Prediction,prevention and management of gastroesophageal reflux after per-oral endoscopic myotomy:An update

Achalasia cardia,the most prevalent primary esophageal motility disorder,is predominantly characterized by symptoms of dysphagia and regurgitation.The principal therapeutic approaches for achalasia encompass pneumatic dilatation(PD),Heller's myotomy,and the more recent per-oral endoscopic myotomy(POEM).POEM has been substantiated as a safe and efficacious modality for the management of achalasia.Although POEM demonstrates superior efficacy compared to PD and an efficacy parallel to Heller's myotomy,the incidence of gastroesophageal reflux disease(GERD)following POEM is notably higher than with the aforementioned techniques.While symptomatic reflux post-POEM is relatively infrequent,the significant occurrence of erosive esophagitis and heightened esophageal acid exposure necessitates vigilant monitoring to preclude long-term GERD-related complications.Contemporary advancements in the field have enhanced our comprehension of the risk factors,diagnostic methodologies,preventative strategies,and therapeutic management of GERD subsequent to POEM.This review focuses on the limitations inherent in the 24-h pH study for evaluating post-POEM reflux,potential modifications in the POEM technique to mitigate GERD risk,and the strategies for managing reflux following POEM.

Role of intestinal ultrasound in ulcerative colitis: A systematic review

BACKGROUND Intestinal ultrasound(IUS)is an emerging,non-invasive,and highly sensitive diagnostic tool in inflammatory bowel disease(IBD),including ulcerative colitis(UC).Despite its potential,its adoption in clinical practice is limited due to a lack of standardization and awareness.AIM To perform a comprehensive scoping review based on a systematic literature review on IUS in UC to inform current practice.METHODS Ninety-nine original articles about ultrasonography in UC were identified among 7608 citations searching PubMed and EMBASE databases for systematic review.RESULTS IUS can be useful as an initial diagnostic strategy in patients with suspected IBD/UC.In UC,IUS can predict endoscopic response,histologic healing,and steroid responsiveness in acute severe cases.IUS can predict response to biologics/small molecules(as early as 2 wk).IUS correlates well with ileocolonoscopy,but IUS could miss rectal,jejunal,and upper GI lesions in suspected IBD and colon polyps or extra-intestinal manifestations in known IBD.IUS is useful in special situations(children,pregnancy,and postoperative Crohn's disease).Inter-observer agreement is acceptable and trained physicians have comparable diagnostic accuracy.Point-of-care ultrasound impacted management in 40%-60%of cases.Hand-held IUS has excellent agreement with conventional IUS.CONCLUSION IUS is a non-invasive,highly sensitive tool in the diagnosis and monitoring of UC,offering excellent patient satisfaction.Point-of-care ultrasound by IBD physicians can significantly impact clinical decision-making.

Non-alcoholic fatty liver disease in type 2 diabetes:Emerging evidence of benefit of peroxisome proliferator-activated receptors agonists and incretin-based therapies

Nonalcoholic fatty liver disease(NAFLD)is a global epidemic,affecting more than half of the people living with type 2 diabetes(T2D).The relationship between NAFLD and T2D is bidirectional and the presence of one perpetuates the other,which significantly increases the hepatic as well as extrahepatic complications.Until recently,there was no approved pharmacological treatment for NAFLD/nonalcoholic steatohepatitits(NASH).However,there is evidence that drugs used for diabetes may have beneficial effects on NAFLD.Insulin sensitizers acting through peroxisome proliferator-activated receptor(PPAR)modulation act on multiple levels of NAFLD pathogenesis.Pioglitazone(PPARγ agonist)and saroglitazar(PPARα/γagonist)are particularly beneficial and recommended by several authoritative bodies for treating NAFLD in T2D,although data on biopsyproven NASH are lacking with the latter.Initial data on elafibanor(PPARα/δ agonist)and Lanifibranor(pan PPAR agonist)are promising.On the other hand,incretin therapies based on glucagon-like peptide-1(GLP-1)receptor agonists(GLP-1RA)and dual-and triple-hormone receptor co-agonists reported impressive weight loss and may have anti-inflammatory and antifibrotic properties.GLP-1 RAs have shown beneficial effects on NAFLD/NASH and more studies on potential direct effects on liver function by dual-and triple-agonists are required.Furthermore,the long-term safety of these therapies in NAFLD needs to be established.Collaborative efforts among healthcare providers such as primary care doctors,hepatologists,and endocrinologists are warranted for selecting patients for the best possible management of NAFLD in T2D.

