Conference Abstracts - Case Reports

Unusual Brain Metastasis of Colorectal Carcinoma Diagnosed following Seizure: A Case Report

Megha Sharma, Deepak Kannan, Rohit Rakholia, M. Preethi

Department of Medical Gastroenterology, Apollo Main Hospital, Chennai, Tamil Nadu, India

Introduction: Colorectal carcinoma is a common malignancy known for metastasizing primarily to the liver and lungs. Brain metastases from colorectal cancer are relatively rare, accounting for approximately 1%–3% of all brain metastases, and are associated with poor overall survival. Lung metastasis and RAS mutation are known risk factors for brain metastasis. Typically, patients with brain metastases present with neurological symptoms such as headaches, focal deficits, or cognitive changes. However, seizures as the initial manifestation of brain metastasis from colorectal carcinoma are exceedingly uncommon. Case: A 48-year-old male patient presented to the emergency department following a witnessed seizure episode. Immediate neurological evaluation, including computed tomography (CT) of the brain, revealed a solitary enhancing lesion in the left parietal lobe consistent with a metastatic brain tumor. Hematological indices suggested severe anemia. Subsequent colonoscopy was performed, which revealed a large ulcerative growth in rectosigmoid colon, following which contrast-enhanced CT scan and positron emission tomography scans revealed the possibility of primary malignant rectosigmoid mass lesion with probable liver and lymph nodal lesions in the body suggestive of metastatic lesions. Further histopathological analysis confirmed adeno colorectal carcinoma. The patient underwent whole-brain radiation therapy, followed by systemic chemotherapy targeting the underlying colorectal cancer. The patient and family opted for palliative care, and the patient is on follow-up. Conclusion: This case underscores the atypical presentation of colorectal carcinoma with brain metastasis. The rarity of such a presentation challenges clinicians in prompt diagnosis and appropriate management. Early recognition followed by an aggressive therapeutic approach may be the best option for long-term disease control and remain critical in enhancing the quality of life and survival outcomes. Prognosis in these patients is poor, with those receiving treatment with surgery and WBRT having the best overall survival.

Beyond the Ordinary: A Rare Case of Diffuse Esophageal Leiomyomatosis

S. Muhammed Shahanas, Sadguna Rao, P. Piramanayagam

Department of Medical Gastroenterology, Apollo Main Hospital and Apollo Speciality Hospital, Chennai, Tamil Nadu, India

Introduction: Diffuse esophageal leiomyomatosis, a rare benign esophageal tumor, differs from the more common esophageal leiomyoma (solitary and well-defined lesion). This condition is usually linked with Alport’s syndrome, characterized by circumferential proliferation of smooth muscle layers. It can manifest at any age, but predominantly affects children and young adults, with a 1.6 times higher incidence in women. Leiomyomatosis predominantly involves middle and distal one-third of the esophagus, with an extension into the cardia and fundus of the stomach observed in approximately 80% of cases. However, the entire esophagus is affected in only 35% of instances. The most common manifestation involves prolonged dysphagia and other symptoms such as regurgitation, dyspepsia, cough, dyspnea, and weight loss can also occur. In our case, the patient presented with complaints of regurgitation and dyspepsia. Case Report: A 30-year-old female presented with a 4-month history of regurgitation and dyspepsia. Her family history and system examination findings were unremarkable and noncontributory. Gastroscopy showed compressed esophageal lumen with normal mucosa and diffuse concentric smooth wall thickening of mid and lower esophagus on computed tomography of the chest. On endoscopic ultrasound, diffuse thickening of muscularis propria from 20 cm extending up to 37 cm from incisor with few specks of calcification and fine-needle biopsy showed smooth muscle bundles. She was symptomatically treated for dyspepsia and kept on regular follow-up. Conclusion: Because of its rarity, diagnosis is usually difficult. Commonly employed diagnostic modalities include chest X-ray, barium swallow, endoscopy, computed tomography scan, magnetic resonance imaging, and endoscopic ultrasound. Some investigators advocate endoscopic ultrasound as the preferred imaging modality to distinguish achalasia from leiomyomatosis, especially when the initial investigation reveals a smooth, tapered narrowing of the distal esophagus. Asymptomatic patients undergo clinical and endoscopic follow-up, whereas individuals experiencing severe and progressive dysphagia are recommended for total esophagectomy.

Untangling a Case of Trichobezoar

R. M. Arun, R. Ravishankar, A. Senthil Vadivu

Department of Medical Gastroenterology, Coimbatore Medical College, Coimbatore, Tamil Nadu, India

Case: A 15-year-old female presented with complaints of early satiety for 3 months and vomiting following food intake with abdominal pain for 1 month duration. The patient was taking medication for depressive disorder, but with poor compliance. 10 cm × 8 cm firm smooth mobile mass palpable in epigastric region. It extended 3 cm to the right and 2 cm to the left from the midline. The lower border 5 cm above the umbilicus upper border could not be made out. There was no visible peristalsis. Contrast-enhanced computed tomography abdomen and pelvis- A heterodense lesion involving entire stomach and part of duodenum with their walls well defined from lesion and with air pockets-Suggestive of Bezoar. Endoscopy- Lumen of stomach filled with huge amounts of hair strands suggestive of Trichobezoar. Scope could not be passed beyond stomach. The patient underwent gastrotomy and trichobezoar involving the stomach and duodenum was delivered by surgeons. Discussion: Trichobezoar should be considered in diagnosis when we encounter young female individuals with symptoms of gastric outlet obstruction and psychiatric history.

Immunodeficiency Disorder with Portal Hypertension: A Rare Complication of a Rare Disease

Bhavishya Sundar, P. Padmanabhan, N. Dhinakaran, Somnath Verma

Department of Medical Gastroenterology, Meenakshi Medical College Hospital and Research Institute, Kancheepuram, Tamil Nadu, India

Introduction: Common variable immunodeficiency (CVID) is a form of severe antibody deficiency with an estimated incidence of 1 in 50,000–1 in 100,000. This disorder results from undefined immune deregulations resulting in failed B-cell differentiation with impaired secretion of immunoglobulins. It can present with heterogeneous clinical manifestations such as recurrent infections of the respiratory tract, chronic lung disease, autoimmune diseases, liver and gastrointestinal disorders, granulomatous infiltrations, lymphoma, and solid tumors. Here, we present a rare case of portal hypertension with CVID. Case Report: A 17–year-old female, born out of consanguineous marriage with history of CVID presented with abdominal discomfort since 2 months associated with loss of appetite. She had prior history bronchiectasis, pulmonary tuberculosis, Hodgkin’s lymphoma. Physical examination was significant for pallor, jaundice, clubbing, and splenomegaly. Laboratory data were complete blood count: Hb: 9 g/dl, TLC: 8100, platelets: 88,000 liver function test: T. Bili: 3.2 D. Bili: 1.6 aspartate aminotransferase/alanine aminotransferase: 37/30, alkaline phosphatase: 298, Albumin: 3.2. USG abdomen: Liver size normal, appearance nodular and heterogeneous echotexture with prominent portal vein suggestive of portal hypertension. Spleen (18 cm) with prominent splenic vein. Transient elastography: 16 kpa. Esophagoduodenoscopy showed Esophageal varices, gastroesophageal varices type-2, portal hypertensive gastropathy. The portal hypertension can be due to nodular regenerative hyperplasia (NRH). She was started on nonselective beta blocker and planned for further evaluation. Discussion: The prevalence of liver involvement is reported between 9% and 79%. NRH is the most common liver disorder in CVID apart from transaminasemia, infective complications, primary biliary cirrhosis, and cirrhosis. The liver involvement occurs late in the course of disease, carrying poor prognosis and diagnostic and management challenges. Liver and hemopoietic stem cell transplantation can be considered in selected cases. Conclusion: This case is presented for its rarity and challenges it poses in diagnosis and management. There is a lack of sufficient data in the Indian context concerning CVID and its association with liver disease.

Cholestatic Jaundice in a Young – Unraveled

Farhanulla Basha, S. Shanmuganathan, P. Ganesh

Department of Medical Gastroenterology, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, India

Introduction: A 23-year-old individual presented with a month-long history of yellowish discoloration of the eyes, accompanied by escalating pruritus, pale-colored stools, and a recent onset of abdominal pain localized in the right hypochondriac region. The abdominal pain, characterized as dull and intermittent, had emerged just 1 day before seeking medical attention, with episodes spontaneously relieved and no discernible aggravating factors. The patient denied any fever, blood transfusions, high-risk behavior, over-the-counter drug intake, or recent use of complementary and alternative medicine. Notably, the patient had encountered two prior episodes of jaundice, indicating a recurrent nature of the symptoms. The diagnostic journey aimed to discern the underlying cause of the current presentation. Initially, autoimmune, viral hepatitis markers, and Wilson’s disease workup were considered, but subsequent testing ruled out these possibilities. Imaging studies, including abdominal ultrasound and magnetic resonance cholangiopancreatography, were unremarkable for structural abnormalities. Liver function tests exhibited an elevated total bilirubin at 17, with a direct fraction of 9. SGOT and SGPT levels were within normal limits, indicating the absence of significant hepatocellular damage. Alkaline phosphatase levels were elevated at 200 with normal GGT aligning with a cholestatic presentation. Importantly, hepatic synthetic functions, including albumin and prothrombin time, remained within normal limits. In addition, a liver biopsy was done, and a report suggestive of a cholestatic pattern further supported the diagnostic evaluation. With clinical history of recurrent jaundice with cholestatic pattern with spontaneous recovery possibility of congenital disorder was entertained and genetic testing was advised, specifically whole-exome sequencing, played a pivotal role in unraveling the mystery. The results identified mutations in the ATP8B1 gene, leading to a conclusive diagnosis of benign recurrent intrahepatic cholestasis (BRIC). This rare autosomal recessive disorder manifested with intermittent and severe cholestatic episodes. Management of BRIC focused on alleviating symptoms and providing supportive care. The patient was prescribed ursodeoxycholic acid and cholestyramine to improve symptoms. Regular follow-up appointments were scheduled to monitor liver function, manage symptoms, and offer psychological support. Conclusion: This case underscores the diagnostic challenges associated with BRIC, highlighting the necessity of a thorough evaluation and consideration of genetic testing in patients with recurrent cholestatic symptoms, especially in the young. Furthermore, the case emphasizes the importance of ongoing research to enhance our understanding of this rare genetic disorder and explore potential targeted therapeutic interventions for improved patient outcomes.

