Progression of Gastrointestinal Injury During Antiplatelet Therapy After Percutaneous Coronary Intervention: A Secondary Analysis of the OPT-PEACE Randomized Clinical Trial.

Importance: Gastrointestinal injury progression induced by antiplatelet therapy in patients after percutaneous coronary intervention (PCI) has not been well studied. Objective: To assess the association of aspirin, clopidogrel, and their combination with gastrointestinal injury progression among patients without high bleeding risk after PCI. Design, Setting, and Participants: This secondary analysis assessed data from the Optimal Antiplatelet Therapy for Prevention of Gastrointestinal Injury Evaluated by ANKON Magnetically Controlled Capsule Endoscopy (OPT-PEACE) double-masked, placebo-controlled, multicenter randomized clinical trial. The OPT-PEACE trial was conducted at 28 centers in China, and recruitment took place from July 13, 2017, to July 13, 2019. The trial included patients with stable coronary artery disease or acute coronary syndromes without ST-segment elevation after PCI. Statistical analysis was conducted from September 13, 2022, to January 23, 2023. Interventions: Patients underwent magnetically controlled capsule endoscopy (MCE) at baseline and after 6 months of dual antiplatelet therapy (DAPT) with aspirin (100 mg/d) plus clopidogrel (75 mg/d). Those with no evidence of gastrointestinal ulcers or bleeding (ie, the intention-to-treat [ITT] cohort) were randomized (1:1:1) to aspirin (100 mg/d) plus matching placebo (aspirin alone), clopidogrel (75 mg/d) plus matching placebo (clopidogrel alone), or DAPT for an additional 6 months. A third MCE was performed 12 months after PCI. Main Outcomes and Measures: The primary outcome was the rate of gastric injury progression as assessed with the results of the 3 MCEs (at baseline, 6 months, and 12 months) in the modified intention-to-treat (mITT) population. The key secondary outcome was the rate of small-intestinal injury progression. Gastric or small-intestinal injury progression was defined as a quantitative increase in erosions or ulcers between the second and third MCEs (at 6 and 12 months, respectively). Results: This study included the 394 patients in the mITT cohort. Their mean (SD) age was 56.9 (8.7) years, and most were men (296 [75.1%]). A total of 132 patients were randomized to aspirin alone, 132 to clopidogrel alone, and 130 to DAPT. Gastric injury progression occurred in 49 aspirin users (37.1%), 64 clopidogrel users (48.5%), and 69 DAPT users (53.1%) (P = .02), reflecting a lower rate of gastric injury progression among aspirin users vs DAPT users (risk ratio [RR], 0.70 [95% CI, 0.49-0.99]; P = .009). No significant difference was observed between clopidogrel alone and DAPT (48.5% vs 53.1%; P = .46) or between aspirin alone and clopidogrel alone (37.1% vs 48.5%; P = .06). A total of 51 aspirin users (38.6%), 65 clopidogrel users (49.2%), and 71 DAPT users (54.6%) (P = .03) developed progressive small-intestinal injury, reflecting a lower rate of small-intestinal injury among aspirin users vs DAPT users (RR, 0.71 [95% CI, 0.50-0.99]; P = .01). No difference was observed between patients treated with clopidogrel vs DAPT (49.2% vs 54.6%; P = .38) or with aspirin vs clopidogrel (38.6% vs 49.2%; P = .08). Conclusions and Relevance: In this secondary analysis of a randomized clinical trial, ongoing use of aspirin, clopidogrel, or their combination between 6 and 12 months after PCI was associated with progressive gastric and small-intestinal injury in a substantial proportion of patients, more so with DAPT than with monotherapy. Clopidogrel was at least as likely as aspirin to induce gastrointestinal injury progression. Future research is warranted to determine what impact the findings from MCEs would have on decision-making of antiplatelet therapy. Trial Registration: ClinicalTrials.gov Identifier: NCT03198741.

