This editorial asks a familiar question in acute pancreatitis: can any tool reliably predict who will do badly, and might the triglyceride-glucose, or TyG, index be a useful new option?

The author reviews the long search for prognostic models in acute pancreatitis. Older scores such as Ranson’s criteria and the Glasgow-Imrie score require 48 hours, which limits practicality. The Acute Physiology and Chronic Health Evaluation, or APACHE II, score is robust but complex and has been seen as impractical, with poor predictive accuracy for 24-hour outcomes. Simpler tools include the systemic inflammatory response syndrome, or SIRS, score, the harmless acute pancreatitis score, or HAPS, and the Bedside Index for Severity in Acute Pancreatitis, or BISAP. But in a meta-analysis of 43 studies, none of Ranson’s, APACHE II, SIRS, or BISAP was helpful in clinical decision-making.

The editorial also notes laboratory and imaging predictors, including hematocrit, blood urea nitrogen, C-reactive protein within 48 hours, interleukin-6, and computed tomography severity scores.

The focus then shifts to a prospective single-centre observational study by Mitrolia and colleagues. In patients aged 18 to 80 years, the TyG index, calculated within 24 hours, was higher in severe acute pancreatitis. Seventeen percent had severe acute pancreatitis, and higher TyG was associated with longer hospital stay, more intensive care unit admissions, and worse fatality rates. Its area under the curve was greater than BISAP and computed tomography severity index, or CTSI, for predicting severe acute pancreatitis.

The key clinical takeaway is that the TyG index is simple and promising, but it still needs validation across different patient groups before it can be trusted in routine practice.

This editorial asks whether pre-procedural coagulation management in acute liver failure, or ALF, and acute-on-chronic liver failure, or ACLF, should move away from conventional coagulation tests toward rotational thromboelastometry, or ROTEM.

The authors highlight a retrospective cohort of 263 patients with ALF or ACLF undergoing plasma exchange catheter insertion through central venous access. ROTEM-guided management was used in 181 patients, while 82 were managed with conventional coagulation tests alone. ROTEM guidance was associated with far fewer prophylactic blood product transfusions, 21 percent versus 73 percent, with p less than 0.001, and no increase in bleeding. Only three bleeding events occurred: two minor events in the ROTEM group and one major bleed in the conventional testing group.

The editorial stresses that ALF and ACLF have different coagulation biology, but in both settings conventional tests such as international normalized ratio, or INR, often overestimate bleeding risk. Fresh frozen plasma may improve INR without meaningfully improving hemostasis, while exposing patients to harms such as transfusion-associated circulatory overload and worsening portal hypertension.

The authors argue that procedural risk, technical factors, and modifiable destabilizers like anemia, infection, and acute kidney injury should guide care. The key clinical takeaway is that restrictive, ROTEM-guided transfusion appears to safely reduce unnecessary blood product use, especially for lower-risk procedures such as plasma exchange catheter placement.

This narrative review asks how upper gastrointestinal bleeding, or UGIB, should be managed using a practical, step-wise approach in current practice, with particular attention to challenges in the Indian setting.

The authors describe UGIB as a common medical emergency and a major cause of morbidity and mortality worldwide. They emphasize that presentation ranges from self-limited bleeding to massive hemorrhage with hemodynamic instability and death. Although endoscopic therapy, pharmacological therapy, and intensive care have advanced substantially, outcomes remain variable and are shaped mainly by the underlying cause, comorbidities, and the timing of intervention.

The review highlights that initial management begins with early risk assessment, prompt resuscitation, and appropriate triage. Endoscopy is presented as the cornerstone of care because it serves both diagnosis and treatment, allowing the bleeding source to be identified and managed in the same setting. The authors summarize the broad endoscopic toolbox now available, including injection therapy, thermal coagulation, mechanical devices, topical hemostatic agents, and advanced rescue techniques.

For patients with refractory or recurrent bleeding, radiologic and surgical options have an important complementary role. The review also stresses that management should be adapted to the clinical setting, local disease patterns, and available resources rather than applying a one-size-fits-all model.

A key theme is the Indian context, where there are major regional differences in the epidemiology of UGIB, along with late presentation, limited access to emergency endoscopy, and a high burden of chronic liver disease. The main clinical takeaway is that a systematic, step-wise strategy centered on early stabilization, timely endoscopic intervention, and careful post-hemostasis management is most likely to improve outcomes and reduce re-bleeding and mortality.

This narrative review asks a practical question: what is the current best approach to diagnosing and managing lower gastrointestinal bleeding, or LGIB.

