Background: Therapeutic plasma exchange (PLEX) removes toxins and different mediators from plasma in patients with acute-on-chronic liver failure (ACLF). Aim: To observe the safety and outcome of PLEX in ACLF patients in Bangladesh. Materials and methods: Twenty-eight patients with ACLF attending Bangabandhu Sheikh Mujib Medical University from September 2020 to May 2021 were enrolled in the study. The patients were given different treatment modalities and followed up for 3 months or up to death. The patients were divided into two groups, each containing 14 patients of ACLF. One group of 14 patients received standard medical therapy (SMT) for ACLF and the second group of 14 patients received SMT plus PLEX. Results: At 90 days, a total of 13 patients (46.43%) survived, of them 8 (57.1%) belonged to PLEX group and 5 (35.7%) were from SMT group. Serum bilirubin and ALT declined significantly after 7 and 30 days but not after 90 days in PLEX group in comparison to SMT group (p <0.05) but other biochemical parameters were not significantly different (p >0.05) between these two groups. Significant (p <0.05) improvement of MELD, MELD-Na, and AARC scores was observed in each group from baseline to subsequent first, second, and third follow-up but no significant (p >0.05) difference was observed in between two groups. Binary logistic regression analysis found that bilirubin, MELD score, MELD-Na score, and AARC score were predictors of mortality. Conclusion: The study presented here has shown that PLEX is safe in Bangladeshi in ACLF patients, but its efficacy remains to be checked in large-scale randomized trial or in combination therapy with other procedures in ACLF patients.

Background: Laparoscopic cholecystectomy is a common operation worldwide, with low mortality (0.01%) and morbidity (2–8%). It has been reported 2.9 to 3.2% of elective laparoscopic cholecystectomies are converted to open surgery. Converted cases are associated with increased complications rates. Method: Two thousand and seventy-five patients, 82.8% females and 17.2% males who underwent elective laparoscopic cholecystectomy in our hospital, between March 1, 2016, and February 28, 2018, were prospectively collected in a database. Pearson's Chi-squared and Fisher's exact tests were used to determine significance, with p <0.05 deemed statistically significant. We analyzed seven risk factors associated with conversion to open surgery; age, gender, body mass index (BMI), previous abdominal surgeries, the presence of contracted gallbladder, Mirizzi syndrome, or choledocholithiasis. Laparoscopic cholecystectomy was performed using a 3-port technique (73%) and a 4-port technique (27%). Results: Finding associated “strong” factors to conversion: male patients, >60-years-old, previous upper abdominal surgery, contracted gallbladder, Mirizzi syndrome or choledocholithiasis. The presence of a higher or lower BMI did not influence the rate of conversion. The most impact association were males over 60 years, and males with an earlier upper abdominal surgery. Conclusion: Laparoscopic cholecystectomy is the gold standard for gallstones and gallbladder disease; however, inflammation, adhesions, and anatomic difficulty continue to challenge the use and safety of this approach in a small number of patients. This study identifies predictors of choice for open cholecystectomy. In view of the raised morbidity and mortality associated with open cholecystectomy, distinguishing these predictors will serve to decrease the rate of conversion and address these factors preoperatively.