Snare-assisted precutting and dual-knife fistulotomy performed during difficult biliary cannulation in a patient with an ectopic papilla of Vater.

Endoscopic retrograde cholangiopancreatography is widely used in the diagnosis and treatment of pancreatobiliary diseases; however, successful biliary cannulation is a prerequisite for this operation. We herein present a new method in a patient in whom cannulation was difficult. A 56-year-old man was admitted to the hospital with choledocholithiasis. Endoscopic retrograde cholangiopancreatography was performed, and duodenoscopy revealed that the patient's duodenal papilla was located at the initial part of the horizontal segment of the duodenum. Because of the ectopic location of the duodenal papilla, the guidewire could not be inserted into the biliary and pancreatic duct. Therefore, we performed a new method to resolve the problem of difficult cannulation. A polypectomy snare was used to excise the mucosa covering the surface of the intramural segment of the common bile duct, and a dual knife was used to form a fistula. A guidewire was then inserted through the stoma into the bile duct. After the procedure, the bile duct was successfully cannulated and the stones were removed. No complications occurred. This new method may be an alternative treatment to precutting for difficult biliary cannulation in patients with a protruded papilla of Vater.

Primary Malignant Melanoma of the Esophagus With Unusual Endoscopic Findings: A Case Report and Literature Review.

Primary malignant melanoma of the esophagus (PMME) is a rare disease with an extremely poor prognosis. We experienced a 79-year-old man with PMME who had unusual endoscopic findings. On endoscopy, an elongated lump was detected on 1 side of the vertical axis of the esophagus. The mass extended progressively for 15 cm along the esophageal longitudinal axis and invaded half of the esophageal circumference. These endoscopic findings were not characteristic of PMME, and the condition was confirmed with biopsy and immunohistochemical staining. Here, we present this rare case and review the recent relevant literature regarding PMME. Doctors should be aware that PMME might present with unusual endoscopic findings.

Non alcoholic steatohepatitis a precursor for hepatocellular carcinoma development.

Hepatocellular carcinoma (HCC) is increasing in prevalence and is one of the most common cancers in the world. Chief amongst the risks of attaining HCC are hepatitis B and C infection, aflatoxin B1 ingestion, alcoholism and obesity. The later has been shown to promote non alcoholic fatty liver disease, which can lead to the inflammatory form non alcoholic steatohepatitis (NASH). NASH is a complex metabolic disorder that can impact greatly on hepatic function. The mechanisms by which NASH promotes HCC are only beginning to be characterized. Here in this review, we give an overview of the recent novel mechanisms published that have been associated with NASH and subsequent HCC progression. We will focus our discussion on inflammation and gut derived inflammation and how they contribute to NASH driven HCC.

Meta-analysis of Barrett's esophagus in China.

AIM: To investigate the epidemiology and characteristics of Barrett's esophagus (BE) in China and compare with cases in the west. METHODS: Studies were retrieved from the China National Knowledge Infrastructure and PubMed databases using the terms "Barrett" and "Barrett AND China", respectively, as well as published studies about BE in China from 2000 to 2011. The researchers reviewed the titles and abstracts of all search results to determine whether or not the literature was relevant to the current topic of this research. The references listed in the studies were also searched. Inclusion and exclusion criteria for the literature were appropriately established, and the data reported in the selected studies were analyzed. Finally, a meta-analysis was performed. RESULTS: The current research included 3873 cases of BE from 69 studies. The endoscopic detection rate of BE in China was 1%. The ratio of male to female cases was 1.781 to 1, and the average age of BE patients was 49.07 ± 5.09 years. Island-type and short-segment BE were the most common endoscopic manifestations, accounting for 4.48% and 80.3%, respectively, of all cases studied. Cardiac-type BE was observed in 40.0% of the cases, representing the most common histological characteristic of the condition. Cancer incidence was 1.418 per 1000 person-years. CONCLUSION: Average age of BE patients in China is lower than in Western countries. Endoscopic detection and cancer incidence were also lower in China.