Patients with inflammatory bowel disease have increased risk of autoimmune and inflammatory diseases

AIM To investigate whether immune mediated diseases(IMD) are more frequent in patients with inflammatory bowel disease(IBD).METHODS In this population based registry study,a total of 47325 patients with IBD were alive and registered in the Danish National Patient Registry on December 16,2013. Controls were randomly selected from the Danish Civil Registration System(CRS) and matched for sex,age,and municipality. We used ICD 10 codes to identify the diagnoses of the included patients. The IBD population was divided into three subgroups: Ulcerative colitis(UC),Crohn's disease(CD) and Both the latter referring to those registered with both diagnoses. Subsequently,odds-ratios(OR) and 95%CI were obtained separately for each group and their respective controls. The use of Bonferoni post-test correction adjusted the significance level to P < 0.00125. P-values were estimated using Fisher's exact test.RESULTS There were significantly more women than men in the registry,and a greater percentage of comorbidity in the IBD groups(P < 0.05). Twenty different IMDs were all significantly more frequent in the IBD group. Sixteen were associated with UC versus twelve with CD. In both UC and CD ORs were significantly increased(P < 0.00125) for primary sclerosing cholangitis(PSC),celiac disease,type 1 diabetes(T1D),sarcoidosis,asthma,iridocyclitis,psoriasis,pyoderma gangrenosum,rheumatoid arthritis,and ankylosing spondylitis. Restricted to UC(P < 0.00125) were autoimmune hepatitis,primary biliary cholangitis,Grave's disease,polymyalgia rheumatica,temporal arteritis,and atrophic gastritis. Restricted to CD(P < 0.00125) were psoriatic arthritis and episcleritis. Restricted to women with UC(P < 0.00125) were atrophic gastritis,rheumatoid arthritis,temporal arteritis,and polymyalgia rheumatica. Restricted to women with CD were episcleritis,rheumatoid arthritis,and psoriatic arthritis. The only disease restricted to men(P < 0.00125) was sarcoidosis. CONCLUSION Immune mediated diseases were significantly more frequent in patients with IBD. Our results strengthen the hypothesis that some IMDs and IBD may have overlapping pathogenic pathways.

Efficacy of low dose peginterferon alpha-2b with ribavirin on chronic hepatitis C

AIM: To assess the effi cacy of peginterferon alpha 2b at doses of 50 μg weekly and 80 μg weekly (based on body weight) plus ribavirin in HCV genotype 2 and genotype 3 chronic hepatitis C patients. METHODS: During the study period of Jan 2002 to Dec 2003, all patients diagnosed as chronic hepatitis C or HCV related compensated cirrhosis were treated with peginterferon alpha 2b 50 μg S/C weekly (body weight < 60 kg) or 80 μg S/C weekly (body weight > 60 kg) plus ribavirin 800 mg/d for 24 wk. RESULTS: Overall 28 patients, 14 patients in each group (based on body weight) were treated during the period. Out of 28 patients, 75% were genotype 3, 18% were genotype 2 and 7% were genotype 1. The mean dose of peginterferon alpha 2b was 0.91 μg/kg in group 1 and 1.23 μg/kg in group 2 respectively. The end of treatment and sustained virologic response rates were 82% and 78% respectively. Serious adverse effects were seen in 3.5% patients. CONCLUSION: Low dose peginterferon alpha 2b in combination with ribavirin for 24 wk is effective in HCV genotype 2 and 3 chronic hepatitis C patients.

