Endoscopic ultrasound- versus ERCP-guided primary drainage of inoperable malignant distal biliary obstruction: systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: We assessed efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. endoscopic retrograde cholangiopancreatography (ERCP) as first-line intervention in malignant distal biliary obstruction (MDBO). METHODS: PubMed/Medline, Embase, and Cochrane databases were searched until 01 /12 /2023 for randomized controlled trials of EUS-BD vs. ERCP for primary biliary drainage in patients with inoperable MDBO. The primary outcome was technical success. Secondary outcomes were clinical success, adverse events, mean procedure time, 1-year stent patency, and overall survival. Relative risk (RR) with 95 %CI were calculated using a random effects model. RESULTS: Five studies (519 patients) were included. RR (95 %CI) for EUS-BD was 1.06 (0.96 to 1.17; P = 0.27) for pooled technical success and 1.02 (0.97 to 1.08; P = 0.45) for clinical success. 1-year stent patency was similar between the groups (RR 1.15, 0.94 to 1.42; P = 0.17), with lower reintervention with EUS-BD (RR 0.58, 0.37 to 0.9; P = 0.01). The RR was 0.85 (0.49 to 1.46; P = 0.55) for adverse events and 0.97 (0.10 to 0.17; P = 0.98) for severe adverse events. On subgroup analysis, EUS-guided placement of lumen-apposing metal stent (LAMS) outperformed ERCP in terms of technical success (RR 1.17, 1.01 to 1.35; P = 0.03). Procedure time was lower with EUS-BD (standardized mean difference -2.36 minutes [-2.68 to -2.05; P < 0.001]). CONCLUSIONS: EUS-BD showed a statistically significant lower reintervention rate than ERCP, but with similar technical success, stent patency, clinical success, and safety. Technical success of EUS-BD with LAMS was better than ERCP.

Predictors of spontaneous passage of ingested foreign bodies in adults: twelve years of experience.

BACKGROUND: Foreign body ingestion in adults is commonly encountered in clinical practice. The therapeutic approach of whether to follow-up or extract is often controversial. AIM: We aimed to explore predictors for spontaneous passage of ingested foreign bodies by focusing on foreign body type, length, and location of impaction. METHODS: We performed a 12-year retrospective single-center study. Logistic regression analysis was done to identify predictors of spontaneous passage. RESULTS: Overall, 365 patients with foreign body ingestion were included. The rate of spontaneous passage was 53.7% in general, while the spontaneous passage rate was 47.9% in food impaction, 44.3% in sharp objects, 88.7% in blunt objects and only 22.2% in long blunt objects (> 6 cm). On regression analysis, esophageal location was associated with a higher impaction rate and lower spontaneous passage vs. stomach and small and large intestine (OR 0.15, 95% CI 0.07-0.31, OR 0.18, 95% CI 0.09-0.37 and OR 0.02, 95% CI 0.003-0.14), respectively. Performing Receiver operating characteristics (ROC) analysis found that the maximal length above which the foreign body will fail to pass spontaneously was 3.5 cm in the stomach and 3 cm in the small intestine, with area under the curve (AUC) of 0.8509 in stomach and 0.8073 in small intestine. CONCLUSION: Endoscopic removal was needed for all esophageal foreign bodies, and all foreign bodies more than 3.5 cm above the duodenum. Spontaneous passage of ingested foreign body in a selected cohort of patients depends on foreign body type, location, and length.

The additive diagnostic value of cytology in fine needle biopsy of pancreatic adenocarcinoma: A tertiary center experience.

OBJECTIVE: Endoscopic ultrasound guide fine needle biopsy (EUS-FNB) is the main diagnostic tool for pancreatic adenocarcinoma. In most instances, only histology is obtained via FNB, without sending cytological slides. The aim of our study was to assess the additive diagnostic yield of cytology performed through FNB. METHODS: We conducted a retrospective study of all patients with histological diagnosis of pancreatic adenocarcinoma who were diagnosed by EUS-FNB. RESULTS: Overall, 80 patients were included in the study period. The overall concordance between cytology and histology all FNB needles was 78.2%. Notably, cytological assessment improved the diagnostic yield for malignancy by 12.8%. The overall kappa coefficient correlation between histology and cytology was .501, 95% CI 0.361-0.641. However, the kappa correlation for suspicious of malignancy and malignant was excellent of .872, 95% CI 0.733-1, suggesting that cytology is crucial when histology is inconclusive. Further analysis showed that the Acquire and Sharkcore needles outperformed the Procore needle in term of concordance between cytology and histology (kappa correlation of .527, 95% CI 0.331-0.724, .515, 95% CI 0.265-0.764, and .297, 95% CI -0.051-0.646), respectively. CONCLUSION: Performing cytology specimen when using FNB improves the diagnostic yield in pancreatic adenocarcinoma.