Challenging Case of Corrosive-induced Gastric Outlet Obstruction: A Case Report

U. Siddharth

Department of Medical Gastroenterology, Coimbatore Medical College, Coimbatore, Tamil Nadu, India

Introduction: Isolated gastric outlet obstruction due to corrosive acid ingestion is a rare but well-known complication. There is a tendency of acids to lick the esophagus and bite the pyloric antrum. Case Presentation: We present an 18-year-old female who presented with complaints of nonbillious vomiting, postprandial fullness, and weight loss. A history of corrosive acid ingestion was present 3 months ago. Barium swallow revealed a grossly distended stomach extending from the left dome of diaphragm to the left iliac fossa (vertical length 22.8 cm) with pyloric stricture at L3 vertebral level. She underwent repeated endoscopic balloon dilatation for 4 times but due to refractory nature surgical opinion obtained and gastrojejunostomy was performed. Discussion: Young adults may consume different corrosives used for house cleaning with suicidal intent. The esophagus is spared because of the short contact time due to rapid transit of acidic corrosive agent. Once in stomach due to pylorospasm there is pooling of ingested corrosive in antral region causing stricture.^[2] Endoscopic balloon dilatation may be tried, but almost half of patients need repeated dilatations or surgical intervention. Conclusion: Refractory pyloric stricture due to corrosive ingestion.

Gastric Glomus Tumor

Ilavarasi Lakshmanan

Consultant, Sanjana Speciality Hospital, Chennai, Tamil Nadu, India

Introduction: Glomus tumor of the stomach is an unusual submucosal mesenchymal tumor of the gastrointestinal tract. Case: We describe a 79-year-old male, who presented with abdominal pain and tiredness. A preoperative diagnosis of probable gastrointestinal stromal tumor was made after endoscopy, computed tomography, and endoscopic ultrasound evaluation. Postsurgical histopathological examination confirmed a glomus tumor, with typical uniform, round cells on HPE with IHC being positive for SMA, negative for CD 117 and DOG 1 which ruled out a GIST. In our case, we did not proceed with IHC preoperatively due to logistic reasons as well we had planned a surgical management as the lesion was nonmetastatic and size being more than 4 cm. Most of the gastric glomus tumors are benign, but factors such as age, symptoms, tumor size, gross appearance, ki67 staining, and mitotic activity should be considered to determine malignant potential. Conclusion: Rarity, limited publications, very close differential of GIST, usually a benign tumor, not commonly included in the differential diagnosis of gastric submucosal lesions marks the rarity in this case.

Double Trouble: Navigating the Diagnostic Maze of Simultaneous Hepatitis A and Dengue Fever in Acute Febrile Illness

Adeep Aslam, A. Anand, M. Malarvizhi, B. Sumathi

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: The coexistence of hepatitis A and dengue fever, prevalent in certain regions, presents a diagnostic challenge due to shared symptoms. Hepatitis A, transmitted through the fecal-oral route, and dengue fever, transmitted by Aedes mosquitoes, complicate diagnosis, particularly when clinical presentations overlap in areas endemic for both infections. Case: A 26-year-old female presented with three days of continuous fever, myalgia, and anorexia, progressing to chills, rigor, and loose stools. Laboratory findings indicated a significant drop in hemoglobin, total leukocyte count, and platelet count. Liver enzymes, notably aspartate aminotransferase (AST) and alanine aminotransferase (ALT), rose exponentially, reaching 3500 IU by day 10. Ultrasound revealed increased liver echoes with signs of serositis, and patient did not experience any bleeding manifestations. Subsequent investigations confirmed a coinfection with positive IgM results for both hepatitis A and dengue. Therapeutic measures included intravenous fluids, ursodeoxycholic acid, and empirical antibiotics. Platelet counts declined further, reaching a nadir, while total bilirubin levels peaked at 10 mg/dL on day 10. The patient exhibited signs of improvement by day 14, accompanied by a subsequent decrease in jaundice. Discussion: Elevated liver enzymes, particularly AST and ALT, reaching 3500 IU, and a concurrent rise in serum bilirubin to 10 mg/dL underscore the severity of hepatocellular injury in this coinfection. The presence of serositis on ultrasound added a layer of complexity to the diagnostic process. The delayed elevation in serum bilirubin levels prompted empirical antibiotics and supportive care. Conclusion: This case emphasizes the critical need for vigilant monitoring and a multidisciplinary approach in regions where hepatitis A and dengue fever coexist. The diagnostic intricacies, dynamic clinical course, and management challenges in such coinfections contribute to our understanding of optimal therapeutic interventions for improved patient outcomes. This case highlights the intricacies encountered in diagnosing and managing these concurrent infections.

Hemobilia: A Rare Cause of Upper Gastrointestinal Bleeding

R. Deepak Kumar, Murali R, Prem Kumar, Ratnakar Kini,

Institute of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Hemobilia, an infrequent cause of upper gastrointestinal (GI) bleeding, is characterized by bleeding from the hepatobiliary tract. More than 50% of cases would have experienced liver trauma, undergone a liver biopsy or manipulation of the hepatobiliary system (endoscopic retrograde cholangiopancreatography [ERCP], Percutaneous transhepatic cholangiography or TIPSS), or have Hepatocellular Carcinoma or a Biliary Parasitic Infection. Case Report: We present a case of a 43-year-old male with a history of ethanol-related decompensated chronic liver disease and recent hepatobiliary interventions, admitted with abdominal pain, jaundice, and melena. The patient had undergone ERCP and CBD stenting 4 months earlier for choledocholithiasis, which became a critical point in understanding the subsequent complications. Upon admission, the patient exhibited symptoms consistent of the right upper quadrant pain, jaundice, and melena. Initial upper GI endoscopy revealed active bleeding from the ampulla, prompting further investigation with computed tomography abdomen angiography which was normal. However, still he had persistent melena for which digital subtraction angiography (DSA). DSA identified a hepatic artery pseudoaneurysm adjacent to the CBD stent, indicating a rare yet severe complication of ERCP. Two units of packed red blood cells were transfused, and the patient underwent DSA-guided arterial embolization with coil placement into the aneurysm. Subsequent imaging confirmed successful occlusion of the aneurysm, leading to symptomatic improvement. Conclusion: This case highlights the diagnostic challenges of hemobilia, especially in patients with recent hepatobiliary manipulation, and underscores the critical role of DSA in identifying and managing severe hemobilia with arterial embolization. Early recognition and intervention are pivotal for achieving favorable outcomes in these complex cases.

Hepatolithiasis – A Rare Cause of Secondary Biliary Cirrhosis

Rijo Sabu, A. Anand, M. Malarvizhi, B. Sumathi

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: Hepatolithiasis is a rare disease in India. Here, we report a patient with extensive hepatolithiasis with biliary obstruction. Case: A 54-year-old male presented with jaundice, ascites, and hepatic encephalopathy. There was no history of fever or abdominal pain. His ultrasound abdomen confirmed liver cirrhosis with dilation of intrahepatic biliary radicles with filling defects. Hepatitis B surface antigen and anti-HCV antibody were nonreactive. His computed tomography of the abdomen confirmed extensive hepatolithiasis with ascites. All other etiological workup for cirrhosis was negative. A diagnosis of secondary biliary cirrhosis was made. Magnetic resonance cholangiopancreatography ruled out common bile duct stones. Arterial ammonia was 182 (normal range, 11–51 µm/l), he had high SAAG (2.15) ascites and no spontaneous bacterial peritonitis. Serum bilirubin 17.97 mg/dl (reference 0-1), direct bilirubin 15.8 mg/dl (reference 0-0.3), alkaline phosphatase 143 units/l (reference 35-105), aspartate aminotransferase 87 units/l (reference 0-40), alanine aminotransferase 56 units /l (reference 0-40), serum albumin 3.22 mg/dl (reference 3.5-5.2) to INR 1.25. There was no history of fever and abdominal pain in the past. There was no prior history suggestive of liver disease. The patient is listed for liver transplantation and is on follow-up. Discussion: Our patient had hepatic encephalopathy as substantiated by features of liver cirrhosis and ascites on computed tomography. He developed rapidly evolving liver failure. Although, he did not have symptoms of biliary obstruction or cholangitis in past. Hepatolithiasis involves the presence of gallstones proximal to the confluence of left and right hepatic ducts, irrespective of presence or absence of common bile duct stones. Hepatolithiasis is frequently encountered in East Asian countries and is rare in other parts of the world. Cause of hepatolithiasis is unknown, parasitic infestations, bacterial infections, dietary factors, environmental and genetic causes have been implicated. Hepatolithiasis may cause in recurrent cholangitis, secondary biliary cirrhosis and cholangiocarcinoma. Feng et al. proposed Dong’s classification for hepatolithiasis, in this classification diffusely distributed stones with biliary cirrhosis were classified as type II c and liver transplant is recommended in such patients. On the other hand, patients with localized stones or diffuse stones without cirrhosis (Types 1 and II a and IIb) are best managed with hepatectomy. Conclusion: It is essential to practice an interdisciplinary approach to best treat and manage these patients to avoid complications.