The review notes that older definitions described LGIB as bleeding distal to the ligament of Treitz, whereas more recent literature defines it as bleeding from the colon or anorectum. Globally, the incidence ranges from 20.5 to 87.0 per 100,000 person-years. Estimated mortality is 2.5 percent to 3.9 percent, and rebleeding after one year ranges from 13 percent to 19 percent.

Etiology varies by region. Diverticular bleeding is the most common cause in the west, while studies from India found colitis and hemorrhoids to be the leading causes. For initial evaluation, the review emphasizes a focused history, physical examination, and laboratory assessment to help localize bleeding and suggest the cause.

Management begins with hemodynamic assessment. Patients with instability should first receive intra-venous crystalloids, with the goal of normalizing heart rate and blood pressure before diagnostic or therapeutic procedures. In hemodynamically stable patients with acute LGIB, colonoscopy should be considered the initial diagnostic modality. The review highlights its dual role, since colonoscopy can both identify the source and provide treatment.

During colonoscopy, endoscopic hemostatic options include adrenaline injection, clip application, thermal coagulation, and or band ligation. Computed tomography angiography, or CTA, also has an important role, especially in hemodynamically unstable patients and when colonoscopy fails to achieve hemostasis.

Finally, the review stresses that patients taking anticoagulants or antiplatelets, and those who have undergone cardiac stenting within one year, should be managed with a multidisciplinary approach. The key clinical takeaway is to stabilize first, use colonoscopy first in stable patients, and use CTA strategically when instability or failed endoscopic hemostasis changes the pathway.

This narrative review asks how chronic mesenteric ischemia is currently diagnosed and managed, with a focus on choosing among endovascular, open surgical, and hybrid revascularization strategies.

The review describes chronic mesenteric ischemia as an underdiagnosed cause of post-prandial pain due to progressive mesenteric arterial stenosis. Although it has traditionally been considered rare, the authors note that more recent evidence suggests it is more prevalent, particularly in elderly females. While multi-vessel disease is the classic pattern, the review emphasizes that symptomatic single-vessel disease can occur when collateral circulation is inadequate.

For diagnosis, the authors highlight a multimodality approach. Duplex ultrasonography, computed tomography angiography, and magnetic resonance angiography are central imaging tools. Conventional angiography and functional studies are reserved for equivocal cases. The key message is that diagnosis depends on integrating symptoms with vascular imaging, rather than relying on any single test alone.

For treatment, revascularization is presented as the cornerstone of definitive management. The review describes a clear shift toward an endovascular-first strategy because of superior peri-operative safety, minimal invasiveness, and shorter hospitalization. Endovascular therapy is favored for most anatomically accessible lesions, especially ostial or short-segment stenoses of the celiac or superior mesenteric arteries, and covered stents are preferred because of enhanced patency. Important limitations include restenosis, technical failure in long-segment occlusions, and contraindications in extrinsic compression syndromes such as median arcuate ligament syndrome.

Open surgical revascularization remains important for complex aortoiliac disease, long occlusions, or failed endovascular treatment. Retrograde bypass from the iliac or infra-renal aorta may be easier in high-risk patients, while antegrade bypass from the supraceliac aorta may be more durable. Hybrid retrograde open mesenteric stenting, or ROMS, is useful when aortic clamping is not feasible and in acute-on-chronic mesenteric ischemia with bowel gangrene.

The key clinical takeaway is that early recognition and individualized revascularization strategy are central to improving long-term outcomes in chronic mesenteric ischemia.

This narrative review asks how artificial intelligence can improve imaging of pancreatic fluid collections in acute pancreatitis.

The authors focus on a central clinical problem: distinguishing fluid-only pseudocysts from debris-containing walled-off necrosis, because that distinction is critical for management. They note that conventional imaging has important limitations. Contrast-enhanced computed tomography can underestimate necrotic debris. Magnetic resonance imaging, or MRI, is costly and time-consuming. Endoscopic ultrasound is invasive.

Against that background, the review describes artificial intelligence, especially deep learning and radiomics, as an emerging way to augment pancreatic imaging. According to the review, artificial intelligence algorithms can automate segmentation of the pancreas and pancreatic fluid collections, which may help with more consistent assessment and volumetry. The authors also highlight objective quantification of necrotic debris, an area that could be particularly useful because the amount of solid material within a collection affects diagnosis and management.

Beyond characterization of collections, the review says artificial intelligence may help predict disease severity and outcomes in acute pancreatitis. It also discusses workflow applications. These include accelerating MRI acquisition times and potentially generating synthetic images, which could reduce scanner dependency.

The review also emphasizes that clinical integration is not straightforward. It discusses challenges and future directions, including the need to address implementation issues before these tools can be routinely adopted.

Overall, the key clinical takeaway is that artificial intelligence has the potential to make imaging of pancreatic fluid collections in acute pancreatitis more objective, efficient, and clinically informative, especially for identifying and quantifying necrotic debris, but it remains an adjunctive technology that still requires careful integration into practice.