Polymorphisms in NF-κB,PXR,LXR,PPARγ and risk of inflammatory bowel disease

AIM:To investigate the contribution of polymorphisms in nuclear receptors to risk of inflammatory bowel disease(IBD) . METHODS:Genotypes of nuclear factor(NF) -κB(NFKB1) NFκB-94ins/del(rs28362491) ;peroxisome proliferatoractivated receptor(PPAR) -γ(PPARγ) PPARγPro12Ala(rs1801282) and C1431T(rs 3856806) ;pregnane X receptor(PXR) (NR1I2) PXR A-24381C(rs1523127) ,C8055T(2276707) ,and A7635G(rs 6785049) ;and liver X receptor(LXR) (NR1H2) LXR T-rs1405655-C and T-rs2695121-C were assessed in a Danish case-control study of 327 Crohn's disease patients,495 ulcerative colitis(UC) patients,and 779 healthy controls.Odds ratio(OR) and 95%CI were estimated by logistic regression models. RESULTS:The PXR A7635G variant,the PPARγPro12Ala and LXR T-rs2695121-C homozygous variant genotypes were associated with risk of UC(OR:1.31,95% CI:1.03-1.66,P=0.03,OR:2.30,95%CI:1.04-5.08,P=0.04,and OR:1.41,95%CI:1.00-1.98,P=0.05,respectively) compared to the corresponding homozygous wild-type genotypes.Among never smokers,PXR A7635G and the LXR T-rs1405655-C and T-rs2695121-C variant genotypes were associated with risk of IBD(OR:1.41,95%CI:1.05-1.91,P=0.02,OR:1.63,95%CI:1.21-2.20,P=0.001,and OR:2.02,95%CI:1.36-2.99,P=0.0005,respectively) compared to the respective homozygous variant genotypes.PXR A7635G(rs6785049) variant genotype was associated with a higher risk of UC diagnosis before the age of 40 years and with a higher risk of extensive disease(OR:1.34,95%CI:1.03-1.75 and OR:2.49,95%CI:1.24-5.03,respectively) . CONCLUSION:Common PXR and LXR polymorphisms may contribute to risk of IBD,especially among never smokers.

Imaging of the gastrointestinal tract-novel technologies

Imaging of the gastrointestinal tract is very useful for research and clinical studies of patients with symptoms arising from the gastrointestinal tract and in visualising anatomy and pathology. Traditional radiological techniques played a leading role in such studies for a long time. However, advances in non-invasive modalities including ultrasound (US), computed tomography (CT), positron emission tomography (PET), magnetic resonance imaging (MRI), etc, have in the last decades revolutionised the way in which the gastrointestinal tract is studied. The resolution of imaging data is constantly being improved and 3D acquisition, tools for fi ltering, enhancement, segmentation and tissue classif ication are continually being developed. Additional co-registration techniques allow multimodal data acquisition with improved classif ication of tissue pathology. Furthermore, new functional imaging techniques have become available. Altogether, the future of gastrointestinal imaging looks very promising which will be of great benef it in clinical and research studies of gastrointestinal diseases. The purpose of this review is to highlight the capabilities of the newest techniques to explore the detailed morphology, biomechanical properties, function and pathology of the gastrointestinal tract.

Heterogeneity of non-alcoholic fatty liver disease: Implications for clinical practice and research activity

Non-alcoholic fatty liver disease(NAFLD)is a heterogeneous condition with a wide spectrum of clinical presentations and natural history and disease severity.There is also substantial inter-individual variation and variable response to a different therapy.This heterogeneity of NAFLD is in turn influenced by various factors primarily demographic/dietary factors,metabolic status,gut microbiome,genetic predisposition together with epigenetic factors.The differential impact of these factors over a variable period of time influences the clinical phenotype and natural history.Failure to address heterogeneity partly explains the sub-optimal response to current and emerging therapies for fatty liver disease.Consequently,leading experts across the globe have recently suggested a change in nomenclature of NAFLD to metabolic-associated fatty liver disease(MAFLD)which can better reflect current knowledge of heterogeneity and does not exclude concomitant factors for fatty liver disease(e.g.alcohol,viral hepatitis,etc.).Precise identification of disease phenotypes is likely to facilitate clinical trial recruitment and expedite translational research for the development of novel and effective therapies for NAFLD/MAFLD.

