Does endoscopic sphincterotomy reduce the risk of post-endoscopic retrograde cholangiopancreatography pancreatitis after biliary stenting? A systematic review and meta-analysis.

BACKGROUND AND AIM: Endoscopic biliary sphincterotomy (ES) is often carried out prior to placement of a biliary stent apparently to reduce the risk of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). However, the protective effect of ES prior to biliary stenting is controversial. The objective of this meta-analysis is to compare the risk of PEP and other complications after the placement of biliary stent with or without ES in patients with biliary obstruction and bile leak. METHODS: We carried out a systematic search in several electronic databases for randomized controlled trials (RCT) and observational studies (OS) comparing the risk of PEP after biliary stenting with or without ES. The Mantel-Haenszel method was used to pool data of adverse outcomes into fixed or random effect model meta-analyses. RESULTS: Seventeen studies (five RCT and 12 OS) with a total of 2710 patients met the inclusion criteria. No significant difference was observed in the risk of PEP with biliary stenting with and without ES (RD -0.01; 95% confidence interval [CI] -0.03, 0.01). In a subgroup analysis of stenting for biliary obstruction, no difference in the risk of PEP was observed with or without ES. However, ES was associated with lower risk of PEP in patients undergoing biliary stenting for bile leak (RD -0.05; CI -0.10, -0.01). CONCLUSIONS: ES shows risk reduction in prevention of PEP in patients undergoing endoscopic stenting for bile leak. However, placement of biliary stent without ES is not associated with an increased risk of PEP in patients with distal bile duct obstruction with involvement of pancreatic duct.

Body mass index predicts cecal insertion time: the higher, the better.

BACKGROUND: It is essential to determine the factors that predict prolonged procedural time during colonoscopy. The aim of this study was to determine the effect of body mass index (BMI) on cecal insertion time (CIT) during colonsocopy. METHODS: Consecutive outpatients who received colonoscopies over a 10 month period (April-October 2007) were enrolled. Exclusion criteria included colonic resection, strictures or exophytic masses precluding colonic evaluation. Data were collected for age, sex, race, height, weight, BMI, waist circumference, prior history of abdominal or pelvic surgery, history of diverticulosis, participation of fellow, CIT, quality of colon cleansing and the amount of sedation used during the procedure. RESULTS: A total of 1430 patients (586 men and 844 women; mean age 60.3 years) were included in the final analysis. The mean CIT was 648.5 seconds (SE = 11.47). Older age, female gender, fellow involvement, poor bowel preparation and lower BMI were associated with prolonged mean CIT on linear regression analysis ((R2) = 0.116; P < 0.001). Mean CIT declined linearly with increasing BMI. CONCLUSION: A higher BMI is strongly associated with progressively shorter CIT.

Pneumoperitoneum after Endoscopic Retrograde Cholangiopancreatography due to Rupture of Intrahepatic Bile Ducts and Glisson's Capsule in Hepatic Metastasis: A Case Report and Review of Literature.

INTRODUCTION: Endoscopic retrograde cholangiopancreatography (ERCP) has been proven to be a safe and effective method for diagnosis and treatment of biliary and pancreatic disorders. Major complications of ERCP include pancreatitis, hemorrhage, cholangitis, and duodenal perforation. We report a third case in literature of pneumoperitoneum after ERCP due to rupture of intrahepatic bile ducts and Glisson's capsule in a peripheral hepatic lesion. CASE REPORT: A 50-year-old male with a history of metastatic pancreatic neuroendocrine tumor and who had a partially covered metallic stent placed in the biliary tree 1 year ago presented to the oncology clinic with fatigue, abdominal pain, and hypotension. He was planned for ERCP for possible cholangitis secondary to obstructed previously placed biliary stent. However, the duodenoscope could not be advanced to the level of the major papilla because of narrowed pylorus and severely strictured duodenal sweep. Forward-view gastroscope was then passed with careful manipulation to the severely narrowed second part of the duodenum where the previously placed metallic stent was visualized. Balloon sweeping of stenting was done. Cholangiography did not show any leak. Following the procedure, the patient underwent CT scan of the abdomen that showed pneumoperitoneum which was communicating with pneumobilia through a loculated air collection in necrotic hepatic metastasis perforating Glisson's capsule. The patient was managed conservatively. CONCLUSION: In our case, pneumoperitoneum resulted from rupture of intrahepatic bile ducts and Glisson's capsule in hepatic metastasis. This case emphasizes the need for close clinical and radiological observation of patients with hepatic masses (primary or metastatic) subjected to ERCP.

