Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study.

BACKGROUND: Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs). METHODS: We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery. RESULTS: Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P = 0.31). CONCLUSION: When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.

Covered Esophageal Stenting Is Effective for Symptomatic Gastric Lumen Narrowing and Related Complications Following Laparoscopic Sleeve Gastrectomy.

BACKGROUND AND STUDY AIMS: Laparoscopic sleeve gastrectomy (LSG) is gaining popularity in treating morbid obesity. Prior studies showed a 3.5% risk of gastric sleeve stenosis (GSS). There is no consensus on how to treat these patients, and the role of endoscopic therapy has been addressed in only a few studies. We aim to assess the efficacy and safety of endoscopic stenting in the management of GSS following LSG. PATIENTS AND METHODS: Retrospective data were reviewed from July 2009 to November 2013. Patients were referred for endoscopic therapy for symptoms or imaging findings suggestive of gastric leak or narrowing following LSG. Endoscopic therapy included the use of fully covered self-expanding esophageal metal stents (FCSEMS) in addition to over-the-scope clip system (OTSC) when necessary. RESULTS: All 27 patients were females with mean age of 40 years; six patients were excluded from the study. Major symptom was nausea and vomiting in 57% of the patients. Five of 21 patients had concomitant leaks. All 21 patients underwent FCSEMS placement, and four out of five patients (80%) with concomitant leak had OTSC. The success rate in both groups for resolution of stricture and leak was 100%, and no surgical intervention was required. There were no immediate or delayed complications of endoscopic therapy. Median follow-up of 6 months was available for 20/21 patients. Among patients with gastric leak, 80% had resolution of their symptoms compared with 93% of patients with GSS. CONCLUSIONS: Endoscopic therapy for LSG-related GSS or leaks with FCSEMS is highly effective and safe.

Prevalence Study of MASLD in Adolescent and Young Adult Pacific Islanders and Asians Living in Hawai'i.

Context: Nonalcoholic fatty liver disease, renamed metabolic dysfunction-associated steatotic liver disease (MASLD), is the most common cause of chronic liver disease with an estimated worldwide prevalence of 30.1% while clinical practice observations reflect a disproportionately lower prevalence of 1.9%, indicating a condition that is underrecognized in clinical care settings. Screening for MASLD is rarely performed, and little is known about the prevalence in Hawai'i. Objective: This pilot aims to develop an understanding of the prevalence and factors associated with MASLD in Hawai'i's adolescent and young adult (AYA) population. Design/Methods: Cross-sectional observational pilot study: We used Fibroscan®-liver ultrasonographic vibration-controlled transient elastography (VCTE) to identify MASLD based on controlled attenuation parameter (CAP) scores ≥238 (dB/m) and collected biometric, anthropometric, and Beverage Intake Questionnaire (sugar-sweetened beverage) survey data. Setting: The study took place at community clinics in Hawai'i on the island of O'ahu. Participants: One hundred individuals were evaluated, age 14 to 34 years. Main Outcome Measures: We used VCTE Fibroscan® with CAP scoring to identify the presence of hepatocyte steatosis (fatty liver). Results: Overall MASLD prevalence in the sample was 44% (95% confidence interval: 34.1%-54.3%). In participants with MASLD, obese Native Hawaiian and other Pacific Islanders (62%) and nonobese Asians (43%) had the highest rates of MASLD. Conclusion: This pilot evaluation of the AYA NHOPI and Asian MASLD population in Hawai'i shows a higher rate of MASLD than those reported in other parts of the United States. Larger population health studies are indicated to expand our knowledge of MASLD in the Hawaiian Islands.

A case of fatal fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and persistent ventricular tachyarrhythmia associated with influenza A (H1N1) virus in a previously healthy pregnant woman.

Several studies have reported influenza A (H1N1) virus as a cause of fulminant myocarditis. We report the first fatal case of fulminant myocarditis presenting as an acute ST-segment elevation myocardial infarction and ventricular tachyarrhythmia associated with influenza A (H1N1) in a previously healthy pregnant woman. A 38-year-old Asian woman, gravida 3, para 1-0-1-1, presented with flu-like symptoms. Initially, she developed wide-complex tachycardia requiring several defibrillations and was later intubated. Electrocardiogram showed ST-segment elevation. Coronary angiogram was negative and a pulmonary angiogram ruled out pulmonary embolism. Fetal compromise was noted on the monitor, and the patient underwent an emergent cesarean section. She subsequently expired. Autopsy confirmed severe myocarditis. Further testing confirmed influenza A (H1N1) virus. This case of a rare, yet lethal, complication of H1N1 infection underscores the importance of increased awareness among health care professionals to provide pregnant women with vaccination and prompt treatment.

Microcarcinoid and Ulcerative Colitis: Case Report and Literature Review.

