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Dhali A, Ray S, Das S, Mandal TS, Khamrui S, Gupta A, Ansari Z, Ghosh R, Dhali GK. Clinical profile and outcome of solid pseudopapillary neoplasm of the pancreas: A retrospective study on 28 patients. Int J Surg 2022; 104:106708. [PMID: 35700958 DOI: 10.1016/j.ijsu.2022.106708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Solid pseudopapillary neoplasms (SPN) of the pancreas are rare tumors accounting for 0.9-2.7% of all exocrine pancreatic tumors. Very few studies comprising of more than 10 patients have been published. The aim of the present study is to report on our experience with SPNs over a period of 14 years from a tertiary center of Eastern India. METHODOLOGY Data of all patients whose histopathology reports of surgically resected specimen confirmed SPN were retrospectively reviewed in the present study. RESULTS Twenty-eight patients had a pathologically confirmed diagnosis of SPN. Twenty-five (89.3%) patients were females with a median age of 26 (15-45) years. Abdominal pain (89.2%) was the most common presenting symptom. Abdominal mass was palpable in 12 (42.8%) patients. The mean size of the tumor was 9.03 cm (range, 4-25 cm). The most common location of the tumor was in the body and tail of pancreas (35.7%). The most commonly performed operation was distal pancreaticosplenectomy (n = 17, 60.7%), followed by Whipple's procedure (n = 8, 28.5%). Thirty postoperative complications developed in 23 (82.1%) patients. The operative mortality was 3.5% (n = 1). The median hospital stay was 10 (5-25) days. Over a median follow-up period of 36 months (range), no patient developed recurrence. CONCLUSION Although the size of tumor was quite large at the time of initial presentation, complete surgical resection was possible in all the patients. In experienced hand, surgery can be performed with acceptable perioperative mortality and excellent long-term outcomes.
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Maheshwari A, Patra PS, Ray S, Dhali GK, Das K. External validation of Chronic Pancreatitis Prognosis Score (COPPS): A prospective cohort study. Dig Liver Dis 2022; 54:654-662. [PMID: 34544675 DOI: 10.1016/j.dld.2021.08.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Prognostic stratification in ChronicPancreatitis(CP) remains suboptimal and cumbersome. Chronic Pancreatitis Prognostic Score(COPPS) was recently developed to predict one-year hospitalisations in CP. AIM External validation of COPPS in a geographically divergent patient population. METHODS A single-center prospective cohort study, conducted on out-patients of a tertiary-care hospital. Consecutive adults with CP were assessed for COPPS risk predictors at baseline, similar to the original development cohort, and followed for one-year for: 1)hospitalisations; 2)development of pancreatitis-related complications; and 3)need for endoscopic and/or surgical interventions. Outcomes were compared by Kendall's tau-b(τb) and other statistical tests. Only those who had complete one-year follow-up were included in analysis. RESULTS There were 177 patients(mean±SD age: 35.9 ± 11.2 years), 116(65%) males and 117(66%) with Idiopathic CP. Despite being younger, with significantly more females and Idiopathic CP, than the original development cohort, our cohort was similar to the latter regarding COPPS severity at baseline. Eight patients died over one-year; 169 were evaluated for outcomes. Increasingly severe COPPS categories correlated with increasing number of hospitalisations(both overall and pancreatitis-related) and increasing number of days spent in hospital(both overall and pancreatitis-related) irrespective of age at symptoms-onset(≤35 vs >35years), etiology(idiopathic vs alcohol) and smoking-status. CONCLUSIONS COPPS is effective in a geographically distinct cohort having a different case-mix of CP patients(ClincialTrials.gov ID:NCT04907266).
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Biswas J, Karpha K, Nath S, Dhali A, Dhali GK. Solid Pseudopapillary Neoplasm of the Pancreas Presenting With Gastric Outlet Obstruction. Cureus 2022; 14:e24092. [PMID: 35573581 PMCID: PMC9106554 DOI: 10.7759/cureus.24092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/13/2022] [Indexed: 11/20/2022] Open
Abstract
Solid pseudopapillary neoplasm (SPN) of the pancreas are rare tumors accounting for a minor portion of all exocrine pancreatic tumors. It usually occurs in young women. It has a very low malignant potential with a relatively indolent clinical course. A small subset of patients exhibits pathological features of malignancy. Herein, we present a rare case of pancreatic SPN that presented with gastric outlet obstruction. Despite the characteristic computed tomography (CT) findings, due to its rarity, it was missed in more common conditions such as gastrointestinal stromal tumors. In our case, we found that the tumor was causing extrinsic duodenal compression leading to gastric outlet obstruction, creating a diagnostic dilemma.
