Online)

ABSTRACT Context Dieulafoy's lesion is an unusual cause of gastrointestinal bleeding with the most common location being the stomach. A periampullary location is rare for a bleeding Dieulafoy's lesion. Case report We present the case of a 52-year-old female who presented with intermittent painless melena. Her upper gastrointestinal endoscopy and colonoscopy were normal. She was a diagnostic challenge as no definite lesion could be identified on capsule endoscopy. However, as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified. A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy's lesion. Immediate hemostasis was achieved with an injection of adrenalin. Other episodes of bleeding occurred and the patient was finally treated surgically. Conclusion A periampullary Dieulafoy's lesion presenting with obscure gastrointestinal bleed is a diagnostic challenge and can be missed on capsule endoscopy

Computed tomography texture-based radiomics analysis in gallbladder cancer: initial experience

Aim of the study: To investigate computed tomography (CT) texture parameters in suspected gallbladder cancer (GBC) and assess its utility in predicting histopathological grade and overall survival. Material and methods: This retrospective pilot study included consecutive patients with clinically suspected GBC. CT images, clinical, and histological or cytological data were retrieved from the database. CT images were reviewed by two radiologists. A single axial CT section in the portal venous phase was selected for texture analysis. Radiomic feature extraction was done using commercially available research software. Results: Thirty-eight patients (31 females, mean age 53.1 years) were included. Malignancy was confirmed in 29 patients in histopathology or cytology analysis, and the rest had no features of malignancy. Exophytic gallbladder mass with associated gallbladder wall thickening was present in 22 (58%) patients. Lymph nodal, liver, and omental metastases were present in 10, 1, and 3 patients, respectively. The mean overall survival was 9.7 months. There were significant differences in mean and kurtosis at medium texture scales to differentiate moderately differentiated and poorly differentiated adenocarcinoma (p < 0.05). The only texture parameter that was significantly associated with survival was kurtosis (p = 0.020) at medium texture scales. In multivariate analysis, factors found to be significantly associated with length of overall survival were mean number of positive pixels (p = 0.02), skewness (p = -0.046), kurtosis (0.018), and standard deviation (p = 0.045). Conclusions: Our preliminary results highlight the potential utility of CT texture-based radiomics analysis in patients with GBC. Medium texture scale parameters including both mean and kurtosis, or kurtosis alone, may help predict the histological grade and survival, respectively

Gallbladder reporting and data system (GB-RADS) for risk stratification of gallbladder wall thickening on ultrasonography:an international expert consensus

The Gallbladder Reporting and Data System (GB-RADS) ultrasound (US) risk stratification is proposed to improve consistency in US interpretations, reporting, and assessment of risk of malignancy in gallbladder wall thickening in non-acute setting. It was developed based on a systematic review of the literature and the consensus of an international multidisciplinary committee comprising expert radiologists, gastroenterologists, gastrointestinal surgeons, surgical oncologists, medical oncologists, and pathologists using modified Delphi method. For risk stratification, the GB-RADS system recommends six categories (GB-RADS 0–5) of gallbladder wall thickening with gradually increasing risk of malignancy. GB-RADS is based on gallbladder wall features on US including symmetry and extent (focal vs. circumferential) of involvement, layered appearance, intramural features (including intramural cysts and echogenic foci), and interface with the liver. GB-RADS represents the first collaborative effort at risk stratifying the gallbladder wall thickening. This concept is in line with the other US-based risk stratification systems which have been shown to increase the accuracy of detection of malignant lesions and improve management. Graphical abstract: [Figure not available: see fulltext.]

Unusual Foreign Body of Pancreas: Surgical Management

Context The foreign ingestion is common occurrence but migration to pancreas is rare entity. Most of foreign bodies pass spontaneously through the anus but about 1% can perforate the wall of stomach or duodenum to reach solid organ. Pancreatic foreign body can results in fatal complication. Pancreatic foreign body can be removed endoscopically or surgically. Case report We are reporting a case of successful removal of pancreatic foreign body (sewing needle) by surgery. Conclusion Pancreatic foreign body is a uncommon entity and surgical removal is warranted in majority of cases.Image: Local resection of a needle bearing part of head pancreas

Periampullary Dieulafoy's Lesion: An Unusual Cause of Gastrointestinal Bleeding

Context Dieulafoy’s lesion is an unusual cause of gastrointestinal bleeding with the most common location being the stomach. A periampullary location is rare for a bleeding Dieulafoy’s lesion. Case report We present the case of a 52-year-old female who presented with intermittent painless melena. Her upper gastrointestinal endoscopy and colonoscopy were normal. She was a diagnostic challenge as no definite lesion could be identified on capsule endoscopy. However, as there was presence of fresh blood in the proximal jejunum, a push enteroscopy was performed which revealed the presence of fresh blood in the duodenum and proximal jejunum. But no bleeding lesion could be identified. A side view endoscopy was performed which revealed a bleeding periampullary Dieulafoy’s lesion. Immediate hemostasis was achieved with an injection of adrenalin. Other episodes of bleeding occurred and the patient was finally treated surgically. Conclusion A periampullary Dieulafoy’s lesion presenting with obscure gastrointestinal bleed is a diagnostic challenge and can be missed on capsule endoscopy.Image: The application of a hemoclip on the Dieulafoy’s lesion