Coronavirus disease-2019 (COVID-19) has shattered the public health delivery system of most of the countries of the world. COVID-19 displays variable clinical presentations. The severe COVID-19 represents a fulminant pathological condition and most of the patients run a downhill course if extensive medical measures are not adopted. The major challenges about COVID-19 are related to develop strategies to manage huge populations of mild and moderate cases of COVID-19 with two realistic purposes: (1) early negativity of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus and (2) arrest of progression of moderate COVID-19 patients from developing severe complications. Although several medications have been repurposed for these purposes, none of these have passed the test of time in global perspective. Thus, there remains a pressing need to develop new and novel innovative management strategies for these patients as new variants of SARS-CoV-2 have been destroying the normal public health delivery system of different countries from time to time. The study presented here has checked the safety and efficacy of a herbal medication, leaves of Euphorbia neriifolia Linn (E. neriifolia), in mild and moderate COVID-19 patients. Sixty patients (30 mild COVID-19 and 30 moderate COVID-19) were enrolled in the study. Fifteen mild COVID-19 patients received standard of care (SOC) management, and the remaining 15 patients received SOC plus E. neriifolia. The moderate COVID-19 patients similarly received either SOC (N = 15) or SOC plus E. neriifolia (N = 15). Although there were marked diversity regarding biochemical parameters of these patients at entry, the moderate COVID-19 patients receiving E. neriifolia showed decrease in C-reactive protein and D-dimer and increase in oxygen saturation 7 days after trial commencement. However, these improvements were not detected in moderate COVID-19 patients receiving SOC. Hospital staying was significantly lower in both mild and moderate COVID-19 patients receiving SOC plus E. neriifolia than those receiving only SOC. Taken together, it may be proposed that usage of E. neriifolia may have beneficial effects regarding management for COVID-19 patients, especially for those in developing and resource-constrained countries, although a conclusive statement may not be given due to small sample size. This herbal medication is also pertinent in the context of emergence of OMICRON variant of COVID-19 as the overload of SARS-CoV-2-infecetd patients may be addressed considerably by this medication without hospitalization, if proper communication between patients and physicians can be ensured.

Introduction: Post-endoscopic retrograde cholangiopancreatography (ERCP) cholangitis (PEC) is associated with increased morbidity and mortality in patients ERCP. The aim of the present study was to analyze the predictors of PEC and to formulate a predictive model for early diagnosis and management. Materials and methods: It was a cross-sectional study that was carried out at the Sindh Institute of Urology and Transplantation from September 2019 to June 2021. All patients aged between 18 and 75 years and undergoing ERCP due to obstructive jaundice were included. Patients with altered biliary anatomy, history of hepatobiliary surgery, and concurrent sepsis were excluded. Endoscopic retrograde cholangiopancreatography intervention was performed by an expert gastroenterologist. Laboratory parameters (total leukocyte count, total bilirubin, alanine transaminase) and patient temperature were checked on admission, at 12 hours, 24 hours, and 36 hours after ERCP to document PEC. Results: A total of 349 patients were included in the study. Among them, 176 (50.4%) patients were males. Common bile duct (CBD) stricture was the most common indication of ERCP seen in 148 (42.4%) patients followed by CBD stone and cholangiocarcinoma in 108 (30.9%) and 48 (13.8%) patients, respectively. The most common presenting complaint was jaundice noted in 300 (86%) patients followed by right hypochondrial pain in 280 (80.2%) and weight loss in 194 (55.6%) patients, respectively. Post-ERCP cholangitis developed in 251 (71.9%) patients. On univariate analysis, age >50 years, female gender, right hypochondrial pain, fever, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, TLC of >10,000 cells/L at 12 hours, 24 hours, and 36 hours post-ERCP and rise in ALT >50 IU 24 and 48 hours post-ERCP were significantly associated with PEC. While on multivariate analysis, female gender, bilirubin >5 mg/dL on admission, CBD stricture on ERCP, post-ERCP fever, and rise in TLC of > 10000 cells/L at 24 hours post-ERCP were independently associated with PEC. HinCh score was formulated and was found to be significantly associated with the presence of cholangitis. Area under the receiver operating characteristics (AUROC) of HinCh score was 0.74 and at cutoff of ≥4, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of HinCh were 81.67%, 59.18%, 83.67%, and 55.71%, respectively with a diagnostic accuracy of 75.36%. Conclusion: The performance of HinCh score in predicting PEC was accurate in 86% of the patients. However, further studies are needed to validate the score.

