Biliary Cyst: An Unusual Cause of Cholestasis Post Cholecystectomy.

Biliary cysts are relatively uncommon and they can be congenital or acquired and can have various presentations such as cholelithiasis, cholangitis, jaundice, and pancreatitis. Biliary cysts are associated with a high risk of biliary cancers and such risk increases with age. Identification of biliary cysts warrants an aggressive approach to lower cancer risk. Surgical management has a high success rate and it lowers morbidity, mortality, and cancer risk. We present a 40-year-old female who had a cholecystectomy in 2016. She presented with obstructive jaundice and was found to have a class I biliary cyst. She underwent endoscopic retrograde cholangiopancreatography with stenting which led to complete resolution of her symptoms. Later, she underwent elective Roux-en-Y hepaticojejunostomy with cyst resection three months later. She underwent a successful recovery.

The Use of Pre-Endoscopic Metoclopramide Does Not Prevent the Need for Repeat Endoscopy: A U.S. Based Retrospective Cohort Study.

BACKGROUND: Peptic ulcer disease (PUD) can cause upper gastrointestinal bleeding (UGIB), often needing esophagogastroduodenoscopy (EGD). Second-look endoscopies verify resolution, but cost concerns prompt research on metoclopramide's efficacy compared to erythromycin. METHODS: We analyzed the Diamond Network of TriNetX Research database, dividing UGIB patients with PUD undergoing EGD into three groups: metoclopramide, erythromycin, and no medication. Using 1:1 propensity score matching, we compared repeat EGD, post-EGD transfusion, and mortality within one month in two study arms. RESULTS: Out of 97,040 patients, 11.5% received metoclopramide, 3.9% received erythromycin, and 84.6% received no medication. Comparing metoclopramide to no medication showed no significant difference in repeat EGD (10.1% vs. 9.7%, p = 0.34), transfusion (0.78% vs. 0.86%, p = 0.5), or mortality (1.08% vs. 1.08%, p = 0.95). However, metoclopramide had a higher repeat EGD rate compared to erythromycin (9.4% vs. 7.5%, p = 0.003), with no significant difference in transfusion or mortality. CONCLUSIONS: The need to repeat EGD was not decreased with pre-EGD use of metoclopramide. If a prokinetic agent is to be used prior to EGD, erythromycin shows superior reduction in the need of repeat EGD as compared to metoclopramide.

The Use of Glucagon-like Peptide-1 Receptor Agonists in Patients with Type 2 Diabetes Mellitus Does Not Increase the Risk of Pancreatic Cancer: A U.S.-Based Cohort Study.

BACKGROUND: GLP-1 RAs are widely used for T2DM treatment due to their cardiorenal and metabolic benefits. This study examines the risk of pancreatic cancer with GLP-1 RA use in patients with T2DM. METHODS: We analyzed TriNetX's deidentified research database using the U.S. Collaborative Network comprising 62 healthcare organizations across the U.S.A. Patients with T2DM were split into two cohorts: one receiving GLP-1 RAs, and one not receiving GLP-1 RAs. We excluded patients with known risk factors for pancreatic cancer, including pancreatic cysts, a personal or family history of BRCA1, BRCA2, CDKN2A, KRAS, MEN1, MLH1, MSH2, NOTCH1, PALB2, PMS2, and PRSS1S genes, family history of pancreatic cancer, and VHL syndrome. Using a 1:1 propensity score-matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then compared the rate of pancreatic cancer between the two cohorts at a 7-year interval. RESULTS: Out of 7,146,015 identified patients with T2DM, 10.3% were on a GLP-1 RA and 89.7% were not. Post-PSM, 721,110 patients were in each group. Patients on GLP-1 RAs had a 0.1% risk compared to a 0.2% risk of pancreatic cancer in the 7-year timeframe. CONCLUSION: The use of GLP-1 RAs in patients with type 2 diabetes mellitus (T2DM) does not appear to substantially elevate the risk of pancreatic cancer; in fact, it may potentially exert a protective effect.

Use of proton pump inhibitors improves outcomes in mild acute pancreatitis: A nationwide cohort study.