Uncommon Presentation of Tuberculosis: A Case Report of Rectal Tuberculosis

A. Rubhika, Murali R, Prem Kumar, Ratnakar Kini

Institute of Medical Gastrenterology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Gastrointestinal tuberculosis (TB) is a form of extrapulmonary TB, of which ileocecal region is the most common site of involvement. Pathogenesis can be attributed to four mechanisms: ingestion of contaminated milk or food (Mycobacterium bovis), swallowing of infected sputum, hematogenous, or consecutive spread from adjacent organs. Rectum is an uncommon site for TB even in endemic countries like India. Case Summary: A 35-year-old male with no known comorbidities presented with complaints of persistent abdominal pain, altered bowel habits, significant loss of weight around 20 kg in 1 year. General examination revealed pallor, systemic examination was normal. ESR-46, hepatitis B, C and HIV negative. Contrast-enhanced computed tomography abdomen showed wall thickening in cecum with IC junction involvement. Computed tomography chest showed normal lung fields. Colonoscopy revealed ulcerative lesions in cecum and ulcerative nodular lesions in rectum, with normal colon in between. Biopsy from cecum showed inflammatory granulation tissue. Rectal biopsy revealed granulomatous inflammation and subsequent molecular testing confirmed MTB with Rif sensitivity. A diagnosis of intestinal TB with rectal involvement was made and the patient was started on ATT. Discussion: Rectal TB is very rare and it mostly occurs along with pulmonary TB. Usually presents with abdominal pain, altered bowel habits, blood in stools and constitutional symptoms. It is a great mimicker of rectal malignancy and IBD. Histopathology can help in diagnosis, but the yield is low due to predominant submucosal involvement. This case showed epitheloid granuloma in endoscopic biopsy with CBNAAT positivity which aided in diagnosis. Conclusion: TB should be considered a differential diagnosis in ulceroproliferative lesions involving any part of the gut even in an immunocompetent individual, especially in regions with high prevalence of TB. Timely recognition and appropriate treatment are crucial for optimal patient outcomes.

A Rare Cause of Acute Pancreatitis – An Enigma Unveiled

C. S. Arun, Kandasmay Alias Kumar, Poppy Rejoice, Shafique A, Geetha G

Department of Medical gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Introduction: Acute pancreatitis (AP) is an important clinical entity in clinical practice in view of its myriads of causative factors and relatively straightforward medical management. Although a variety of causes of AP have been reported, it is always difficult to be certain about the cause in a given patient. Here, we present a case of AP with a rare cause as etiology. Case: A 45-year-old teetotaler male presented with vomiting, abdominal pain, and abdominal distension. He had pathological fracture in the right hip 1 year before and left hip 3 months back for which he underwent surgery and was on injection teriparatide. On general examination, he had a swelling over the right side of the neck. Abdominal examination showed tenderness over the left hypochondrium with the presence of moderate ascites. Basic laboratory investigations showed elevated serum amylase (597 U/L), normal liver function test except for elevated alkaline phosphatase of 327 IU/L, serum calcium of 12.3 mg/dl with ascitic fluid analysis showing low SAAG-high protein and amylase of 614 U/L. USG abdomen was consistent of AP along with the presence of moderate ascites. USG neck showed 4.1 cm × 2.6 cm-sized lesion in the right lobe of the thyroid. Further evaluation showed elevated serum PTH of 110 pg/ml. 99 m-Tc-sestamibi scan showed a hypermetabolic soft tissue lesion (28 mm × 27.5 mm × 35.5 mm) posterior to the right lobe of the thyroid suggestive of parathyroid adenoma. Diagnosis of AP due to hypercalcemia secondary to primary hyperparathyroidism was made. AP and hypercalcemia were managed conservatively and the patient finally underwent parathyroidectomy with complete clinical recovery. Discussion: AP is a common disease with varied etiological factors. Prompt diagnosis of the underlying cause for AP is as important as the treatment of the episode. Parathyroid adenoma causing hypercalcemia is a rare cause of pancreatitis. Middle-aged male with pathological fracture and hypercalcemia needs meticulous evaluation. In the era of lost art of clinical examination, thorough comprehension of patient history general physical examination and virtual arsenal of tools to use to arrive at a diagnosis.

A Curious Case of Ascites: A Case Report

Shaoli Ghosh, T. Ravishankar, A. Senthil Vadivu

Department of Medical Gastroenterology, Coimbatore Medical College and Hospital, Coimbatore, Tamil Nadu, India

Introduction: Ascites is accumulation of fluid in peritoneal cavity. Here, we present a case of a young boy presenting with ascites, diagnosed as pancreatic ascites, and found have Disrupted Pancreatic Duct, a rare occurrence, without a history of immediate trauma or severe necrotising pancreatitis, the two most cited causes of the same. Case: A 13–year-old previously healthy boy presented with gradually increasing abdominal distension with postprandial epigastric pain for 2 weeks. He was found to have acute pancreatitis with BISAP score 0/5, increased amylase levels (>1500) in ascitic fluid, suggestive of pancreatic ascites. Thus, the search for pancreatic ductal injury started and magnetic resonance cholangiopancreatography revealed pancreatic duct discontinuity between head and neck region, suggestive of duct disruption. The patient gave a history of abdominal trauma 2 months before symptoms. He was managed conservatively with paracentesis, octreotide injections to decrease pancreatic secretions, analgesics, adequate hydration, to which he responded well, was successfully discharged without any complications. He is keeping well in follow-up. Discussion: Disconnected pancreatic duct syndrome (DPDS) is a rare circumferential disruption (partial or complete) of the continuity of the pancreatic duct between viable secreting distal pancreatic tissues and the gastrointestinal tract. Acute pancreatitis, chronic pancreatitis, pancreatic surgery, and trauma are possible causes. The disconnected segment is commonly seen in head or body, leading to extraductal leakage of pancreatic secretions and destruction of viable pancreatic tissue surrounding the duct. The treatment includes conservative management, percutaneous drainage of fluid surrounding the detached segment, ERCP-guided stent installation between the two detached ends of the main pancreatic duct, Roux-en-Y internal drainage, distal pancreatic splenectomy, for whom other nonsurgical measures have failed. Conclusion: DPDS, although rare, should be considered a diagnosis in pancreatic ascites or traumatic/necrotizing pancreatitis, for timely management.

Unmasking the Invisible: Confronting the Giant Splenomegaly in a Cryptic Case of Autoimmune Hepatitis-primary Biliary Cholangitis Overlap Syndrome

Aparna P, Prem Kumar K, Ratnakar Kini P, Murali R

Institute of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Autoimmune hepatitis (AIH) and primary biliary cholangitis (PBC) are distinct immune-mediated liver diseases, but their overlap, AIH-PBC overlap syndrome, presents a diagnostic and therapeutic challenge, particularly with atypical presentations. Case: We report a rare case of AIH-PBC overlap syndrome initially manifesting as massive splenomegaly in a 51-year-old female. The patient’s clinical journey underscores the complexity of diagnosing and managing overlap syndromes, especially when complicated by severe comorbidities. The patient presented with acute abdominal pain, jaundice, fever, and a past history of fatigue, weight loss, severe anemia requiring multiple transfusions, upper gastrointestinal bleeding, and endoscopic variceal ligation (EVL). Physical examination revealed jaundice, fever, right hypochondrial tenderness, and massive splenomegaly. Laboratory investigations highlighted pancytopenia and obstructive jaundice. Diagnostic imaging showed chronic liver disease (CLD) with portal hypertension, acute calculous cholecystitis, and choledocholithiasis. The patient was immediately started on antibiotics and other supportive management for acute cholecystitis. The symptoms recovered in 3–4 days with complete resolution of jaundice and normal liver function test. In view of the massive splenomegaly, the patient was worked up for hematologic malignancies including a bone marrow biopsy and JAK2, which were normal. In view of the underlying CLD with multiple collaterals, an extensive evaluation of the cause of CLD was done, including the autoimmune workup which was significant for positive ANA and antimitochondrial antibodies. A liver biopsy revealed features consistent with AIH-PBC overlap syndrome, meeting the Paris Criteria for diagnosis. The patient was started on ursodeoxycholic acid, along with multiple transfusions for severe pancytopenia, attributed to hypersplenism. OGD suggested large esophageal varices, fundal varices with severe portal hypertensive gastropathy. Despite management efforts, the patient’s thrombocytopenia persisted, precluding further EVL for esophageal varices. Ultimately, a splenectomy was attempted but was complicated by uncontrollable intraoperative bleeding, leading to the patient’s demise. Conclusion: This case emphasizes the importance of considering overlap syndromes in patients with atypical presentations of autoimmune liver diseases. Massive splenomegaly as an initial presentation of AIH-PBC overlap syndrome is unusual and warrants a high index of suspicion for timely diagnosis and intervention. The case also highlights the potential complications and high mortality associated with this unique patient subset, underscoring the need for careful and comprehensive management strategies.

An Interesting Case of Chronic Cholestatic Liver Disease (Autoimmune Cholangitis)

Vel murugan, R. Karthikeyan

Departments of Medical Gastroenterology, Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India

Introduction: Chronic cholestatic liver diseases are characterized by failure of bile transport to the duodenum. Fatigue and pruritus are the most common presenting symptoms of CCD with increased serum levels of alkaline phosphatase and/or GGT. Ultrasonography could distinguish intrahepatic versus extrahepatic biliary tract disease. Case: A case of 56-year-old female was admitted with complaints of itching all over the body and yellowish discoloration of eyes for 2 years. The patient had no history of fever, abdominal pain, drug intake, any previous comorbidity or addiction and there was no similar illness in the family members. On examination, the patient had icterus, scratch mark all over the body and shiny nails, hepatomegaly which was firm and not tender, no vitiligo. Rest of the examination was normal. Her investigation reports showed direct hyperbilirubinemia with raised alkaline phosphatase and GGT. ANA was positive and AMA was negative. USG abdomen showed hepatomegaly with no intrahepatic biliary radicle dilatation. Liver biopsy showed mild portal and lobular inflammation, moderate hepatocanalicular and ductular cholestasis and with portal and periportal irregular bridging fibrosis with incomplete nodularities. There is no significant steatosis, stainable iron or copper. Based on clinical presentation, biochemical, serology, and histopathology, possibility of autoimmune cholangitis was made. The patient was treated with ursodeoxycholic acid and azathioprine. Liver functions tests returned to normal and hepatomegaly regressed during follow-up. Discussion: Primary biliary cholangitis (PBC) is an autoimmune liver disease that generally affects middle-aged women and is characterized by progressive intrahepatic cholestasis. Diagnosis of PBC is made with ANA and AMA positive. In a retrospective study of 200 histologically diagnosed patients with PBC, Goodman et al. found that 20% were AMA negative but ANA positive, 10% were negative for both markers, and the remaining cases were all AMA positive. Perhaps, with clinical and histologic features, diagnosis of autoimmune cholangitis can be made irrespective of either AMA status.