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Dhali A, Mukherjee S, Gupta A, Ray S, Dhali GK. Duodenal Adenocarcinoma Versus Foreign Body Granuloma in the Background of Postcholecystectomy Migration of Endoclip Into Duodenum: A Histopathological Surprise. Cureus 2022; 14:e23086. [PMID: 35464582 PMCID: PMC9001855 DOI: 10.7759/cureus.23086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2022] [Indexed: 11/30/2022] Open
Abstract
A surgical endoclip in the cystic pedicle rarely migrates to the duodenum and is considered a rare complication of laparoscopic cholecystectomy. Duodenal adenocarcinoma endoscopically mimicking a foreign body granuloma in the background of postcholecystectomy endoclip migration has never been reported before. A 53-year-old Indian male presented with progressive weakness and melena for the last three months. He underwent laparoscopic cholecystectomy a year ago with an uneventful clinical course and post-operative recovery. A complete hemogram revealed hemoglobin of 4.5g/dL. Upper gastrointestinal endoscopy revealed a large necrotic polypoidal mass arising from the lateral wall of the first part of the duodenum. Contrast-enhanced computed tomography (CT) of the abdomen showed an impacted surgical clip into the lateral wall of the first part of the duodenum. Intraluminal extension of the surgical clip was not appreciated in the imaging. We suspected the diagnosis to be foreign body granuloma in the duodenal wall. He underwent open duodenal wedge resection. Microscopic evaluation of resected specimens revealed poorly differentiated adenocarcinoma. All the resection margins were free. He had an uneventful recovery and was discharged on the seventh post-op day. He was symptom-free and doing well on follow-up at 12 months. The purpose of reporting the case was to make the readers aware of the delayed massive upper gastrointestinal hemorrhage as a rare complication of endoclip migration (ECM) post laparoscopic cholecystectomy. In our case, the duodenal adenocarcinoma mimicked a foreign body granuloma endoscopically, and hence a possibility of duodenal adenocarcinoma as a potential delayed complication of ECM cannot be ruled out. Although rare, in case of upper gastrointestinal hemorrhage in the background of the previous history of laparoscopic cholecystectomy, endoclip migration should be kept as a differential diagnosis.
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Dhali A, Ray S, Dhali GK, Khamrui S, Ghosh R. Extrahepatic mucinous biliary cystadenoma: A rare cause of gastric outlet obstruction. Clin Case Rep 2022; 10:e05531. [PMID: 35251654 PMCID: PMC8886638 DOI: 10.1002/ccr3.5531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Revised: 02/03/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022] Open
Abstract
Extrahepatic mucinous biliary cystadenoma is an extremely rare clinical entity that can present with varieties of vague clinical signs and symptoms. Gastric outlet obstruction caused due to this has never been reported before. We highlighted the diagnostic dilemma we faced when radiological investigations could not suggest the accurate organ of origin.
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Dhali A, Ray S, Mandal TS, Das S, Sarkar A, Khamrui S, Dhali GK. Outcome of surgery for chronic pancreatitis related pancreatic ascites and pancreatic pleural effusion. Ann Med Surg (Lond) 2022; 74:103261. [PMID: 35111305 PMCID: PMC8790598 DOI: 10.1016/j.amsu.2022.103261] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 11/20/2022] Open
Abstract
Background An internal pancreatic fistula involves an abnormality in the way that the pancreas communicates with organs and spaces within the body. This is usually due to a disrupted pancreatic duct or psuedocyst leakage (Ascitic or pleural fluid amylase level >1000 S units/dl and fluid protein level >3 g/dl). The study aims to report our experience with surgery for chronic pancreatitis-related pancreatic ascites and pancreatic pleural effusions. Methods All the patients, who underwent surgical intervention for pancreatic ascites and pancreatic pleural effusion between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. Results Of the total 14 patients, 10 (71.4%) were men with a median age of 40 (4–49) years. The median interval between onset of symptoms of CP and diagnosis of IPF was 27 (3–60) months. All patients had a history of chronic abdominal pain and 5 (35.7%) had a prior history of hospitalization for pain. Eleven patients (78.5%) presented with abdominal distension and 3 (21.4%) patients had respiratory distress. Six (42.8%) patients had undergone endotherapy before surgery. Contrast-enhanced computed tomography detected pancreatic pseudocyst in 10 (71.42%) patients. The most commonly performed operation was lateral pancreaticojejunostomy (n = 11, 78.5%). Seven postoperative complications developed in 4 (28.5%) patients. After a median follow-up of 60 (6–86) months, no patient developed recurrence of pancreatic ascites or pleural effusion. Conclusion In the experienced hand, surgery can be performed with acceptable perioperative morbidity and mortality and long-term satisfactory outcomes. Internal Pancreatic fistula is a rare complication of chronic pancreatitis. Surgery is indicated after failure of medical and endoscopic therapy. Surgery can be performed with acceptable perioperative morbidity and mortality and long-term good results.
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Dhali A, Ray S, Biswas DN, Dhali GK. Myelolipoma: an unusual differential of duodenal polyp. BMJ Case Rep 2021; 14:e246444. [PMID: 34887292 PMCID: PMC8663102 DOI: 10.1136/bcr-2021-246444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2021] [Indexed: 11/04/2022] Open
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Biswas DN, Dhali A, Parvin S, Singh A, Dhali GK. Macrodystrophia Lipomatosa: A Rare Cause of Bilateral Lower Limb Gigantism. Cureus 2021; 13:e18986. [PMID: 34820241 PMCID: PMC8607350 DOI: 10.7759/cureus.18986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2021] [Indexed: 11/05/2022] Open
Abstract
Macrodystrophia lipomatosa (MDL) is a rare congenital overgrowth syndrome characterised by inadvertent proliferation of all the mesenchymal elements resulting in localised gigantism. Herein, we present an eight-month-old female child, who presented to us with a history of gradual enlargement of both lower limbs along with the toes which was noticed by the parents a few days after birth. There was no history of trauma, pain or skin changes. Physical examination revealed unusual hypertrophy of both feet and toes. It was non-tender with no evidence of oedema or bruit over the swelling. X-ray of lower limbs revealed bony hypertrophy and overgrowth of all the bones with increased soft tissue shadow of bilateral foot. On ultrasound evaluation of the lower limbs, there was increased soft tissue in both dorsal and plantar aspect of bilateral foot without any vascular malformation. To characterise the swelling better, magnetic resonance imaging was warranted which revealed accumulation of excessive fat in the subcutaneous tissue without discernible capsule. Fibrous strand within the fat in bilateral feet, both in the plantar and dorsal aspect (more in plantar aspect), was seen. Core tissue biopsy was performed which showed abundant adipose tissue dispersed in mesh-like fibrous tissue and infiltrating the dermal connecting, suggestive of macrodystrophia lipomatosa. Currently, patient is advised for corrective surgery. Clinicians should be aware of these atypical presentations of MDL to differentiate it from other causes of local gigantism like fibrolipohamartoma (FLH) of nerve sheath, lymphangiomatosis, hemangiomatosis, Proteus syndrome, Klippel-Trenaunay syndrome and neurofibromatosis 1 as they differ in management and outcome.