Gastrointestinal microcarcinoid tumors are rare, and the concomitant diagnosis of microcarcinoid tumor and inflammatory bowel disease is even rarer. A 54-year-old African American male with an eight-year history of ulcerative colitis (UC) presented with a three-day history of abdominal pain and bloody diarrhea. Rectal biopsy on colonoscopy was notable for small nests of neuroendocrine cell proliferation in the mucosa consistent with a diagnosis of microcarcinoid tumor. Whether the incidence is coincidental or represents an epiphenomenon of chronic inflammation remains to be determined.

Colonic Perineurioma's Malignant Proximity to Serrated Colonic Polyps.

A colonic perineurioma is often considered a benign cousin to a colonic polyp. However, in the submucosal type of perineurioma, it is important to rule out the malignant gastrointestinal stromal tumor (GIST). Alternatively, in the BRAF-positive serrated types of perineuriomas, surveillance is equivalent to intervals designated to serrated polyps due to a similar malignant potential. These versions serve as reminders that colonic perineuriomas are not to be disregarded.

Marshall Islands Pinworm.

Pinworm infections are usually under the spectrum of the Infectious Diseases department, however, they can fall into a gastroenterologist's lap when found incidentally during a screening colonoscopy. This case expands on the epidemiology, clinical presentation, diagnosis, and treatment of pinworms in the patient and household.

Duodenal Xanthoma: From Specks to Obstruction.

Xanthomas within the gastrointestinal tract occur secondary to a mucosal insult. When enough cells accumulate, their appearance can range from small nodules studding the intestinal mucosa to bandlike infiltrations to pseudotumor-like masses within the intestine with fibrosis and inflammation resembling malignancy. When large enough, they can produce symptoms of obstruction such as vomiting, abdominal pain, distention, and dysmotility. This case demonstrates the epidemiology, clinical presentation, diagnosis, and treatment of duodenal xanthomas.

Outlasting a Rare Duodenal Angiosarcoma.

With current life expectancies exceeding 78 years on average, to be confronted with the discovery of a rare cancer often found in advanced stages is a startling devastation. Angiosarcoma of the intestine is a rare and aggressive tumor that is not often considered in the differential diagnosis of intestinal obstruction. Once found and accurately diagnosed, it is a bewildering race against time as its median survival time is 150 days from diagnosis. This case report details a rare small intestinal angiosarcoma with its host surpassing current epidemiological standards of survival time despite only being eligible for chemotherapy.

Proctitis and Abdominal Aortic Aneurysm: Six Degrees of Separation.

Cytomegalovirus (CMV) is an aggressive virus responsible for a considerable amount of case fatalities. In the overwhelming majority of cases, this affects only the immunocompromised. Herein, we present a 76-year-old immunocompetent female who presented with gastrointestinal bleeding found to have rectal ulceration secondary to CMV infection. This manuscript aims to raise awareness of a rare cause of rectal bleeding. Hopefully, as such, our case will also prevent long-standing inflammation from persisting in patients with CMV and prevent it from contributing to cardiovascular pathology as seen in our patient.

WITHDRAWN: Giant gastric lipoma presenting as partial gastric outlet obstruction.

This article has been withdrawn at the request of the editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.

An Unlikely Route: Metastatic Ovarian Malignancy within the Duodenum.

The small bowel is an uncommon site for cancer metastasis. Despite this, cases have reported the duodenum as a metastatic site from local organs. However, duodenal involvement from more distant organs, such as the ovaries, has rarely been reported. Herein, we present a case of a 68-year-old female who developed duodenal metastatic disease from a primary ovarian serous adenocarcinoma. The goal of this report is to encourage clinicians to keep a broad differential in patients complaining of abdominal pain, especially in those with a history of primary ovarian malignancy.

Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study.

Background and study aims The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON. Patients and methods This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery. Results A total of 189 patients (mean age 55.2 ±â€Š15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS ( P  = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS ( P  = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS, P  = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS, P  = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS ( P  = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively ( P  = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS, P  = 0.04). Conclusions When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.

Endoscopic ultrasound-guided through-the-needle microforceps biopsy in the evaluation of pancreatic cystic lesions: a multicenter study.

Background and study aims Accurate diagnosis and classification of pancreatic cysts (PCs) remains a challenge. The aims of this study were to: (1) evaluate the safety and technical success of a novel microforceps for EUS-guided through-the-needle biopsy (TTNB) of PCs; and (2) assess its diagnostic yield for mucinous PCs when compared to FNA cyst fluid analysis and cytology. Patients and methods This was a multicenter retrospective analysis of 47 patients who underwent EUS-FNA and TTNB for PCs between January 2014 and June 2017. Technical success was defined as acquisition of a specimen adequate for cytologic or histological evaluation. Cyst fluid carcinoembryonic antigen (CEA) was used to initially categorize cysts as non-mucinous (CEA < 192 ng/mL) or mucinous (CEA ≥ 192 ng/mL). Final diagnosis was based on identifiable mucinous pancreatic cystic epithelium on cytology, microforceps histology and/or surgical histology when available. Results Forty-seven patients with PCs (mean size 30.7 mm) were included. TTNB was successfully performed in 46 of 47 (97.9 %). Technical success was significantly lower with FNA (48.9 %) compared to TTNB (85.1 %) ( P  < .001). For cysts with insufficient amount of fluid for CEA (n = 19) or CEA < 192 ng/mL, the cumulative incremental diagnostic yield of a mucinous PC was significantly higher with TTNB vs. FNA (52.6 % vs 18.4 %; P  = .004). TTNB alone (34.4 %) diagnosed more mucinous PCs than either CEA ≥ 192 ng/mL alone (6.3 %) or when combined with FNA cytology (9.4 %). One episode of self-limited bleeding (2.1 %) and one of pancreatitis (2.1 %) occurred. Conclusions EUS-TTNB is safe and effective for evaluating PCs. TTNB may help increase the diagnostic yield of mucinous PCs.