An Interesting Case of Upper GI Bleeding in Acute Pancreatitis

Sonali Chaturvedi, R. Karthikeyan, Santosh Kumar¹

Departments of Medical Gastroenterology and ¹Interventional Radiology, Government Mohan Kumaramangalam Medical College, Salem, Tamil Nadu, India

Introduction: Upper gastrointestinal bleeding from the pancreas is a rare cause. It is characterized by hemorrhage due to rupture of a peripancreatic pseudoaneurysm or visceral artery pseudoaneurysm. Among the visceral artery, gastroduodenal artery pseudoaneurysms are among the rarest. Here, we report a case of successful coil embolization of a ruptured large GDA leak in a patient with gastrointestinal bleeding. Case Presentation: We present the case of a 24-year-old male, known case of recurrent pancreatitis, came with a chief complaint of abdominal pain for 2 week, blood in vomitus for 2 days, 2 episodes about 100 ml each episode and predominantly melena. Heart rate was 76 beats/min. Blood pressure was 130/84 mmHg. Clinically, the patient appeared calm and hemodynamically stable; neurologically, he was nonfocal deficits. On per abdomen, there was tenderness present in the epigastric region with bowel sound 3–4/min. USG abdomen showed heterogeneous two hypoechoic lesion seen in distal body and t ail of pancreas. Computed tomography (CT) angiogram of the abdomen showed large duodenal hematoma of 12 cm × 7 cm with evidence of active vascular contrast leak into duodenal hematoma from GDA. The patient underwent coil embolization. Postprocedure, the patient maintained hemoglobin and CT angiogram was repeated, which showed no leak from gastrodudenal artery. Discussion: This case illustrates the prompt and high suspicion and timely intervention in the patient of vascular bleed is life-saving.

An “Adult” with ARPKD: A Roller Coaster Ride toward Diagnosis

Santhan Reddy, S. Keerthivasan, Sundeep Kondari, Jayanthi Venkataraman

Department of Medical Gastroenterology, Gleneagles Global Health City, Chennai, Tamil Nadu, India

Introduction: A 23-year-old male with end-stage renal disease (ESRD) on hemodialysis had an incidental splenomegaly. Further interrogation for chronic liver disease and portal hypertension were noncontributory. Diagnosis of ESRD was made at 13 years of age when screening for acute abdominal pain and recurrent urolithiasis. On examination, the patient was hypertensive, pallor was present; there was no icterus, and KF ring was absent. Per abdomen: Normal liver span, moderate splenomegaly; no abdominal veins, no ascites. Other systems were normal. Lab investigations: pancytopenia with deranged renal function. Liver biochemistry: hypoalbuminemia, raised alkaline phosphatase. Ultrasound with Doppler study of the abdomen: shrunken liver, splenomegaly, portal vein 1.5 cm; mild dilation of the common bile duct, shrunken kidneys. Increased hepatopetal blood flow seen in the portal vein. Upper endoscopy: small esophageal varices. Clinical Diagnosis: Non-Cirrhotic Intrahepatic Portal Hypertension with ESRD. Magnetic resonance imaging and magnetic resonance cholangiopancreatography gave a clue to the diagnosis. Findings were consistent with a variant of congenital hepatic fibrosis and polycystic kidney disease. Retrospectively, an interesting revelation from the father was the presence of an antenatal history of hydramnios and the presence of “cysts in the kidney” on day one of delivery and history of consanguinity. The parents were warned that baby would require a check around 30 years of age. Final diagnosis: Autosomal recessive polycystic kidney disease with Caroli syndrome. Patient has been listed for kidney transplant and needs monitoring progression of hepatobiliary disease. Conclusion: Antenatal and childhood history provides a clue to the diagnosis in pediatric ESRD with portal hypertension.

Uncommon Hematological Complication in Acute Hepatitis A

B. Surya Naik, M. Kannan, R. Ramani, C. Vijai Shankar, P. B. Sriram

Department of Medical Gastroenterology, Madurai Medical College, Madurai, Tamil Nadu, India

Introduction: The spectrum of clinical presentation of acute hepatitis A can range from asymptomatic to acute liver failure. Several extrahepatic manifestations have been recognized in this setting, of which hematological and renal abnormalities were commonly reported. The hematological manifestations can range from anemia to severe bone marrow suppression and aplastic anemia requiring bone marrow transplantation. Case Report: A 16-year-old female was admitted with prodromal symptoms fever, loss of appetite, and fatigue, followed by jaundice. She presented to us on the 7^th day of symptom onset. On examination pallor icterus, raised jugular venous pressure, and a systolic murmur. Abdominal examination revealed mild splenomegaly. Blood count showed pancytopenia with an elevated ESR. Liver function tests SGOT > SGPT, and moderately elevated alkaline phosphatase. Serum proteins and renal function tests were normal. Conclusion: This case of acute hepatitis A, complicated by pancytopenia secondary to marrow suppression and possible autoimmune destruction underscores the importance of a systematic diagnostic approach in elucidating complex clinical presentations of a relatively common disease.

A Case of Retrograde Dilation of Esophagus for Corrosive Stricture

Susanta Kumar Dash, Sivasankar Amarapathy, Somasekar Durairajan

Department of Surgical Gastroenterology and GI Oncology, Government Mohan Kumaramangalam Medical College and Hospital, Salem, Tamil Nadu, India

Introduction: Corrosive acid ingestion is a common health problem in developing countries. We present a case of short-segment esophageal stricture where endoscopic dilation was done by a retrograde manner. Case Report: A 45–year-old female came with a history of corrosive acid ingestion 6 months back. Now, the patient came to us with chief complaints of inability to swallow solid food with a history of regurgitation and loss of weight. Barium swallow showed short-segment esophageal stricture in midesophagus for a length of 4 cm. OGD scopy showed nonpassable stricture at about 26 cm from incisor. Considering the poor nutritional status and high surgical risk (hypoalbuminemia, low pulmonary reserve, and low body mass index), we decided against proceeding for an esophageal replacement surgery. Hence, we planned for retrograde dilation of esophageal stricture. An upper midline incision of 5 cm given above the umbilicus. Two centimeters gastrotomy made in anterior wall of stomach near lesser curvature in the lower part. Upper gastrointestinal endoscope put through the gastric opening. It was passed distally, antrum was found normal and scope could be passed into duodenum. Then, ultraslim pediatric scope was passed proximally and stricture was visualized in a retrograde manner about 10 cm from esophagogastric junction. We passed guidewire through the stricture. Serial dilation of stricture done using Savary–Gilliard dilators, 5 mm, 7 mm, 9 mm, 11 mm, 12.8 and 14 mm. Each time the position of guidewire was checked using c-arm. Finally, the adult scope could be passed through the stricture both through retrograde and antegrade route. Discussion: Surgery as an option for esophageal strictures, carries high rate of morbidity and mortality, especially in a nutritionally compromised patient. The straight antegrade dilation cannot be used with complete luminal occlusion and inability to traverse the stenosis. Retrograde dilation of completely occlusive esophageal strictures was done for cases of stricture following radiotherapy and postesophagectomy. Conclusion: Retrograde dilation of esophageal strictures following corrosive ingestion is a useful and highly effective technique. It is especially useful in patients who are high-risk candidates for esophageal replacement surgery and antegrade dilation is not possible.

A Yuk Therapy Becomes a Yup Therapy

Murugaraj, Arulraj Ramakrishnan, Sibithooran, Aravindh

Department of Medical Gastroenterology, Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

Introduction: The prevalence of Clostridium difficile infection (CDI) in India varies from 1.2% to 29% dependent on antibiotic usage across different regions. We report a case of severe CDI treated with fecal microbiota transplantation (FMT). Case History: An 80-year-old female presented with lower abdomen pain and diarrhea for 3 weeks following antibiotic exposure for toe gangrene hospitalization. Past medical history included diabetes, hypertension, coronary, and peripheral vascular disease. Diarrhea was foul-smelling mucusy type 6/7 stools with no blood but a frequency of 20/day. Examination revealed mucosal dehydration with stable vital signs but LIF tenderness. The rectal examination revealed an empty rectum. After initial resuscitation, IV metronidazole with probiotics and nutrition support was commenced. Investigations revealed raised WCC 18400 cells/cu. mm, creatinine 2.1 mg/dl, CRP 73 mg/L, and serum albumin 2.2 g/dl. Stool C Difficile toxin assay was positive. Imaging showed features of Pancolitis, and sigmoidoscopy confirmed Pseudomembranous Colitis. Oral vancomycin was also initiated after sigmoidoscopy. She developed pulmonary edema and needed ICU care with inotropes and NIV support. There was only a partial response after dual antibiotics with stool frequency decreasing to 8-10/day and CRP to 48 mg/L but type 6/7 stools and abdominal tenderness persisted. In view of being in severe CDI colitis with multi organ dysfunction and only a partial response to synergistic metronidazole and vancomycin, FMT was considered. After appropriate donor screening and consent, colonoscopic FMT instillation was done. Discussion: Following FMT, stool frequency decreased from 8 to 10 type 6/7 stools per day to 3-4 type 4 stools/day. After rehabilitation and aggressive feeding was transferred to ward and eventually discharged with a stool frequency of 2 type 3 stools/day. In view of our elderly patient fitting with severe CDI and significant comorbidity, FMT was required with alternatives like Fidaxomycin not available in India. There was improvement in laboratory values with total white cell count and CRP normalizing and gradual improvement in albumin after initiation of NG feeding. Conclusion: Similar to worldwide experience in severe CDI, careful donor screening and ease of administration makes FMT a yup therapy from being a perceptional yuk therapy.

