Annular Pancreas in Adults Presenting as Chronic Pancreatitis and Duodenal Obstruction: Literature Review and a Case Report

Background: Annular pancreas is a rare congenital anomaly with an estimated incidence of 3.4 per 1,00,000 live births. It is more commonly diagnosed in infants. Its occurrence in adults is exceptionally rare but clinically significant, as seen in our case, where it presented as a duodenal obstruction. Case presentation: We present a case of an adult male who presented with a 3-week history of projectile bilious vomiting associated with postprandial abdominal pain and early satiety. Imaging studies revealed a segment of the pancreas encircling the second part of the duodenum, along with pancreatolithiasis. Based on the diagnosis of annular pancreas with chronic calcific pancreatitis, the patient underwent pylorus-preserving pancreatoduodenectomy. Materials and Methods: A structured literature review was performed using PubMed and Scopus databases, covering the period from 2018 to 2024. A total of 24 case reports were analyzed. Results: The review confirms that annular pancreas remains a rare condition, often undiagnosed in asymptomatic individuals with abdominal pain (83.3%) and vomiting (41.6%) as the most common symptoms. The most common diagnostic modality is the CT scan (computed tomography), at 64.1%, and surgical procedures, such as gastrojejunostomy, are the most common treatment modality, at 46.5%.  Conclusions: It is a rare congenital condition that usually remains undiagnosed in asymptomatic individuals but typically presents with abdominal pain and vomiting when symptomatic. Diagnosis relies primarily on CT imaging. Conservative management is preferred for asymptomatic cases, and surgery is for symptomatic patients. Further research is needed to develop standardized management protocols

Dexmedetomidine as an Adjunctive Sedative in Patients Undergoing Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis

Introduction: Endoscopic submucosal dissection (ESD) is a technique for removing dysplastic lesions in the gastrointestinal tract, but it carries risks like pain and perforation. Dexmedetomidine, an α2-receptor agonist, offers potential benefits as an adjunct sedative during ESD by providing anxiolysis and analgesia. This systematic review and meta-analysis assess its efficacy and safety. Methodology: We searched databases including Embase, Medline/PubMed, Scopus, and Web of Science up to April 21, 2024, following PRISMA guidelines. Eligible studies used dexmedetomidine with other sedatives for ESD. We analyzed outcomes such as en-bloc and complete resection rates, sedation duration, and adverse events, using RevMan for meta-analysis with a random-effects model. Results: The initial search retrieved 216 studies, and eight studies were included in the final analysis after screening. Dexmedetomidine showed no significant difference in en-bloc or complete resection rates compared to controls. Sedation and procedure times were similar between the two groups as well. Dexmedetomidine significantly reduced restlessness (OR 0.15, 95% CI:0.07 to 0.29) and increased bradycardia (OR 7.15, 95% CI 3.17 to 16.11) compared to controls. Upon subgroup analysis, Dexmedetomidine plus Propofol and Dexmedetomidine plus Midazolam revealed the same findings regarding restlessness and bradycardia compared to controls, which confirmed the adjunctive effects of Dexmedetomidine. Conclusion: Dexmedetomidine appears safe and effective as an adjunctive sedative in ESD, reducing restlessness without significant adverse events. The risk of bradycardia is increased, which may reflect reduced physiological stress. Future studies should explore optimal dosing and compare Dexmedetomidine with other sedatives in diverse populations

Efficacy and Safety of Tislelizumab in Combination with Chemotherapy versus Placebo Plus Chemotherapy in Patients with Advanced Gastric Cancer or Gastroesophageal Junction Cancer: A Systematic Review of Randomized Controlled Trials

