Applicability of Child-Turcotte-Pugh Score in Anticipating Post-ERCP Adverse Events in Patients With Cirrhosis: A Systematic Review and Meta-analysis.

Limited objective data exist on the comparison of post-endoscopic retrograde cholangiopancreatography (ERCP) complications in patients with cirrhosis based on the severity of the disease. We evaluated the effectiveness of the Child-Turcotte-Pugh (CTP) score system in anticipating the risk of post-ERCP complications in patients with cirrhosis. The PubMed, Scopus, Embase, and Cochrane databases were searched from inception through September 2022 to identify studies comparing post-ERCP complications in patients with cirrhosis based on CTP score. Odds ratios (ORs) and their associated 95% CIs were pooled using a random-effect model to calculate effect size. The reference group for analysis was the CTP class C patient group. Seven studies comprising 821 patients who underwent 1068 ERCP procedures were included. The CTP class C patient population exhibited a higher risk of overall post-ERCP adverse events compared with those with class A or B (OR: 2.87, 95% CI: 1.77-4.65, P = 0.00 and OR: 2.02, 95% CI: 1.17-3.51, P = 0.01, respectively). Moreover, CTP class B patients had a significantly higher complication rate than CTP class A patients (OR: 1.62, 95% CI: 1.04-2.53, P = 0.03). However, no statistically significant differences were found in the occurrence of specific types of complications, including bleeding, pancreatitis, cholangitis, perforation, or mortality across the three CTP groups. We demonstrated that the CTP classification system is a reliable predictor of ERCP complications in patients with cirrhosis. Consequently, caution should be exercised when performing ERCP in patients classified as CTP class C.

Pre- and Post-Implant Endoscopy in Left Ventricular Assist Device Recipients: A Single-Center Experience.

Background: Gastrointestinal bleeding (GIB) is common in left ventricular assist devices (LVADs) patients, but the optimal screening approach before LVAD implantation is still unclear. The aim of the study was to describe our experience with pre- and post-LVAD implantation endoscopic screening and subsequent GI bleeding in this cohort. Methods: A retrospective review was conducted among all patients who underwent LVAD implantation at Saint Luke's Hospital, between 2010 and 2020. The data were reviewed to determine the yield and safety of endoscopic procedures performed within 1 month before LVAD placement and the incidence of GIB within 1 year after implantation. Results: A total of 167 LVAD patients met the inclusion criteria, and 23 underwent pre-implantation endoscopic evaluation. Angiodysplasia had a significantly higher odds ratio (OR) of 9.41 (95% confidence interval (CI): 2.01 - 44.09) in post-LVAD endoscopy, while there was no significant difference in bleeding from other sources such as peptic ulcer disease or diverticular bleeding. There was no difference in the incidence of GIB in patients who underwent endoscopic evaluation pre-LVAD compared to post-LVAD GIB (32.6% vs. 39.1%, P = 0.64). Endoscopy was well-tolerated in this cohort, and argon plasma coagulation was the most commonly used intervention to achieve hemostasis. Conclusions: According to our results, we recommend against routine pre-LVAD endoscopic screening. Instead, we suggest an individualized approach, where decisions are made on a case-by-case basis.

Endoscopic Ultrasound-Guided Fine-Needle Biopsy Versus Aspiration for Tissue Sampling Adequacy for Molecular Testing in Pancreatic Ductal Adenocarcinoma.

BACKGROUND AND AIMS: There is limited literature on sample adequacy for molecular testing in pancreatic ductal adenocarcinoma obtained via endoscopic ultrasound (EUS) fine-needle aspiration (FNA) versus EUS fine-needle biopsy (FNB). We aimed to compare these two modalities regarding sample adequacy for molecular and genomic sequencing. METHODS: We reviewed all patients with pancreatic ductal adenocarcinoma who underwent EUS at Saint Luke's Hospital from 2018 to 2021. The patients were categorized based on the method of EUS tissue acquisition, specifically FNA or FNB. A comprehensive evaluation was conducted for all cases by cytotechnologists. RESULTS: Out of 132 patients who underwent EUS-guided biopsies, 76 opted for FNA, 48 opted for FNB, and 8 opted for a combination of both. The average number of passes required for FNB and FNA was 2.58 ± 1.06 and 2.49 ± 1.07, respectively (p = 0.704), indicating no significant difference. Interestingly, 71.4% (35) of FNB-obtained samples were deemed adequate for molecular testing, surpassing the 32.1% (26) adequacy observed with FNA (p < 0.001). Additionally, 46.4% (26) of FNB-obtained samples were considered adequate for genomic testing, a notable improvement over the 23.8% (20) adequacy observed with FNA (p = 0.005). CONCLUSION: Although the number of passes required for cytologic diagnosis did not differ significantly between EUS-FNB and EUS-FNA, the former demonstrated superiority in obtaining samples adequate for molecular testing. Tumor surface area and cellularity were crucial parameters in determining sample adequacy for molecular testing, irrespective of the chosen tissue acquisition modality.