Previous studies showed a potential anti-inflammatory effect of proton pump inhibitors (PPI) as well as possible inhibition of pancreatic secretion. This presents the question of their possible use in acute pancreatitis (AP). Current clinical evidence does not address the role of PPI and the present review for possible therapeutic use and safety is lacking. Therefore, our study aims to address the role of PPI in the management of AP and their association with the different outcomes of AP. We queried the Diamond Network through TriNetX-Research Network. This network included 92 healthcare organizations. Patients with mild AP with Bedside Index of Severity in Acute Pancreatitis (BISAP) score of Zero regardless of etiology were divided into 2 cohorts; 1st cohort included patients on PPI, and 2nd cohort included patients not on any PPI. Patients with BISAP score equal to or more than 1 or on PPI prior to the study date were excluded. Two well-matched cohorts were created using 1:1 propensity-scored matching model between cohorts. We compared the incidence of intensive care unit admission, mortality, and other associated complications. A total of 431,571 patients met the inclusion criteria. Of those, 32.9% (n = 142,062) were on PPI, and 67% (n = 289,509) were not on any PPI. After propensity matching, the sample included 115,630 patients on PPI vs 115,630 patients not on PPI. The PPI group had a lower rate of mortality (3.7% vs 4.4%, P < .001), a lower rate of intensive care unit admission (3.9% vs 5.5%, P < .001), a lower rate of necrotizing pancreatitis (1.1% vs 1.9%, P < .001), a lower rate of Hospital-Acquired Pneumonia (3.6% vs 4.9%, P < .001), a lower rate of respiratory failure (2.8% vs 4.2%, P < .001), and a lower rate of acute kidney injury (6.9% vs 10.1%, P < .001). There was no statistical difference in the rate of Clostridium difficile infection between the 2 cohorts (0.9% vs 0.8%, P = .5). The use of PPI in mild AP with a BISAP-score of zero is associated with reduced pancreatitis-related complications and improved mortality. Prospective studies are needed to confirm these findings.

SARS-CoV-2 Infection Is an Independent Risk Factor for Decompensation in Cirrhosis Patients.

BACKGROUND: SARS-CoV-2 causes varied gastrointestinal symptoms. Cirrhosis patients face higher mortality rates from it, especially those with decompensated cirrhosis. This study examines SARS-CoV-2's impact on decompensation in previously compensated cirrhotic patients. METHODS: We analyzed the Global Collaborative Network, comprising 98 healthcare organizations across sixteen countries, using TriNetX's deidentified research database. Compensated cirrhosis patients were split into two groups: one with SARS-CoV-2-positive patients and another testing negative. Using a 1:1 propensity score matching model based on baseline characteristics and comorbidities, we created comparable cohorts. We then assessed decompensation, mortality, and GI bleed at 1 and 3 months. RESULTS: Out of 252,631 identified compensated cirrhosis patients, 27.3% (69,057) tested SARS-CoV-2-positive, while 72.6% (183,574) remained negative. Post PSM, 61,963 patients were in each group. SARS-CoV-2-positive patients showed significantly higher decompensation rates (4.4% vs. 1.9% at 1 month; 6% vs. 2.6% overall). Rates of complications, like ascites, SBP, HE, and HRS, increased notably. Mortality (2.5% vs. 1.7% at 1 month; 3.6% vs. 2.7% at 3 months) and GI bleed (1.3% vs. 0.9% at 1 month; 1.9% vs. 1.2% at 3 months) were also elevated in SARS-CoV-2 patients. CONCLUSIONS: SARS-CoV-2 increases decompensation over 2-fold in compensated cirrhosis patients and raises mortality and increases rates of complications at 1 and 3 months.

Risk of Esophageal and Gastric Cancer in Patients with Type 2 Diabetes Receiving Glucagon-like Peptide-1 Receptor Agonists (GLP-1 RAs): A National Analysis.

INTRODUCTION: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are becoming more popular in managing type 2 diabetes mellitus (T2DM). Concerns linger over potential links to malignancies like pancreatic and thyroid cancers, requiring more research to clarify their safety profiles. Additionally, evidence suggests GLP-1 RAs may lower colorectal and pancreatic cancer risk, especially in obese and overweight individuals, indicating a protective effect beyond weight loss. Current studies leave a gap in comprehensively understanding cancer risks associated with GLP-1 RAs, which prompts further research to enhance our understanding of their overall safety. METHODS: We queried the US Collaborative Network (63 health care organizations) of the TriNetX research database. Patients with T2DM were identified and divided into two cohorts: patients on GLP-1 RAs and patients not on GLP-1 RAs. We excluded tobacco use and alcohol use disorders, obese patients with a body mass index (BMI) of >25 kg/m2, and those with a family history of gastrointestinal malignancy, infectious mononucleosis, chronic gastritis, pernicious anemia, helicobacter pylori infection, or gastroesophageal reflux disease (GERD). We used a 1:1 propensity score matching (PSM) model using patients' baseline characteristics, medications, labs, and genetics. We compared the rate of gastric cancer and esophageal cancer at the seven-year mark. RESULTS: A total of 2,748,431 patients with T2DM were identified. Of those, 6% (n = 167,077) were on a GLP-1 RA and 94% (n = 2,581,354) were not on a GLP-1 RA. After PSM, both cohorts included 146,277 patients. Patients with T2DM who were on a GLP-1 RA, compared to those who were not, had a statistically significant lower risk of both gastric cancer (0.05% vs. 0.13%, p < 0.0001) and esophageal cancer (0.04% vs. 0.13%, p < 0.0001) at the seven-year mark. CONCLUSION: The use of GLP-1 RAs in patients with T2DM does not significantly increase the risk of gastric or esophageal cancer. This finding supports the continued use of GLP-1 analogues as a therapeutic option in managing T2DM, considering their well-established benefits and low risk of complications. Based on the study results, these medications may even have a protective effect against these malignancies.