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Dhali A, Ray S, Sarkar A, Khamrui S, Das S, Mandal TS, Biswas DN, Dhali GK. Peripancreatic arterial pseudoaneurysm in the background of chronic pancreatitis: clinical profile, management, and outcome. Updates Surg 2021; 74:1367-1373. [PMID: 34816352 DOI: 10.1007/s13304-021-01208-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/18/2021] [Indexed: 01/04/2023]
Abstract
BACKGROUND Bleeding pseudoaneurysm (PSA) is a rare but potentially lethal complication of chronic pancreatitis (CP). It requires expeditious management by a multidisciplinary team. The study aims to report our experience with PSA in the background of CP. METHODS All the patients, who underwent intervention for CP-related PSA between August 2007 and December 2020 in the Department of Surgical gastroenterology, Institute of Postgraduate Medical Education and Research, Kolkata, India were retrospectively reviewed. RESULTS Of the total 26 patients, 25 (96%) were men with a median age of 38 (11-63) years. The most commonly involved vessel was the splenic artery (n = 18, 69%). The interval between onset of GI bleed and intervention was 7 (0-120) days. Embolization was attempted in 11(42%) patients and was successful in six patients. Surgery was performed in 20 (77%) patients including five patients after failed embolization. The most commonly performed operation was distal pancreatectomy with splenectomy. The median operating time was 216 (115-313) minutes. The median intraoperative blood loss was 325 (100-1000) ml. Seventeen (85%) patients' required intraoperative blood transfusion. Four patients in the embolization group and five patients in the surgical group developed procedure-related complications. The most common postoperative complication was wound infection followed by pancreatic fistula. There was no procedure-related death. Over a median follow-up of 24 (6-122) months, no patient developed recurrent hemorrhage. CONCLUSIONS Both embolization and surgery play an important role in the management of PSA. The choice of procedure depends upon the local availability and feasibility of a particular technique.
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Dhali A, Roger BR, Pasangha E, D'Souza C, Dhali GK. Reversal of portal gastropathy with partial internal biliary diversion in a case of progressive familial intrahepatic cholestasis. Qatar Med J 2021; 2021:45. [PMID: 34692433 PMCID: PMC8502119 DOI: 10.5339/qmj.2021.45] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/26/2021] [Indexed: 11/30/2022] Open
Abstract
Progressive intrahepatic cholestasis is a rare, genetic disorder causing bile acid secretion or transport defects. It can result in intrahepatic cholestasis that can progress to end-stage liver disease. Diagnosis is made using a combination of clinical and biochemical approaches. Genetic testing is currently the gold standard for investigation. We report a case of an 18-month-old male child with cholestatic pattern of jaundice from 16 months of life, which was associated with features suggestive of portal gastropathy. Detailed workup led to the diagnosis of progressive intrahepatic cholestasis (type 2). Early diagnosis prevented the need for liver transplant, and the child underwent surgical treatment with partial internal biliary diversion. Portal gastropathy and disease progression dramatically changed with corrective surgery. The patient was symptom-free at 10-week follow-up. Detecting this rare genetic disorder early has very good therapeutic implications from the patient's perspective and their morbidity and mortality profile; if untreated, it has a high propensity to progress to end-stage liver disease. The requirement of surgical interventions and liver transplantation is individualized on a case-to-case basis. An early diagnosis and initiation of treatment can prevent the need for a liver transplant as shown in the present case.