This systematic review with meta-analysis asked whether splenic stiffness measurement, or SSM, can accurately predict esophageal or gastric varices and clinically significant varices in children with portal hypertension.

The authors searched PubMed, Scopus, and Embase up to January 2025 and included studies of children younger than 18 years with portal hypertension who underwent splenic stiffness measurement by elastography, using esophagogastroduodenoscopy, or EGD, as the reference standard. Data were pooled with a hierarchical summary receiver operating characteristic model, and risk of bias was assessed with the Quality Assessment of Studies of Diagnostic Accuracy, or QUADAS-2, tool.

Ten studies including 618 patients were analyzed. For prediction of esophageal or gastric varices, based on 3 studies with 158 patients, pooled sensitivity was 0.80, with 95 percent confidence interval 0.70 to 0.88. Pooled specificity was 0.89, with 95 percent confidence interval 0.80 to 0.95. The diagnostic odds ratio was 26.22, with 95 percent confidence interval 5.39 to 98.83, and the area under the receiver operating characteristic curve was 0.838, with 95 percent confidence interval 0.806 to 0.864.

For clinically significant varices, based on 7 studies with 460 patients, pooled sensitivity was 0.86, specificity 0.82, and diagnostic odds ratio 31.00, with 95 percent confidence interval 12.33 to 80.21. The area under the receiver operating characteristic curve was 0.905, with 95 percent confidence interval 0.882 to 0.924. There was substantial heterogeneity for pooled sensitivity in clinically significant varices, with I squared equals 69.2 percent and p equals 0.0006. Sources of heterogeneity included the etiology of portal hypertension, elastography technique, and ethnicity. Accuracy was higher in non-cirrhotic portal hypertension than cirrhotic portal hypertension, with diagnostic odds ratios of 48.61 versus 18.89.

The key clinical takeaway is that splenic stiffness measurement shows good, and for clinically significant varices very good, noninvasive diagnostic performance in pediatric portal hypertension, but standardized protocols and disease-specific cutoffs are still needed before routine screening use.

This systematic review with meta-analysis asked a straightforward clinical epidemiology question: how common is human astrovirus, or HAstV, associated acute gastroenteritis among hospitalized pediatric patients in Asia.

The authors note that viral gastroenteritis remains a major public health problem in developing countries, especially in children under five years, and that HAstV is one of the key viral causes. Although HAstV is recognized globally as a cause of acute gastroenteritis, the burden in Asian hospitalized children has been unclear.

To address this, the investigators conducted a systematic review and meta-analysis according to PRISMA guidelines and registered the protocol in PROSPERO with ID CRD42024519527. They searched PubMed, Web of Science, and Scopus for studies published from January 2000 through December 2023, using terms related to astrovirus, prevalence, pediatric populations, hospitalization, and Asia. Data were extracted with a pre-designed Excel sheet, study quality was assessed with the Joanna Briggs Institute critical appraisal tool, and effect sizes were calculated using Generalized Linear Mixed Models with logit transformation.

The final analysis included 49 studies from various Asian countries. The pooled prevalence of HAstV in hospitalized pediatric patients with acute gastroenteritis was 2.39 percent. The subgroup analysis showed considerable differences in HAstV prevalence among Asian countries.

The authors conclude that this review summarizes the prevalence of HAstV among hospitalized pediatric patients in Asia and supports the need for country-specific strategies to improve surveillance and diagnostics.

The key clinical takeaway is that HAstV accounts for a measurable share of acute gastroenteritis hospitalizations in children across Asia, with variation between countries, so local surveillance and diagnostic approaches matter.

This original article asked whether using rotational thromboelastometry, or ROTEM, before plasma exchange, or PLEX, port insertion could reduce prophylactic blood product transfusion in patients with acute liver failure, or ALF, and acute-on-chronic liver failure, or ACLF.

The authors retrospectively analyzed consecutive patients who underwent PLEX through central venous access between October 2016 and February 2022. Adult patients received an 11.5 F catheter and pediatric patients a 10 F catheter. In the conventional coagulation group, prophylactic transfusion was guided by conventional coagulation tests, or CCT. In the ROTEM group, transfusion was guided by both CCT and ROTEM. Propensity score matching was performed separately for ALF and ACLF.

Overall, 88 out of 113 patients with ALF or ACLF underwent PLEX. In the propensity score matched cohort of 77 ALF and 108 ACLF patients, prophylactic blood product use was significantly lower in the ROTEM group than in the conventional group. In ALF, this was 18 out of 50, or 36 percent, versus 21 out of 27, or 78 percent. In ACLF, it was 12 out of 85, or 14 percent, versus 18 out of 23, or 78 percent, with p less than 0.001.

