The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions.

Background: The finding of pancreatic cystic lesions (PCL) on incidental imaging is becoming increasingly common. International studies report a prevalence of 2.2-44.7% depending on the population, imaging modality and indication for imaging, and the prevalence increases with age. Patients with PCL are at risk of developing pancreatic cancer, a disease with a poor prognosis. This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency (PEI) from a group of local specialists. Methods: Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022. The expert panel included gastroenterologists, hepatobiliary surgeons, oncologists, radiologists, and endocrinologists. Results: Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions. They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient. Where indicated, patients should undergo pancreatectomy to excise PCL. Following pancreatectomy, patients are at risk of PEI, leading to gastrointestinal dysfunction and malnutrition. Therefore, such patients should be monitored for symptoms of PEI, and promptly treated with pancreatic enzyme replacement therapy (PERT). Patients with poor response to PERT may require increases in dose, addition of a proton pump inhibitor, and/or further investigation, including tests for pancreatic function. Patients are also at risk of new-onset diabetes mellitus after pancreatectomy; they should be screened and treated with insulin if indicated. Conclusions: These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.

Idiopathic mesenteric phlebosclerosis: A rare cause of chronic diarrhea.

We report a 45-year-old healthy Chinese woman who presented with chronic diarrhea and iron deficiency anemia, with colonoscopy showing multiple ulcers from cecum to sigmoid on a background of dark-purple mucosa. She was initially suspected to be suffering from inflammatory bowel disease, but the peculiar colonic biopsy findings and computed tomography (CT) imaging features, together with her habit of using Chinese herbal supplements, supported the rare diagnosis of idiopathic mesenteric phlebosclerosis.

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

BACKGROUND AND OBJECTIVES: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field. METHODS: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. RESULTS: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year. CONCLUSION: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Novel use of cap-assisted enteroscopy for detection of colorectal tumor in a patient with incarcerated inguinal hernia.

Multiple reports have documented unsuspected inguinal hernias which result in difficulties during the colonoscopic examinations of patients. In most cases, the colonoscopy can be delayed until a surgical consult has further evaluated the inguinal hernia. This case report documents a patient who required a colonoscopy but surgical intervention for the detected inguinal hernia was not appropriate due to his co-morbid medical conditions. With the use of the combination of an enteroscope fitted with a cap and fluoroscopy, the inguinal hernia was able to be negotiated and the diagnosis of a cecal carcinoma was able to be confirmed.

Incarceration of a colonoscope in an inguinal hernia: Case report and literature review.

Incarceration of an endoscope in an inguinal hernia may occur during the course of routine colonoscopy. The incarceration may occur on insertion or withdrawal and frequently the hernia is not suspected prior to the colonoscopy. Most commonly, a left sided inguinal hernia is involved, however right inguinal hernias may be implicated in subjects with altered anatomy post abdominal surgery. Incarceration of an endoscope in an inguinal hernia has been seldom reported in the literature which is likely to be related to under reporting. A range of techniques have been suggested by various authors over the last four decades to manage this unusual complication of colonoscopy. These techniques include utilizing fluoroscopy, manual external pressure and/or the fitting of a cap onto the tip of the colonoscope to facilitate colonoscopic navigation. The authors present a case report of incarceration of the colonoscope on withdrawal in an unsuspected left inguinal hernia with a review of the literature on the management of this colonoscopic complication. A management strategy is suggested.

The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation: a meta-analysis of randomized controlled trials.

OBJECTIVES: The role of cap-assisted colonoscopy (CAC) in polyp detection and cecal intubation is unclear. We conducted a meta-analysis to compare the efficacy of CAC vs. standard colonoscopy (SC). METHODS: Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts in major international conferences were searched for controlled trials comparing CAC and SC. Outcome measures included the proportion of patients with polyps or adenomas detected, cecal intubation rate, cecal intubation time, and total colonoscopy time. The statistical heterogeneity of trials was examined and the effects were pooled by random-effects model. The risk of bias was evaluated by the assessment tool from the Cochrane Handbook. Subgroup analyses were performed for possible clinical and methodological heterogeneities. RESULTS: From 2,358 citations, 16 randomized controlled clinical trials were included consisting of 8,991 subjects (CAC: 4,501; SC: 4,490). Mean age of subjects was 61.0 years old and 60% were males. CAC detected a higher proportion of patients with polyp(s) (relative risk (RR): 1.08; 95% confidence interval (CI): 1.00-1.17) and reduced the cecal intubation time (mean difference: -0.64 min; 95% CI: -1.19 to -0.10). Cecal intubation rate (RR: 1.00; 95% CI: 0.99-1.02) and total colonoscopy time (mean difference: -0.97 min; 95% CI: -2.33 to 0.40) were comparable between the two groups. In subgroup analyses, a short cap (≤4 mm) was associated with improved polyp detection, whereas a long cap (≥7 mm) was associated with a shorter cecal intubation time. CONCLUSIONS: CAC demonstrated marginal benefit over SC for polyp detection and shortened the cecal intubation time.

Efficacy of cap-assisted colonoscopy in comparison with regular colonoscopy: a randomized controlled trial.