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Dhali A, Ray S, Ghosh R, Sinha MGM, Khamrui S, Dhali GK. Mixed neuroendocrine-non-neuroendocrine tumour of pancreas mimicking groove pancreatitis: Case report. Int J Surg Case Rep 2021; 88:106524. [PMID: 34688070 PMCID: PMC8536533 DOI: 10.1016/j.ijscr.2021.106524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/13/2021] [Accepted: 10/14/2021] [Indexed: 12/03/2022] Open
Abstract
Introduction Mixed neuroendocrine-non-neuroendocrine neoplasm (MiNEN) is a rare tumour of the pancreas which can mimic groove pancreatitis. Case report We present a 49-year-old Indian male presented with constant, dull-aching epigastric pain for last 6 months radiating to back, not associated with jaundice, gastrointestinal bleed, fever or weight loss. He also had history of alcohol abuse for last 15 years. Physical examination was unremarkable. Laboratory investigations were within normal limits. Contrast enhanced computed tomography (CT) of the abdomen was suggestive of groove pancreatitis. CA 19.9, CEA and IgG4 levels were normal. Upper gastrointestinal endoscopy revealed an oedematous mucosa with narrowing of second part of duodenum. Endoscopic ultrasound (EUS) showed bulky pancreas with ill-defined heteroechoic head with periduodenal soft tissue thickening. EUS guided fine needle aspiration revealed chronic inflammatory cells. Based on the endoscopic findings and imaging, we suspected the diagnosis to be groove pancreatitis. He underwent open Whipple's pancreaticoduodenectomy. Histopathological evaluation revealed well differentiated neuroendocrine tumour and immunohistochemistry revealed features which was consistent with mixed neuroendocrine-non-neuroendocrine tumour (MiNEN). Post-operative period was uneventful and he was discharged on post-op day 7. A PET-CT scan was done to look for any silent metastasis and it was negative. He recieved 4 cycles of cisplatin-based chemotherapy. He was symptom free and doing well on 12 months follow up with no evidence of recurrence in surveillance CT imaging. Discussion Pancreatic MiNEN is characterised by presence of two malignant tissues, adenocarcinoma and NET, with one constituent involving at least 30% of the tumour. We report the pitfalls in diagnostic work-up which can lead to misdiagnosis of this rare entity. Specially due to admixture of different kinds of tissue, radiological investigations can be misleading. Conclusion Our case highlights the fact that MiNEN of pancreas can mimic a benign condition like groove pancreatitis. If routine histopathological and immunohistochemical evaluation is not done on the resected samples, relying on radiological and fine-needle aspiration cytology evidences, the actual diagnosis could be missed. MiNEN of pancreas is a rare pathology and difficult to diagnose preoperatively. MiNENs should be considered as a differential for groove pancreatitis. Histopathology with immunohistochemistry should be done for all pancreatoduodenectomy specimen to diagnose such rare tumors.
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Dhali A, Ray S, Dhali GK, Ghosh R, Sarkar A. Duodenal Ganglioneuroma: A Rare Tumor Causing Upper Gastrointestinal Bleed. Surg J (N Y) 2021; 7:e255-e258. [PMID: 34541318 PMCID: PMC8440055 DOI: 10.1055/s-0041-1735644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 07/19/2021] [Indexed: 12/03/2022] Open
Abstract
Neuroblastic tumors (NTs) include neuroblastoma, ganglioneuroblastoma, and ganglioneuroma (GN). They are very rare in adults. The Surveillance, Epidemiology, and End Results identified 144 patients ≥20 years old at diagnosis (6.1%) from 1973 to 2002. GNs account for 14% of all localized NT. Since 1957, a total of four cases of GN of the duodenum have been reported. We report a novel case of GN of the periampullary region in the duodenum in a 41-year-old man presenting with chronic upper gastrointestinal bleed. Given the rarity of GNs in this age group and the nonspecificity of radiological features, this diagnosis is often missed until histopathology is done. This may negatively affect the prognosis of an otherwise well-prognosticated disease.
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Dhali A, Dhali GK, Ghosh R, Sarkar A. Primary tubercular granulomatous hepatitis presenting as fluctuating jaundice. Int J Mycobacteriol 2021; 10:320-323. [PMID: 34494573 DOI: 10.4103/ijmy.ijmy_92_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Granulomatous hepatitis is an uncommon presentation of tuberculosis (TB). It is even more peculiar to have TB confined to the liver alone with no pulmonary or a disseminated form. In either form, there is the usual presentation of nonprogressive cholestatic jaundice, but no documented case with fluctuating jaundice in the literature was found. In order to highlight this rare presentation aiding the right diagnosis, we present one such case of a 46-year-old woman with no known comorbidities, who complained of fluctuating and painless type of jaundice, associated with fatiguability, pruritus, and weight loss. Preliminary blood investigations showed anemia and cholestatic pattern of jaundice. Ultrasonography and computed tomography imaging showed hepatomegaly with heterogeneous texture. Magnetic resonance cholangiopancreatography further revealed features of cholecystitis with hepatic ducts near proximal common bile duct showing postinflammatory change. The periampullary region was normal. Sputum acid-fast staining and cartridge-based nucleic acid amplification test were negative. Eventually, liver biopsy was done which showed caseating granulomas with Langhans giant cells. The tissue was abundant in acid-fast bacilli. The patient was started on a 9-month course of first-line Antitubercular treatment (ATT) and responded well. Fluctuating jaundice is a rare and undocumented presentation of primary hepatic TB and can cause diagnostic dilemmas.