Bleeding at the local port site was uncommon. There were no events in ALF, and only two in ACLF, one in each group.

Correlations between ROTEM and conventional tests were weak for clotting time and prothrombin time international normalized ratio, at 0.29 in ALF and 0.35 in ACLF, but stronger for maximum clot firmness with fibrinogen, 0.68 and 0.76, and with platelet count, 0.56 and 0.71.

The key clinical takeaway is that a ROTEM-based strategy before PLEX port insertion reduced prophylactic blood product use in both ALF and ACLF, without an apparent increase in local bleeding events.

This original article asked which patients undergoing endoscopic ultrasound-guided drainage of walled-off necrosis with metal stents are most likely to need re-intervention.

The study included consecutive patients treated at a tertiary referral center between January 2023 and December 2024, with demographic, clinical, and radiological data collected prospectively. The investigators then used multivariate logistic regression to identify independent predictors of re-intervention, and they assessed model performance with a receiver operating characteristic curve, calibration plot, decision curve analysis, and a validation cohort.

Among 500 patients, 83.2 percent were male. Alcohol-related pancreatitis accounted for 28.6 percent, and biliary pancreatitis for 10 percent. Re-intervention was required in 24 percent, or 120 patients. The main reasons were stent unclogging in 85.8 percent, nasocystic tube placement in 70 percent, and necrosectomy in 50 percent.

Three factors independently predicted re-intervention. Larger walled-off necrosis size had an odds ratio of 1.38, with a 95 percent confidence interval of 1.25 to 1.52. Paracolic extension had an odds ratio of 9.96, with a 95 percent confidence interval of 1.77 to 55.98. Higher solid debris content had an odds ratio of 1.10, with a 95 percent confidence interval of 1.08 to 1.13.

The model showed good discrimination, with an area under the curve of 0.85, and good calibration, with a Hosmer-Lemeshow p value of 0.19. In the validation cohort, overall accuracy was 86.67 percent, with a 95 percent confidence interval of 73.21 to 94.95 percent. Adverse events occurred in 6 percent, including bleeding in 11 patients, stent migration in 13, and sepsis-related death in 6.

The key clinical takeaway is that larger collections, paracolic extension, and greater solid debris identify patients at higher risk for re-intervention after endoscopic ultrasound-guided drainage.

This original article asked whether Clostridioides difficile superinfection is a major cause of acute flares in patients with moderate to severe ulcerative colitis in northern India.

The investigators performed a prospective study at a tertiary care center in India over 13 months, from May 2023 to May 2024. They included patients with ulcerative colitis who presented with an acute flare. The team also asked about antibiotic exposure in the preceding eight weeks before admission. Within 24 hours of admission, all patients underwent simultaneous testing for glutamate dehydrogenase, or GDH, and Clostridioides difficile toxin by enzyme-linked immunosorbent assay, or ELISA.

In total, 140 patients with an acute flare associated with ulcerative colitis were evaluated for Clostridioides difficile infection. Only four patients tested positive for both GDH and toxin A and or B, giving an overall prevalence of 2.9 percent. Among these four patients, two, or 50 percent, had prior exposure to antibiotics at the time of admission. The abstract also reports that each of the four patients with Clostridioides difficile infection had an uneventful recovery after treatment with oral vancomycin and metronidazole.

The authors conclude that Clostridioides difficile was not a major causative factor for flares in patients with moderate to severe ulcerative colitis at this tertiary care hospital in northern India. The key clinical takeaway is that in this setting, Clostridioides difficile superinfection appeared uncommon among hospitalized patients presenting with acute ulcerative colitis flares.

This original article asked whether trans-jugular intrahepatic portosystemic shunt, or TIPS, is safe and effective for patients with liver cirrhosis, hepatorenal syndrome non-acute kidney injury, or HRS-NAKI, and refractory ascites who are not candidates for liver transplantation.

The authors performed a retrospective analysis of 35 patients treated with TIPS and 134 who received standard medical therapy alone. They then used one-to-one propensity score matching based on age, sex, model for end-stage liver disease, or MELD, score, Child-Turcotte-Pugh, or CTP, score, serum bilirubin, serum creatinine, serum sodium, and ascites severity, yielding 35 matched controls.

By six months, patients who underwent TIPS showed improved renal parameters, with serum creatinine falling from 1.72 plus or minus 0.31 to 1.41 plus or minus 0.28 milligrams per deciliter, and urea falling from 78.6 plus or minus 21.4 to 52.3 plus or minus 18.9 milligrams per deciliter. In contrast, controls deteriorated. Urinary sodium rose significantly after TIPS, from 14.0 plus or minus 6.9 to 55.5 plus or minus 25.0 millimoles per liter at three months, with a p value of 0.001. Mean large-volume paracentesis frequency was also lower with TIPS, 0.52 versus 1.16 per month, with a p value of 0.002. Plasma renin activity declined from 13.9 plus or minus 1.5 to 4.8 plus or minus 1.2 nanograms per milliliter per hour at six months.