A comparison of career plans of gastroenterology fellows compared to fellows in other internal medicine subspecialties.

Background: The career trajectory of medical professionals, particularly in specialized fields like gastroenterology, can significantly impact healthcare and research. This study aimed to analyze career choices among gastroenterology fellows in the US and investigate the factors influencing these choices. Methods: We utilized data from the American Medical Association on internal medicine subspecialty fellows. The study examined career plans of gastroenterology fellows and compared them with those of other subspecialties. A chi-square test was performed to assess differences in career choices and practice settings. Results: Among gastroenterology fellows, 46% opted for private practice, 28% pursued further training, and 26% chose academia. Notably, gastroenterology fellows were more inclined toward private practice than their counterparts in other subspecialties (46.3% vs 38.4%) and were less likely to pursue academic careers (25.6% vs 30.7%). Conclusion: This study highlights a concerning trend among recent gastroenterology fellowship graduates favoring private practice over academic careers or additional training. To sustain and strengthen academic medicine in gastroenterology, interventions such as scholarships, mentorship programs, and loan repayment initiatives tailored to academic pursuits could play a crucial role.

Gastroenterology fellowship application and match trends in the United States over a 12-year period, 2010 to 2022.

Introduction: Gastroenterology has recently gained prominence as a competitive internal medicine subspecialty. The intense competition within the gastroenterology fellowship match (GFM) presents challenges for both applicants and programs, particularly in virtual interviews due to the COVID-19 pandemic. We analyzed the variables impacting GFM competitiveness to provide insights for prospective gastroenterologists and programs to enhance the match process. Methods: We used publicly available National Resident Matching Program (NRMP) data to examine applications and match data for internal medicine subspecialties from 2010 to 2022. We considered factors such as the number of positions, applicants, and programs, utilizing the specialty competitiveness ratio (SCR) to assess competitiveness. Annual growth rates for positions and applications and average annual growth rates were calculated. Correlation coefficients between annual salaries and SCR were computed using various compensation reports. Results: GFM's competitiveness has increased recently, evidenced by substantial growth in positions (4.61%) and applications (3.81%) since 2010. Gastroenterology ranked as the second-fastest growing specialty in positions and applications. In 2022, GFM ranked fourth in applications (974) and positions offered (616). Among internal medicine subspecialties, gastroenterology exhibited the highest SCR (1.58). Correlation analysis highlighted a positive link between SCR and compensation across specialties. Conclusion: The escalating competition within GFM necessitates an expansion of positions to address potential shortages. Complex factors, such as academic interest and financial considerations, require multifaceted strategies to ensure an adequate supply of gastroenterologists. Further research is warranted to examine the long-term consequences of this trend.

The National Burden of Colorectal Cancer in the United States from 1990 to 2019.