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Basak D, Jamal Z, Ghosh A, Mondal PK, Dey Talukdar P, Ghosh S, Ghosh Roy B, Ghosh R, Halder A, Chowdhury A, Dhali GK, Chattopadhyay BK, Saha ML, Basu A, Roy S, Mukherjee C, Biswas NK, Chatterji U, Datta S. Reciprocal interplay between asporin and decorin: Implications in gastric cancer prognosis. PLoS One 2021; 16:e0255915. [PMID: 34379688 PMCID: PMC8357146 DOI: 10.1371/journal.pone.0255915] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 07/26/2021] [Indexed: 12/24/2022] Open
Abstract
Effective patient prognosis necessitates identification of novel tumor promoting drivers of gastric cancer (GC) which contribute to worsened conditions by analysing TCGA-gastric adenocarcinoma dataset. Small leucine-rich proteoglycans, asporin (ASPN) and decorin (DCN), play overlapping roles in development and diseases; however, the mechanisms underlying their interplay remain elusive. Here, we investigated the complex interplay of asporin, decorin and their interaction with TGFβ in GC tumor and corresponding normal tissues. The mRNA levels, protein expressions and cellular localizations of ASPN and DCN were analyzed using real-time PCR, western blot and immunohistochemistry, respectively. The protein-protein interaction was predicted by in-silico interaction analysis and validated by co-immunoprecipitation assay. The correlations between ASPN and EMT proteins, VEGF and collagen were achieved using western blot analysis. A significant increase in expression of ASPN in tumor tissue vs. normal tissue was observed in both TCGA and our patient cohort. DCN, an effective inhibitor of the TGFβ pathway, was negatively correlated with stages of GC. Co-immunoprecipitation demonstrated that DCN binds with TGFβ, in normal gastric epithelium, whereas in GC, ASPN preferentially binds TGFβ. Possible activation of the canonical TGFβ pathway by phosphorylation of SMAD2 in tumor tissues suggests its role as an intracellular tumor promoter. Furthermore, tissues expressing ASPN showed unregulated EMT signalling. Our study uncovers ASPN as a GC-promoting gene and DCN as tumor suppressor, suggesting that ASPN can act as a prognostic marker in GC. For the first time, we describe the physical interaction of TGFβ with ASPN in GC and DCN with TGFβ in GC and normal gastric epithelium respectively. This study suggests that prevention of ASPN-TGFβ interaction or overexpression of DCN could serve as promising therapeutic strategies for GC patients.
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Dhali A, Ray S, Khamrui S, Dhali GK. Mucinous cystadenocarcinoma of pancreas mimicking gastrointestinal stromal tumor of stomach: Case report. Int J Surg Case Rep 2021; 85:106240. [PMID: 34343789 PMCID: PMC8349996 DOI: 10.1016/j.ijscr.2021.106240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Revised: 07/23/2021] [Accepted: 07/24/2021] [Indexed: 11/19/2022] Open
Abstract
Introduction Pancreatic mucinous cysadenocarcinoma is a rare neoplasm of pancreas which rarely presents as upper gastrointestinal bleed. Case report A 45-year-old woman presented with history of repeated episodes of melena and abdominal pain. Upper gastrointestinal endoscopy revealed a growth in the body of the stomach likely to be a gastrointestinal stromal tumor (GIST). Endoscopic biopsy was inconclusive for GIST or malignancy. Computed tomography scan of the abdomen showed a well-defined multiloculated cystic lesion (11.8 × 11.1 × 6.4 cm) in the body and tail of the pancreas with involvement of the stomach. Preoperative diagnosis was a cystic neoplasm of the pancreas with tumor ingrowth into the stomach. The patient underwent enbloc resection of the stomach with distal pancreatectomy and splenectomy. Histopathological examination revealed low grade mucinous cystadenocarcinoma of the pancreas. Discussion Upper gastrointestinal bleed as a manifestation of cystic neoplasms of pancreas are rarely reported. Although some cases of hemoperitoneum were reported due to rupture of tumor; luminal gastrointestinal bleed is even rarer. It may be due to involvement of porto-mesenteric axis with portal hypertension, direct invasion of the gastric wall with ulceration of the gastric mucosa, communication between the tumor and the main pancreatic duct, and from the infiltrating tumor. Conclusion Our case highlights the fact that mucinous cystadenocarcinoma of pancreas rarely can present with upper gastrointestinal hemorrhage, Moreover, if it is large enough to compress or invade the stomach, endoscopy may misdiagnose it as GIST. Mucinous cystadenocarcinoma of pancreas; is a rare pacreatic neoplasm which can present with upper gastrointestinal hemorrhage. If it is large enough to compress or invade the stomach, endoscopy may misdiagnose it as gastrointestinal stromal tumor. Clinicians should be aware of this atypical manifestation and correlate with cross-sectional imaging accordingly.
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Dhali A, Ray S, Ghosh R, Sarkar A, Dhali GK. Massive Upper Gastrointestinal Hemorrhage in Brunner's Gland Hamartoma of Duodenum. Cureus 2021; 13:e15875. [PMID: 34336406 PMCID: PMC8312786 DOI: 10.7759/cureus.15875] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 11/17/2022] Open
Abstract
Brunner's gland hamartoma (BGH) is a rare benign small bowel tumor, mostly encountered in the duodenum. Massive upper gastrointestinal (UGI) hemorrhage is an unusual presentation rarely reported in English literature. Symptomatic patients mostly present with features of gastric outlet obstruction, occult bleeding, or intussusception. Herein, we report a case of BGH presenting with overt UGI bleed and features of gastric outlet obstruction. Esophagogastroduodenoscopy revealed a smooth polypoidal swelling in the posterior wall of the duodenal bulb. An endoscopic ultrasound (EUS) guided fine-needle-aspiration was performed, which was inconclusive. Contrast-enhanced computed tomography showed the absence of any extraluminal component of the lesion. Endoscopic polypectomy was attempted but failed due to the broad base of the lesion, and hence the patient was managed by open surgical excision. Histological examination of the resected specimen confirmed the diagnosis to be BGH. The patient had an uneventful recovery and was doing well at the 15-month follow-up. BGH should be considered as a differential diagnosis of a polypoidal lesion of the duodenum. Any lesion larger than 2 cm or symptomatic should be removed either by endoscopic or surgical intervention.