Adverse events were important: hepatic encephalopathy occurred in 35.1 percent, liver failure in 5.7 percent, and heart failure in 5.7 percent. Six-month mortality was 11.4 percent with TIPS and 20 percent in controls.

The key clinical takeaway is that TIPS may improve renal function, neuro-hormonal activation, and ascites control in this non-transplant population, but it carries substantial risk and needs careful patient selection.

This original article asked how common gut colonization with multidrug-resistant organisms, or MDRO, is in hospitalized patients with gastrointestinal illness, and how often stool findings match MDRO detected in other clinical samples.

The investigators performed a single-centre, cross-sectional study at All India Institute of Medical Sciences, New Delhi. They collected rectal swabs at a single time point from consecutive patients admitted to the gastroenterology ward and intensive care unit over October to November 2022. Isolates underwent antibiotic sensitivity testing with VITEK 2 compact and anti-microbial resistance, or AMR, gene testing by polymerase chain reaction, or PCR.

The study included 107 patients with a mean age of 40.3 plus or minus 14.8 years, and 27.1 percent were female. Chronic liver disease was present in 41.1 percent, acute pancreatitis in 27.1 percent, and other gastrointestinal diseases in 31.8 percent. Median hospitalization before rectal swab collection was nine, with an interquartile range of 6 to 17.5, days.

MDRO colonization was found in 106 patients, or 99.1 percent, with a 95 percent confidence interval of 94.9 to 99.9 percent. The most common organisms were Escherichia coli at 75.7 percent, Klebsiella pneumoniae at 16.8 percent, and Enterococcus fecium at 9.3 percent. The most prevalent AMR gene was NDM, New Delhi metallo-beta-lactamase, at 64.5 percent, followed by TEM at 58.9 percent and OXA at 55.1 percent.

Fifteen percent of other clinical samples were MDRO positive, most commonly K. pneumoniae at 50 percent. Mortality was 22 percent in isolated gut colonization and 50 percent when MDRO was present in both stool and another clinical sample. The key clinical takeaway is that this hospitalized gastrointestinal population had an extremely high burden of gut MDRO colonization, supporting stringent infection control, antimicrobial stewardship, and surveillance.

This original article asked whether therapeutic plasma exchange improves outcomes over standard medical treatment in hepatitis A virus-related acute liver failure.

The investigators performed a retrospective multicenter comparison across 13 centers in India. They studied consecutive patients with hepatitis A virus-related acute liver failure treated with plasma exchange from 2018 to 2024, and compared them with patients treated with standard medical treatment from 2011 to 2024. The main outcome was in-hospital native liver survival. They also looked specifically at patients who were hemodynamically stable and not receiving inotropes.

The study included 84 patients in the plasma exchange group and 150 in the standard medical treatment group. In the plasma exchange group, 61 were male, median age was 23.5 years with interquartile range 21 to 33, and King’s College Criteria were fulfilled in 22 patients, or 26.2 percent. In the standard medical treatment group, 101 were male, median age was 24 years with interquartile range 19 to 32.3, and King’s College Criteria were fulfilled in 16 patients, or 10.7 percent.

Overall survival was similar between groups: 70.2 percent with plasma exchange and 65.3 percent with standard medical treatment, with a p-value of 0.47.

In the subgroup not on inotropes, univariate analysis suggested better survival with plasma exchange: 52 out of 54, or 96.3 percent, versus 81 out of 104, or 77.9 percent, with odds ratio 0.135, 95 percent confidence interval 0.03 to 0.6, and p-value 0.002. However, this apparent benefit was not seen in propensity score matched or regression analyses.

The key clinical takeaway is that plasma exchange did not improve overall in-hospital outcome in hepatitis A virus-related acute liver failure, though a possible benefit in hemodynamically stable patients not requiring inotropes remains unproven and needs larger studies.

This original article asked a straightforward but important question: across India, what are the causes, clinical characteristics, and short-term outcomes of acute upper gastrointestinal bleeding, and what factors determine overall outcome?

The Indian Society of Gastroenterology created a task force to build a national database representative of all parts of India. In this prospective longitudinal cohort study, 93 centres participated, and data were collected from October 2014 to September 2018. Patients were followed for 30 days, either by telephone or during a hospital visit, to assess rebleeding up to 30 days from first presentation, need for surgery, and 30-day mortality.