CRC accounts for approximately a tenth of all cancer cases and deaths in the US. Due to large differences in demographics among the different states, we aim to determine trends in the CRC epidemiology and across different states, age groups, and genders. CRC rates, age-adjusted to the standard US population, were obtained from the GBD 2019 database. Time trends were estimated as annual percentage change (APC). A pairwise comparison was conducted between age- and gender-specific trends using the tests of parallelism and coincidence. Age-specific trends were also assessed in two age subgroups: younger adults aged 15-49 years and older adults aged 50-74 years. We also analyzed the prevalence, incidence, mortality, and DALYs in the US between 1990 and 2019. A total of 5.53 million patients were diagnosed with CRC in the US between 1990 and 2019. Overall, CRC incidence rates have significantly increased in younger adults (11.1 per 100,000 persons) and decreased in older adults (136.8 per 100,000 persons) (AAPC = 1.2 vs. -0.6; AAPC difference = 1.8, p < 0.001). Age-specific trends were neither identical (p < 0.001) nor parallel (p < 0.001), suggesting that CRC incidence rates are different and increasing at a greater rate in younger adults compared to older adults. However, for both men and women (49.4 and 35.2 per 100,000 persons), incidence rates have decreased over the past three decades at the same rate (AAPC = -0.5 vs. -0.5; AAPC difference = 0, p = 0.1). Geographically, the southern states had the highest mortality rates with Mississippi having the highest rate of 20.1 cases per 100,000 population in 2019. Massachusetts, New York, and the District of Colombia had the greatest decreases in mortality over the study period (-42.1%, -41.4%, and -40.9%). Decreased mortality was found in all states except Mississippi, where the mortality of CRC increased over the study period (+1.5%). This research provides crucial insights for policymakers to tailor resource allocation, emphasizing the dynamic nature of CRC burden across states and age groups, ultimately informing targeted strategies for prevention and intervention.

Pylephlebitis Complicated by Hepatic Abscesses due to Fusobacterium Nucleatum: A Case of Lemierre's Syndrome Variant and Literature Review.

In gastrointestinal-variant Lemierre syndrome, Fusobacterium nucleatum can cause pylephlebitis and liver abscesses. We report a 62-year-old woman presenting with abdominal pain and altered mental status. Abdominal computed tomography showed hepatic lesions and thrombosis in the superior mesenteric and portal veins. Magnetic resonance cholangiopancreatography showed multiple cystic hepatic masses suspicious for abscess vs metastases. Malignancy workup was unrevealing. F. nucleatum grew on both blood and ultrasound-guided liver aspirate cultures. Twelve weeks of antibiotics and anticoagulants resolved her condition. Given the high mortality rates, prompt detection and treatment of gastrointestinal-variant Lemierre syndrome is critical to delivering quality, patient-centered care.

Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis.

Background: The role of variceal embolization (VE) during transjugular intrahepatic portosystemic shunt (TIPS) creation for preventing gastroesophageal variceal rebleeding remains controversial. Therefore, we performed a meta-analysis to compare the incidence of variceal rebleeding, shunt dysfunction, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS in combination with VE. Methods: We performed a literature search using PubMed, EMBASE, Scopus, and Cochrane databases for all studies comparing the incidence of complications between TIPS alone and TIPS with VE. The primary outcome was variceal rebleeding. Secondary outcomes include shunt dysfunction, encephalopathy, and death. Subgroup analysis was performed based on the type of stent (covered vs. bare metal). The random-effects model was used to calculate the relative risk (RR) with the corresponding 95% confidence intervals (CIs) of outcome. A P value < 0.05 was considered statistically significant. Results: Eleven studies with a total of 1,075 patients were included (597: TIPS alone and 478: TIPS plus VE). Compared to the TIPS alone, the TIPS with VE had a significantly lower incidence of variceal rebleeding (RR: 0.59, 95% CI: 0.43 - 0.81, P = 0.001). Subgroup analysis revealed similar results in covered stents (RR: 0.56, 95% CI: 0.36 - 0.86, P = 0.008) but there was no significant difference between the two groups in the subgroup analysis of bare stents and combined stents. There was no significant difference in the risk of encephalopathy (RR: 0.84, 95% CI: 0.66 - 1.06, P = 0.13), shunt dysfunction (RR: 0.88, 95% CI: 0.64 - 1.19, P = 0.40), and death (RR: 0.87, 95% CI: 0.65 - 1.17, P = 0.34). There were similarly no differences in these secondary outcomes between groups when stratified according to type of stent. Conclusions: Adding VE to TIPS reduced the incidence of variceal rebleeding in patients with cirrhosis. However, the benefit was observed with covered stents only. Further large-scale randomized controlled trials are warranted to validate our findings.

Selective Androgen Receptor Modulators (SARMs)-Induced Liver Injury: A Case Report and Review of Literature.