Unfolding the Gastric Folds – A Rare Trouble between Margin and Center

E. Sathish Kumar, T. Ravishankar, A. Senthilvadivu

Department of Medical Gastroenterology, Coimbatore Medical College, Coimbatore, Tamil Nadu, India

Introduction: Mantle cell lymphoma (MCL) is non-Hodgkin lymphoma (NHL)-2.5% of lymphoid neoplasms worldwide. Primary gastrointestinal (GI) lymphomas account for 1-4% of all GI malignancies, with few reports of primary MCL presenting as synchronous lesion at stomach and colon as presenting finding. Accurate and timely diagnosis of disease help in early staging and chemotherapy initiation because MCL has rapid disease progression and early chemotherapeutic intervention improve outcomes. Case Presentation: 69 years male (smoker and ethanolic) c/o diffuse spasmodic abdominal pain-on and off constipation-3 months, good appetite, no weight loss. vitals stable. On P/A-splenomegaly present. Contrast-enhanced computed tomography -homogeneously enhancing circumferential wall thickening of gastric pylorus, proximal D1, ICJ and entire colon, multiple peritoneal, retroperitoneal lymphadenopathy. OGD-gastric mucosal hypertrophy. colonoscopy-multiple nodular polypoid lesion-from rectum to cecum. HPE-colonic mucosa intact lining lamina propria-nodular aggregates of atypical lymphoid cells, angulated nuclei, coarse chromatin, inconspicuous nucleoli, scanty to moderate cytoplasm (rare mitotic figures) suggesting NHL. IHC-diffusely positive atypical lymphoid cells for CD20, CD5, CYCLIN D1 and Bcl-2. Negative for CD3, CD23, bcl 6 and CD10, ki labeling index– (30%-40%)-NHL-MCL (HEAM5). Discussion: Reporting first case to our knowledge of synchronous gastric and colonic MCL, discussed work-up of this rare lymphoma that clinicians may be required to diagnose and manage. Conclusion: This report serves as reminder to maintain broad differential inclusive of uncommon diseases and unanticipated pathology. Practicing with thorough understanding of medical principles and clinical acumen is essential for optimal patient care, preventing potentially unnecessary surgical intervention, thus delaying appropriate chemotherapy.

Jaundice – An Overlooked Symptom in Clinical Practice?

R. Ramalingam, N. A. Rajesh, Joy Varghese

Consultant, Institute of Gastro and Liver Sciences, SRM Global Hospital, Chennai, Tamil Nadu, India

Introduction: Jaundice is often considered an ominous sign resulting from either prehepatic, hepatic, or posthepatic causes. Though it can be differentiated easily most of the time, poses difficulty rarely. Here, we report a case of jaundice that is overlooked. Case Report: A 56-year-old male, a known diabetic and chronic alcohol consumer, had a history of recurrent jaundice for 15–20 years. Recently, admitted and evaluated elsewhere. He had a bilirubin value of 57 with a direct fraction of 27 and < 2-fold elevation of liver enzymes. Ultrasonography abdomen showed hepatomegaly, dilated portal vein (16 mm), splenomegaly, and GB-filled with multiple stones. He was worked up for liver disease including HBsAg, anti-HCV, and autoimmune profile and diagnosed with autoimmune hepatitis. He was started on steroids and referred to us for further management. On examination, he did not have stigmata of chronic liver disease. His mother and elder son have similar illnesses. On evaluation, he had a Hb of 7.6 with MCHC 35. He had unconjugated hyperbilirubinemia (12.9/2.3) and SGOT/SGPT - 47/49. The possibility of hereditary hemolytic anemia was kept and evaluated. He had raised LDH and decreased haptoglobin. Peripheral smear showed predominantly microcytic hypochromic RBCs with few spherocytes. On further evaluation, the osmotic fragility test was positive with a normal Hb electrophoresis, sickling test, and G6PD levels. Diagnosis of hereditary spherocytosis was made, and he was advised for splenectomy and family screening. Discussion: In our case, the clues favoring hereditary hemolytic anemia are (1) intermittent jaundice of long duration that did not require any treatment; (2) similar illnesses in family members; (3) hereditary spherocytosis is the only condition that has high MCHC; and (4) no features of liver decompensation without any treatment for more than two decades. The dilated portal vein with splenomegaly in a person with significant alcohol consumption would have created some doubt about liver disease with portal hypertension. However, that could be explained by hyperdynamic circulation because of splenomegaly. Conclusion: Patients presenting with jaundice, multiple GB stones, and splenomegaly should be evaluated thoroughly for hemolytic jaundice.

Light at the End of the Tunnel

J. Deepa, T. A. Sindhuja, D. Nirmala, R. Senthil Kumar, Winston Thomas

Department of Paediatric Gastroenterology, ICH and HC, Chennai, Tamil Nadu, India

Introduction: IgG4-related disease (IgG4-RD) is an immune-mediated fibro-inflammatory condition that can virtually involve any organ. This is a case report of a 10-year-old girl with IgG4-related disease (IgG4-RD) and the evolution of disease in the child and complexity in diagnosis. Case Details: The child had recurrent episodes of abdominal pain once in 3-6 months from 3 years of age. The child was diagnosed to have pseudocyst and was on conservative treatment and followed up with ultrasound. At 6 years of age, the child was developed splenomegaly and USG showed that portal vein was replaced by collaterals. Endoscopy was normal. The child was then followed up in local district medical college because of COVID, where at 7 years of age, the child was taken up for laparotomy for pseudocyst, but intraoperatively pseudocyst was not present, duodenotomy was done. At 8 years of age, the child presented with variceal bleed and referred back to our institute, where child was on regular endoscopic sclerotherapies and surveillance scopy since then. At 10 years of age, the child had significant upper gastrointestinal bleeding even after eradication of esophageal varices. Hence, extensive evaluation was carried out to find the source of bleeding. Active bleeding could not be visualized endoscopically except for antral gastritis and bulbar duodenitis. Biopsy was taken which revealed Helicobacter pylori and treatment was started. Computed tomography angio was done to rule out Hemosuccus pancreaticus. Magnetic resonance imaging abdomen showed, diffuse enhancement of soft tissue in periportal, peripancreatic and para-aortic location encasing the surrounding structures. Pancreas appeared bulky with smoothening of the margins and diffuse wall thickening of the common bile duct in its entire length was noted. Focal aneurysmal dilatation of the celiac axis was noted without any other extravasation. Serum IgG4 levels were elevated 143 mg/dl. Pancreatic biopsy revealed focal mild fibrosis without any diagnostic features. Hence, a diagnosis of IgG4-related disease autoimmune pancreatitis (AIP) was made according to EULAR/ACR criteria and INSPPIRE Criteria for AIP in children and steroid was started. Discussion: Although AIP is reported in children with increasing frequencies, IgG4-related biliopancreatic disease is commonly reported only in the sixth and seventh decade with a male preponderance. We report this case for rarity and to highlight the importance of suspecting and diagnosing AIP and other IgG4-related diseases, as response to steroids is characteristic and can improve the disease outcome compared to other idiopathic and hereditary pancreatitis.

Multifocal Primary Hepatic Leiomyosarcoma: A Case Report

R. Ramalingam, N. A. Rajesh, Joy Varghese

Consultant, Institute of Gastro and Liver Sciences, SRM Global Hospital, Chennai, Tamil Nadu, India

Introduction: Hepatic sarcomas are rare mesenchymal tumors of the liver accounting for 1%–2% of primary liver tumors. Primary hepatic leiomyosarcoma is extremely rare and only about 70 cases were reported in literature. Here, we report a case of multifocal primary hepatic leiomyosarcoma. Case Report: A 74-year-old male came with right upper quadrant dull pain, anorexia, and weight loss for 3 months. He never had jaundice, hematemesis, melena, abdominal distension, or altered sensorium. He had a medical history of diabetes mellitus and coronary artery disease. He does not consume alcohol or a smoker. On examination, he had tender hepatomegaly with stable vitals. Blood investigations revealed mildly deranged liver function tests with normal complete blood count and renal function tests. HBsAg and anti-HCV were negative. Contrast computed tomography (CT) of the abdomen showed multiple hypodense lesions involving both lobes of the liver with thin peripheral rim enhancement, the largest of 4.7 cm × 3.4 cm in segment 6. Tumor markers such as AFP, CA19-9, and CEA were normal. Positron emission tomography/CT showed multiple hypermetabolic liver lesions with a maximum standardized uptake value of 10.9, suggestive of malignancy with no evidence of extrahepatic lesions. USG-guided liver biopsy was done that was suggestive of spindle cell neoplasm and IHC was strongly positive for SMA with a Ki-67 index of 25%. Diagnosis of primary hepatic leiomyosarcoma was made and advised for liver transplantation. Discussion: Primary hepatic leiomyosarcoma of the liver generally arises from the mesenchymal tissues such as smooth muscles of blood vessels. The median age of presentation is usually 58 years with no gender predilection. It can be asymptomatic or may present with nonspecific symptoms such as RUQ pain, anorexia, weight loss, jaundice, or a lump. Imaging generally reveals a single heterogeneous lesion with thin peripheral enhancement and multifocal lesions are exceedingly rare. Histopathological examination shows spindle cell morphology with immunohistochemistry positive for smooth muscle actin, desmin, and vimentin. Surgical resection and liver transplantation are the only available curative treatments. Conclusion: Primary hepatic leiomyosarcoma usually presents with nonspecific symptoms and has a grave prognosis. Liver transplantation is the only curative treatment available for multifocal primary hepatic leiomyosarcoma.