The Role of Non-Operative Strategies in the Management of Severe Acute Pancreatitis

Context Non-operative strategies are gaining preference in the management of patients with severe acute pancreatitis. Objective The present study was undertaken to evaluate the efficacy of a non-operative approach, including percutaneous drainage, in the management of severe acute pancreatitis. Design Prospective study. Setting Tertiary care centre in India. Patients Fifty consecutive patients with severe acute pancreatitis were managed in an intensive care unit. Interventions The patients were initially managed conservatively. Those with 5 cm, or more, of fluid collection having fever, leukocytosis or organ failure underwent percutaneous catheter drainage using a 10 Fr catheter. Those not responding underwent a necrosectomy. Depending on the outcome of their supportive care, the patients were divided into three groups: those responding to intensive care, those needing percutaneous catheter drainage and those requiring surgical intervention. Twelve patients were managed conservatively (Group 1) while 24 underwent percutaneous catheter drainage (Group 2), 9 of whom were not operated (Group 2a) and 15 of whom underwent necrosectomy (Group 2b). Fourteen patients were operated on directly (Group 3). Main outcome measures Hospital stay, intensive care unit stay, and mortality. Results Among patients requiring surgery, the patients in Group 2b had a shorter intensive care unit stay (22.1±11.1 days) as compared to the patients in Group 3 (25.0±15.6 days) and a longer interval to surgery, 30.7±8.9 days versus 25.4±8.5 days. However, these differences did not reach statistical significance (P=0.705 and P=0.133, respectively). The two groups did not differ in terms of mortality (5/15 versus 3/14; P=0.682). Conclusion The use of percutaneous catheter drainage helped avoid or delay surgery in two-fifths of the patients with severe acute pancreatitis.Image: Schematic representation of the management of the 50 patients with severe acute pancreatitis

Antimicrobial susceptibility patterns of organisms causing secondary abdominal infections in patients with perforated abdominal viscus

Background: Secondary peritonitis, following intestinal perforation, constitutes a significant proportion of cases admitted as a surgical emergency and has a mortality rate of 6–21% worldwide. As a part of an antimicrobial stewardship program, we noted considerable variation among the choice of empirical regimens among such cases. Hence, we conducted a prospective study to generate the evidence for a rational empiric regimen for patients with secondary peritonitis following intestinal perforation. Methods: The study included a complete follow up of 77 cases of secondary peritonitis admitted during a 12 month period. The intraoperative fluid (peritoneal) sample of the patient was sent for culture and sensitivity pattern analysis. Results: The sites of perforation as seen in decreasing order were lower gastrointestinal (GI) (50.6%), upper GI (36.4%), and unclassified (13%). The most common organism found in the intraoperative fluid was Escherichia coli (47.9%) followed by Klebsiella pneumoniae (12.5%). amikacin, cefoperazone-sulbactam, piperacillin-tazobactam and imipenem were sensitive in 22 (out of 23 tested), 5 (out of 9), 13 (out of 13) and 22 (out of 22) isolates of E. coli and 3 (out of 6), 1 (out of 3), 4 (out of 6), 4 (out of 6) isolates of K. pneumoniae , respectively. The most common empirical antibiotic was cefoperazone-sulbactam (38.7%) followed by piperacillin-tazobactam (29.3%). Conclusion: Based on our prospective study, piperacillin-tazobactam or imipenem should be used empirically in patients presenting with complicated intra-abdominal infections secondary to perforated viscus, especially if they have sepsis or septic shock

Buprenorphine versus diclofenac for pain relief in acute pancreatitis: A double-blinded randomized-controlled trial

Background: While both non-steroidal anti-inflammatory drugs (NSAIDs) and opioids are used for analgesia in acute pancreatitis (AP), the analgesic of choice is not known. We compared buprenorphine, an opioid, and diclofenac, an NSAID, for analgesia in AP. Methods: In a double-blind randomized controlled trial, AP patients were randomized to receive IV diclofenac or IV buprenorphine. Fentanyl was used as rescue analgesia, delivered through a patient- controlled analgesia pump. Primary outcome was the difference in the dose of rescue fentanyl required. Secondary outcomes were the number of effective and ineffective demands of rescue fentanyl, pain-free interval, reduction in visual analogue scale (VAS) score, adverse events, and organ failure development. Results: Twenty-four patients were randomized to diclofenac and 24 to buprenorphine. The two groups were matched at baseline. The total amount of rescue fentanyl required was significantly lower in the buprenorphine group:130 μg, interquartile range (IQR) 80-255 vs. 520 μg, IQR 380-1065 (p&lt;0.001). The number of total demands was 32[IQR 21-69] in the diclofenac vs 8[IQR 4-15] in the buprenorphine arm (p&lt;0.001). The buprenorphine group had more prolonged pain-free interval (20 hrs. vs. 4 hrs.; p &lt; 0.001) with greater reduction in the VAS score at 24, 48 and 72 hrs. compared to the diclofenac group. These findings were confirmed in the subgroup of moderately severe /severe pancreatitis. Adverse events profile was similar in the two groups. Conclusions: Compared to diclofenac, buprenorphine appears to be more effective and equally safe for pain management in AP patients, even in the sub-cohort of moderately severe or severe pancreatitis (Trial Registration number: CTRI/2020/07/026914)