Aim: This study aimed to assess the demographic details of coronavirus disease-2019 (COVID-19) patients, their comorbid conditions, preexisting illnesses such as tuberculosis (TB), the prevalence of gastrointestinal (GI) symptoms, duration of GI symptoms, gender-wise distribution of GI symptoms, age-wise distribution of GI symptoms, lab investigation, and computed tomography (CT) scanning was done to record the grading. Materials and methods: In total, 956 COVID-19 patients admitted to an isolation ward of a tertiary care center were screened for 3 months. Patients were confirmed positive for SARS-CoV-2 virus by real-time polymerase chain reaction (RT-PCR) test with a throat swab. Patient's age, demographic details, preexisting illness, and GI symptoms such as fever, impairment of appetite, loss of taste, loss of smell, hiccups, nausea, vomiting, diarrhea, abdominal pain, symptom's duration, history of chronic drug intake, biological markers, CT scanning, and comorbidities were recorded. Based on the provided protocol, standard care management was given to the admitted COVID-19 patients. Statistical analysis was performed using SPSS version 20.0. Frequencies with percentages, median (min, max), Chi-square test, and Mann–Whitney U test were used to test the statistical significance, and a p-value of <0.05 was considered statistically significant. Results: In our prospective study of 956 COVID-19 hospitalized patients, details were analyzed and the results are: the median age was 45 years, 70% of male, 60% were above 35 years, comorbidities like diabetes present in 42%, hypertension in 36%, asthma in 8%, cardiovascular diseases (CVD) in 5%, and history of chronic drug intake in 21%. Among 956 COVID-19 patients, GI symptoms were loss of smell (29.2%), loss of taste (26.4%) for 3 days; nausea (10%), vomiting (7.1%), abdominal pain (12.7%), and fever (42.5%) were observed for 2 days among the 36–45 years of age-group; and the loss of appetite (19%) for 3 days among the age-group of 46–55 years. The loss of appetite (23.7 vs 16.9%) (p = 0.014), taste (32.4 vs 23.8%) (p = 0.005), nausea (14.6 vs 8.2%) (p = 0.003), and vomiting (10.8 vs 5.5%) (p = 0.004) were higher in females than in males. No gender difference was observed in loss of smell (p = 0.057), abdominal pain (12 vs 14.3%) (p = 0.491), hiccups (4 vs 2.1%) (p = 0.132), and fever (41.3 vs 45.3%) (p = 0.329). Females had significantly higher levels of C-reactive protein (CRP) than males (6.1 vs 3.8) (p = 0.002). No gender difference was observed in neutrophil/lymphocyte ratio (NLR) (p = 0.772), ferritin, and lactate dehydrogenase (LDH). CT-grade IV was higher in males than in females (1.7 vs 1.5%), but the rest of the CT grades were higher in females than in males. Conclusion: In conclusion, GI symptoms are the onset of symptoms that are first expressed after being infected with the SARS-CoV-2 virus. Several studies showed the GI symptoms but did not analyze the age and gender that are risk factors for any disease, but our study showed all GI symptoms and their association with age and gender, which will shed light for our clinicians for early symptom identification, diagnosis, and appropriate treatment.

Hydatid cyst is a zoonotic disease that most commonly occurs in liver and lungs. Here, we present five cases of hydatid cyst occurring in axillary subcutaneous region, adnexal region, ovary, gallbladder, and pancreas Echinococcus should be considered in the differential diagnosis of any cystic lesions in any anatomic location, with or without viscera involvement particularly in endemic areas.

