Abstract Dyspepsia is characterized by chronic or recurrent pain in the upper abdomen and is the most common indication for upper gastrointestinal endoscopy. One-third of dyspeptic patients in India have Helicobacter pylori infection. Endoscopic findings suggestive of H. pylori infection include mucosal atrophy, diffuse redness, spotty redness, mucosal swelling, ulcerations, and nodularity. Lymphoid hyperplasia of the stomach is a benign and nonspecific condition that occurs due to chronic H. pylori infection and is characterized histologically by an increase in the size and number of lymphoid follicles. It appears endoscopically as a nodule or rarely as an umbilicated polypoid lesion. We report a case of dyspepsia who presented with epigastric pain and post-prandial abdominal fullness that did not respond to proton-pump inhibitors and underwent gastroscopy, which revealed an umbilicated polypoidal lesion in the antrum, which turned out to be H. pylori-associated chronic active gastritis.

Abstract Ascaris lumbricoides is one of the most common helminthic infections globally, mainly prevalent in tropical and subtropical developing countries with poor hygiene and sanitation. Though rare, intestinal perforation can occur due to clumping up of worms, causing partial or complete obstruction, eventually leading to bowel wall necrosis and perforation. We report a case of a 14-year-old boy from rural North India, who presented with abdominal pain, vomiting, abdominal distension, and anemia for 5 days. An immediate exploratory laparotomy was done, and an enterotomy was performed to remove the worm masses. Gastric perforation was found and repaired, and a loop ileostomy was performed. The majority of intestinal obstructions due to ascariasis are managed conservatively. However, in case of complications like perforation, early surgery is required to reduce morbidity and mortality. Ascariasis remains a global health challenge. Prevention through health education and awareness programs is essential, especially in the endemic areas. Improvements in sanitation, periodic deworming, and early diagnosis are crucial. In cases with complicated presentations like perforation peritonitis, timely surgery is lifesaving.

Abstract Gallbladder being an uncommon site of tuberculosis, we are presenting a case of tubercular cholecystitis in a 61-year-old female who presented with pain abdomen and was operated for cholelithiasis. The diagnosis was clinched on histopathological examination. She was treated accordingly and has responded well for antitubercular therapy.This case is unique as the patient had no symptoms of gastrointestinal or pulmonary tuberculosis. It was only after histopathological examination, the diagnosis was reached.

Abstract Spontaneous internal biliary fistulas (IBFs) are quite uncommon (<1%). These fistulas can develop between the gallbladder and bile duct with an internal organ, cavity, or a free surface. IBF is associated with chronic cholelithiasis in 90% of the cases. We report a rare case of choledochal fistula with an intra-abdominal abscess in a patient with chronic pancreatitis and diabetes mellitus, which were successfully managed with combined procedures of endoscopic retrograde cholangiopancreatography biliary stenting and ultrasound-guided drainage of the abscess.

Abstract Background Cholangitis is one of the commonest emergencies encountered by gastroenterologists that may warrant drainage of biliary system. Serum procalcitonin (PCT) is an important biomarker of cholangitis with a potential to guide early therapeutic decision. Materials and Methods We did a retrospective analysis of prospectively maintained data of patients admitted in the hospital from March 2018 to September 2020 with a diagnosis of acute cholangitis based on Tokyo 18 guidelines (TG-18). All the demographic parameters, biochemical and hematological parameters, and the result were recorded. Results One-hundred two patients were admitted to our hospital with a mean age of 51.07 ± 7.99 years, among which 58.5% (59/102) were females with most common etiology being choledocholithiasis (64%). Fever, jaundice, and abdominal pain were seen in 78% (80/102), 73.3% (74/102), and 76.9% (78/102) of patients, respectively. Organ failure was seen in 29.3% (29/102) of patients with most common organ failure being acute kidney injury. Mild, moderate, and severe cholangitis as per TG-13 was seen in 43.9, 26.8, and 29.3% of patients, respectively. Elevated PCT levels were associated with severe disease (76.7 vs. 26.5%, p < 0.05). Forty-three percent (44/102) patients were managed with delayed biliary drainage, while the majority of remaining specifically with raised PCT levels needed early endoscopic intervention. Conclusion In this retrospective analysis, we showed that most common etiology of cholangitis in was choledocholithiasis. Raised serum PCT levels were significantly associated with increased severity of cholangitis.