A Case of Nonalcoholic Steatohepatitis- Chronic Liver Disease with Acute Hepatic Injury Due to DILI

Anbu Krithigha, P. Ganesh

Department of Medical Gastroenterology, SRMC, Chennai, Tamil Nadu, India

Introduction: Amiodarone is a commonly used anti-arrthymic drug that has been known to cause asymptomatic hepatitis with elevation of liver enzymes in 15%–50% of patients on long-term therapy.^[1] The hepatitis can be of hepatocellular or cholestatic pattern. Irreversible cirrhosis due to amiodarone toxicity is rare, but an analysis of 37 case reports from January 1970 to November 2012 showed that amiodarone-induced cirrhosis carries a mortality risk of 60% at 5 months.^[2] Here, we report an unusual case of chronic amiodarone use causing rapid onset of cirrhosis in a patient with nonalcoholic steatohepatitis (NASH). Case Details: A 59-year-old diabetic and hypertensive presented to her physician with complaints of dyspepsia and significant weight loss over 1 year She also gave history of Paroxysmal Atrial Fibrillation for which she was on Amiodarone since 4 years. Laboratory investigations revealed elevated serum transaminases (SGOT > SGPT), elevated alkaline phosphatase, and GGT with albumin–globulin reversal. Magnetic resonance imaging showed mild fatty liver with cirrhotic appearance. FibroScan revealed F4 fibrosis. Workup for other causes of liver disease was negative. Liver biopsy revealed hepatic and canalicular type of cholestatic liver injury with early fibrosis. She was managed conservatively with UDCA and was on follow-up. 5 weeks later, she developed acute decompensation in the form of massive ascites and required large volume paracentesis and diuretics. This sudden worsening was attributed to the cumulative long-term effect of amiodarone. The patient was then advised to stop amiodarone after clearance from the cardiologist. Within 3 weeks, she showed drastic improvement with normalization of liver function test except for albumin–globulin reversal. Ascites subsided completely with a short course of diuretics. Conclusion: Our case was a rare occurrence of sudden worsening of a stable NASH-chronic liver disease due to chronic amiodarone ingestion, which showed a drastic recovery once the amiodarone exposure was stopped.

Neuroendocrine Carcinoma in Esophagus

Nayan Sri, Prem Kumar, Ratnakar Kini, Murali R

Institute of Medical Gastroenterology, Madras Medical College, Chennai, Tamil Nadu, India

Introduction: Neuroendocrine carcinoma (NEC) in the esophagus account for <0.04% of all NET. Large cell type of esophageal NEC is an extremely rare malignant tumor with poor prognosis of which there are fewer than twenty cases published. Case: A 60-year-old healthy male, with no known comorbidities, chronic smoker with ~20 pack years presented with c/o globus sensation for 2–3 weeks with history of weight gain and symptoms of GERD. Upper gastrointestinal endoscopy revealed an ulceroproliferative lesion extending from distal esophagus to 1 cm below the EG junction. The pathological findings indicated poorly differentiated carcinoma. IHC revealed large-cell NEC with tumor cells that were positive for CD56, synaptophysin, and Ki-67 (>80%). Positron emission tomography–computed tomography revealed spread of tumor to left gastric and common hepatic nodes. MDT suggested chemotherapy ± radiotherapy. Conclusion: All undifferentiated carcinomas must have IHC done and managed with expertise from a MDT.

Case Report-metastatic Malignant Melanoma – Gastric Melanoma

Nimish George Jacob, N. Arun, B. Sumathi

Department of Medical Gastroenterology, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: Malignant melanoma is a tumor of melanocytes and predominantly involves skin. It is highly aggressive with high rates of lymphogenic or hematogenic metastasis to distant organs, posing significant challenges for diagnosis and treatment. Approximately 60%–80% of primary metastasis from melanoma are regional sites including nodes Common sites of visceral metastasis are lung, liver, brain, and gastrointestinal tract (small bowel [51%–70%], large intestine [22%], anorectum [25%] gallbladder [20%], stomach [18%] esophagus [5%]). In the presence of metastasis, prognosis is usually poor due to frequent delay in diagnosis due to late presentation and inherent aggressive nature of the tumor. The median survival was 6–9 months. Case: This is a rare case report of 50 years male, who presented with complaints of easy fatiguability, exertional dyspnea of 1 month duration and passing of black tarry stools for 2 weeks with unintentional unquantified loss of weight. He had a history of acral lentiginous melanoma of the left thumb 4 years back, for which he had undergone amputation of the left thumb followed by left axillary nodal dissection and radiotherapy of left axilla following which he did not turn up for further follow-up. Blood investigations showed iron-deficiency anemia (Hb-6 mg/dl). Contrast-enhanced computed tomography abdomen done showed suspicious wall thickening in body of the stomach. Upper gastrointestinal endoscopy was done and showed large ulcerated melanotic mucosa in proximal body of the stomach. Mucosal biopsy HPE showed atypical cells with extensive melanin pigment and fibrin exudates– suspicious of gastric melanoma. IHC staining was positive for HMB 45 and S100– markers for melanoma. Further positron emission tomography scan was done, which showed metabolically active irregular gastric wall thickening in proximal body of the stomach with metabolically active lesions in gallbladder and mid ileum suggestive of multiple metachronous malignant melanoma metastasis. The patient was referred to medical oncology was managed with Hemostatic radiotherapy and immunotherapy. Conclusion: This case shows the importance for proper follow-up in a case of melanoma as it has high potential for metastasis and the importance to keep a high level of suspicion regarding metastatic melanoma when a patient with past history of cutaneous melanoma presents with gastrointestinal symptoms.

A Case of Budd–Chiari Syndrome with an Unusual Etiology

Kannari Naveena, S. Chithra, R. Balamurali

Department of Medical Gastroenterology, Government Stanley Medical College, Chennai, Tamil Nadu, India

Case: A 66-year-old male presented with c/o pain abdomen for the past 3 weeks followed by abdominal distension and bilateral lower limb swelling for the past 5 days and no significant family history. A history of HTN, MVR in 2022, recently diagnosed DM. On examination, icteric, pale with bilateral pitting pedal edema. On systemic examination, liver was palpable by 10 cm below right costal margin, tender, surface irregular, firm in consistency. Liver parameters with total and direct bilirubin fractionation 4.3/2.5 and SGOT/SGPT/ alkaline phosphatase 55/32/203, AFP 1.23. Imaging suggestive of liver of size 23 cm, and near total replacement of hepatic parenchyma with multiple thin walled cysts of varying sizes showing fluid filled levels, few of the cysts show chronic hemorrhagic residue with the intraparenchymal hepatic veins and inferior vena cava (IVC) appears compressed by the cyst without renal cysts. PV Doppler suggesting dilated portal vein with hepatopetal flow, mild compression/narrowing of intrahepatic IVC, hepatic veins due to liver cyst. Computed tomography brain angiography normal, two-dimensional echo adequate LV systolic function, prosthetic mitral valve in position. Diagnosed as a case of isolated polycystic liver disease with secondary Budd–Chiari syndrome and is on conservative management with follow-up. Discussion: Isolated polycystic liver disease is rare with incidence of <0.01%. Isolated PCLD is an autosomal dominant disease with genetic and clinical heterogeneity. It is due to embryonal mal-development and of progressive cystjc dilatation of bile ducts. It is genetically distinct frkm polycystic kidney disease. It can be caused by PRKCSH or SEC63 mutations causing aberrant maturation of newly synthesized glycoproteins including polycystins. Majority of the patients (>80%) are asymptomatic or subclinical. Only a small fraction develop acute liver cyst related complications and/or massive cystic liver enlargment causing morbidity and mortality. Extrahepatic manifestations included increased incidence of cardiac valve abnormalities and of intracranial aneurysms. Currently, the management for symptomatic PCLD is centered on palliating symptoms and treating complications. Though several agents to prevent or retard cystic liver enlargment are undergoing clinical studies. Conclusion: This case is being presented as it is a rare case of isolated cystic liver disease presenting as Budd–Chiari syndrome.

A Rare Case of Abdominal Tuberculosis

Stephen Alexander, B. Sumathi, Jayakumar Jayakrishnan, M. Malarvizhi

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: Tuberculosis (TB) is caused by Mycobacterium tuberculosis and remains a major public health problem in India and other developing countries. Recently, there has been a resurgence of TB due to factors such as multidrug resistance, HIV coinfection, and intravenous drug abuse. Even though the most common presentation is pulmonary TB, extra pulmonary disease accounts for around 15% of all TB. Isolated splenic TB in the absence of disseminated disease is exceedingly rare and poorly described in literature. The diagnosis is difficult and delayed due to nonspecific clinical and imaging features. Case Report: This is the case of a 54-year-old female patient who presented with complaints of mild, dull aching, continuous, nonradiating pain in epigastric and left hypochondrial region associated with loss of appetite, loss of weight, with no aggravating or relieving factors for 3 months. There was no history suggestive of GI bleeds/jaundice/fever. There was no significant family/personal history. There was no known addictions. On examination, the patient was moderately built and poorly nourished with a body mass index of 18.0 kg/m². Abdomen was soft, nontender, spleen tip was palpable, no free fluid demonstrable, no other organomegaly. Other systems were within normal limits. No external markers of TB or malignancy were seen. Imaging studies done showed hypodense lesion in spleen, biopsy of which showed foci of necrosis with suppuration and surrounding ill formed histiocytic granulomatous reaction. Based on which patient was empirically started on ATT and to which she responded clinically and radiologically. Discussion: Isolated splenic TB in the absence of disseminated disease is exceedingly rare. Apart from lymphoma, metastasis and other granulomatous conditions, such as sarcoidosis and fungal infections, TB should also be included in the differentials for multiple hypodense lesions in the spleen. Imaging features of isolated splenic TB are nonspecific and a high index of suspicion is needed for their early detection and management.