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Dhali A, Ray S, Dhali GK. Primary Small Cell Neuroendocrine Tumour of Gallbladder Presenting as Pyrexia of Unknown Origin. Cureus 2021; 13:e15874. [PMID: 34327099 PMCID: PMC8302456 DOI: 10.7759/cureus.15874] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Herein, we report a case of primary small cell neuroendocrine tumor (NET) of the gallbladder in a 45-year-old female who presented with complaints of fever accompanied by abdominal pain on the right upper quadrant for one month. Contrast-enhanced computed tomography abdomen showed a large gallbladder mass. It was infiltrating the segments IVa, IVb, and V of the liver. Ultrasound-guided fine-needle-aspiration-cytology was performed. Based on preoperative pathological and immunohistochemical investigations, it was diagnosed to be a primary small cell NET of the gallbladder. The patient underwent radical cholecystectomy after three cycles of cisplatin-based neoadjuvant chemotherapy. She had an uneventful recovery and received adjuvant chemo-radiotherapy. The patient was well at the 18-month follow-up.
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Dhali A, Pasangha E, D'Souza C, Hazra A, Dhali GK. Pseudopapillary Tumor of the Pancreas: A Rare Cause of Extrahepatic Portal Hypertension. Cureus 2021; 13:e15707. [PMID: 34290913 PMCID: PMC8288586 DOI: 10.7759/cureus.15707] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
A solid pseudopapillary tumor (SPT) of the pancreas is an uncommon neoplasm, characterized by a well-encapsulated mass, with low malignant potential. It occurs predominantly in young females. We present a case of SPT of the pancreas which presented with sinistral portal hypertension. Despite characteristic radiological findings due to its rarity, it may be missed to more common conditions like peptic ulcer disease. Delayed diagnosis can lead to complications like portal hypertension. To the best of our knowledge, in existing medical literature, SPT of the pancreas in males has rarely been described. In our case, we found that the tumor was causing extrahepatic portal hypertension which is also a very unique presentation of this tumor. Due to its vague clinical manifestations, definitive diagnosis is often a challenge hence requiring prompt investigations.
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Dhali A, Ray S, Dhali GK, Ghosh R, Sarkar A. Refractory hypoglycaemia in a localised gastrointestinal stromal tumour: Case report. Int J Surg Case Rep 2021; 83:106023. [PMID: 34090190 PMCID: PMC8188391 DOI: 10.1016/j.ijscr.2021.106023] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION GIST and NICTH are mesenchymal in origin however there are very few reports of GIST associated with NICTH which is a para neoplastic syndrome, generally diagnosed when a tumour induced hypoglycaemia is noted. CASE PRESENTATION A 46 years old female with prime complain of awareness of a mass in the upper abdomen was admitted for evaluation and further management. Detailed investigation revealed the mass to be gastrointestinal stromal tumour. On the day of admission patient was found to be hypoglycaemic which didn't resolve even after 10% glucose infusion. A growth hormone releasing peptide-2 (GHRP-2) assay was carried out which showed an excessive reaction of basal growth hormone however corticotropin releasing hormone (CRH) tests were within normal limits. She was suspected to be Non Islet cell tumour hypoglycaemia (NICTH) and hypoglycaemia resolved upon administering dexamethasone. Later she underwent chemotherapy and surgical resection after which her blood sugar levels were within normal limits. DISCUSSION Expression of big IGF-II on the surface of GIST be it metastatic or nonmetastatic can cause refractory hypoglycaemia and can be fatal if left untreated. CONCLUSION Clinicians should be aware of refractory hypoglycaemia in patients with large GIST's as glucocorticoid therapy may prove to be extremely useful and lifesaving even before considering any forms of definitive management of the tumour.
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Patra PS, Das A, Ahmed SKM, Mitra S, Dhali GK. Treatment response and long-term outcomes in biliary ascariasis: A prospective study. Arab J Gastroenterol 2021; 22:164-169. [PMID: 33752976 DOI: 10.1016/j.ajg.2020.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/30/2020] [Accepted: 11/20/2020] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND STUDY AIMS Anti-helminthic therapy and endoscopic worm extraction had variable success rates in biliary ascariasis. Recurrent biliary events after worm clearance are common. We aimed to evaluate the outcomes of management in biliary ascariasis and find out the incidence and risk factors for the development of recurrent biliary events. PATIENTS AND METHODS Consecutive patients with biliary ascariasis detected on abdominal ultrasound (AUS), were selected. Initial conservative treatment with oral Albendazole (400 mg) and analgesics was started in all. Successful therapy was defined as symptomatic resolution, and AUS confirmed biliary clearance after three weeks. ERCP (Endoscopic retrograde cholangiopancreatography) was performed in patients with failed conservative management. The patients were prospectively followed up for a minimum period of 1 year. RESULTS Among 98 patients with biliary ascariasis, 23 (23.5%) responded to medical management alone. A presentation with obstructive jaundice (p = 0.04) and cholangitis (p = 0.007) was significantly associated with failure to medical management. Sixty-five (86.7%) among 75 patients had successful biliary clearance with ERCP. During a median follow up of 16 months, 24 (24.5%) patients had recurrent biliary events. Lower socioeconomic status (OR = 0.78, p = 0.023) and longer follow-up (OR = 1.16, p = 0.001) were independent risk factors for recurrent biliary events. CONCLUSION Early ERCP among high-risk patients and proper hygiene are the keys to successful management in biliary ascariasis.