Introduction: Advanced gastric cancer or gastroesophageal junction cancer (GC/GEJC) is an aggressive malignancy often having a poor prognosis. Despite current systemic therapies, GC/GEJC remains the third most common cause of cancer-related deaths worldwide. Tislelizumab, an anti-PD1 antibody, has shown promising results in treating various cancers. Therefore, this systematic review investigated the efficacy and safety of tislelizumab plus chemotherapy for patients with GC/GEJC. Methods: Five databases were systematically searched until July 10, 2024. Articles identified in the screening process included two RCTs based on predefined inclusion criteria. We performed data extraction sheets and quality assessments using the Cochrane ROB2 tool. Results: Out of the two randomized controlled trials (RCTs), 1646 patients were included in our systematic review. In Rational-306, efficacy outcomes improved, overall survival (OS) significantly improved from 10.6 months (95\% CI 9.3–12.1) to 17.2 months (95\% CI 15.8–20.1), and progression-free survival (PFS) from 5.6 months (4.9–6.0) to 7.3 months (6.9–8.3). Rational-305 also notably significantly improved. Outcomes: Improved OS from 12.9 months (12.1-14.1) to 15 months (13.6-16.5), and PFS from 6.2 months (5.6 to 6.9) to 6.9 months (5.7 to 7.2). The proportion of patients with any grade 3 or worse treatment-related adverse events was similar between treatment groups. Conclusion: Compared with chemotherapy and placebo, Tislelizumab plus chemotherapy demonstrates superior efficacy with a similar safety profile in the two groups, encouraging the use of the tislelizumab group in patients with GC/GEJC

A Systematic Review and Meta-Analysis of Liver Transplant Outcomes in Lean Versus Non-Lean Metabolic Dysfunction-Associated Steatotic Liver Disease Patients

Introduction: Metabolic dysfunction-associated steatotic liver disease (MASLD) is a prevalent hepatic disease with metabolic dysfunction-associated steatohepatitis (MASH) as its severe necro-inflammatory subtype. At present, it is the second leading cause of liver transplant. A systematic literature review (SLR) was conducted to assess the effect of lean vs non-lean BMI on clinical outcomes after transplant in MASLD patients. Methods: A systematic search of PubMed, Cochrane Library, and Google Scholar databases was executed. Review Manager 5.4.1 was used for statistical analyses. A random-effect model was used with the results reported as Odds Ratio (OR) and 95% confidence interval (CI). A narrative approach was used where it was not feasible to conduct a meta-analysis. Results: Eleven observational studies were included in the SLR. Pooled results from three studies showed no significant difference in mortality between lean and non-lean patients at 1 year (OR= 0.78, p= 0.76), 2 years (OR= 0.83, p= 0.24), and 5 years (OR= 1.07, p= 0.51) post-transplant. There was also no significant relation of lean and non-lean BMI in graft survival, observed over 30 days (OR= 1.34, p= 0.27), 1 year (OR= 0.75, p= 0.25), 2 years (OR= 1.20, p= 0.45), and 5 years (OR= 1.07, p= 0.60) post-transplant. Qualitative analysis suggested morbid obesity is linked with higher waitlist dropout in MASH patients. Conclusion: The qualitative analysis of eight studies indicates a trend towards poorer outcomes in the non-lean group. There is a need for further investigations to comprehensively examine the factors influencing the relationship between BMI and post-transplant outcomes

Mycophenolate Mofetil for the Treatment of Resistant Inflammatory Bowel Disease: A Systematic Review and Meta-Analysis

Background: This systematic review evaluates the efficacy and safety of Mycophenolate Mofetil (MMF) for managing treatment‐resistant Inflammatory Bowel Disease (IBD), emphasizing remission rates and adverse effects. Methods: Observational and controlled trials assessing MMF’s impact on IBD were included, excluding non-English and pediatric studies. Comprehensive searches were conducted in Embase, Medline/PubMed, Scopus, and Web of Science through October 2023. The risk of bias was evaluated using the NIH quality assessment tool, and results were synthesized using a random-effects meta-analysis model. Results: Twelve studies comprising 446 participants (333 with Crohn’s disease and 113 with ulcerative colitis) were analyzed. The meta-analysis revealed remission rates of 62.2% at 8 weeks and 52.8% at 6 months. Adverse effects occurred in 26.1% of patients, with nausea and vomiting being the most common. Treatment discontinuation due to failure and intolerance was observed in 29.7% and 20% of cases, respectively. Discussion: The findings suggest that MMF effectively induces remission in IBD patients unresponsive to conventional therapies, although a notable proportion experienced adverse events or treatment failure. Careful patient selection and monitoring are essential. Conclusion: MMF presents a promising alternative for managing resistant IBD, but its adverse effect profile warrants cautious application. Further research is needed to optimize dosing strategies and assess long-term outcomes in this challenging patient population. These results underscore the potential of MMF as an effective therapeutic option while emphasizing the importance of individualized treatment plans and rigorous clinical monitoring. Future studies should focus on long-term safety and dosing. Additional robust research is required