OBJECTIVES: Colonoscopy cannot be completed in up to 10% of cases. We postulate that cap-assisted colonoscopy (CAC), by fitting a mucosectomy cap to the tip of a colonoscope, could improve the outcome. METHODS: We conducted a prospective randomized controlled trial in two regional endoscopy centers. All colonoscopies were performed by experienced colonoscopists. Patients 18 years or older undergoing their first colonoscopy were recruited. Patients were randomized to the CAC group or to the regular colonoscopy (RC) group. The first successful cecal intubation rate, rescue cecal intubation rate, cecal intubation and total colonoscopy times, and polyp detection rate were compared. RESULTS: One thousand patients were enrolled (mean age 52.6 years, 46% men). There was no statistically significant difference in the first successful cecal intubation rate between CAC and RC groups (96.2% vs. 94.6%, P=0.23). The cecal intubation and total colonoscopy times were shorter in the CAC group than in the RC group (6.0+/-4.0 min vs. 7.2+/-4.8 min, P<0.001; 14.7+/-8.6 min vs. 16.7+/-10.3 min, P=0.001). The adenoma detection rate was significantly lower in the CAC group than in the RC group (30.5% vs. 37.5%, P=0.018), but there was no significant difference in the detection of advanced lesions. In case of failing cecal intubation, use of CAC as a rescue method could achieve a higher success rate than RC (66.7% vs. 21.1%, P=0.003). CONCLUSIONS: Among experienced colonoscopists, CAC did not improve the initial cecal intubation rate and had a lower adenoma detection rate. However, it shortened the cecal intubation time and performed better as a rescue method. Its utilization should be reserved for selected cases, especially when initial cecal intubation fails.

Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial.

BACKGROUND: A double-blind placebo-controlled randomized trial was conducted to investigate the safety and the efficacy of orally administered midazolam as premedication for patients undergoing elective EGD. METHODS: A total of 130 patients were randomized to receive either 7.5 mg of midazolam orally (n = 65) or a placebo (n = 65) as premedication. Outcomes measures included the anxiety score (visual analog scale) during EGD, overall tolerance, extent of amnesia, overall satisfaction, patient willingness to repeat the procedure, recovery time, and hemodynamic changes after medication. RESULTS: The median (interquartile range) anxiety score during the procedure in the midazolam group was significantly lower than that in the control group (2.0 [0-4.9] vs. 3.8 [2.1-7.95], p < 0.001). A significantly greater number of patients in the midazolam group graded overall tolerance as "excellent or good" (70.8% vs. 49.2%, p = 0.012) and reported a partial to complete amnesia response (52.3% vs. 32.3%, p = 0.02) when compared with the control group. Patients in the midazolam group were more willing to repeat the procedure if necessary (89.2% vs. 69.2%, p = 0.005). The median (interquartile range) recovery time was significantly longer in the midazolam group than in the control group (5 [5-15] minutes vs. 5 [5-10] minutes, p = 0.014). There were no statistically significant differences in satisfaction score and hemodynamic changes between groups. CONCLUSIONS: Premedication by oral administration of midazolam is a safe and an effective method of sedation that significantly reduces anxiety and improves overall tolerance for patients undergoing EGD.

EUS in the management of uninvestigated dyspepsia.

BACKGROUND: Management of dyspepsia often involves multiple diagnostic tests. By virtue of luminal and extraluminal imaging, EUS may be a satisfactory single test for the evaluation of patients with dyspepsia. METHODS: Patients with uninvestigated dyspepsia of more than 4 weeks duration were recruited. All underwent transabdominal US followed by EUS and EGD to look for both luminal and extraluminal lesions that could account for the dyspeptic symptoms. Each of these studies was performed by an independent operator blinded to the results of the other examinations. Patients were followed for 1 year to monitor clinical outcome. RESULTS: Two hundred patients were recruited. Compared with EGD, EUS had accuracies of 92% to 100% for the diagnosis of different luminal lesions. All gastric ulcers and cancers were detected by EUS, but 3 duodenal ulcers were missed. EUS also identified 48 pancreaticobiliary lesions, 23 of which were detected by US, that could account for the dyspeptic symptoms. Other extraintestinal lesions including mediastinal malignant lymphadenopathy and a dissecting aortic aneurysm were also diagnosed by EUS. Through the identification of extraluminal lesions, staging of tumors, and exclusion of pancreaticobiliary diseases, EUS altered clinical management in 50 patients (25%). CONCLUSION: EUS is a useful one-step investigation in patients with dyspepsia.

Empirical treatment based on "typical" reflux symptoms is inappropriate in a population with a high prevalence of Helicobacter pylori infection.

BACKGROUND: Empirical therapy or early endoscopy have been recommended as acceptable management options for GERD. The objective of this study was to determine whether diagnosis and empirical treatment based on reflux symptoms alone are appropriate as initial management for patients with gastroesophageal reflux. METHOD: Consecutive patients presenting with weekly reflux symptoms were evaluated with a structured questionnaire followed by endoscopy. Patients with dyspepsia as the predominant symptom, "alarm" symptoms (weight loss, dysphagia, or bleeding), history of peptic ulcer or gastric surgery, or recent nonsteroidal anti-inflammatory drugs intake were excluded. RESULTS: Four hundred sixty patients were studied: 82 (18%) were found to have peptic ulcer disease and 78 (95%) were infected with Helicobacter pylori. Concomitant erosive esophagitis was found in 26 (32%) of these patients with peptic ulcer disease. In the remaining 378 patients, 218 (58%) had erosive esophagitis and 1 had esophageal cancer. Among the 159 patients with no endoscopic lesion, 148 (93%) had relief of symptoms when treated with a proton pump inhibitor. Multivariate analysis showed that male gender (OR: 1.8, p = 0.03), age greater than 60 years (OR: 2.2, p = 0.01) and H pylori infection (OR: 3.6, p = 0.008) were significantly associated with a diagnosis of peptic ulcer disease. Coexisting dyspeptic symptom was not a predictor (p = 0.13) for peptic ulcer disease. CONCLUSIONS: In populations with a high prevalence of H pylori infection, a significant proportion of patients with GERD have concomitant peptic ulcer disease. Empirical treatment based on "typical" GERD symptoms alone may not be appropriate.