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Das P, Vaiphei K, Amarapurkar AD, Sakhuja P, Nada R, Paulose RR, Chaturvedi R, Sekaran A, Kini U, Rastogi A, Kumari N, Pulimood A, Banerjee M, Kinra P, Singh L, Puri A, Pai G, Kochhar R, Dhali GK, Ramakrishna BS, Sood A, Ghoshal UC, Ahuja V, DattaGupta S, Makharia GK, Misra V. Best practices of handling, processing, and interpretation of small intestinal biopsies for the diagnosis and management of celiac disease: A joint consensus of Indian association of pathologists and microbiologists and Indian society of gastroenterology. INDIAN J PATHOL MICR 2021; 64:S8-S31. [PMID: 34135135 DOI: 10.4103/ijpm.ijpm_1405_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Indian Association of Pathologists and Microbiologists (IAPM) and Indian Society of Gastroenterology (ISG) decided to make a joint consensus recommendation for handling, processing, and interpretation of SI biopsies for the diagnosis and management of celiac disease (CD) recognizing the inhomogeneous practice of biopsy sampling, orientation, processing, and interpretation. A modified Delphi process was used to develop this consensus document containing a total of 42 statements and recommendations, which were generated by sharing the document draft, incorporating expert's opinion, followed by three cycles of electronic voting as well as a full-day face-to-face virtual ZOOM meeting and review of supporting literature. Of the 42 statements, 7 statements are on small intestinal (SI) biopsy in suspected patients of CD, site and the number of biopsies; 7 on handling, fixative, orientation, processing, and sectioning in pathology laboratories; 2 on histological orientation; 13 statements on histological interpretation and histological grading; 3 on the assessment of follow-up biopsies; 2 statements on gluten-free diet (GFD)-nonresponsive CD; 4 on challenges in the diagnosis of CD; 2 statements each on pathology reporting protocol and training and infrastructure in this area. The goal of this guideline document is to formulate a uniform protocol agreed upon both by the experienced pathologists and gastroenterologists to standardize the practice, improve the yield of small bowel biopsy interpretation, patients' compliance, overall management in CD, and generate unified data for patient care and research in the related field.
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Devarbhavi H, Joseph T, Sunil Kumar N, Rathi C, Thomas V, Prasad Singh S, Sawant P, Goel A, Eapen CE, Rai P, Arora A, Leelakrishnan V, Gopalakrishnan G, Vardhan Reddy V, Singh R, Goswami B, Venkataraman J, Balaraju G, Patil M, Patel R, Taneja S, Koshy A, Nagaraja Rao P, Kumar Sarin S, Rathi P, Dhiman R, Duseja AK, Vargese J, Kumar Jain A, Wadhawan M, Ranjan P, Karanth D, Ganesh P, Nijhawan S, Krishna Dhali G, Adarsh CK, Jhaveri A, Nagral A, Rao P, Shalimar. The Indian Network of Drug-Induced Liver Injury: Etiology, Clinical Features, Outcome and Prognostic Markers in 1288 Patients. J Clin Exp Hepatol 2021; 11:288-298. [PMID: 33994711 PMCID: PMC8103312 DOI: 10.1016/j.jceh.2020.11.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/09/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Etiology of and outcomes following idiosyncratic drug-induced liver injury (DILI) vary geographically. We conducted a prospective study of DILI in India, from 2013 to 2018 and summarize the causes, clinical features, outcomes and predictors of mortality. METHODS We enrolled patients with DILI using international DILI expert working group criteria and Roussel Uclaf causality assessment method. Follow-up was up to 3 months from onset of DILI or until death. Multivariate logistics regression was carried out to determine predictors of non-survival. RESULTS Among 1288 patients with idiosyncratic DILI, 51.4% were male, 68% developed jaundice, 68% required hospitalization and 8.2% had co-existing HIV infection. Concomitant features of skin reaction, ascites, and encephalopathy (HE) were seen in 19.5%, 16.4%, and 10% respectively. 32.4% had severe disease. Mean MELD score at presentation was 18.8 ± 8.8. Overall mortality was 12.3%; 65% in those with HE, 17.6% in patients who fulfilled Hy's law, and 16.6% in those that developed jaundice. Combination anti-TB drugs (ATD) 46.4%, complementary and alternative medicines (CAM) 13.9%, anti-epileptic drugs (AED) 8.1%, non-ATD antimicrobials 6.5%, anti-metabolites 3.8%, anti-retroviral drugs (ART)3.5%, NSAID2.6%, hormones 2.5%, and statins 1.4% were the top 9 causes. Univariate analysis identified, ascites, HE, serum albumin, bilirubin, creatinine, INR, MELD score (p < 0.001), transaminases (p < 0.04), and anti-TB drugs (p = 0.02) as predictors of non-survival. Only serum creatinine (p = 0.017), INR (p < 0.001), HE (p < 0.001), and ascites (p = 0.008), were significantly associated with mortality on multivariate analysis. ROC yielded a C-statistic of 0.811 for MELD and 0.892 for combination of serum creatinine, INR, ascites and HE. More than 50 different agents were associated with DILI. Mortality varied by drug class: 15% with ATD, 13.6% with CAM, 15.5% with AED, 5.8% with antibiotics. CONCLUSION In India, ATD, CAM, AED, anti-metabolites and ART account for the majority of cases of DILI. The 3-month mortality was approximately 12%. Hy's law, presence of jaundice or MELD were predictors of mortality.