Serum midkine levels for the diagnosis and assessment of response to interventional therapy in patients with hepatocellular carcinoma

Objective:To explore the clinical significance of serum midkine(MDK) levels for the diagnosis of hepatocellular carcinoma(HCC) and evaluate the efficacy of interventional therapy.Methods:Eighty-four patients with HCC were enrolled in this retrospective study.They received an interventional treatment.A follow-up was performed every 2 months,using magnetic resonance imaging,to determine whether the treatment should be continued.Serum alpha-fetoprotein(AFP) and MDK levels were measured at the first diagnosis and during the follow-ups,and the HCC detection rates based on the cutoff values of these two measurements were compared.The relationships between AFP and MDK and the clinical tumor characteristics and changes in APK and MDK before and after treatment were also compared using a rank sum test and χ2 test,respectively.The prognostic significance of MDK for HCC was determined through regression analysis.A twosided P <0.05 was considered statistically significant.Results:MDK expression was detected in 95.24% of the cases.Subgroup analysis revealed MDK expression in95.35%,95.12%,85.19%,86.67%,and 83.33% of the AFP-positive,AFP-negative,stage A Barcelona clinic liver cancer(BCLC-A),BCLC-A/AFP-positive,and BCLC-A/AFP-negative cases,respectively.MDK expression after the interventional treatment(66.7%) was significantly lower than that before the treatment(95.2%).The mean posttreatment MDK level was 0.67 ng/mL in patients with a positive response to therapy as compared with 3.66 ng/mL in those with no positive response.All patients were followed up for 18 months,and those positive for MDK expression before the intervention were more likely to relapse than patients without MDK expression.Subgroup analysis revealed the highest recurrence rate for patients who were positive for MDK expression before and after treatment.Conclusions:Serum MDK may serve as a powerful complement to AFP in the diagnosis of HCC.MDK measurement may improve the detection rate of BCLC-A and AFP-negative HCC.Serum MDK may help to determine the vascular invasion and poor clinical staging of HCC tumors.Patients with MDK-positive HCC before treatment may be more prone to postoperative tumor progression.

Primary hyperparathyroidism presenting as acute pancreatitis: An institutional experience with review of the literature

BACKGROUND Acute pancreatitis(AP)presenting as an initial manifestation of primary hyperparathyroidism(PHPT)is uncommon,and its timely diagnosis is crucial in preventing recurrent attacks of pancreatitis.AIM To determine the clinical,biochemical,and radiological profile of PHPT patients presenting as AP.METHODS This is a retrospective observational study,51 consecutive patients admitted with the diagnosis of PHPT during January 2010 and October 2021 at a tertiary care hospital in Puducherry,India was included.The diagnosis of AP was established in the presence of at least two of the three following features:abdominal pain,levels of serum amylase or lipase greater than three times the normal,and characteristic features at abdominal imaging.RESULTS Out of the 51 consecutive patients with PHPT,twelve(23.52%)had pancreatitis[5(9.80%)AP,seven(13.72%)chronic pancreatitis(CP)].PHPT with AP(PHPT-AP)was more common among males with the presentation at a younger age(35.20±16.11 vs 49.23±14.80 years,P=0.05)and lower plasma intact parathyroid hormone(iPTH)levels[125(80.55-178.65)vs 519.80(149-1649.55,P=0.01)]compared to PHPT without pancreatitis(PHPT-NP).The mean serum calcium levels were similar in both PHPT-AP and PHPT-NP groups[(11.66±1.15 mg/dL)vs(12.46±1.71 mg/dL),P=0.32].PHPT-AP also presented with more gastrointestinal symptoms like abdominal pain,nausea,and vomiting with lesser skeletal and renal manifestations as compared to patients with PHPT-NP.CONCLUSION AP can be the only presenting feature of PHPT.Normal or higher serum calcium levels during AP should always draw attention towards endocrine causes like PHPT.