Safety and Efficacy of Na Alginate and Mesna in Endoscopic Submucosal Dissection: A Systematic Review and Meta-analysis

Background: Sodium hyaluronate, commonly used in ESD, has drawbacks such as high cost and potential tumorigenesis. Sodium alginate (Na alginate) and Mesna offer promising alternative solutions with their viscoelastic and mucolytic properties. In this review we aimed to evaluate the safety and efficacy of Na alginate and Mesna solutions in ESD. Methods: A systematic search was conducted across multiple databases. Inclusion criteria were randomized controlled trials and observational studies assessing Na alginate and Mesna in ESD. Primary outcome included en-bloc resection rates. Secondary outcomes included adverse events such as perforation and delayed bleeding, and procedural time. Results: Eight studies involving 255 patients were included in this analysis. Overall en-bloc resection rate for sodium alginate was 97% [95% CI (93%-99%); I2:0%]. En-bloc resection subgroup analysis revealed 97% [95% CI (93%-99%); I2:0%] for 0.6% sodium alginate and 95% [95% CI (70%-99%); I2: 0%] for 0.4% sodium alginate. Moreover, En-bloc resection rate for Mesna was 98% [95%CI: 92%-100%); I2: 0%]. Delayed bleeding rates for sodium alginate were 5% [95% CI (1%-20%); I2: 65.2%]; however, after subgroup analysis delayed bleeding was 2% [95% CI (1%-6%); I2: 0%] for 0.6% sodium alginate and 22% [95% CI (8%-49%); I2:0%] for 0.4% sodium alginate. Perforation rate for 0.6% sodium alginate was 1% [95% CI (0%-5%); I2: 0%]. Conclusion: Na alginate (0.6%) and Mesna are effective and safe alternatives to sodium hyaluronate for submucosal injection in ESD. These solutions offer potential cost-effective and safer options for clinical practice, with Na alginate (0.6%) showing particularly low adverse event rates

Alternative Gastrointestinal Conditions Identified in Patients Meeting Rome IV Criteria for Irritable Bowel Syndrome or Functional Diarrhea Referred to Secondary Care: A Prospective Study

Introduction: Organic gastrointestinal (GI) disorders can be missed in individuals with irritable bowel syndrome (IBS). This study investigated the frequency of organic disorders in patients with diarrhea-predominant IBS or functional diarrhea and the impact of treatment for any identified alternative diagnoses. Methods: Between April 2019 and March 2020, the results of comprehensive investigations, including blood and fecal tests, a 75selenium homophobic acid taurine scan, a breath test, and endoscopies performed on consecutive eligible patients, were recorded. Symptom burden was reassessed after treatment for any GI conditions identified. Results: 66 (15 males) consecutive patients were included. Two patients (3%) were diagnosed with colonic malignancy; 21 (38%) had bile acid diarrhea; one (1%) had pancreatic exocrine insufficiency; and 31 (54%) had small intestinal bacterial overgrowth. 21 patients (32%) had at least two GI diagnoses. Significant improvement in symptoms occurred following treatment (p<0.0001). Conclusions: Multiple co-existing conditions were detected in many of these patients, with one-third of the cohort having more than one abnormal test. When these alternative diagnoses were treated, patients reported significant symptomatic improvement. Larger studies are required to validate our findings, and these patients\u27 investigative and management pathways should be amended accordingly

Insights into the Epidemiology and Determinants of Helicobacter Pylori Negative Gastritis: A Retrospective Study

