Guidelines for the management of acute pancreatitis (AP) are based on the Western experience, which may be difficult to extrapolate in India due to socioeconomic constraints. Hence, modifications based on the available resources and referral patterns should be introduced so as to ensure appropriate care. We reviewed the current literature on the management of AP available in English on Medline and proposed guidelines locally applicable. Patients of AP presenting with systemic inflammatory response syndrome are at risk of moderate-severe pancreatitis and hence, should be referred to a tertiary center early. The vast majority of patients with AP have mild disease and can be managed at smaller centers. Early aggressive fluid resuscitation with controlled fluid expansion, early enteral nutrition, and culture-directed antibiotics improve outcomes in AP. Infected pancreatic necrosis should be managed in a tertiary care hospital within a multidisciplinary setup. The “step up” approach involving antibiotics, percutaneous drainage, and minimally invasive necrosectomy instituted sequentially based on clinical response has improved the outcomes in this subgroup of patients.

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As the population ages, bioprosthetic heart valves are increasingly being used to replace diseased native valves. Bioprosthetic valve durability depends on patient age and other factors, but rarely exceeds 15 years. Explanted bioprosthetic valves commonly show tissue degeneration, tears, and calcification. Host tissue overgrowth (pannus), to the extent of interfering with their function, is another finding in bioprostheses that have been in place for long periods. We present a case in which a bovine pericardial valve was explanted after more than 20 years of implantation. The longevity of this pericardial valve may have been related to excessive pannus growth, which most likely protected the valve from earlier failure.

A 57-year-old female patient presented with complaints of abdominal pain and persistent vomiting for one month. The abdominal pain was predominantly in the epigastrium, non-radiating and associated with post prandial vomiting. The pain was relieved after the bout of vomiting. The patient had occasional febrile episodes and loss of appetite. The patient was a known case Chronic Calcific Pancreatitis and Diabetes Mellitus with both exocrine and endocrine deficiency. She was on pancreatic supplements and human insulin for the past 5 years. On examination, mild epigastric tenderness was present.Blood picture showed normochromic normocytic cells. Prothrombin Time (PT), Liver Function Tests (LFT), Thyroid Function Tests (TFT), serum calcium and Parathormone levels were normal. Serum amylase and lipase were within normal range. Cancer Antigen 19-9 (CA 19-19) was not elevated. Random Blood Sugar and Glycated Haemoglobin (HbA1c) were high. Urine showed glycosuria but urinary ketones were negative. Blood and Urine cultures were sterile.Chest X-Ray was normal. Ultrasound abdomen showed chronic calcific pancreatitis with dilated Main Pancreatic Duct (MPD) and tiny intraductal calculi. Common Bile Duct (CBD) was dilated with dilated Inta Hepatic Biliary Radicles. Upper GI endoscopy showed reflux esophagitis with bile reflux. CECT of abdomen showed calcifications in pancreatic head, body and tail with atrophic parenchyma, dilated MPD and multiple intraductal calculi [Table/ Fig-1]. A mass was suspected to be present inferiomedial to the head of the pancreas. Intestinal obstruction was confirmed as Barium meal and follow through showed narrowing in the second part of duodenum. Endoscopy showed pus oozing out from the second part of the duodenum [Table /Fig-2]. Biopsy from the periampullary region of the duodenum showed that there was chronic nonspecific duodenitis with no evidence of invasive malignancy. EUS guided FNAC was done and revealed that the head of pancreas had features of chronic pancreatitis with a few acid fast bacilli. This enabled to arrive at the diagnosis of Tuberculosis of the pancreas.She was started on ATT and Naso Jejeunal (NJ) feeds. She was given Streptomycin, Ethambutol, Isoniazid, Pyrizinamide and Rifampicin in compliance with standardized treatment regimes. She tolerated the treatment well. Repeat LFTs were done and were normal. Her condition progressively improved and she was started on oral feeds. Keywords: Anti tuberculosis therapy, Endoscopic ultrasound, Pancreas ABSTRACTPancreatic Tuberculosis is an uncommon form of extra pulmonary tuberculosis that resembles malignancy of pancreas and serve as a diagnostic challenge for physicians. Conservative management with Anti Tuberculosis Therapy (ATT) will suffice for pancreatic tuberculosis whereas a malignancy may require major surgeries which may lead to significant morbidity. Here, we discuss the case of a female patient who presented with abdominal pain and vomiting and is a known case of chronic calcific pancreatitis. Radiological findings were tha...