Impact of surgery for chronic pancreatitis on the risk of pancreatic cancer:Untying the Gordian knot

Pancreatic ductal adenocarcinoma is an aggressive tumor with poor long-term outcomes.Chronic pancreatitis(CP)is considered a risk factor for the development of pancreatic cancer(PC).Persistent pancreatic inflammation and activation of pancreatic stellate cells play a crucial role in the pathogenesis of CPrelated PC by activating the oncogene pathway.While genetic mutations increase the possibility of recurrent and persistent pancreatic inflammation,they are not directly associated with the development of PC.Recent studies suggest that early surgical intervention for CP might have a protective role in the development of CP-related PC.Hence,the physician faces the clinical question of whether early surgical intervention should be recommended in patients with CP to prevent the development of PC.However,the varying relative risk of PC in different subsets of CP underlines the complex gene-environment interactions in the disease pathogenesis.Hence,it is essential to stratify the risk of PC in each individual patient.This review focuses on the complex relationship between CP and PC and the impact of surgical intervention on PC risk.The proposed risk stratification based on the genetic and environmental factors could guide future research and select patients for prophylactic surgery.

Clinical nutrition in the hepatogastroenterology curriculum

Gastroenterology(GE) used to be considered a subspecialty of internal medicine. Today, GE is generally recognized as a wide-ranging specialty incorporating capacities, such as hepatology, oncology and interventional endoscopy, necessitating GEexpert differentiation. Although the European Board of Gastroenterology and Hepatology has defined specific expertise areas in Advanced endoscopy, hepatology, digestive oncology and clinical nutrition, training for the latter topic is lacking in the current hepatogastroenterology(HGE) curriculum. Given its relevance for HGE practice, and being at the core of gastrointestinal functioning, there is an obvious need for training in nutrition and related issues including the treatment of disease-related malnutrition and obesity and its associated metabolic derangements. This document aims to be a starting point for the integration of nutritional expertise in the HGE curriculum, allowing a central role in the management of malnutrition and obesity. We suggest minimum endpoints for nutritional knowledge and expertise in the standard curriculum and recommend a focus period of training in nutrition issues in order to produce well-trained HGE specialists. This article provides a road map for the organization of such a training program. We would highly welcome the World Gastroenterology Organisation, the European Board of Gastroenterology and Hepatology, the American Gastroenterology Association and other(inter)national Gastroenterology societies support the necessary certifications for this item in the HGE-curriculum.

Reversibility of central neuronal changes in patients recovering from gallbladder stones or acute cholecystitis

AIM: To investigate the referred pain area in patients 2-7 years after cholecystectomy in order to test the hypothesis that neuroplastic changes could give rise to post cholecystectomy pain. METHODS: Forty patients were tested. Twenty five were cholecystectomized due to uncomplicated gallbladder stones and 15 because of acute cholecystitis. Sensitivity to pinprick, heat, cold, pressure and single and repeated electrical stimulation was studied both in the referred pain area and in the control area on the contra lateral side of the abdomen. RESULTS: Five patients still intermittently suffered from pain. But in the objective test of the 40 patients, no statistical significant difference was found between the referred pain area and the control area. CONCLUSION: This study does not support the hypothesis that de novo neuroplastic changes could develop several years after cholecys-tectomy.

Effect of Frey's procedure on islet cell function in patients with chronic calcific pancreatitis