Metastatic renal cell carcinoma from a native kidney of a renal transplant patient diagnosed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy.

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy sampling of enlarged lymph nodes is increasingly used to diagnose metastatic tumors, especially of the gastrointestinal tract and the lungs. Herein, we describe the diagnosis of metastatic renal cell carcinoma from a native kidney of a 54 year-old male patient, who had a 5-years history of renal transplant, by EUS-FNA of mediastinal and celiac lymph nodes. Histological and immunohistochemical findings confirmed the origin of metastatic tumor. EUS-FNA with proper cytological evaluation can be useful in the diagnosis of metastatic renal cell carcinoma in renal transplant patients.

Acute Cholangitis following Biliary Obstruction after Duodenal OTSC Placement in a Case of Large Chronic Duodenocutaneous Fistula.

Over-the-Scope Clip system, also called "Bear Claw," is a novel endoscopic modality used for closure of gastrointestinal defect with high efficacy and safety. We present a patient with history of eosinophilic gastroenteritis and multiple abdominal surgeries including Billroth II gastrectomy complicated by a large chronic duodenocutaneous fistula from a Billroth II afferent limb to the abdominal wall. Bear Claw clip was used for closure of this fistula. The patient developed acute cholangitis one day after placement of the Bear Claw clip. Acute cholangitis due to papillary obstruction is a potential complication of Bear Claw placement at the dome of the duodenal stump (afferent limb) in patient with Billroth II surgery due to its close proximity to the major papilla.

Two Cases of Type Va Extrahepatic Bile Duct Duplication With Distal Klatskin Tumor Surgically Treated with Whipple Procedure and Hepaticojejunostomy.

We describe the diagnostic and therapeutic challenges of a type Va extrahepatic bile duct duplication coexistent with distally located hilar cholangiocarcinoma (Klatskin tumor). We present 2 cases that were diagnosed preoperatively and treated with a modified surgical technique of a combined pylorus-preserving Whipple procedure and hepaticojejunostomy.

Efficacy and safety of, and patient satisfaction with, colonoscopic-administered fecal microbiota transplantation in relapsing and refractory community- and hospital-acquired Clostridium difficile infection.

OBJECTIVE: To report the efficacy and safety of, and patient satisfaction with, colonoscopic fecal microbiota transplantation (FMT) for community- and hospital-acquired Clostridium difficile infection (CDI). METHODS: A retrospective medical records review of patients who underwent FMT between July 1, 2012 and August 31, 2013 was conducted. A total of 22 FMTs were performed on 20 patients via colonoscopy. The patients were divided into 'community-acquired' and 'hospital-acquired' CDI. Telephone surveys were conducted to determine procedure outcome and patient satisfaction. Primary cure rate was defined as resolution of diarrhea without recurrence within three months of FMT, whereas secondary cure rate described patients who experienced resolution of diarrhea and return of normal bowel function after a second course of FMT. RESULTS: Nine patients met the criteria for community-acquired CDI whereas 11 were categorized as hospital-acquired CDI. A female predominance in the community-acquired group (88.89% [eight of nine]) was found (P=0.048). The primary cure rate was 100% (nine of nine) and 81.8% (nine of 11 patients) in community- and hospital-acquired CDI groups, respectively (P=0.189). Two patients in the hospital-acquired group had to undergo a repeat FMT for persistent symptomatic infection; the secondary cure rate was 100%. During the six-month follow-up, all patients were extremely satisfied with the procedure and no complications or adverse events were reported. CONCLUSION: FMT was a highly successful and very acceptable treatment modality for treating both community- and hospital-acquired CDI.