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Key Words
- AED, Anti-epileptic drugs
- ALF, Acute liver failure
- ALT, Alanine aminotransferase
- ART, Anti-retroviral drugs
- AST, Aspartate aminotransferase
- ATD, Anti- tuberculosis drugs
- Anti-tuberculosis drugs
- C.I, Confidence interval
- CAM, Complementary and alternative medicine
- Complimentary medicines
- DILI, Drug-induced liver injury
- DILIN, Drug induced liver injury network
- HE, Hepatic encephalopathy
- HIV, Human immunodeficiency virus
- INR, International normalised ratio
- Isoniazid
- Jaundice
- MELD, Model for end stage liver disease
- Mortality
- NSAID, Nonsteroidal anti-inflammatory drugs
- OR, Odds ratio
- Prognosis
- Pyrazinamide
- ROC, Receiver operating characteristic
- RUCAM, Roussel uclaf causality assessment method
- Rifampicin
- TB, Tuberculosis.
- TCM, Traditional chinese medicines.
- Traditional medicines
- ULN, Upper limit of normal
- USA, United states of america
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Santra S, Bishnu D, Dhali GK, Santra A, Chowdhury A. Expression of type I collagen in response to Isoniazid exposure is indirect and is facilitated by collateral induction of cytochrome P450 2E1: An in-vitro study. PLoS One 2020; 15:e0236992. [PMID: 32735603 PMCID: PMC7394448 DOI: 10.1371/journal.pone.0236992] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 07/18/2020] [Indexed: 01/04/2023] Open
Abstract
We wanted to investigate whether Isoniazid (INH) can directly stimulate activation of hepatic stellate cells (HSCs) and enhance production of collagen. Treatment of human hepatic stellate cell line LX2 with or without 5μM INH for 24 to 72 hours was performed to look into content of cytochrome P450 2E1 (CYP2E1), activity of NADPH oxidase (NOX) and intracellular oxidative stress. Protein level as well as mRNA expression of alpha smooth muscle actin (α-SMA) and collagen1A1 (COL1A1) were assessed by western blot and real time PCR. In some experiments pyrazole (PY) was pre-treated to LX2 cells to induce CYP2E1 prior to INH treatment. CYP2E1 level as well as NOX activity was gradually increased with INH treatment in LX2 cells till 72 hours. Following 72 hours of INH exposure, intracellular glutathione (GSH) level was found to be reduced compared to control (p<0.01) and showed expression of α-SMA, indicating activation of HSC. We could not found any change in collagen expression in this experimental study. Pyrazole (PY) pre-treatment to LX2 cells caused significant increase in cellular CYP2E1 content associated with increase of NOX, intracellular reactive oxygen species (ROS), and expression of α-SMA and collagen1 after INH exposure. CYP2E1 is present in insignificant amount in HSCs and INH treatment could not induce collagen expression, although altered cellular oxidant levels was observed. But in LX2 cells when CYP2E1 was over-expressed by PY, INH administration provokes oxidative stress mediated stellate cells activation along with collagen type I expression.
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Ghosh S, Bhowmik S, Majumdar S, Goswami A, Chakraborty J, Gupta S, Aggarwal S, Ray S, Chatterjee R, Bhattacharyya S, Dutta M, Datta S, Chowdhury A, Dhali GK, Banerjee S. The exosome encapsulated
microRNAs
as circulating diagnostic marker for hepatocellular carcinoma with low alpha‐fetoprotein. Int J Cancer 2020; 147:2934-2947. [PMID: 32441313 DOI: 10.1002/ijc.33111] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 04/15/2020] [Accepted: 05/05/2020] [Indexed: 12/21/2022]
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Kedia S, Sharma R, Makharia G, Ahuja V, Desai D, Kandasamy D, Eapen A, Ganesan K, Ghoshal UC, Kalra N, Karthikeyan R, Madhusudhan KS, Philip M, Puri A, Puri S, Sinha SK, Banerjee R, Bhatia S, Bhat N, Dadhich S, Dhali GK, Goswami BD, Issar SK, Jayanthi V, Misra SP, Nijhawan S, Puri P, Sarkar A, Singh SP, Srivastava A, Abraham P, Ramakrishna BS. Indian guidelines on imaging of the small intestine in Crohn's disease: A joint Indian Society of Gastroenterology and Indian Radiology and Imaging Association consensus statement. Indian J Radiol Imaging 2019; 29:111-132. [PMID: 31367083 PMCID: PMC6639863 DOI: 10.4103/ijri.ijri_153_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The Indian Society of Gastroenterology (ISG) Task Force on Inflammatory Bowel Disease and the Indian Radiological and Imaging Association (IRIA) developed combined ISG-IRIA evidence-based best-practice guidelines for imaging of the small intestine in patients suspected to have or having Crohn's disease. The 29 consensus statements, developed through a modified Delphi process, are intended to serve as reference for teaching, clinical practice, and research.
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