A 22-year-old male with a history of chronic alcohol abuse presented with abdominal pain, bilious vomiting, and abdominal distension for 2 days. He had been ill for 15 days with loose stools and fever. On clinical examination, the patient had abdominal distension with absent bowel sounds. His abdominal X-ray showed dilated small bowel loops with multiple air fluid levels ([Fig. 1A]). A complete hemogram suggested leukocytosis with 82,000 total leucocyte count with a neutrophilic (70%) predominance. He was admitted with a clinical suspicion of acute intestinal obstruction. He underwent computed tomography of the abdomen which showed a left lobe ruptured liver abscess ([Fig. 1B]) of size 5 cm × 4 cm × 4 cm with dilated proximal and mid jejunal loops with a smooth transition at distal jejunal and ileal junction and intra-abdominal collection ([Fig. 1C]). The patient was started on broad-spectrum antibiotics (injection piperacillin/tazobactam and injection metronidazole) for treatment of the abscess. He underwent an ultrasound-guided pigtail catheter insertion into the left paracolic gutter. The patient's condition improved with the same treatment with the resolution of fever and intestinal obstruction. The pus drained from the abscess was positive for Entamoeba histolytica polymerase chain reaction. The patient's condition again deteriorated after 6 days of in-hospital stay with the patient developing shock. A repeat ultrasound of the abdomen was done, which showed persistence of pus collection in the pelvic cavity into which a second pigtail catheter was inserted. Antibiotics were upgraded to injection meropenem and injection teicoplanin. The pus aspirated from the pelvic cavity showed growth of Escherichia coli sensitive to meropenem. The patient responded to the above therapy with a resolution of shock. He was discharged with both the pigtail catheters in situ which were removed once drainage stopped. Metronidazole was given for a total of 14 days. The therapy was shifted to oral faropenem for a total therapy of 4 weeks. An ultrasound at 4 weeks showed significant resolution of abscess with two small lesions of 1 to 2 cm with an organized appearance. The patient remains well on follow-up.

A 20-year-old lady presented with recurrent episodes of abdominal pain. She had previously received antitubercular therapy for a diagnosis of gastrointestinal tuberculosis on the basis of abdominal lymph node cytology showing granuloma with acid-fast bacilli. She underwent a colonoscopy for suspected post-tubercular intestinal stricture. Just beyond the hepatic flexure, an appendix-like structure was identified ([Fig. 1A] and [B]). However, because of nonvisualization ileocecal valve and intubation of the terminal ileum, we applied suction, which showed a flow of fluid (bowel preparation) from this opening. A wire-guided controlled radial expansion balloon was passed across this narrowing completely (CRE, Microvasive, Boston Scientific Co., Natick, MA, United States), and dilatation was performed up to 12 mm diameter for 30 seconds. The colonoscopy was not negotiated across post-dilatation ([Fig. 1C] and [D]). The patient became asymptomatic after a single dilatation procedure and was advised to follow up.

