Anatomical Location of Pathology Is Predictive of Prolonged Fluoroscopy Time During ERCP: A Multicenter American Study.

BACKGROUND: Different factors have been associated with prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP). AIM: We hypothesize that FT depends on both the anatomical location of the pathology managed during ERCP and the complexity of the ERCP. METHODS: Three centers participated in a retrospective multi-center cohort study. Data on patient demographics, ERCP complexity, and the location of pathology were collected. The relationships between FT and the location of pathology, ERCP complexity, patient demographics, and ERCP maneuvers, respectively, were analyzed. Prolonged FT was defined as a FT > 10 min. RESULTS: A total of 442 cases underwent ERCP in three different centers (301 cases, 76 cases, and 65 cases in centers A, B, and C, respectively) by six endoscopists. The median FT for all cases was 282 (range 8-3,516) s. Mean FT increased progressively according to anatomical location in the order extrahepatic cases {n = 298; mean FT 292 [95 % confidence interval (CI) 263-322] s}, pancreatic cases [n = 27; mean FT 359 (95 % CI 200-517) s], and intrahepatic cases [n = 117; mean FT 736 s (95 % CI 635-836) s]. Mean FT increased progressively with the complexity scale, with mean FT for Grade I, 218 (95 % CI 138-299) s; Grade II, 295 (95 % 261-329) s; Grade III, 586 (95 % CI 508-663) s; Grade IV, 636 (95 % CI 437-834) s. Multivariable analysis confirmed that prolonged FT was independently associated with anatomical location of the targeted pathology during ERCP-but not with ERCP complexity and endoscopy center. CONCLUSION: Prolonged FT during ERCP is associated most strongly with intrahepatic cases. FT can be used most effectively as a quality measure if it is stratified according to presence or absence of intrahepatic cases.

Incidental pancreatography via ERCP in patients with anomalous pancreaticobiliary junction does not result in pancreatitis in a North American population.

INTRODUCTION: Anomalous pancreaticobiliary junction (APBJ) is the term used to describe anatomical variants of pancreatic and biliary ductal junctional anatomy. Patients have junction of the pancreatic and bile ducts located outside the duodenal wall, forming a long common channel. We report our findings and clinical outcomes in a North American series of patients with APBJ undergoing ERCP. METHODS: Retrospective chart review. RESULTS: We reviewed 2,218 ERCP performed on 1,050 patients. Twelve patients (1.1%) with APBJ were identified (5F, 7M). No patient had an associated choledochocele. Mean age was 53.2 (range 17-85). A total of 43 ERCP procedures were performed on these 12 patients. All patients experienced passive pancreatography. No patient developed post-ERCP pancreatitis. Only one patient had a history of antecedent pancreatitis. CONCLUSIONS: In North American patients undergoing ERCP, 1.1% of patients had APBJ. Our study population was predominately Caucasian, male, and in all but one patient lacked a history of prior pancreatitis. No patient developed post-ERCP pancreatitis. This suggests that APBJ may have different clinical manifestations in a North American population when compared to Asian populations.

Clinical Yield of Ileal Intubation During Screening Colonoscopy.

Objectives Ileal intubation during screening colonoscopy can serve as supportive evidence of complete examination. However, most studies conducted in Western countries showed a limited value of ileal inspection in asymptomatic patients undergoing colonoscopy. Therefore, our aim is to determine the clinical yield of routine ileal examination during the performance of screening colonoscopy in a cohort of patients in the Middle East and identify factors associated with successful ileal intubation in this setting. Methods A retrospective review of a prospectively collected database of all screening colonoscopies was performed at a single endoscopy unit. The patients were divided into two groups; group A included patients in whom the extent of examination was the cecum and group B comprised of those who underwent ileal intubation as well. We summarized the endoscopic and pathological findings of the ileoscopic examinations and their clinical impact. Univariate and multivariate analyses were used to compare both groups and to identify factors predictive of ileal intubation in the setting of screening colonoscopy.  Results Two thousand four hundred seventy-three unique completed screening colonoscopies were analyzed (group A=1465 patients, group B=1008 patients). Overall Ileal intubation rate was 40.8%. Of the patients in group B, 3.7% were noted to have findings on ileoscopy, which were deemed to be clinically significant in almost half (1.8% overall). Univariate analysis identified the following factors as being predictive of ileal intubation during screening colonoscopy: patients' age (51.7 vs. 53.5 years, p<0.001), short cecal insertion time, endoscopists' specialty (gastroenterology 42.3% vs. surgery 24.3%, p<0.001), type of colonoscope (pediatric 47.1% vs. adult 33.5% colonoscope, p<0.001), and quality of preparation in the right colon (poor vs. adequate/good : (25.6% vs. 42.5%, p<0.001). Mixed-effects logistic regression identified patients' age, endoscopist specialty, quality of right colon preparation, and cases with short insertion time as independent variables predicting ileal intubation during SC Conclusion The clinical yield of routine ileal intubation during screening colonoscopy is low. Ileal intubation during screening colonoscopy in our cohort was more likely in younger patients with adequate/good right colon preparation and when the exam is performed by a gastroenterologist, in cases with short insertion time. Prospective studies are needed to assess our research findings and to determine the clinical value of routinely intubating terminal ileum during screening colonoscopy in the population of the Middle East.

