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Ascites

❇️ A ReviewBudd-Chiari Syndrome and Pregnancy

Journal of Clinical and Experimental Hepatology, 20 August 2025

❇️ PEG Tube (Percutaneous Endoscopic Gastrostomy) 👉 Tube placed directly into stomach through abdominal wall 👉 Inserted with help of an endoscope 👉 Used for long-term enteral feeding (weeks–months) 👉 Indications : stroke, head & neck cancer, neuro disorders, severe swallowing problems 👉 Allows giving liquid feeds, medicines, water directly into stomach 👉 Safer and more comfortable than long-term NG tube 👉 Complications : infection at site, tube blockage, accidental dislodgement.

clinical findings in hypothyroidism and cirrhosis. The overlapping section represents shared clinical features.

❇️ A 72-year-old patient presents with hemorrhagic shock, melena, and has a history of heavy NSAID use. ➡️ A visible vessel in this anterior duodenal ulcer is seen, which is larger than the diameter of the gold probe (3.3 mm, 10 Fr). Attempting cautery in this scenario risks triggering arterial bleeding, even after epinephrine injection. The decision was made to use a primary (first-line) over-the-scope clip (OTSC) due to its large volumetric capture. Excellent tissue capture was achieved, and hemostasis was durable and without complications. 🔆 Take Home Point: If a vessel is larger than 3 mm (i.e., larger than the thermal device), consider using OTSC as primary therapy.

❇️ Hemostatic forceps are ideal for precise capture of actively bleeding vessels, especially those on the apex of a fold or in areas where compression is unsafe due to thin walls. Soft coagulation generates shallow cautery and is safe even with the jaws closed. ❇️ Examples : 1) A patient with aortic stenosis presented with persistent melena and was found to have an actively bleeding gastric AVM. confirmation that the vessel was captured during active bleeding was achieved by closing the forceps and washing prior to cauterization. 2) A patient on anticoagulation had persistent bleeding following esophageal disimpaction. The forceps can be gently used in a closed position to resemble a heater probe. Significant compression should be avoided due to the use of monopolar cautery. 3) A patient on anticoagulation experienced post-polypectomy bleeding with a visible vessel on the apex of a fold. The forceps are more precise and stable for capturing a vessel on a ridge or fold than a bipolar probe, which can slip.

❇️ A patient with persistent iron deficiency anemia (IDA) from gastric antral vascular ectasia (GAVE) refractory to argon plasma coagulation (APC). ➡️ Endoscopic band ligation was performed for nodular GAVE. Care should be taken to avoid banding too close to the pylorus, as this can cause nausea and pain. 🔆 Take Home Point: Band ligation for GAVE, especially the nodular type, can be more effective than APC.

❇️ Three methods to control immediate and prevent post-polypectomy bleeding include cauterization, clipping, or hemostatic gel application. ➡️ Thermal Technique – Snare Tip Coagulation: For immediate post-polypectomy bleeding, snare tip coagulation (soft or spray coagulation, 60W) is quickest, as the snare is already in the channel. ➡️ Thermal – Hemostatic Forceps: For larger bleeding vessels, exchange for monopolar hemostatic forceps (soft coagulation, 60W). Close on the vessel, wash (to ensure bleeding has stopped), and then cauterize. Avoid tenting the vessel excessively. ➡️ Mechanical Clip Closure: The gold standard for prevention remains mechanical closure with clips. Some large defects can be closed with anchor-pronged clips starting from the widest aspect of the defect to make one wide defect into two smaller ones. ➡️ Topical Hemostatic Gel: Topical hemostatic gels are a very efficient alternative for prevention of bleeding. 🔆Consider a combination with clip closure (gold standard).

❇️ a case of actively bleeding AVM, the clip was closed but not immediately deployed. Irrigation was used prior to deployment to confirm hemostasis. The clip was only deployed when confident the vessel was fully ligated. Similarly, in a case of immediate post-polypectomy bleeding, the clip was closed and only deployed once the bleeding stopped. This approach reduces the number of clips needed. In active bleeding, one well-placed clip is more effective than multiple indirect ones. ❇️ Take Home Point: Close TTS clips, but resist the urge to deploy prematurely—especially under the stress of active bleeding. Irrigate first, confirm hemostasis, and only then deploy the clip.

causes of bloating and how to improve

H.Pylori treatment in INDIA

❇️ Baveno VII consensus is the most recent international expert agreement on the diagnosis and management of portal hypertension and its complications in patients with advanced chronic liver disease.The Baveno Cooperation, a consortium of leading hepatology experts, updates these recommendations every five years, and they are endorsed by major scientific societies. Key advancements in Baveno VII include: 1. Non-invasive diagnosis of clinically significant portal hypertension (CSPH):Baveno VII introduced liver stiffness measurement (LSM) and platelet count-based criteria for CSPH in compensated advanced chronic liver disease (cACLD). CSPH is ruled out if LSM ≤15 kPa and platelet count ≥150 G/L, and ruled in if LSM ≥25 kPa. Patients not meeting these thresholds are classified as "grey zone" and require further risk stratification. 2. Spleen stiffness measurement (SSM): For patients not meeting Baveno VI criteria, Baveno VII recommends SSM ≤40 kPa as a safe threshold to rule out high-risk varices (HRVs) and avoid unnecessary endoscopic screening. SSM at both 50 Hz and 100 Hz has been validated for this purpose, with higher frequencies sparing more endoscopies without increasing missed HRV rates. 3. Recompensation of cirrhosis: Baveno VII formally defines "recompensation" as the removal of the primary etiological factor, resolution of decompensating events, and sustained improvement in hepatic function. This recognizes that patients with prior decompensation can achieve clinical improvement and favorable outcomes after etiological cure. 4. Risk stratification and management: The consensus emphasizes the use of non-invasive tests to stratify risk for hepatic decompensation and guide surveillance and prophylaxis. It also highlights the need for further research to refine personalized management strategies. Baveno VII criteria have been validated in various populations, including HBV-related cirrhosis and pediatric biliary atresia, demonstrating high sensitivity and negative predictive value for ruling out high-risk varices and predicting decompensation risk.However, limitations exist in certain subgroups, such as patients with hepatocellular carcinoma, where the criteria may not reliably rule in/out CSPH or large varices.

Bloating and abdominal distention #UEG