Of 12,500 patients, 10,564 patients with upper gastrointestinal bleeding, or UGIB, were included in the study. Among them, 6450, or 61.1 percent, had non-variceal upper gastrointestinal bleeding, and 4114, or 38.9 percent, had variceal upper gastrointestinal bleeding.

In the non-variceal upper gastrointestinal bleeding group, 92 patients, or 1.4 percent, had rebleeding, 20, or 0.3 percent, required surgery, and 184, or 2.8 percent, died. In variceal upper gastrointestinal bleeding, 67 patients, or 1.6 percent, had rebleeding within 30 days, five, or 0.12 percent, underwent surgery, and mortality was 151 patients, or 3.67 percent.

The authors conclude that this is the first large national database on upper gastrointestinal bleeding in India, describing causes, treatment outcomes, complications, and predictors of complications. The key clinical takeaway is that in this large Indian cohort, non-variceal bleeding was more common than variceal bleeding, while 30-day mortality was higher in variceal upper gastrointestinal bleeding.

This research letter asks whether endoscopic ultrasound-guided angioembolization can control refractory tumor-related gastrointestinal bleeding when initial endoscopic therapy fails and interventional radiology cannot localize the feeder vessel.

The authors describe three patients with metastatic gastrointestinal or related tumors who rebled after topical hemospray. In all three, computed tomography angiography failed to localize the culprit vessel, so endoscopic ultrasound-guided angioembolization was performed using a 19-G fine-needle aspiration needle and undiluted N-butyl cyanoacrylate glue, 1 to 1.5 milliliters, directed at feeder vessels measuring 2 to 3 millimeters. Doppler confirmed complete obliteration in each case. One patient with distal esophageal carcinoma had no further bleeding for seven months. One with metastatic gestational trophoblastic tumor had bleeding cessation and partial tumor necrosis on repeat endoscopy at 24 hours, with no further gastrointestinal bleeding, but later died of the underlying illness after nine months. A third patient with metastatic gastric carcinoma had no further bleeding for six months.

The key clinical takeaway is that endoscopic ultrasound-guided angioembolization with N-butyl cyanoacrylate may be a feasible rescue option for refractory tumor bleeding in expert centers, but larger studies are needed.

This Research Letter asks whether an indigenous endoscopic vacuum therapy approach can successfully treat a post-esophagectomy esophageal leak when commercial systems may be costly or unavailable.

The authors describe a 72-year-old man who had undergone Ivor-Lewis esophagectomy with gastric pull-up for mid-esophageal carcinoma two months earlier. He presented with cough and worsening dyspnea, and contrast-enhanced computed tomography of the thorax showed an esophageal leak at the esophagogastric anastomosis, bilateral ground-glass opacities suggesting aspiration pneumonitis, and a mediastinal cavity measuring approximately 140 mL. Endoscopy showed a cavity with fistulous communication at 24 cm.

Because of frailty, aspiration pneumonia, and high anesthetic risk, the team chose endoscopic vacuum therapy, or EVT. They built an indigenous intra-cavitary EndoVAC using an open-pore polyurethane sponge about 20×15 mm sutured to a 14-Fr Ryle’s tube, connected to a portable negative-pressure wound therapy device delivering continuous suction at minus 120 mmHg. The patient underwent 11 sessions, with sponge exchanges every four to five days and repeated resizing as the cavity remodeled.

Follow-up endoscopy three weeks after the last session showed complete cavity closure with pseudodiverticulum formation. Aspiration resolved after the fifth EVT session, oral feeding began after the 11th session, and a later anastomotic stricture was treated with controlled radial expansion balloon dilation. At three and six months, he tolerated oral feeds without fistula recurrence.

The key clinical takeaway is that indigenous EndoVAC may be a practical, affordable option for esophageal leaks in low-resource settings, but the evidence here is limited to a single case.

This research letter asks whether cyclosporine can be used safely and effectively as rescue therapy in steroid-refractory acute severe ulcerative colitis, or ASUC, when blood cholesterol is low.

The authors retrospectively reviewed 65 patients with ASUC admitted from January 2021 to September 2023. Twenty-five, or 38.5 percent, did not respond to intravenous steroids and were considered for rescue therapy. Fifteen received intravenous cyclosporine at 2 mg per kg. Mean baseline cholesterol was 111.01 plus or minus 34.72 mg per deciliter. Seven of 15 patients, or 46.7 percent, had cholesterol less than 100 mg per deciliter, and 11, or 73.3 percent, had cholesterol less than 120 mg per deciliter.

Fourteen of 15 patients, or 93.3 percent, had a clinical response after five days of intravenous infusion and were switched to oral cyclosporine, then discharged on oral cyclosporine and azathioprine. One patient underwent colectomy. No patient developed deterioration in renal or liver function, and no neurological adverse events were reported.