Brendish et al conducted a first of its kind large-scale randomized controlled trial to evaluate the clinical impact of syndromic molecular point-of-care testing (mPCOT) for gastrointestinal pathogens in adults hospitalized with suspected gastroenteritis.[1] An increasing number of pathogens have been identified to be the causative agents of diarrhea. Most of the times, diarrhea is self-limiting and manageable with fluid therapy, whereas the severe episodes can be life threatening and require optimal antimicrobial therapy that varies with the specific causative pathogen. The diagnosis of diarrheal pathogens has always been cumbersome and problematic by conventional approaches. Patients with diarrhea are typically placed in isolation in single occupancy rooms to prevent transmission of infectious pathogens to other patients as well healthcare staff. The National Health Services in United Kingdom has approximately 40,000 of these single occupancy rooms out of a total of 111,000 acute hospital beds, with only around 1,700 designated for isolation.[2] [3] Above-mentioned study was conducted during the coronavirus disease 2019 pandemic, causing further diagnostic delays and strained healthcare resources for patients with diarrhea seeking hospital admission and care. Authors studied 278 adult patients of diarrhea over a period of 3 years who were randomly assigned to either mPCOT (n = 137) group or routine clinical care group (n = 140). Patients admitted to the hospital with suspected gastroenteritis were recruited to study the clinical implications on various outcomes including utilization of a single occupancy room turn-around time of tests, time to de-isolation, antibiotic administration, and safety outcomes. Acute diarrheal illness was defined as three or more stools for at least 1 day. Inclusion criteria included patients who had acute diarrhea or vomiting for up to 14 days, were at least 18 years old, and could provide written consent. Recruitment occurred within 48 hours of first triage in an emergency or 48 hours of community admission to the acute medicine and surgical unit or inpatient ward. Patients allocated to the intervention group had a stool sample or rectal swab obtained and analyzed immediately by Film-Array Gastrointestinal Panel (BioFire Diagnostics, bioMérieux, Salt Lake City, Utah, United States). Patients who were randomly assigned to receive routine clinical care (i.e., control group) had stool testing done by standard laboratory testing at the discretion of the clinical team.

Background Endoscopic retrograde cholangiopancreatography (ERCP) may be associated with a risk of postprocedural cholangitis in case of failed drainage of the injected contrast. The present meta-analysis was conducted to assess whether air cholangiography reduces the risk of post-ERCP cholangitis compared with contrast injection. Methods A comprehensive search of MEDLINE, EMBASE, and Science Direct from inception to September 2022 was done for studies comparing air or CO2 and contrast agent for cholangiography during ERCP, with the last search on September 31, 2022. Dichotomous outcomes were analyzed using risk ratios (RRs) with 95% confidence intervals (CIs). Results A total of seven studies were included in the final analysis. Among these, there were three randomized trials and four retrospective studies. The included studies had moderate to high risk of bias. There was no difference in the clinical success rate (RR: 1.02, 95% CI: 0.94–1.09; I 2 = 0%), but a lower risk of all-cause adverse events (AEs) (RR: 0.21, 95% CI: 0.12–0.36; I 2 = 0%) with air cholangiography, compared with contrast cholangiography. Concerning individual AEs, this difference was seen only for cholangitis (RR: 0.51, 95% CI: 0.37–0.69; I 2 = 0%) but not for post-ERCP pancreatitis, perforation, and bleeding. Reintervention and 30-day mortality remained comparable between groups. The certainty of evidence remained low to very low. Conclusion Air or CO2 cholangiography reduces the risk of overall AE, especially post-ERCP cholangitis, compared with contrast cholangiography. Further trials are required to validate the findings of the study.

Acute pancreatitis (AP) is an acute inflammatory disease of the pancreas due to different etiologies.[1] Severe AP occurs in around 20% of cases with high mortality of 20 to 40%.[2] However, the course of the disease is not uniform, and the dynamics change with the phase of illness. The initial phase entails the sterile “inflammatory” cytokine storm leading to systemic complications, while the later “infective” phase can lead to sepsis.[3] Organ failure (OF), a key determinant of outcome in AP, can be early due to an inflammatory burst (primary OF) or late due to infective complications (secondary OF). Evidently, the management of the early phase would be organ support, and that of the later phase is sepsis management in a “step-up” approach starting with antibiotics. Unfortunately, in a real clinical scenario, it is not that simple, as there is no water-tight demarcation line between the two phases. Both the “sterile” and “infective” phase would manifest with the systemic inflammatory response. Moreover, cholangitis, cholecystitis, and extra-pancreatic infection can complicate the picture further. As a result, prophylactic antibiotic use is rampant but is not associated with better outcomes.[4] Recent analysis has suggested that there is more than 50% overuse of antibiotics in AP worldwide[5] and more than 80% in Asian countries. Inadvertent antibiotic use can lead to an increased risk of antibiotic-resistant strains, Clostridium difficile infection, fungal infection, longer hospital stay, and higher healthcare cost.