Navigating Rare Uncommon: Splenic Pseudocyst in Acute Pancreatitis Treated Conservatively

S. Vysakh, M. Malarvizhi, B. Sumathi, N. Arun

Department of Medical Gastroenterology, Kilpauk Government Medical College, Chennai, Tamil Nadu, India

Introduction: Splenic pseudocysts, a rare complication of pancreatitis, pose intricate challenges in diagnosis and management. While exact prevalence figures vary, studies generally report an incidence ranging from 1% to 5% among pancreatitis-related complications, highlighting their relative rarity. This introduction delves into the complexity surrounding splenic pseudocysts, emphasizing the need for tailored approaches in navigating their clinical manifestations. Case Report: A 47-year-old male presented with a complex medical history, marked by chronic alcoholism, smoking, and diabetes, amplifying the intricacies of the case. Symptoms of upper abdominal pain, distension for 15 days associated with loss of apetite and weight with similar episodes in the past were present. Examination findings showed malnutrition, pedal edema, and ascites. Elevated serum amylase and ascitic fluid analysis showing low SAAG ascites with elevated amylase level pointed toward the diagnosis of acute on chronic pancreatitis. The patient was also diagnosed to have HbsAg positive. Imaging exposed multiple intra and extra parenchymal pseudocysts, notably a 4 cm × 5 cm × 6 cm pseudocyst in the inferior pole of spleen. While initially contemplating surgical gastroenterology intervention, the decision pivoted upon negative results from culture analysis/CBNAAT of the USG-guided pseudocyst of spleen aspirate. This unexpected outcome prompted a conservative approach, diverging from the initially planned pigtail catheter insertion. The patient was started on PERT, octreotide antibiotics, IV fluids, and other supportive medications. As the viral load was low with liver being normal in imaging, antivirals were not started. The patient symptomatically improved evident by decrease in abdominal girth, no pedal edema and regaining of appetite. Size of splenic pseudocyst has reduced gradually during follow-up USG. Discussion: Pancreatic pseudocyst is a complication of acute and chronic pancreatitis. Splenic pseudocyst is an encapsulated mature collection located within the splenic tissues. It is rare in chronic pancreatitis (1%–5%). The management options include conservative treatment, percutaneous or endoscopic drainage, and surgery. In patients hemodynamically stable with improving symptoms, the nonoperative approach can be a suitable alternative, as in our case. Nevertheless, the spontaneous resolution of intrasplenic pseudocyst is very unusual. Conclusion: This case being rare presentation (1%–5%) underscores the importance of adaptability in treatment plans, with conservative measures proving effective in certain scenarios. Further research is warranted to refine strategies for managing similar presentations and optimizing outcomes for patients with complex pancreatic pathologies.

All Pancreatic Space-occupying Lesions are Not Neoplasms

P. S. Sairam, Anoop Paul¹, Harsha Veena², A. Joseph

Departments of Medical Gastroenterology, ¹Hepatobiliary and Pancreatic Sugery and ²Radiology, CMC, Vellore, Tamil Nadu, India

Introduction: We report a young male with imaging suggestive of cystic neoplasm of pancreas and the patient was initially planned for surgery. Endoscopic ultrasound (EUS) fine-needle aspiration done from the lesion changed the line of management and the fate of the patient. Case Presentation: Mr. PK from Bihar, with no significant past, personal or family history presented with progressive upper abdominal pain for 4 months that was radiating to the back. He had jaundice associated with pruritus and intermittent low-grade fever for 2 months. He had lost appetite and weight: 20 kg in 4 months. On examination, he appeared icteric with mild epigastric fullness and tenderness. He weighed 53.9 kg. His liver biochemistry revealed a cholestatic pattern. CA 19-9 was 151 U/mL. Contrast-enhanced computed tomography abdomen with magnetic resonance cholangiopancreatography showed peripherally enhancing multilocular cystic lesions with thickened internal septae (4.4 cm × 3 cm) in the head of the pancreas suggestive of cystic neoplasm. There was double duct sign and regional lymphadenopathy. EUS showed a multiloculated macrocystic lesion in the head of the pancreas, causing biliary obstruction, suggestive of a mucinous neoplasm. EUS-guided fluid aspirated was straw-colored and turbid; there were abundant colloid-like extracellular mucin and scanty epithelial clusters. Fluid glucose and CEA levels were low; amylase and CA 19-9 were elevated. Pancreatic fluid XPERT tuberculosis (TB) polymerase chain reaction (PCR) detected Mycobacterium tuberculosis. After multidisciplinary discussion, he was started on anti-tuberculous treatment. 8 weeks later, his abdominal pain had improved and he started gaining weight. Liver function test had completely normalized. After completing 9 months of ATT, he was pain-free and weighed 56.6 kg. Follow-up cross-sectional imaging showed near-complete resolution of the cystic lesion and regional lymphadenopathy. Conclusion: If not for the XPERT TB PCR from the pancreatic cyst fluid, our patient would have ended with Whipple’s surgery. TB should be considered in the differential diagnoses of pancreatic masses, especially in regions endemic to tuberculosis.

A Rare Case of Space-occupying Lesion in Liver

K. R. Srinanthini, A. Anand, M. Malarvizhi, B. Sumathi

Department of Digestive Health and Diseases, Government Kilpauk Medical College, Chennai, Tamil Nadu, India

Introduction: Primary hepatic lymphoma (PHL) is a rare condition. It represents 0.016% of all non-Hodgkin’s lymphomas and 0.4% of all extranodal lymphoma. PHL is lymphoma confined to the liver with no evidence of lymphomatous involvement in the spleen, lymph nodes, bone marrow, or other lymphoid structures. Case Details: A 74-year-old female was admitted with complaints of abdominal pain 20 days, yellowish discoloration of eyes and urine 10 days with poor appetite and vomiting for 10 days. Physical examination revealed enlargement of the liver; there was no lymphadenopathy. Routine investigations were unremarkable. Liver function test was altered with elevated total bilirubin alanine transferase level, aminotransferases, alkaline phosphates and gamma-glutamyl transferase level. Serum LDH, serum alpha fetoprotein, and serum CEA were within normal limits. Viral markers for hepatitis B virus, hepatitis C virus, and HIV 1 and 2 were nonreactive. Contrast-enhanced computed tomography (CT) abdomen showed a large enhancing mass lesion in the right lobe of the liver. Fluorodeoxyglucose positron emission tomography CT scan with magnetic resonance imaging screenings revealed a large mass lesion with patchy arterial enhancement and washout of contrast involving the right lobe of the liver and favors a diagnosis of hepatic primary tumor with probable regional lymphonodal spread and no obvious distant metastases. Peripheral smear was normal. Bone marrow biopsy showed normal cellularity with trilineage hematopoiesis, with normal maturation and proportion. Liver biopsy was suggestive of lymphoproliferative disease. Immunohistochemistry report that were positive for CD20, bcl-6, PAX 5 MUM-1 suggesting the diagnosis of high grade B cell lymphoma. Oncologist opinion obtained patient was started on chemotherapy since 1 month and on follow-up. Discussion: PHL usually affects patients in the seventh to eighth decade of life, but no consensus has been reached regarding the male-to-female ratio of incidence. The main presenting features are abdominal pain, hepatomegaly, palpable mass, fever, night sweats, and weight loss. The etiology of PHL is unknown; however, recent reports have described an increased incidence of PHL in patients with hepatitis C virus infection. Other viruses include Epstein–Barr virus and human immunodeficiency virus and conditions such as cirrhosis of liver, autoimmune diseases, and patients on immunosuppressive drugs. PHL presents radiologically as one of the followings: (1) a solitary lesion, (2) multiple lesions within the liver, and (3) diffuse hepatic infiltration. Liver biopsy is the gold standard for diagnosis. Immunohistochemical studies help in identifying the type of lymphoma. The majority of cases of PHL are diffuse large B-cell lymphoma. Treatment options for PHL include surgery, chemotherapy, radiation, or varying combinations of these modalities. There is no consensus on the optimal treatment of PHL. Conclusion: Due to the rarity of this disease entity, the nonspecific clinical presentation, one should have suspicion of PHL when there is imaging evidence of space-occupying lesion.

Spontaneous Hematoma in a Patient with Alcoholic Liver Disease

B. Javeed Ziyavudeen, R. Ramani, M. Kannan, C. Vijaishankar, P. B. Sriram

Department of Medical Gastroenterology, Madurai Medical College, Madurai, Tamil Nadu, India

Introduction: Decompensated liver disease can disrupt hemostasis, leading to either spontaneous bleeding or thrombosis. Alcohol consumption in advanced liver disease increases the risk of spontaneous bleeding. Spontaneous muscle hematoma is a rare occurrence in cirrhotic patients, often associated with anticoagulation or hemostatic disorders. This report highlights a case of alcohol-related cirrhosis presenting with a spontaneous hematoma. Case Report: A 43-year-old male with a 3-month history of jaundice developed abdominal distension over the subsequent month. Known for diabetes and hypertension with irregular follow-ups, he presented with a spontaneous hematoma in the left forearm during admission. Imaging ruled out deep vein thrombosis, and there was no history of trauma or anticoagulant use. Blood investigations revealed a prolonged coagulation profile. Esophageal varices (Grade 1) were observed during OGD screening, and a normal cardiac status was confirmed through two-dimensional echocardiography. The patient received FFP, PRBC transfusion, and tranexamic acid infusion. Two cycles of plasmapheresis were performed, leading to symptomatic improvement and hematoma resolution. A prompt diagnosis and appropriate management are crucial. Conclusion: Spontaneous gastrocnemius muscle hematoma is a rare complication of alcoholic liver disease, often linked to hyperfibrinolysis. In this case, successful diagnosis and treatment were achieved using plasmapheresis and tranexamic acid, an antifibrinolytic agent, to prevent life-threatening bleeding. Liver transplantation remains the definitive treatment for advanced liver disease in the absence of sustained alcohol abstinence, as a terminal course is common without this intervention.

The Ambush – A Team Approach

S. Vadivel Kumaran

Consultant, Kauvery Hospital, Chennai, Tamil Nadu, India

Introduction: Reactivation of an occult hepatitis B infection mandates a proper search for hidden hepatitis B virus beyond our routine viral screening tests before any immunotherapy with anti-HBc total. Reactivation of an occult HBV infection can cause ACLF necessitating even liver transplantation. This is the first case to be reporting on the utility of combination therapy of ETV + TDF with plasmapheresis in ACLF due to reactivation of an occult HBV infection when started on immunotherapy, who was otherwise a candidate for an urgent liver transplantation. Case: Mr. X, 83 years old male, a known case of Carcinoma Prostate– on Immunotherapy (Calutide and Lupride). He developed jaundice and was detected to have hepatitis B infection. He rapidly decompensated due to high viral load. He had no risk factor for acquiring acute hepatitis B. Hence, a diagnosis of acute on chronic hepatitis B infection–reactivation was made. He was started on tenofovir alafenamide. But developed acute kidney injury and was switched to entecavir. With progressively rising bilirubin and persistent HBeAg and immunoglobulin M-anti-HBc positivity, started on combined antivirals (TAF + Entecavir). Once jaundice raised to 40 mg/dl was started on plasmapheresis for a short duration. Then, his bilirubin started to decrease with improvement in renal parameters. Conclusion: This case emphasizes on the importance of screening for an occult HBV infection, in addition to the routine viral screening done before any immunosuppressive therapy or immunotherapy. This case also portrays the efficacy, safety, and utility of combined antiviral therapy of TenofovirAlafenamide with Entecavir in HBV reactivation, leading to ACLF. This case also shows the utility of plasmapheresis in ACLF not only as a bridge to transplantation but also as a component of treatment in ACLF with combined antiviral therapy.