The key clinical takeaway is that, in this small retrospective series, intravenous cyclosporine at 2 mg per kg appeared safe and effective in steroid-refractory ASUC despite relatively low cholesterol levels, but larger prospective studies are needed.

This research letter asked how acute hepatitis A presents and evolves in patients with glucose 6-phosphate dehydrogenase, or G6PD, deficiency who develop both hemolytic anemia and methemoglobinemia. In a retrospective case series from a tertiary care center in Kerala, 10 of 750 admitted patients with acute hepatitis A met these criteria. The median age was 30 years, and eight were male.

All patients developed disproportionate indirect hyperbilirubinemia within the first week, along with hemolytic anemia, methemoglobinemia, and confirmed G6PD deficiency. Median total bilirubin was 46 milligrams per deciliter, hemoglobin 7 grams per deciliter, lactate dehydrogenase 1200 international units per liter, and methemoglobin 12 percent. Eight patients developed acute kidney injury, six acute liver injury, and three acute liver failure. Two developed myocarditis, and one met criteria for hemophagocytic lymphohistiocytosis.

Management was supportive. Four patients with methemoglobin greater than 10 percent received high-dose ascorbic acid, methylene blue was avoided, and two underwent exchange transfusion. Five patients, or 50 percent, died. The key clinical takeaway is to suspect hemolysis, methemoglobinemia, and underlying G6PD deficiency in acute hepatitis A with disproportionate hyperbilirubinemia, anemia, and desaturation, and to avoid oxidant drugs while considering early exchange transfusion.

This correspondence asks whether conclusions that non-selective beta blockers, or NSBB, are well tolerated during pregnancy in portal hypertension are methodologically justified. Kothalkar argues for caution. The letter notes that fetal outcomes are infrequent and only 51 patients were exposed to NSBB, limiting confidence about rare harms. Although fetal outcomes were not significantly different, the groups may not have been comparable, especially by etiology and disease severity. Mean birth weight was lower with NSBB exposure, 2.5 kg versus 2.7 kg, p equals 0.12, while low birth weight was more frequent in decompensated disease, 2.2 versus 2.6 kg, p equals 0.004, and NSBB use was more common there, 62.3 percent versus 41.7 percent, p equals 0.10. The key takeaway is that NSBB safety conclusions in pregnancy should remain guarded.

This correspondence asks whether a simplified high-resolution manometry measure of esophagogastric junction barrier function can truly substitute for the conventional esophagogastric junction contractile integral. The authors praise the effort to simplify a technically demanding metric and note the reported time reduction from approximately 43 seconds to 11 seconds per study. But they argue that a strong Spearman correlation of 0.839 shows rank association, not interchangeability. They also question construct validity, because the modified metric uses a fixed 20 millimeters of mercury contour and a standardized 10-second window, while the conventional method references gastric pressure and respiratory cycles. Their main message is that agreement, reclassification, reproducibility, and links to acid exposure and treatment response must be shown before adopting the simplified metric clinically.

This correspondence asks whether the reported safety of non-selective beta-blockers in pregnancy with portal hypertension is fully supported by the underlying study design. The author praises the original cohort of 134 pregnancies and notes that the conclusion that non-selective beta-blockers appear safe, without association with adverse fetal outcomes such as intra-uterine growth restriction, is reassuring. But she raises several concerns. The cohort mixed cirrhotic patients, 48.4 percent, with non-cirrhotic patients, 51.6 percent, which may obscure important differences in outcomes and tolerance. She also notes likely selection bias in this retrospective study, since treatment was based on physician judgment. Finally, she questions whether reassuring fetal safety could reflect low dosing. The key takeaway is that prospective, etiology-specific studies with standardized surveillance are still needed.

This correspondence asks whether the reported tolerance of non-selective beta-blockers in pregnancy with portal hypertension has been fully interpreted. The author praises the original study for addressing an under-studied clinical problem, but raises several concerns. He notes that platelet count and spleen length were not reported, and argues these are better markers of severe portal hypertension than aspartate aminotransferase to platelet ratio index, or APRI. He also stresses the need to distinguish cirrhosis from non-cirrhotic portal fibrosis, because non-cirrhotic portal fibrosis is a pre-sinusoidal disorder without loss of liver synthetic capacity, so usual scores may not reflect portal hypertension in the same way. He also asks for causes of neonatal death, possible links to non-selective beta-blockers, and explanation for hospital stays of 5.5 days and 58 days. The key takeaway is that more detailed reporting and further research are needed before drawing firm conclusions about beta-blocker safety in this setting.

