Performance of European and American Societies of Gastrointestinal Endoscopy Guidelines for Prediction of Choledocholithiasis in Patients with Acute Biliary Pancreatitis.

Background and Objectives: Up to one-third of patients with acute biliary pancreatitis also present with choledocholithiasis. Guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and the American Society for Gastrointestinal Endoscopy (ASGE) for investigating suspected choledocholithiasis suggest endoscopic retrograde cholangiopancreatography in patients with high-likelihood (ESGE)/high-probability (ASGE) predictors and endoscopic ultrasound in those with intermediate-likelihood (ESGE)/intermediate-probability (ASGE) predictors. Although both guidelines are similar, they are not identical. Furthermore, these algorithms were mainly developed from cohorts of patients without pancreatitis and are therefore poorly validated in a subset of patients with acute pancreatitis. We aimed to assess the performance of the ESGE and ASGE algorithms for the prediction of choledocholithiasis in patients with acute biliary pancreatitis. Materials and Methods: This was a retrospective analysis of 86 consecutive patients admitted to a tertiary referral centre in the year 2020 due to acute biliary pancreatitis. Results: Choledocholithiasis was confirmed in 29/86 (33.7%) of patients (13 with endoscopic retrograde cholangiopancreatography and 16 with endoscopic ultrasound). All 10/10 (100%) ESGE high-likelihood and 14/19 (73.7%) ASGE high-probability patients had choledocholithiasis. Only 19/71 (26.8%) patients with ESGE intermediate likelihood and 15/67 (22.4%) with ASGE intermediate probability had choledocholithiasis. Only 8/13 (61.5%) patients with the ASGE high-probability predictor of dilated common bile duct plus bilirubin > 68.4 µmol/mL had choledocholithiasis. Since this predictor is not considered high likelihood by ESGE, this resulted in a superior specificity of the European compared to the American guideline (100% vs. 91.2%). Following the American instead of the European guidelines would have resulted in five unnecessary endoscopic retrograde cholangiopancreatographies and five unnecessary endoscopic ultrasound examinations. Conclusions: This retrospective analysis suggests that the European guidelines may perform better than the American guidelines at predicting choledocholithiasis in the setting of acute pancreatitis. This was because dilated common bile duct plus bilirubin > 68.4 µmol/mL was not a reliable predictor for persistent bile duct stones.

Pathogenesis and potential reversibility of intestinal metaplasia - a milestone in gastric carcinogenesis.

BACKGROUND: Non-cardia gastric cancer remains a major cause of cancer-related mortality worldwide, despite declining incidence rates in many industrialized countries. The development of intestinal-type gastric cancer occurs through a multistep process in which normal mucosa is sequentially transformed into hyperproliferative epithelium, followed by metaplastic processes leading to carcinogenesis. Chronic infection with Helicobacter pylori is the primary etiological agent that causes chronic inflammation of the gastric mucosa, induces atrophic gastritis, and can lead to intestinal metaplasia and dysplasia. Both intestinal metaplasia and dysplasia are precancerous lesions, in which gastric cancer is more likely to occur. Atrophic gastritis often improves after eradication of Helicobacter pylori; however, the occurrence of intestinal metaplasia has been traditionally regarded as "the point of no return" in the carcinogenesis sequence. Helicobacter pylori eradication heals non-atrophic chronic gastritis, may lead to regression of atrophic gastritis, and reduces the risk of gastric cancer in patients with these conditions. In this article, we discuss the pathogenesis, epigenomics, and reversibility of intestinal metaplasia and briefly touch upon potential treatment strategy. CONCLUSIONS: Gastric intestinal metaplasia no longer appears to be an irreversible precancerous lesion. However, there are still many controversies regarding the improvement of intestinal metaplasia after Helicobacter pylori eradication.

Endoscopic ultrasound-guided transrectal drainage of a pelvic abscess after Hinchey II sigmoid colon diverticulitis: A case report.

BACKGROUND: Acute diverticulitis is one of the most prevalent complications of diverticular disease and may result in abscess formation, perforation, fistula formation, obstruction, or bleeding. Diverticular abscesses may be initially treated with antibiotics and/or percutaneous drainage and/or surgery. Endoscopic ultrasound (EUS)-guided drainage techniques are increasingly used as a minimally invasive alternative to percutaneous or surgical approaches, as they are associated with better treatment outcomes, shorter recovery time and duration of hospitalization. CASE SUMMARY: A 57-year-old female presented to the emergency department on account of abdominal pain and fever. Clinical examination revealed tenderness in the left lower abdominal quadrant, with elevated inflammatory markers in laboratory tests. Abdominal computed tomography (CT) revealed an 8 cm × 8 cm × 5 cm well-encapsulated abscess of the sigmoid colon, surrounded by numerous diverticula. A diagnosis of Hinchey II diverticular abscess was made, and the patient was admitted and commenced on appropriate antibiotic treatment. A transrectal EUS showed a fluid collection in direct contact with the sigmoid colon. Transluminal drainage was performed, and a lumen-apposing metal stent was inserted into the abscess collection. A follow-up CT scan showed a regression of the collection. The patient's general condition improved, and the stent was removed during a follow-up transrectal EUS that revealed no visible collection. CONCLUSION: We report the first successful management of a pelvic abscess in patient with Hinchey II acute diverticulitis using EUS-guided transluminal drainage in Slovenia. The technique appears effective for well-encapsulated intra-abdominal abscesses larger than 4 cm in direct contact with the intestinal wall of left colon.

Intramural Hematoma Causing Hematochezia After Colonoscopy With Polypectomy.

Intramural hematoma of the colon is a rare complication of colonoscopy. We present a case of a 78-year-old woman on warfarin who presented with hematochezia and hypotension due to intramural hematoma of the sigmoid colon after colonoscopy with polypectomy of small polyps in the right colon.