Dysphagia in a Middle-aged Woman: Relevance of Clinical History Taking

Mankare Sudhir, Pazhanivel Mohan¹, K. Senthamizh Selvan¹, S. Siva Krishna¹

Departments of Gastroenterology and ¹Medical Gastroenterology, JIPMER, Puducherry, India

Introduction: Dysphagia is a common clinical problem which can be due to mechanical or motor disorders of the esophagus. We report a middle-aged woman who presented with progressive dysphagia for 8 weeks. Case: A 40-year-old female underwent endoscopic evaluation for dysphagia elsewhere. The upper endoscopy showed an ulcerated lesion below the cricopharynx, biopsy of which was inconclusive. She was referred to our department for the evaluation of cricopharyngeal malignancy. On reviewing the clinical history, she could only recollect her difficulty in swallowing to start abruptly for solids, which then gradually progressed for liquids. Her appetite and weight was preserved. Contrast esophagogram showed a narrowing below the level of cricopharynx. Contrast computed tomography scan of the thorax showing a circumferential wall thickening below the cricopharynx and a suspicious radiodense linear object within the wall of the esophagus. Upper gastrointestinal (GI) endoscopy under sedation showed esophageal mucosal ulceration below the cricopharynx and a large hard impacted material covered with mucous and exudate. On gentle manipulation, the foreign body-like material was slowly disimpacted and easily passed below into the stomach. The foreign body measured 3 cm × 4 cm with sharp edges and was identified to be the hard covering of the seed of a mango. A lithotripter basket was used through one of the channels of a double channel gastroscope to grasp and fold the hard covering reducing its size, while a foreign body grasping forceps was used through the other channel to retain the hard foreign body in the folded shape. This technique helped in successfully retrieving the foreign body without any complication. Conclusion: This case highlights the importance of a good medical history which still forms the basis of clinical assessment of dysphagia to avoid needless evaluation. It also demonstrates the usefulness of a double-channel gastroscope in successful retrieval of upper GI foreign bodies.

An Enigmatic Encounter of Crohn’s Disease Presenting as Acute Budd–Chiari Syndrome

Mutyala Trivenu Venkata Chowdary, E. Kandasamy Alias Kumar, Poppy Punithan, A. Shafique, D. Geetha

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Introduction: Crohn’s disease is a chronic inflammatory bowel disease predominately involving the bowel. However, there is a varied spectrum of extraintestinal manifestations, which makes the disease more complex. In this case, we present a rare presentation of Crohn’s disease as acute Budd–Chiari syndrome. Case Details: This is a 24-year-old male who presented to the hospital with complaints of abdominal pain and distension for 10 days. The patient had a history of loss of weight in the past 6 months and the patient had no complaints of hematemesis or melena or jaundice. On evaluation, the patient had hemoglobin of 9.9 and other basic investigations were within normal limits. USG abdomen revealed mild hepatomegaly and moderate ascites. Ascitic fluid analysis revealed high SAAG and high protein, with predominate lymphocytes and ADA-16. Contrast-enhanced computed tomography (CECT) abdomen revealed moderate ascites with edematous wall thickening in the cecum, ascending and transverse colon. Viral markers were nonreactive. OGD revealed prominent esophageal veins and mild congestive gastropathy changes. Colonoscopy revealed severely inflamed ileum, ascending colon with ulcerations. Biopsy report came out to be Crohn’s disease. Doppler study showed nonvisualization of hepatic veins and CECT triple phase also confirmed the nonvisualization of hepatic veins. Ocular examination was normal. Thrombotic workup, JAK2 and ANA, comes to be negative. A diagnosis of acute Budd–Chiari syndrome with active Crohn’s disease was made. The patient was started on anticoagulants, prednisolone and azathioprine. Discussion: Budd–Chiari syndrome is a rare manifestation of inflammatory bowel disease and there are only a handful of cases reported in literature. In majority of those cases, the patients are already a diagnosed case on treatment and developed Budd–Chiari syndrome during flare. However, this case is peculiar in its lack of bowel symptoms and presentation of Budd–Chiari syndrome before onset of symptomatic bowel disease.

When Two Worlds Collide – A Unique Entity

E. Dhivya, E. Kandasamy Alias Kumar, Poppy Rejoice, A. Shafique, D. Geetha

Department of Medical Gastroenterology, Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India

Case: A 60-year-old male patient, chronic smoker and alcoholic, had come with complaints of abdominal pain, vomiting, and jaundice for the past 3 months. O/E pt was icteric, had bilateral pitting pedal edema and abdominal examination was normal. Liver function test was altered with hepatocellular pattern, decreased albumin, INR-1.8 and other lab parameters were within normal limits. USG abdomen showed parenchymal liver disease with cholelithiasis. OGD revealed multiple small polypoidal lesions in D2 segment and multiple biopsies taken. Endoscopic ultrasound showed multiple hyperechoic lesions with central necrotic areas in the D2 region in the submucosal plane and biopsy was taken. Contrast-enhanced computed tomography (CECT) abdomen showed chronic liver disease, cholelithiasis, and circumferential wall thickening in duodenum with enlarged perilesional nodes. Microscopic examination of the biopsies revealed a large, neuroendocrine neoplasm with numerous nests and trabecular groups of monotypic cells with central nuclei, having salt-pepper chromatin, mitosis <2–10/hpf (Grade 1 lesion). In addition, there was another lesion in the same region, located below the neuroendocrine tumor, which revealed a moderately differentiated adenocarcinoma infiltrating the subserosal tissue with focal areas of necrosis. The two neoplasms were geographically separate with no areas of transition. Immunohistochemical analysis was done to identify the origin of the two tumors. The tumor showed immunoreactivity with neuroendocrine markers such as synaptophysin, chromogranin, and CD56 with a low Ki67 index. The solid lesion with adenocarcinoma component had strong cytoplasmic reactivity for CK7 and nuclear staining for CDX2 with nonreactivity for the neuroendocrine markers. Finally, a diagnosis of periampullary collision tumor with both neuroendocrine and adenocarcinoma as its components was made. Serum chromogranin A levels were elevated. Gallium Dotanoc Positron emission tomography CECT scan done showed low grade SSTR expressing nodular thickening involving the entire duodenum with non SSTR expressing para duodenal nodes. The patient was planned for Whipple’s surgery after neoadjuvant chemotherapy. Discussion: Collision tumor is an extremely rare phenomenon characterized by coexistence of two completely different and independent tumors in the same site. Neuroendocrine tumors account only for about 0.4% in the duodenal region and mixed endocrine-exocrine tumors comprising neuroendocrine and adenocarcinoma is much more uncommon. Review of literature shows only about 53 cases of collision tumor with just seven cases of coexisting adenocarcinoma and neuroendocrine tumors. This case highlights the importance of histological examination for the prompt diagnosis and management of such rare tumors.

A Case of Pancreatic Tuberculosis Mimicking Pancreatic Malignancy

Sony Thomas, T. Ravishankar, A. Senthil Vadivu

Department of Medical Gastroenterology, Coimbatore Medical College, Coimbatore, Tamil Nadu, India

Introduction: Pancreatic tuberculosis (PTB) is a rare entity which seldom affects the pancreas alone. Focal pancreatic involvement without tuberculosis (TB) elsewhere in an immunocompetent patient is rarer. Pancreas is usually spared because of the presence of pancreatic enzymes which interfere with seeding of Mycobacterium tuberculosis. Primary PTB (PPTB) has a reported incidence of only 0.46% among TB patients. We report a case of pancreatic mass and elevated CA 19-9 levels mimicking pancreatic cancer. PPTB diagnosis requires high index of suspicion to avoid unnecessary diagnostic and therapeutic procedures. Case: A 45-year-old healthy female presented with epigastric pain unrelated to meals, anorexia, and weight loss (5 kg) of 1 month duration. She denied any fever, cough, vomiting, jaundice, and altered bowel habits. There was no history of pulmonary tuberculosis and physical examination was unremarkable. Laboratory evaluation revealed anemia (HB-8), ESR-30, normal liver function test, amylase, lipase, negative viral markers, and CA 19-9 levels of 501. Contrast-enhanced computed tomography (CECT) revealed 2.0 cm × 3.1 cm minimally enhancing soft tissue lesion in the body of pancreas with multiple peripherally enhancing lymph nodes in the peripancreatic, paraaortic, and splenic hilum. Multiple heterogeneous enhancing soft tissue lesions were seen in both liver lobes. Provisional diagnosis of pancreatic cancer with nodal and hepatic metastases was made. USG-guided liver biopsy was done which was suggestive of hemangioma liver. Endoscopic ultrasound (EUS) revealed hypoechoic mass 3.2 cm × 2.2 cm in the body of pancreas. FNB revealed aggregates of epithelioid histiocytes with islets of Langerhans suggestive of tuberculous etiology. The patient was initiated on ATT for 6 months. On follow-up, the patient was well, gained weight and repeat CECT showed complete resolution of lesions. Conclusion: PTB has various clinical presentations and tends to masquerade as pancreatic malignancy. It occurs because of hematogenous or lymphatic dissemination or direct spread from adjacent organs. Definitive diagnosis is based on histopathological examination of a specimen that is obtained from pancreas or peripancreatic lymph nodes. The advent of EUS-fine-needle aspiration helps in avoiding unnecessary diagnostic laparotomy. PTB is a treatable and curable condition. Hence, it is important for physicians to consider this diagnosis especially in endemic countries to avoid unnecessary interventions.