Outpatient use of antibiotics in uncomplicated diverticulitis decreases hospital admissions.

INTRODUCTION: Recently, antibiotics use in uncomplicated acute diverticulitis (AD) has been controversial in Europe. The American Gastroenterological Association (AGA) in their 2015 guidelines recommend their selective use. Our study highlights their role in outpatient management. METHODS: We queried the Diamond Network through TriNetX-Research Network including 92 healthcare organizations. We included large intestine diverticulitis without perforation, abscess or bleeding. Exclusion criteria included any of sepsis criteria, CRP > 15 mg/L, immunodeficiency or HIV, coronary artery disease, chronic kidney disease, history of Crohn's disease or ulcerative colitis, heart failure, hypertension, diabetes or any of the following in the 3 months before study date; clostridium difficile (C. diff) infection, diverticulitis or antibiotics. Patients with AD were divided into two cohorts; patients on antibiotics, and patients not on antibiotics. Cohorts were compared after propensity-score matching (PSM). RESULTS: 214,277 patients met inclusion criteria. 58.9% received antibiotics, and 41% did not. After PSM, both cohorts had 84,320. Rate of hospital admission was lower in the antibiotic group (3.3% vs 4.2%, p < .001). There was a statistical difference between ICU admission (0.1% vs 0.15%, p < .01) and the rate of bowel perforation, peritonitis, abscess formation or bleeding (1.3% vs 1.4%, p = .044). There was no difference in mortality (0.1% vs 0.1%, p = .11), C. diff (0.1% vs 0.1%, p = .9), colectomies (0.2% vs 0.2%, p = .33), or Acute Kidney Injury (AKI) (0.1% vs 0.1%, p = .28). CONCLUSION: Outpatient use of antibiotics in patients with uncomplicated AD is associated with lower rates of hospital admissions and complications without changing mortality rate or surgical intervention.

Incidence and Dynamics of CRC Stage Migration: A Regional vs. a National Analysis.

BACKGROUND/OBJECTIVES: Due to an increased rate of surveillance colonoscopy, we aim to determine the impact of stage migration on the incidence and overall survival (OS) of patients who underwent pathological staging of colorectal cancer (CRC) at our Health Network System. METHODS: Two datasets were included: subjects from the tumor registry at a regional Comprehensive Cancer Center (n = 1385) and subjects from the Surveillance, Epidemiology, and End Results (SEER) national database (n = 202,391). RESULTS: A significant increase in the diagnosis of CRC Stage 1 and 4 was observed, with a decrease in stage 2, and no change in Stage 3 in the National datasets (p < 0.01). There was an increase in Stage 4 CRC diagnosis, with a concurrent decrease in stage 2, and no changes in stages 1 and 3 in the regional dataset (p < 0.05). OS followed the expected and progressive decrease in OS by stage (from 1 to 4, p < 0.01). CONCLUSIONS: The present findings confirmed CRC stage migration in our Health Network System, along with a national trend conducive to an increased OS for early CRC stages.

Thrombotic Long-Term Consequences of SARS-CoV-2 Infection in Patients with Compensated Cirrhosis: A Propensity Score-Matched Analysis of a U.S. Database.