Impact of pediatric versus adult colonoscope on terminal ileum intubation: a retrospective study.

Background: Various possible predictors of successful terminal ileal intubation (TII) have been explored but the role of the type of colonoscope is unclear. Methods: We carried out a retrospective review of a prospectively collected database of all colonoscopies performed at a single endoscopy unit between May 2015 and July 2020. The primary outcome measure was successful TII in patients with specific indications for ileal examination. The primary predictor was the type of endoscope, pediatric or adult, used during the procedure. Univariate and multivariate analyses were performed. Results: In 5845 colonoscopies fulfilling the study criteria, the overall TII rate was 67.8%. In univariate analysis, the use of a pediatric colonoscope was associated with a higher TII rate (72.1% vs. 58.8%, P<0.001). Other variables associated with successful TII based on univariate analysis included the patient's age, male sex, body mass index, endoscopists' specialty, place of training, shorter colonoscope insertion time, shorter duration of the procedure, longer withdrawal time, procedures performed in the afternoon, type of sedation administered during colonoscopy, and cleanliness of the colon. Multivariate analysis yielded an adjusted odds ratio (OR) of 1.40 (95% confidence interval [CI] 1.21-1.62) for the use of a pediatric colonoscope. Propensity score-matching analysis also showed superiority of the pediatric colonoscope in achieving TII compared to an adult colonoscope, OR 1.35 (95%CI 1.17-1.57). Conclusions: Pediatric colonoscope increases the success of TII during colonoscopy. For endoscopists performing colonoscopy with intent to examine the terminal ileum, it is recommended to choose a pediatric colonoscope to maximize the success rate.

Post-cholecystectomy Mirizzi Syndrome.

Post-cholecystectomy Mirizzi syndrome (PCMS) is characterized by symptoms of recurrent abdominal pain, jaundice, and fever in patients who underwent cholecystectomy. Imaging is crucial in the diagnosis of PCMS and Mirizzi syndrome. Imaging modalities have evolved over the years with abdominal ultrasonography, computed tomography of the abdomen, and magnetic resonance cholangiopancreatography being used in the diagnosis of PCMS and Mirizzi syndrome. The imaging findings show obstruction of the common hepatic duct due to impingement by a stone in the cystic duct or gallbladder infundibulum. PCMS management has evolved over the years with the current first-line management being endoscopic intervention. This case describes a 61-year-old male presenting with recurrent right upper quadrant pain two years after undergoing cholecystectomy due to cholelithiasis. The patient was later diagnosed with PCMS, and endoscopic management was performed with complete resolution of the symptoms.

Comorbidities, sphincterotomy, and balloon dilation predict post-ERCP adverse events in PSC patients: operator experience is protective.

BACKGROUND: Primary sclerosing cholangitis (PSC) is a chronic cholestatic disease. Interventional ERCP improves survival in PSC patients. AIMS: To describe the frequency and risk factors for post-ERCP adverse events in patients with PSC via multivariate analysis. METHODS: Retrospective cohort study included patients with a diagnosis of PSC who underwent ERCP at academic institutions between February 2000 and October 2009. Demographis, co-morbid conditions, antibiotic use, cannulation method, ERCP maneuvers and 30-day post-ERCP adverse events were collected. Multivariate analysis was performed using logistic regression. RESULTS: A total of 185 procedures were performed on 75 PSC patients (58 M,17 F). Seven endoscopists performed ERCPs. Comorbidies included ulcerative colitis (44%, n = 33), Crohn's disease (12%, n = 9 patients), Cirrhosis (8%, n = 6 patients) and autoimmune hepatitis (2.7%, n = 2). Cannulation was achieved using dye-free guidewire cannulation techniques in 139/185 procedures (76%) and with contrast-based techniques in 46/185 procedures (24%). Thirty-day post-ERCP adverse events included post-ERCP pancreatitis (5%, n = 9, cholangitis (1%, n = 2), acute cholecystitis (0.5%, n = 1), stent occlusion (0.5%, n = 1), stent migration (0.5%, n = 1), and bile leak (0.5%, n = 1). In the multivariate analysis, associations with specific endoscopists who performed the procedure (P = 0.01), biliary dilation (P = 0.02), sphincterotomy (P = 0.03), presence of cirrhosis (P = 0.05), Crohn's disease (P < 0.001), and autoimmune hepatitis (P < 0.001) significantly predicted a complication following ERCP. Gender, stenting during procedure, presence of a dominant stricture, and cholangitis were not predictive for post-ERCP adverse events. CONCLUSIONS: Factors predicting 30-day post-ERCP adverse events included certain co-morbid conditions, the endoscopist ERCP volume, maneuvers during ERCP including dilation and sphincterotomy. Stenting was not associated with adverse events.