Introduction: Gallbladder cancer (GBC) is the most common malignant biliary tract tumor with the shortest survival from the time of diagnosis. This poor prognosis is due to the destructive biologic behavior of GBC, lack of sensitive screening tests for early detection, and vague nature of first presentation. Here in this study, we will evaluate the baseline characteristics of the patients presenting with gallbladder carcinoma in our population. Materials and methods: This retrospective study was conducted in the Department of Gastroenterology at Sindh Institute of Urology and Transplantation (SIUT), Karachi. Patient data were compiled and composed from the in-patient health records, radiology, and operational records. Those patients with suspicion of GBC, but negative at histology, or patients having inconclusive radiologic findings, were excluded. Baseline characteristics were recorded. Results were presented as means ± SD for quantitative data or as numbers with percentages for qualitative data. Continuous variables were analyzed using the Student's t-test, while categorical variables were analyzed using the Chi-square test. A p-value of <0.05 was considered statistically significant. Results: A total of 162 patients were included in our study. Among them, 101 (62.3%) were females. Hypertension was the most common comorbid illness noted in 29 (17.9%) patients while 91 (56.2%) patients had no concurrent comorbidities. Most common risk factor for carcinoma of gallbladder was gallstones seen in 106 (65.1%) patients. The most common presenting complaint was combination of obstructive jaundice, weight loss with right hypochondrial pain seen in 66 (40.7%) patients. On CT abdomen, direct liver infiltration without lymphovascular invasion was noted in 77 (47.5%) patients followed by liver infiltration along with lymphovascular invasion in 26 (16%) patients and distant metastasis in 24 (14.8%) patients. On gallbladder (GB) mass biopsy, 58 (35.8%) patients had well-differentiated, 46 (28.4%) had moderately differentiated, while 33 (20.4%) had poorly differentiated adenocarcinoma. Of 162 patients, 103 (63.6%) patients underwent endoscopic retrograde cholangiopancreatography (ERCP). The most common finding on ERCP was proximal common bile duct (CBD) stricture with intrahepatic biliary system dilatation which was noted in 95 (58.6%) patients. Percutaneous transhepatic cholangiography (PTC) was performed only in 9 (5.6%) patients. Seventeen (10.5%) patients were managed by simple cholecystectomy, 39 (24.1%) patients underwent extended cholecystectomy, 14 (8.6%) patients underwent chemotherapy, while 102 (56.8%) patients were given palliative management. When followed for 1 year, 101 (62.3%) patients died within 6 months. Conclusion: The baseline characteristics, biopsy findings, modes of treatment, and rates of 1 year mortality were studied in patients with gallbladder carcinoma in our population. Advanced age, high white blood cell counts, and serum bilirubin at presentation with low lymphocyte count and presence of comorbid illnesses were the factors independently associated with increased mortality in patients with gallbladder carcinoma. However, further studies with large sample size and stratification with respect to age, gender, and different variables can be done in terms of mortality in patients with gallbladder carcinoma.

Background: Every year, worldwide, the celebration for patient safety is carried out; since about 2.6 million people are documented who die each year from events that can potentially be avoided during their medical care, it is even estimated that around 15% of hospital costs can be attributed to treatment resulting in patient safety. As an important part of its dissemination in the medical–surgical community, we present the following article in relation to the critical vision of safety in the bile duct, promoted and published initially by Dr Steven Strasberg, which aims to reduce the number of complications during laparoscopic cholecystectomies. Materials and methods: A bibliographic search was carried out in PubMed, Medline, Clinical Key, and Index Medicus. From May 2020 to July 2021 in Spanish and English with the following. Conclusions: Strasberg's critical view is a proposed strategy to minimize the risk to zero during laparoscopic gallbladder surgery. It consists of obtaining a plane in which the surgeon can visualize the anatomical structures that make up the bile duct, as well as its irrigation and drainage. Being able to clearly observe these structures allows the surgeon to cut freely and safely to avoid bile duct injuries which are not so uncommon during this procedure.