This correspondence responds to comments on whether non-selective beta blockers, or NSBBs, are well tolerated in pregnancy with portal hypertension. The authors stress that their original study was not meant to prove definitive fetal safety, especially because the number of NSBB-exposed pregnancies was modest. Instead, they say their real-world data showed no significant increase in adverse maternal or fetal outcomes, despite more frequent NSBB use in patients with more severe portal hypertension.

They add that lower fetal weight was linked more strongly to hepatic decompensation than to NSBB exposure. On multivariable regression, decompensation predicted fetal weight with p equals 0.005, whereas NSBB exposure did not, with p equals 0.246. The key clinical takeaway is cautious reassurance: in this retrospective cohort, NSBB use appeared tolerable during pregnancy, but disease severity remained the main concern.

This correspondence asks how colorectal cancer screening should start in India. The authors argue that the best first step is organized, urban fecal immunochemical test, or FIT, first screening, backed by audited colonoscopy capacity and a symptom-triggered fast-track pathway for early-onset colorectal cancer.

They stress that the main constraint is not the FIT kit, but timely, high-quality colonoscopy. Programs should be registry-linked and auditable, tracking FIT positivity, time to colonoscopy, completion rates, adenoma detection rates, interval cancers, complications, and standardized pathology reporting.

For younger patients, they recommend fast-tracking rectal bleeding, iron-deficiency anemia, persistent change in bowel habit, or unexplained weight loss. The key clinical takeaway is to build FIT-first screening only where colonoscopy quality and follow-up can be guaranteed.

This correspondence asks whether an “Obesity First” approach should become a central strategy in healthcare. The author argues that obesity should be treated as a primary chronic, relapsing, multifactorial disease, rather than managing each complication separately. Nearly 890 million adults worldwide are currently classified as obese, and obesity is linked to type-2 diabetes mellitus, cardiovascular disease, hypertension, and metabolic dysfunction-associated steatotic liver disease, or MASLD. The piece says lifestyle measures remain the cornerstone of care, but long-term weight loss is often difficult to sustain. It also highlights glucagon-like peptide-1 receptor agonists, or GLP-1 receptor agonists, such as semaglutide, as promising tools for weight reduction and metabolic improvement. The key clinical takeaway is to consider obesity itself as the main therapeutic target, while recognizing barriers to implementation, especially in low and middle-income countries such as India.

This Images in Clinical Gastroenterology article asks how a bleeding umbilical ectopic varix in cirrhosis can be controlled when transjugular intrahepatic portosystemic shunt, or TIPS, is relatively contraindicated. A 53-year-old man with Child-Pugh B alcohol-related cirrhosis, esophageal varices, and non-traumatic bleeding from an umbilical hernia varix did not respond to pressure, hemostatic gauze, or octreotide, and had a significant hemoglobin drop. Temporary suture control stabilized the bleed. He then underwent ultrasound-guided percutaneous embolization with 11 coils, ranging from 8 millimeter by 20 centimeter to 20 millimeter by 50 centimeter, plus gelfoam slurry. Computed tomography confirmed successful occlusion without complications. The key takeaway is that temporary suture control plus percutaneous embolization may be a practical alternative to TIPS or surgery in rare bleeding ectopic varices.

This Images in Clinical Gastroenterology article asks how bleeding ectopic varices at a hepaticojejunostomy can present and be managed. A 75-year-old man with extra-hepatic portal venous obstruction, portal biliopathy, and prior Whipple’s surgery presented with intermittent melena, fatigue, and hemoglobin of 5.2 grams per deciliter. Computed tomography angiography showed portal cavernomatous collaterals near the bilioenteric anastomosis. Endoscopy found two 1 centimeter ectopic varices with active ooze near the hepaticojejunostomy. One milliliter of n-butyl-2-cyanoacrylate was injected into each varix, achieving hemostasis. At three months, there was no recurrent melena. The key takeaway is to consider hepaticojejunostomy varices in obscure bleeding after bilioenteric anastomosis.

This Images in Clinical Gastroenterology article asks whether Henoch-Schonlein purpura can present as hematochezia in an adult. A 35-year-old woman had four weeks of large-joint pain and swelling with purpural rash, then seven days of diffuse abdominal pain and hematochezia. Erythrocyte sedimentation rate was 45 millimeters per hour, C-reactive protein 18 milligrams per liter, and 24-hour urinary protein excretion 930 milligrams. Colonoscopy showed multiple aphthous ulcers, and biopsies showed necrotizing small vessel vasculitis. Skin biopsy with direct immunofluorescence confirmed immunoglobulin A, or IgA, vasculitis. Oral prednisolone led to prompt symptom resolution. The key takeaway is that Henoch-Schonlein purpura, though rare in adults, can cause hematochezia and responds to glucocorticoids.