Drug-induced liver injury (DILI) is one of the leading causes of death from acute liver failure (ALF) in the United States, accounting for approximately 13% of ALF cases in the United States. Selective androgen receptor modulators (SARMs) were first developed to increase muscle mass while avoiding the side effects of conventional androgenic steroids. Although not Food and Drug Administration (FDA) approved, they are widely available online and are consumed to enhance athletic performance. We report a 22-year-old, previously healthy male, who presented with a two-week history of worsening jaundice, nausea, fatigue, pruritus, dark urine, and light stools. He reported taking the SARM, RAD-140, for 16 weeks. Examination showed scleral icterus. The liver panel showed alkaline phosphatase (ALP) 5.3 µkat/L, alanine transaminase (ALT) 1.66 µkat/L, aspartate transaminase (AST) 1.18 µkat/L, direct bilirubin 294 µmol/L, total bilirubin 427.5 µmol/L, and international normalized ratio (INR) 0.9. Viral hepatitis and autoimmune panel were unremarkable. Alpha-1 antitrypsin and ceruloplasmin levels were within normal limits. Bile sludge was seen on ultrasound. Magnetic resonance cholangiopancreatography (MRCP) abdomen showed segmental narrowing of the intrahepatic ducts. Endoscopic retrograde cholangiopancreatography (ERCP) was unremarkable. Liver biopsy showed mixed portal hepatitis, cholestasis, and biliary reactive changes with ceroid-loaded macrophages; a picture consistent with DILI. The patient was treated supportively and discharged with scheduled hepatology follow-up. At the one-month follow-up, his total bilirubin had fallen from a peak of 530 mol/L to 188 mol/L. The diagnosis of DILI can be made based on the timing of exposure and the exclusion of other etiologies. Liver enzymes normalized three to 12 months after product discontinuation. We hope this report will remind primary care physicians of the potential hepatotoxic side effects of muscle-building compounds and encourage them to report suspected DILI to the FDA using the MedWatch system.

It Is Not Always Diverticular Bleeding: Fatal Subtle Primary Aorto-Duodenal Fistula Associated With Abdominal Aortic Aneurysm.

Primary aorto-duodenal fistula (PADF) is a connection between the aorta and duodenum without prior aortic surgery. We present a case of an 80-year-old female who presented with hematochezia. She was vitally stable but later developed a large episode of hematemesis followed by cardiac arrest. A computed tomography angiogram (CTA) chest scan showed an abdominal aortic aneurysm (AAA) with no leakage or rupture. Esophagogastroduodenoscopy (EGD) demonstrated blood in the stomach and duodenum, but no source was identified. Tagged RBC scan showed massive hemorrhage in the stomach and proximal small bowel. Further review of the CT images identified a subtle PADF. The patient underwent endovascular aneurysm repair but died shortly after. Physicians should maintain a high awareness of PADF, particularly in elderly patients with obscure gastrointestinal bleeding with or without known AAA. Herald bleeding in the setting of an aortic aneurysm should raise suspicion for PADF even in the absence of extravasation on CTA.

Safety of gastrointestinal endoscopy in patients with acute coronary syndrome and concomitant gastrointestinal bleeding.

