110 002, India

Sreekanth Appasani, R B Thandassery, Vikas Gupta, Anish Bhattacharya, Usha Dutta, K Singh, R Kochhar Departments of Gastroenterology, Surgery and Nuclear Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India

Background and Aim: Duodenal tuberculosis accounts for <2 % of abdominal tuberculosis and usually manifests with recurrent vomiting. Existing guidelines suggest surgery as the mainstay for both obtaining a definitive diagnosis as well as for therapy. The aim of this prospective study was

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to describe the clinical presentation and usefulness of endoscopic techniques in the diagnosis and treatment of duodenal tuberculosis. Methods: Data of patients diagnosed to have duodenal tuberculosis over a 3-year period were analyzed for age, presenting symptoms and outcome of therapy. Diagnosis was based on histological evidence of granulomatous inflammation along with unequivocal improvement in vomiting and other symptoms over 6–8 weeks following a combination of antitubercular drug therapy and endoscopic balloon dilatation. Results: Ten patients with recurrent vomiting (median age 27 years) were diagnosed to have duodenal tuberculosis. Significant narrowing was seen at endoscopy in 9 patients with post bulbar area being the commonest site in 5 patients.

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Histological diagnosis of granulomatous duodenitis was possible in 9 (90 %) patients. Balloon dilatation achieved resumption of normal diet at a median duration of 7 days (range 2–40). Symptomatic improvement was substantiated by a median increase in BMI of 5 kg/m2 over the baseline value. Surgical intervention was not required in any patient. Conclusions: Recurrent vomiting due to gastric outlet obstruction is commonest presentation of duodenal tuberculosis. Endoscopically a histological diagnosis of granulomatous inflammation can be achieved in most of the patients. Endoscopic balloon dilatation coupled with anti-tubercular drug therapy is safe and effective treatment for this uncommon disease.