Atypical Presentation of Gastric Volvulus.

Gastric volvulus has been reported in all age groups; however, it is typically diagnosed in the elderly. Organo-axial volvulus is the most common type, followed by the mesentero-axial and the combined types. Depending on the etiology, gastric volvulus can also be classified as primary (idiopathic) or secondary. Treatment of acute gastric volvulus involves laparoscopic or endoscopic procedures/maneuvers, depending on the severity of symptoms and surgical eligibility of the patient. Chronic gastric volvulus is typically managed conservatively, although laparoscopic or endoscopic interventions can also be employed depending on the severity of presentation.

Paraneoplastic Dermatomyositis Syndrome Presenting as Dysphagia.

Dermatomyositis (DM) is a rare autoimmune condition which predominantly affects females in the fifth and sixth decades of life. DM presents acutely or progressively as painless proximal skeletal muscle weakness and can be associated with a heliotropic rash around the eyes, and Gottron's papules on extensor surfaces of the hands. While the pathophysiology of DM is still unclear, abnormal T- and B-cell immune activity has been reported. DM has been associated with malignancy and has been shown to appear before, concurrently with, or after diagnosis of cancer. We report a 72-year-old female with renal clear cell carcinoma, breast cancer, and papillary serous carcinoma of the uterus, who presented with progressive weakness, 30 pound weight loss, and dysphagia over the past 3 months. She also reported difficulty in ambulating, facial rash, and inability to extend her fingers. Left bicep muscle biopsy and staining with nicotinamide adenine dinucleotide tetrazolium reductase (NADH-TR) identified frequent myofibers with targetoid-like changes consistent with DM. Despite immunosuppression with intravenous corticosteroids, she did not respond to the treatment and a percutaneous gastrostomy tube was placed for enteral feeding.

Autoimmune hepatitis in the setting of human immunodeficiency virus infection: A case series.

Liver injury in the setting of human immunodeficiency virus (HIV) infection is more commonly attributed to viral hepatitis or highly active antiretroviral treatment (HAART) toxicity. The severity of liver injury is an important cause of morbidity and mortality. The emergence of autoimmune diseases, particularly autoimmune hepatitis (AIH) in the setting of HIV infection, is rare. Previous reports indicate that elevated liver enzymes are a common denominator amongst these patients. We present two patients with HIV infection, on HAART, with virological suppression. Both patients presented with elevated liver enzymes, and following liver biopsies, were diagnosed with AIH. The clinical course of these patients underscore the therapeutic value of corticosteroids, and in some cases, addition of immunosuppression for AIH treatment.

Upper Gastrointestinal Bleeding Due to Idiopathic Oesophageal Ulceration in the Era of HAART: A Vanishing yet Pernicious Aetiology.

Oesophageal ulcers are a rare cause of upper Gastrointestinal Bleeding (GIB). In patients with Acquired Immune Deficiency Syndrome (AIDS), oesophageal diseases including oesophageal ulcers are very common. Idiopathic Oesophageal Ulcers (IOU) comprises a subgroup of oesophageal ulcers with no identifiable cause. IOU mainly present as odynophagia, retrosternal chest pain, decreased oral intake, and weight loss. Upper GIB is a rare presentation. In the era of Highly Active Anti Retroviral Therapy (HAART), with improvement in CD4 count, this entity is almost forgotten.

Colonic Ganglioneuroma: A Rare Finding during Colorectal Cancer Screening.

Ganglioneuromas are very rare clinical entities, and their occurrence in the large bowel lays further emphasis on their rarity. Ganglioneuromas are benign tumors of undifferentiated neural crest cells. Their clinical presentation is mostly asymptomatic, and if any symptoms are present at all, they are usually nonspecific, with excellent prognosis. We report an asymptomatic, 65-year-old male with a solitary ascending colonic polyp found on screening colonoscopy. Histology revealed benign polypoid spindle-cell proliferation as well as S100 reactivity, consistent with ganglioneuroma. We report on the clinical presentation and discuss the origin, epidemiology, treatment, and management of this lesion.