BACKGROUND: Cirrhosis causes an imbalance in the coagulation pathway and leads to a tendency for both bleeding and clotting. SARS-CoV-2 has been reported to be associated with a hypercoagulable state. This study examines SARS-CoV-2's impact on hemostasis in compensated patients with cirrhosis. METHODS: We analyzed the US Collaborative Network, which comprises 63 HCOs in the U.S.A. Compensated cirrhosis patients were split into two groups: SARS-CoV-2-positive and -negative. Patients' baseline characteristics were used in a 1:1 propensity score-matched module to create comparable cohorts. We compared the risk of portal vein thrombosis (PVT), deep venous thrombosis (DVT), and pulmonary embolism (PE) at 6 months, and 1 and 3 years. RESULTS: Of 330,521 patients, 27% tested positive and 73% remained negative. After PSM, both cohorts included 74,738 patients. Patients with SARS-CoV-2 had a higher rate of PVT compared to those without at 6 months (0.63% vs 0.5%, p < 0.05), 1 year (0.8% vs 0.6%, p < 0.05), and 3 years (1% vs. 0.7%, p < 0.05), a higher rate of DVT at 6 months (0.8% vs. 0.4%, p < 0.05), 1 year (1% vs. 0.5%, p < 0.05), and 3 years (1.4% vs. 0.8%, p < 0.05), and a higher rate of PE at 6 months (0.6% vs. 0.3%, p < 0.05), 1 year (0.7% vs. 0.4%, p < 0.05), and 3 years (1% vs. 0.6%, p < 0.05). CONCLUSIONS: The presence of SARS-CoV-2 infection in patients with compensated cirrhosis was associated with a higher rate of PVT, DVT, and PE at 6 months, and 1 and 3 years.

Safety of DOACs in patients with Child-Pugh Class C cirrhosis and atrial fibrillation.

Background: Anticoagulation (AC) is used for stroke prevention in atrial fibrillation (AF). Direct Oral Anticoagulants (DOACs) are safe in patients with AF without cirrhosis, they are hardly studied in patients with advanced cirrhosis. Our study evaluates the safety and outcomes of DOACs in patients with Child-Pugh class C cirrhosis (CPC). Methods: We queried TriNetX Database. Patients with CPC and AF were divided into three cohorts: patients on DOACs, no AC, and warfarin. Three study arms were created using a 1:1 propensity score matching system (PSM). Results: Totally 16 029 patients met the inclusion criteria. Of those, 20.2% (n = 3235) were on DOACs, 47.1% (n = 7552) were not on AC, and 32.7% (n = 5242) were on warfarin. First arm comparing AC versus no AC, a statistically significant benefit was identified in 3-year mortality risk (47% vs 71%, P < 0.0001) and transplant status (17% vs 5%, p < 0.0001) with AC. However, no significant difference was identified regarding intracranial hemorrhage and GI bleeding risk. Second arm comparing patients on DOACs versus no AC, we identified mortality benefit (40% vs 72%, P < 0.0001) and a higher transplant rate (9% vs 3.2%, P < 0.0001) with DOACs. Intracranial hemorrhage rates (6% vs 4%, P = 0.03) were higher in patients on DOACs. Third arm comparing patients on DOACs versus Warfarin, a statistically significant lower risk of intracranial hemorrhage (6.6% vs 8.7%, P = 0.004) and GI bleed (2% vs 2.4%, P < 0.0001) were identified in patients on DOACs. Conclusion: Anticoagulation is safe in patients with CPC with AF and may provide a mortality benefit. DOACs are a safer alternative to warfarin.

Acute Gallstone Pancreatitis in Pregnancy: A Multidisciplinary Approach.

A common cause of gastrointestinal-related hospitalizations in the United States of America is acute pancreatitis (AP), with an annual incidence of up to 80 cases per 100,000 people. The incidence of AP in pregnancy varies and is approximately 1 in 1000 to 1 in 10,000 births due to the prevalence of obesity and gallstone-related conditions. Deciding on the timing of surgical intervention in acute biliary pancreatitis during pregnancy remains challenging, and there are no consensus recommendations. Gallstone pancreatitis has a high recurrence rate of up to 50% during the first trimester. A 30-year-old G3P2 at 34 weeks of gestation presented to the emergency room (ER) with recurrent intermittent sudden severe epigastric and right upper quadrant abdominal pain radiating to the back. She had no history of alcohol consumption, and lipid studies were normal on presentation. A right upper quadrant ultrasound scan showed cholelithiasis without signs of acute cholecystitis and a common bile duct diameter of 0.5 cm. However, her serum lipase level was 824, compared to normal levels on her previous ER visits. Other significant labs included elevated alkaline phosphatase (ALP) of 125 and mild transaminitis, with alanine transaminase (ALT) and aspartate aminotransferase (AST) levels of 84 and 57, respectively. She was admitted on account of suspected gallstone pancreatitis and was treated supportively with IV fluids and adequate pain control with opioids. A subsequent magnetic resonance cholangiopancreatography (MRCP) revealed no obvious choledocholithiasis. After consultation with the obstetrics, gastroenterology, and general surgery teams, it was decided to defer cholecystectomy until after delivery. The patient was induced at 36 weeks of gestation, and she had an uneventful vaginal delivery. Two weeks later, she had an elective laparoscopic cholecystectomy with no complications.