Introduction: The prevalence of Helicobacter pylori (HP)-negative gastritis is rising in the United States, yet its origins and risk factors remain largely unexplored. This study aims to assess the prevalence of HP-negative gastritis and explore the demographic, clinical, and risk factor profiles that differentiate HP-negative from HP-positive subjects with histological evidence of gastritis. Methods: We conducted a retrospective analysis of 241 patients who underwent Esophagogastroduodenoscopy (EGD) for upper gastrointestinal symptoms at a tertiary care center between July 2020 and July 2021. Symptoms prompting referral included dysphagia, abdominal pain, nausea, and others. Gastric biopsies were collected from the antrum and body, and clinical, demographic, and laboratory data were analyzed to compare HP-negative and HP-positive gastritis cases. Results: Of the patients biopsied, 38.2% (n=92) showed histological evidence of gastritis, with 78% of these being HP-negative and 22% HP-positive. HP-negative cases were predominantly chronic chemical gastritis (61.5%), while all HP-positive cases were active chronic gastritis. Significant ethnic disparities were noted; 61.5% of HP-negative patients were Caucasian, and 72.7% of HP-positive patients were African American. Medical comorbidities, particularly gastroesophageal reflux disease (GERD), were more associated with HP-negative gastritis. The antrum was more frequently affected in HP-negative cases compared to HP-positive cases. Conclusion: HP-negative gastritis is significantly linked with Caucasian ethnicity and existing medical comorbidities but shows no strong associations with the analyzed lifestyle or medication factors. These findings highlight the need for further large-scale prospective studies to better understand the etiology, risk factors, and clinical implications of HP-negative gastritis

An Unusual Case of Disseminated Hydatid Disease: A Laparoscopic Wonder

Human echinococcosis, caused by Echinococcus tapeworms, is a zoonotic disease in which ingested eggs of the tapeworm form cysts in the organs known as Hydatid cysts. These cysts are commonly found in the Liver and lungs, but in rare cases, they can also be found in the spleen, ovaries, round ligament, and peritoneal cavity. Treatment typically involves surgery. This is a case of a 32-year-old female who presented with chief complaints of pain in the abdomen for 2 months, which was associated with nausea, vomiting, reduced appetite, and increased size of mass per abdomen. Further investigations revealed the presence of multiple disseminated hydatid cysts in the upper abdomen and the peritoneal cavity. This was a rare & unusual entity that was meticulously managed by minimally invasive laparoscopic surgery. Echinococcosis can occur anywhere in the body, with concurrent localizations in the liver, spleen, round ligament, ovaries, and peritoneal cavity, which are rare and pose a diagnostic as well as a surgical management challenge. The inconvenience of multiple localization and the risk of contamination usually lead to open surgery in these cases. The presented case is unique due to the laparoscopic approach to the multiple localizations of hydatid disease, advocating for a minimally invasive first-line approach even in these particular localizations

Evaluating Biliary Complications in Jaundiced Patients with Alcohol-Related Hepatitis: A Retrospective Study

Introduction: This study aims to differentiate whether jaundice in patients with alcoholic hepatitis (AH) is due to alcohol-related liver disease or underlying biliary pathology, including choledocholithiasis, primary sclerosing cholangitis, primary biliary cholangitis, benign strictures, cholangiocarcinoma, or pancreatic cancer. Accurate differentiation is crucial for appropriate treatment decisions. Methods: A non-interventional retrospective study examined patients admitted to our institute for presumed alcohol-related hepatitis management from 2016 to 2023. The primary outcome was the occurrence of biliary processes, whether benign or malignant, in patients managed for alcohol-related hepatitis within 90 days. Secondary outcomes assessed bilirubin level trends over seven days to evaluate steroid effects on alcohol-related hepatitis and predict underlying biliary processes. Variables were analyzed using bivariate and multivariate logistic regression with biliary process as the dependent variable. Results: Our study revealed that patients with alcohol-related hepatitis and jaundice who had dilated common bile duct (CBD) or pancreatic duct (PD) on cross-sectional imaging were more likely to have biliary processes regardless of cholecystectomy history p-value 0.007 (CI 0.03-0.242) OR 7.5 and p-value 0.001 (CI 0.58-1.34), OR 1.2 respectively. However, there was no correlation between biliary process incidence and various demographic or clinical factors. Conclusion: Cross-sectional imaging should be routinely used to evaluate biliary tree conditions in alcohol-related hepatitis patients with jaundice who have dilated CBD, particularly those with previous cholecystectomy or gallstones on imaging studies. This systematic approach enables early identification of underlying biliary issues and facilitates prompt, appropriate management decisions