Background: Frey’s procedure involves both drainage and resection of the pancreas in subjects with chronic calcific pancreatitis(CCP). The procedure may affect the pancreatic endocrine function after surgery. The present study was to evaluate the effect of Frey’s procedure on both beta and alpha cell function in CCP patients.Methods: Thirty CCP patients who underwent Frey’s procedure were included. According to the glycemic status, patients were divided into the diabetes mellitus(DM), prediabetes, and normal glucose tolerance(NGT) groups. Islet cell function was assessed before and 3 months after surgery.Results: At baseline, there was a significant difference in beta cell function among the three groups [NGT group 1.71(1.64–2.07) vs prediabetes group1.50(0.83–1.61) vs DM group 0.33(0.12–0.55), P < 0.0001], but the insulin resistance was not different among them. Post glucose hyperglucagonemia representing alphacell dysfunction during oral glucose tolerance test was present in all of them, but showed no significant difference [NGT group 0.15(0.06–0.31) vs prediabetes group 0.32(0.05–0.70) vs DM group 0.07(0.02–0.18), P = 0.20]. Frey’s procedure did not change beta cell function and insulin resistance. However, alphacell dysfunction deteriorated after surgery [0.10(0.03–0.27) vs 0.33(0.09–0.68), P = 0.004].Conclusions: Although Frey’s procedure does not affect the beta cell function and insulin resistance in CCP patients, the alpha-cell dysfunction deteriorates after surgery.

Ectopic pancreas at the ampulla of Vater diagnosed with endoscopic snare papillectomy: A case report and review of literature

BACKGROUND Ectopic pancreas is a rare developmental anomaly that results in a variety of clinical presentations.Patients with ectopic pancreas are mostly asymptomatic,and if symptomatic,symptoms are usually nonspecific and determined by the location of the lesion and the various complications arising from it.Ectopic pancreas at the ampulla of Vater(EPAV)is rare and typically diagnosed after highly morbid surgical procedures such as pancreaticoduodenectomy or ampullectomy.To our knowledge,we report the first case of confirmed EPAV with a minimally invasive intervention.CASE SUMMARY A 71-year-old male with coronary artery disease,presented to us with new-onset dyspepsia with imaging studies revealing a‘double duct sign’secondary to a small subepithelial ampullary lesion.His hematological and biochemical investigations were normal.His age,comorbidity,poor diagnostic accuracy of endoscopy,biopsies and imaging techniques for subepithelial ampullary lesions,and suspicion of malignancy made us acquire histological diagnosis before morbid surgical intervention.We performed balloon-catheter-assisted endoscopic snare papillectomy which aided us to achieve en bloc resection of the ampulla for histopathological diagnosis and staging.The patient’s post-procedure recovery was uneventful.The en bloc resected specimen revealed ectopic pancreatic tissue in the ampullary region.Thus,the benign histopathology avoided morbid surgical intervention in our patient.At 15 mo follow-up,the patient is asymptomatic.CONCLUSION EPAV is rare and remains challenging to diagnose.This rare entity should be included in the differential diagnosis of subepithelial ampullary lesions.Endoscopic en bloc resection of the papilla may play a vital role as a diagnostic and therapeutic option for preoperative histological diagnosis and staging to avoid morbid surgical procedures.

Interesting and unusual cases of chronic abdominal pain-intermittent gastric volvulus

Objective: Intermittent gastric volvulus is a rare disease that requires high index of suspicion for diagnosis and treatment. The incidence and prevalence is unknown, may be due to under reporting or under diagnosis. Gastric volvulus may be transient producing few symptoms. The Borchardt’s Triad may be present only during an acute presentation. Common symptoms may mislead to diagnose a nonsurgical disease if an evaluation is not done, keeping in mind a possibility of gastric volvulus, even if a UGI scopy is normal. Cases may be submerged in the community being undiagnosed. Case Series: CASE 1: 21 yrs old male with intermittent abdominal pain for 1(1/2) yrs with marfanoid habitus, MVP and a normal UGI scopy. BMS revealed an Organo-Axial Volvulus and ligament laxity per-operatively. CASE 2: 65 yrs old diabetic female with vomiting and abdominal pain for 3 months and left sided pneumonitis. UGI scopy showed twisted gastric folds immediately below OGJ and inability to visualise antrum. BMS revealed mixed volvulus with paraesophageal herniation of distal stomach. Per-operatively there was laxity of ligaments with omental content alone within the diaphragmatic rent. Posterior retrocolic sub-mucosal gastrojejunostomy(pexy) was done for all cases. Conclusion: Gastric volvulus should be thought of in a case of chronic intermittent abdominal pain with normal baseline evaluation. A Chest X-ray and BMS should be done, at the time of symptoms.