BACKGROUND: Gastrointestinal bleeding (GIB) is a major concern in patients hospitalized with acute coronary syndrome (ACS) due to the common use of both antiplatelet medications and anticoagulants. Studies evaluating the safety of gastrointestinal endoscopy (GIE) in ACS patients with GIB are limited by their relatively small size, and the focus has generally been on upper GIB and esophago-gastroduod-enoscopy (EGD) only. AIM: To evaluate the safety profile and the hospitalization outcomes of undergoing GIE in patients with ACS and concomitant GIB using the national database for hospitalized patients in the United States. METHODS: The Nationwide Inpatient Sample database was queried to identify patients hospitalized with ACS and GIB during the same admission between 2005 and 2014. The International Classification of Diseases Code, 9th Revision Clinical Modification was utilized for patient identification. Patients were further classified into two groups based on undergoing endoscopic procedures (EGD, small intestinal endoscopy, colonoscopy, or flexible sigmoidoscopy). Both groups were compared regarding demographic information, outcomes, and comorbi-dities. Multivariate analysis was conducted to identify factors associated with mortality and prolonged length of stay. Chi-square test was used to compare categorical variables, while Student's t-test was used to compare continuous variables. All analyses were performed using SAS 9.4 (Cary, NC, United States). RESULTS: A total of 35612318 patients with ACS were identified between January 2005 and December 2014. 269483 (0.75%) of the patients diagnosed with ACS developed concomitant GIB during the same admission. At least one endoscopic procedure was performed in 68% of the patients admitted with both ACS and GIB. Patients who underwent GIE during the index hospitalization with ACS and GIB had lower mortality (3.8%) compared to the group not undergoing endoscopy (8.6 %, P < 0.001). A shorter length of stay (LOS) was observed in patients who underwent GIE (mean 6.59 ± 7.81 d) compared to the group not undergoing endoscopy (mean 7.84 ± 9.73 d, P < 0.001). Multivariate analysis showed that performing GIE was associated with lower mortality (odds ratio: 0.58, P < 0.001) and shorter LOS (-0.36 factor, P < 0.001). CONCLUSION: Performing GIE during the index hospitalization of patients with ACS and GIB was correlated with a better mortality rate and a shorter LOS. Approximately two-thirds of patients with both ACS and GIB undergo GIE during the same hospitalization.

Achalasia after bariatric Roux-en-Y gastric bypass surgery reversal.

Achalasia is a rare esophageal motility disorder that is characterized by a loss of peristalsis in the distal esophagus and failure of lower esophageal sphincter relaxation. The risk of developing esophageal motility disorders, including achalasia, following bariatric surgery is controversial and differs based on the type of surgery. Most of the reported cases occurred with laparoscopic adjustable gastric banding. To our knowledge, there are only three reported cases of achalasia after Roux-en-Y gastric bypass and no reported cases after revision of the surgery. We present a case of a 70-year-old female who had a previous history of Roux-en-Y gastric bypass with revision. She presented with persistent nausea and regurgitation for one month. Esophagogastroduodenoscopy showed a dilated esophagus without strictures or stenosis. A barium study was performed after the endoscopy and was suggestive of achalasia. Those findings were confirmed by a manometry. The patient was referred for laparoscopic Heller's myotomy.

Randomized sham-controlled trial evaluating efficacy and safety of endoscopic gastric plication for primary obesity: The ESSENTIAL trial.

OBJECTIVE: Evaluate safety and efficacy of the pose™ procedure for obesity treatment. METHODS: Subjects with Class I to II obesity were randomized (2:1) to receive active or sham procedure, after each investigator performed unblinded lead-in cases. All subjects were provided low-intensity lifestyle therapy. Efficacy end points were the mean difference in percent total body weight loss (%TBWL) at 12 months between randomized groups, and responder rate achieving ≥5% TBWL. The primary safety end point was incidence of reported adverse events. RESULTS: Three hundred thirty-two subjects were randomized (active, n = 221; sham, n = 111); thirty-four subjects were included in the unblinded lead-in cohort. Twelve-month results were mean TBWL 7.0 ± 7.4% in lead-in, 4.95 ± 7.04% in active, and 1.38 ± 5.58% in sham groups, respectively. Responder rate was 41.55% in active and 22.11% in sham groups, respectively (P < 0.0001); mean responder result was 11.5% TBWL. The differences observed between active and sham groups for co-primary end points were statistically significant (P < 0.0001); however, super superiority margin as set forth in the study design was not met. No unanticipated adverse events or deaths occurred. Procedure-related serious adverse event rates were 5.0% (active) and 0.9% (sham), P = 0.068. CONCLUSIONS: The pose procedure was safe and resulted in statistically significant and clinically meaningful weight loss over sham through 1 year.

Massive upper gastrointestinal hemorrhage due to invasive hepatocellular carcinoma and hepato-gastric fistula.

A 36-year-old male Asian immigrant with a history of hepatitis B and hepatitis C related unresectable hepatocellular carcinoma in the left lobe of the liver presented with hematemesis and severe anemia. He was diagnosed with a liver mass that was resected 8 years ago described as a benign tumor in his home country. He had received trans-arterial chemoembolization (TACE) four months ago after subsequent diagnosis of unresectable hepatoma, and currently was receiving chemotherapy with Sorafenib. After resuscitation, a contrast enhanced computerized tomography was performed which showed fistulization of hepatocellular carcinoma into adjacent stomach. This finding was confirmed during endoscopy with direct visualization of the fistulous opening. Hepatocellular carcinoma (HCC) invading the gastrointestinal (GI) tract is rare. We present a case and literature review of HCC with local invasion of the stomach causing massive upper GI bleeding after receiving TACE.