Caroli's syndrome in a post renal transplant patient: case report and review of the literature.

Caroli's syndrome is characterized by bile duct ectasia in association with hepatic fibrosis. It is usually transmitted in an autosomal recessive fashion and has been well documented to be associated with autosomal recessive polycystic kidney disease and occasionally with autosomal dominant polycystic kidney disease. However, there has been only few case reports published with Caroli's syndrome diagnosed postrenal transplantation.

Aberrant right hepatic duct draining into the cystic duct: clinical outcomes and management.

Background. Aberrant right hepatic duct (ARHD) draining into cystic duct (CD) is relatively rare but clinically important because of its susceptibility to injuries during cholecystectomy. These injuries are often-times missed or diagnosed late and as a result can develop serious complications. Methods. Four consecutive patients diagnosed with ARHD draining into CD were identified for inclusion. Results. The mean age of patients was 42.5 years. The diagnosis in one of the patient was incidental during a routine endoscopic retrograde cholangiopancreatography (ERCP). Other three patients were diagnosed post-cholecystectomy- one presented with suspected intra-operative biliary injury, one with persistent bile leak and another with recurrent cholangitis. Inadequate filling of the segment of liver on ERCP with dilation of intrahepatic ducts in the corresponding segment on imaging was present in two patients with complete obstruction of ARHD which was managed surgically. In another patient, the partially obstructed ARHD was managed by endoscopic therapy. Conclusion. ARHD draining into the CD can have varied clinical manifestations. In appropriate clinical settings, it should be suspected in patients with persistence of bile leak early after cholecystectomy, segmental dilation of intrahepatic-bile ducts on imaging and paucity of intrahepatic filling in a segment of liver on ERCP.

Irritable bowel syndrome: update on pathogenesis and management.

Irritable bowel syndrome (IBS) comprises a major proportion of gastrointestinal and primary care practice worldwide. The past several years have seen the rapid evolution of a new and comprehensive model of IBS based on alterations in brain-gut interactions. Alterations in the bidirectional communication between the enteric nervous system and the central nervous system are implicated in the pathogenesis of IBS. 5-Hydroxytryptamine (5-HT; serotonin), a major neurotransmitter in the gastrointestinal tract, and its receptors 5-HT3 and 5-HT4 are involved in the control of gastrointestinal function. A number of abnormal motor and sensory patterns have been reported in patients with IBS. However, it is not known whether these abnormalities are related to symptoms or have a role in establishing a diagnosis of functional gastrointestinal disorders. Visceral hyperalgesia in IBS patients can be secondary to altered receptor sensitivity at the viscus itself and altered central modulation of sensation involving psychological influences in the interpretation of these sensations. The development of diagnostic criteria for IBS helps to avoid unnecessary and costly investigations. A detailed history allows us to diagnose IBS and search for another cause if warning symptoms are present. The Rome criteria are presently used to define IBS and are currently the most widely applied criteria used in clinical diagnosis and research purposes. Abdominal pain or discomfort associated with chronic altered bowel habits are the mainstay in diagnosis, while the supportive criteria may be used to further classify IBS patients into diarrhea-predominant or constipation-predominant subgroups. Minimal diagnostic tests have been advocated in the initial diagnostic approach to patients with suspected IBS, depending on the predominant symptom. The therapeutic goals in IBS must focus on the overall well-being of the patient, including abdominal symptoms and the accompanying nonbowel symptoms and affective disorders. It is important to establish an effective physician-patient relationship and to reassure the patient once the diagnosis of IBS is made. Dietary modification may be of value in some patients with IBS. Dietary fiber is frequently recommended for patients with constipation-predominant IBS. Two novel serotonin agonists are currently under development for constipated IBS patients, tegaserod and prucalopride. Antidiarrheal agents, including loperamide and diphenoxylate, may help patients with diarrhea-predominant IBS. 5-HT3 receptor antagonists may play a role in the management of such patients in the future. Psychological treatment and antidepressants should be considered when IBS symptoms are severe or refractory or associated with psychological distress and impaired quality of life.