Pancreatic stellate cell: Pandora's box for pancreatic disease biology

Pancreatic stellate cells(PSCs) were identified in the early 1980 s, but received much attention after 1998 when the methods to isolate and culture them from murine and human sources were developed. PSCs contribute to a small proportion of all pancreatic cells under physiological condition, but are essential for maintaining the normal pancreatic architecture. Quiescent PSCs are characterized by the presence of vitamin A laden lipid droplets. Upon PSC activation, these perinuclear lipid droplets disappear from the cytosol, attain a myofibroblast like phenotype and expresses the activation marker, alpha smooth muscle actin. PSCs maintain their activated phenotype via an autocrine loop involving different cytokines and contribute to progressive fibrosis in chronic pancreatitis(CP) and pancreatic ductal adenocarcinoma(PDAC). Several pathways(e.g., JAK-STAT, Smad, Wnt signaling, Hedgehog etc.), transcription factors and mi RNAs have been implicated in the inflammatory and profibrogenic function of PSCs. The role of PSCs goes much beyond fibrosis/desmoplasia in PDAC. It is now shown that PSCs are involved in significant crosstalk between the pancreatic cancer cells and the cancer stroma. These interactions result in tumour progression, metastasis, tumour hypoxia, immune evasion and drug resistance. This is the rationale for therapeutic preclinical and clinical trials that have targeted PSCs and the cancer stroma.

Ultrasonography in diagnosing chronic pancreatitis: New aspects

The course and outcome is poor for most patients with pancreatic diseases.Advances in pancreatic imaging are important in the detection of pancreatic diseases at early stages.Ultrasonography as a diagnostic tool has made,virtually speaking a technical revolution in medical imaging in the new millennium.It has not only become the preferred method for first line imaging,but also,increasingly to clarify the interpretation of other imaging modalities to obtain efficient clinical decision.We review ultrasonography modalities,focusing on advanced pancreatic imaging and its potential to substantially improve diagnosis of pancreatic diseases at earlier stages.In the first section,we describe scanning techniques and examination protocols.Their consequences for image quality and the ability to obtain complete and detailed visualization of the pancreas are discussed.In the second section we outline ultrasonographic characteristics of pancreatic diseases with emphasis on chronic pancreatitis.Finally,new developments in ultrasonography of the pancreas such as contrast enhanced ultrasound and elastography are enlightened.

Islet cell dysfunction in patients with chronic pancreatitis

Chronic pancreatitis(CP)is characterized by progressive inflammation and fibrosis of the pancreas that eventually leads to pancreatic exocrine and endocrine insufficiency.Diabetes in the background of CP is very difficult to manage due to high glycemic variability and concomitant malabsorption.Progressive beta cell loss leading to insulin deficiency is the cardinal mechanism underlying diabetes development in CP.Alpha cell dysfunction leading to deranged glucagon secretion has been described in different studies using a variety of stimuli in CP.However,the emerging evidence is varied probably because of dependence on the study procedure,the study population as well as on the stage of the disease.The mechanism behind islet cell dysfunction in CP is multifactorial.The intra-islet alpha and beta cell regulation of each other is often lost.Moreover,secretion of the incretin hormones such as glucagon like peptide-1 and glucose-dependent insulinotropic polypeptide is dysregulated.This significantly contributes to islet cell disturbances.Persistent and progressive inflammation with changes in the function of other cells such as islet delta cells and pancreatic polypeptide cells are also implicated in CP.In addition,the different surgical procedures performed in patients with CP and antihyperglycemic drugs used to treat diabetes associated with CP also affect islet cell function.Hence,different factors such as chronic inflammation,dysregulated incretin axis,surgical interventions and anti-diabetic drugs all affect islet cell function in patients with CP.Newer therapies targeting alpha cell function and beta cell regeneration would be useful in the management of pancreatic diabetes in the near future.

Helicobacter pylori eradication in patients with chronic immune thrombocytopenic purpura

AIM: To assess the effect of Helicobacter pylori (H. pylori) eradication on platelet counts in patients with chronic immune thrombocytopenic purpura (cITP).