Incidental Diagnosis of Duodenal Giardiasis.

Giardia lamblia is a protozoan that results in the commonly diagnosed giardiasis. Due to its prevalence and incidence worldwide, it is essential to recognize the different presentations of giardiasis, routes of transmission, modalities of diagnosis, treatments, and complications. Diagnostic modalities have evolved over the years and can be achieved reliably through noninvasive stool testing. Endoscopic duodenal aspirate and biopsies can also be used; however, they yield lower sensitivity and specificity rates and are therefore not used as a first-line modality for diagnosing giardiasis. Nonetheless, its use should be considered in cases with high suspicion and unremarkable stool testing. Herein, we discuss the case of a 27-year-old male with chronic weight loss and abdominal pain for six months diagnosed with G. lamblia through a duodenal biopsy.

RIFLE criteria accurately identifies renal dysfunction and renal failure in elderly patients with upper gastrointestinal hemorrhage: a pilot study.

BACKGROUND: The incidence of acute kidney injury (AKI) as a complication of acute upper gastrointestinal bleeding (AUGIB) is not known. Recently, RIFLE criteria were used widely in the medical research to identify patients with different degrees of renal insufficiency. OBJECTIVES: Our purpose is to determine the incidence, clinical presentations, endoscopic findings and outcomes of AKI in the elderly presenting with AUGIB using RIFLE criteria. The study was conducted in a community hospital in Washington State. This was a retrospective pilot study of elderly patients (≥60 years old) presenting with AUGIB. Categorical variables were analyzed using the Chi-square test. The Student t-test was used to compare continuous variables. A total of 113 patients were included (52 males and 61 females) in the study. The patients were classified into those with AKI based on RIFLE criteria and those without. The two groups were compared in regard to clinical presentations, laboratory and endoscopic findings, complications, length and cost of hospitalization. RESULTS: Fifty five patients (48.7%) met RIFLE criteria for AKI, while 58 patients did not develop any renal dysfunction. Patients with AUGIB complicated with AKI tend to be residents at nursing homes (38% vs. 14%, P < 0.004), present with weakness (49% vs 29%., P < 0.04) and altered mental status (25% vs. 55%, P < 0.003), have higher serum creatinine at presentation (1.8 mg/dL vs. 1.2 mg/dL, P < 0.002), have less incidence of gastritis/gastric ulcers (67% vs. 42%, P < 0.007), have nondiagnostic upper endoscopic examination (29% vs. 14%, P < 0.05), higher incidences of cardiac complications including myocardial infarction (9% and 0%, P < 0.02), longer lengths of stay (5.0 days vs. 2.37 days, P < 0.005) and higher hospitalization costs ($20,230 vs. $11,779, P < 0.02). CONCLUSION: The incidence of developing AKI as a consequence of AUGIB in the elderly is very common. Those with AKI tend to have a more complicated clinical course in the hospital.

Endosonographic examination of thyroid gland among patients with nonthyroid cancers.

OBJECTIVES: There is limited endosonographic literature regarding thyroid gland pathology, which is frequently visualized during upper endoscopic ultrasound (EUS). Our objective was to assess the prevalence of benign and malignant thyroid lesions encountered during routine upper EUS within a cancer center setting. MATERIALS AND METHODS: The data were prospectively collected and retrospectively analyzed. All upper EUS procedures performed between October 2012 and July 2014 were reviewed at a large referral cancer center. Data collected included patient demographics, preexisting thyroid conditions, thyroid gland dimensions, the presence or absence of thyroid lesions, and EUS morphology of lesions if present, and interventions performed to characterize thyroid lesions and pathology results when applicable. RESULTS: Two hundred and forty-five EUS procedures were reviewed. Of these, 100 cases reported a detailed endosonographic examination of the thyroid gland. Most of the thyroid glands were endosonographically visualized when the tip of the scope was at 18 cm from the incisors. Twelve cases showed thyroid lesions, out of which three previously undiagnosed thyroid cancers were visualized during EUS (two primary papillary thyroid cancers and one anaplastic thyroid cancer). Transesophageal EUS-guided fine needle aspiration of thyroid lesions was feasible when the lesion was in the inferior portion of the thyroid gland, and the tip of the scope was at 18 cm or more from the incisors. CONCLUSIONS: Routine EUS examination may detect unexpected thyroid lesions including malignant ones. We encourage endosonographers to screen the visualized portions of the thyroid gland during routine withdrawal of the echoendoscope.