Aim: To briefly discuss the imaging features of different types of intra-abdominal fat necrosis. Background: Trauma and ischemic insult may result in intra-abdominal fat necrosis. Fat necrosis may present with acute abdomen, clinically simulating with other etiologies, such as acute diverticulitis and acute appendicitis. Main body: Imaging plays a crucial role in making the exact diagnosis and differentiating it from other pathologies that may require surgical intervention. Computed tomography (CT) is the most commonly used imaging modality. A small fat attenuation lesion with a hyperattenuating rim in contact with the ventral surface of the sigmoid colon indicates epiploic appendagitis while a larger fat-attenuation lesion on the right side of the abdomen in between the colon and anterior abdominal wall indicates omental infarction. Fat stranding at the root of the mesentery with fat ring sign represents inflammatory mesenteric panniculitis while retractile or sclerosing mesenteritis appears as a fibrotic spiculated mass with or without calcification, mimicking mesenteric carcinoid. In patients with acute pancreatitis, the amount of inflamed fat correlates with clinical severity and outcome. Conclusions: Familiarity with the imaging features of different types of intraabdominal fat necrosis helps in establishing an accurate diagnosis, thus avoiding unnecessary intervention.

Aim: To evaluate the efficacy of intravascular ultrasound (IVUS) in transjugular intrahepatic portosystemic shunt (TIPS) revision associated with phlebography and invasive pressure measurement in patients with clinical or radiological signs of TIPS malfunction. Background: Four patients underwent TIPS revision between February and August 2021. Right internal jugular vein access was achieved under ultrasonographic guidance, a catheter was advanced to achieve the Inferior Vena Cava (IVC) and afterward the Portal vein through the TIPS. Once the Portal vein was achieved, a phlebography was performed, followed by invasive pressure measurement and IVUS exam over the guidewire. Based on the combination of phlebography, invasive pressure measurement, and IVUS evaluations, TIPS dysfunction was treated either with angioplasty or stent apposition. Case description: In all patients, we obtained the reduction of porto-systemic gradient. In three patients, angioplasty with a 10 mm diameter balloon catheter was performed. Anticoagulation therapy was added to one patient. In one patient, the Viatorr's proximal extremity in the suprahepatic vein wall was dislocated, so it was lengthened with a “Viabahn” covered stent. None of the patients developed hepatic encephalopathy after both TIPS placement and TIPS revision. No complications related to the procedure were observed during the follow-up. Clinical improvement in the immediate follow-up period was observed in all patients. In two patients, the abdominal ascites resolved. In another one, the abdominal pain disappeared, and a reduction of the longitudinal spleen diameter was recorded at 3 months follow-up. Conclusion: The use of IVUS allowed us to correctly visualize the organic cause of TIPS malfunction and to obtain direct visualization of the results of endovascular treatment.

Barrett's esophagus, which results from chronic gastroesophageal reflux disease, is a known precursor to dysplasia and ultimately esophageal adenocarcinoma. Mixed neuroendocrine – nonneuroendocrine neoplasm (MiNEN) is a rare and heterogenous group of neoplasm with aggressive clinical behavior in general. There have been rare reports of MiNEN arising in Barrett's esophagus, and its pathogenesis remains unclear. Surgical resection with lymph node dissection remains the most effective treatment of MiNEN of the esophagus to date, although the evidence on its optimal treatment is scant.

Disconnected pancreatic duct syndrome (DPDS) is a condition where there is a ductal disconnection between viable secreting distal pancreatic tissues and the gastrointestinal tract. It may follow acute or chronic pancreatitis, abdominal trauma, and pancreatic surgery, leading to necrosis or structural disintegration of the pancreatic duct. Aim: The aim of our study is to describe the imaging features of DPDS on ultrasound, computed tomography, and magnetic resonance cholangiopancreatography (MRCP) that helps in diagnosis. We present a case series of DPDS with their imaging features in two settings, one in the patient with acute necrotizing pancreatitis and the other with blunt abdominal trauma. Conclusion: Imaging plays a significant role in preoperative diagnosis. Contrast-enhanced computed tomography provides a comprehensive assessment of pancreatic duct integrity, and it shows its type and site of ductal disruption. It is a simple, effective noninvasive imaging modality in diagnosing pancreatic duct disruption.