Risk of bleeding after percutaneous endoscopic gastrostomy (PEG).

BACKGROUND: Patients who undergo percutaneous endoscopic gastrostomy (PEG) placement are often on anticoagulation and/or antiplatelet therapy with a potential thromboembolic risk if these medications are discontinued. Data on the safety of peri-procedural use of these drugs is limited. AIMS: To assess the risk and to identify any predictive factors for post-PEG bleeding, and to determine if clopidogrel increases the risk of bleeding following PEG. METHODS: A retrospective chart audit was conducted from January 1, 2002 to June 30, 2011. RESULTS: A total of 1,541 patients underwent PEG placement during this period. Gastrointestinal bleeding after PEG placement occurred in 51 cases (3.3%) and bleeding directly attributed to PEG was noted in six patients (0.4%). Multivariate logistic regression analysis of variables (age, gender, length of hospitalization, indication for PEG, antiplatelet or anticoagulant medications) showed that heparin infusion (P = 0.018) and length of hospitalization (P = 0.029) were statistically significant predictors of bleeding. The mean period for cessation and resumption of clopidogrel with PEG placement were 2.2 and 1.3 days, respectively. CONCLUSION: Although PEG is classified as a high-risk endoscopic procedure, bleeding with PEG placement was rare, even with use of anticoagulation and antiplatelet medications. In selected patients on heparin infusion undergoing PEG, delaying the procedure, alternative use of low-molecular-weight heparin or close monitoring and frequent assessments should be considered. Clopidogrel did not contribute to an increase in bleeding risk, despite being held for a much shorter peri-procedural period as recommended by expert consensus.

Jejunoileal bypass: a surgery of the past and a review of its complications.

Jejunoileal bypass (JIB), popular in the 1960s and 1970s, had remarkable success in achieving weight loss by creating a surgical short bowel syndrome. Our patient had an unusual case of liver disease and provided no history of prior bariatric surgery. Later, it was recognized that he had a JIB in the 1970s, which was also responsible for the gamut of his illnesses. Patients with JIB are often not recognized, as they died of complications, or underwent reversal of their surgery or a liver-kidney transplant. Early identification with prompt reversal, and the recognition and treatment of the life-threatening consequences play a critical role in the management of such patients.

Clinicopathological predictors to predict sustained viral response rates in patients with chronic hepatitis C infection.

BACKGROUND: Treatment of patients with chronic hepatitis C virus (HCV) infection remains suboptimal, with the current pegylated interferon (PEG-IFN) and ribavirin combination therapy providing sustained viral response (SVR) rates of 54 - 63%. The aim of this study was to identify clinical, laboratory and histological findings that can predict non-response to this treatment. METHODS: Medical records of patients who had completed PEG-IFN and ribavirin therapy for chronic HCV infection between December 2002 and November 2005 and had undergone a liver biopsy prior to starting treatment were retrospectively reviewed. Data on various clinical and biochemical parameters were extracted and liver biopsy slides were reviewed by a pathologist who was blinded to the clinical and laboratory findings. RESULTS: Of 67 patients studied (mean [SD] age 46.3 [6.3] years; 36 men), 42/57 (74%) had an early viral response (EVR) and 37/64 (58%) had an SVR. On univariate analysis, absence of EVR (p=0.0002), non-white race (p=0.008), AST/ALT ratio > or = 1.0 (p=0.008), INR > or = 1.0 (p=0.02) and presence of steatosis > or = 5% on liver biopsy (p=0.03) were associated with lack of SVR. In multivariate analysis, all of these except INR were significant independent predictors of SVR. CONCLUSIONS: Absence of EVR, non-white race, AST/ALT ratio > or = 1.0 and presence of steatosis > or = 5% on liver biopsy are independent predictors of absence of SVR in patients with chronic HCV infection receiving PEG-IFN and ribavirin combination treatment.