Yield of alarm features in predicting significant endoscopic findings among hospitalized patients with dyspepsia.

BACKGROUND: Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex. Some of these symptoms might arise from serious underlying diseases, so the promotion of evidence-based guidelines could potentially better align evaluation and treatment. AIM: To determine the value of alarm features as a predictive factor for significant endoscopic findings (SEFs) among hospitalized patients presenting with dyspepsia. METHODS: We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients. Patients were divided into two groups, with and without SEFs, and compared to elucidate the ability of the different alarm features to predict SEFs. RESULTS: During the study, 605 patients fulfilled the inclusion criteria. When the demographics and clinical characteristics of the two groups were compared, tachycardia (P < 0.05), normocytic anemia, (P < 0.05), leukocytosis (P < 0.05), and hypoalbuminemia (P < 0.05) documented on admission prior to endoscopy were strong predictors of SEFs. Among the alarm features, upper gastrointestinal bleeding, persistent vomiting, odynophagia [odds ratio (OR) = 3.81, P < 0.05; OR = 1.75, P = 0.03; and OR = 7.81, P = 0.07, respectively] were associated with SEFs. Unexplained weight loss was strongly associated with malignancy as an endoscopic finding (OR = 2.05; P < 0.05). In addition, long-term use of anti-aggregate medications other than aspirin (P < 0.05) was correlated to SEFs. CONCLUSION: Novel predictors of SEFs were elucidated in this study. These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia.

Obesity Is Associated with Distal Migration of Pancreatic Adenocarcinoma to Body and Tail: A Multi-Center Study.

(1) Background: Pancreatic adenocarcinoma (PAC) is one of the most lethal types of cancer. Most cases of PAC occur in the head of the pancreas. Given the proximity of the pancreatic head to the bile duct, most patients present clinically during early stages of the disease, while distally located PAC could have delayed clinical presentation. (2) Aims: To assess predictors of non-head PAC. (3) Methods: A retrospective multicenter study was conducted, including all patients who had endoscopic ultrasound (EUS) for pancreatic masses and who had histologic confirmation of PAC. (4) Results: Of the 151 patients included, 92 (60.9%) had pancreatic head cancer, and 59 (39.1%) had distal pancreatic cancer. PAC at body was the most common location in the distal PAC group (31 patients (52.5%)). Logistic regression analysis demonstrated a significant association of obesity with distal migration of PAC (OR 4.44, 95% CI 1.15-17.19, p = 0.03), while none of the other assessed parameters showed a significant association. Notably, abdominal pain was more significantly associated with distal PAC vs. head location (OR 2.85, 95% CI 1.32-6.16, p = 0.008). (5) Conclusions: Obesity shows a significant association as a clinical predictor of distal PAC. Further studies are needed to better explore this association.

Clinical Predictors of Gastrointestinal Bleeding Source before Computed Tomography Angiography.

BACKGROUND: Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen. METHODS: We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA. RESULTS: We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB. CONCLUSIONS: We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.

Neurosarcoidosis: The Presentation, Diagnosis and Treatment Review of Two Cases.

Sarcoidosis is a chronic granulomatous disease of unknown cause characterized by the presence of non-caseating granulomas. The disease can affect any organ including the nervous system. Neurosarcoidosis occurs in about 5% patients with sarcoidosis. The clinical presentation of neurosarcoidosis is varied, and it can involve the brain, spinal cord and peripheral nervous system, separately or in different combinations. The diagnosis of neurosarcoidosis is challenging, as biopsies from the nervous system are not readily available. Anti-TNFα agents are becoming one of the cornerstone treatments for neurosarcoidosis. In this case-based review, we discuss two cases of neurosarcoidosis with different clinical presentations. The first patient presented with confusion, while the second presented with walking difficulty and neurogenic bladder. Both patients were treated with methylprednisolone pulse therapy with rapid, but non-complete, improvement. Therefore, infliximab was initiated in both cases with subsequent improvement in the clinical manifestations and imaging findings, emphasizing the effectiveness and safety of infliximab in cases of severe neurosarcoidosis. In conclusion, the goal of neurosarcoidosis management is to prevent organ system damage and minimize the toxic cumulative adverse effects of glucocorticoid use. In this case-based review we discuss the various presentations, the diagnosis and the treatment of neurosarcoidosis.