Bowel preparation using 2-L split-dose polyethylene glycol regimen plus lubiprostone versus 4-L split-dose polyethylene glycol regimen: a randomized controlled trial.

BACKGROUND: Colonoscopy is a standard procedure for evaluating colon diseases and screening for colorectal cancer, and bowel cleanliness prior to colonoscopy is key. The aim of this study was to compare the bowel cleansing efficacy of low-volume (2 L) split-dose polyethylene glycol (PEG) plus single-dose (24 µg) lubiprostone (LB) and high-volume (4 L) split-dose PEG. METHODS: Patients scheduled to undergo outpatient colonoscopy between December 2019 and June 2021 at Rajavithi Hospital were enrolled and randomized into two groups: 2 L PEG + LB or 4 L PEG. Colon cleanliness was evaluated using the Boston Bowel Preparation Scale (BBPS) by reviewing images of the colon after completion of colonoscopy. Secondary outcomes comprised cecal intubation rate, procedure time, withdrawal time, polyp detection rate, adenoma detection rate, patient satisfaction, compliance (based on complete ingestion of bowel preparation regimen), willingness to repeat the preparation regimen, and associated adverse events. RESULTS: One hundred and forty patients were included, with 70 in each group. The mean total and segment-specific BBPS scores were not significantly different between groups. However, the rate of adequate bowel preparation was significantly higher in the 2 L PEG + LB group than the 4 L PEG group (100% [95% CI 94.6-100] versus 88.4% [95% CI 78.4-94.9], p = 0.004) in the per-protocol analysis. Colonic polyps were the most common finding. The polyp detection rate, adenoma detection rate, and all secondary outcomes were statistically similar in the two groups (p > 0.05). CONCLUSIONS: The combination of 2 L split-dose PEG plus LB improves bowel cleanliness (based on BBPS scores) to a comparable degree to the standard 4 L split-dose PEG, without additional adverse events and with a lower PEG volume.

Effectiveness and Safety of a Single 7-French Plastic Stent for Endoscopic Ultrasound-guided Pancreatic Pseudocyst Drainage and Long-term Follow-up Outcomes.

BACKGROUND: Endoscopic ultrasound (EUS)-guided cystogastrostomy with a single 7-French (Fr) double-pigtail stent (DPS) is less popular due to the concern of stent patency. We aimed to assess the effectiveness, complications, and long-term outcomes of a single 7-Fr DPS in the endoscopic drainage of uncomplicated pseudocysts, containing no or minimal (<10%) debris. METHODS: A retrospective review of patients with pancreatic pseudocysts, who underwent EUS-guided cystogastrostomy during 2010-2018, and a systematic review of the literature were conducted. RESULTS: Of 45 patients, 14 patients underwent endoscopic drainage of uncomplicated pseudocysts using a single 7-Fr × 5 cm DPS. The mean cyst size was 10.2 ± 3.5 cm. Stent placement had a 100% technical and clinical success, defined as complete resolution of symptoms and regression of the cyst size by more than 50% at 8 weeks after drainage. The median follow-up was 42.4 months (range, 10-103). The pseudocysts resolved without recurrence in 92.8%. Spontaneous stent dislodgment was noted in 70% at a mean follow-up of 18 months. Additional interventions were required in 14% of cases due to stent occlusion and migration. A systematic review of literature related to EUS-guided cystogastrostomy using single and multiple plastic stents included 9 of 333 studies (222 patients). The analysis showed the pooled clinical success of 89% (95% confidence interval [CI], 82.0-94.2) and complication rate of 13% (95% CI, 5.7-21.8). CONCLUSION: Selected uncomplicated pseudocysts can be treated effectively with a single 7-Fr DPS as it provides comparable clinical success and long-term outcomes as using larger or multiple stents.

Combination of EUS-FNA and elastography (strain ratio) to exclude malignant solid pancreatic lesions: A prospective single-blinded study.

BACKGROUND: Negative results of EUS-FNA for solid pancreatic lesions (SPL) can be false ones. Combination with strain ratio (SR) may ensure a correct benign diagnosis of SPL. AIMS: We prospectively evaluated the sensitivity rate of EUS-FNA and EUS elastography using the strain ratio method for diagnosing SPL. METHODS: Thirty-eight patients with SPL identified by CT or MRI between January 2013 and November 2013 were included in our prospective study. EUS diagnoses were made using SR by an endosonographer who was blinded to all clinical information. In SPL with adequate cellularity, the results of EUS-FNA were combined with strain ratio to diagnose SPL and the diagnostic value was calculated. RESULTS: Benign SPL were diagnosed in nine patients with surgical or guided-biopsy pathology (n = 3) and benign cells from FNA with stable disease during the 12-month follow-up time (n = 6). Using the best cut-off strain ratio level at 3.17, sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy rate of EUS elastography were 86.2%, 66.7%, 89.3%, 60%, and 81.6%, respectively. For the 28 patients who underwent EUS-FNA with results of adequate cellularity; EUS-FNA alone versus combination of results of cytology and SR provided sensitivity, specificity, PPV, NPV, and accuracy rate at 90% versus 95.2, 100% versus 71.4%, 100% versus 90.9%, 80% versus 83.3, and 92.9% versus 89.3%, respectively. CONCLUSIONS: In this prospective single-blinded study, the negative results of both EUS-FNA and SR were more reliable to exclude malignant SPL. The sensitivity of EUS elastography by SR was not superior to EUS-FNA. © 2015 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Revolution of hands-on model for interventional EUS: How to make a training model.

EUS interventions have an increasing role in the treatment for hepatobiliary-pancreatic diseases. However, the procedure itself is not frequently performed, needs expertise, and carries a high risk of complications. With these limitations, the hands-on practice model is very important for the endoscopist in training for EUS intervention. There have been various hands-on models for EUS interventions, ranging from in vivo living pig model to all-synthetic model. Although a living model provides realistic sensation, the preparation is complex and increases concerns for zoonotic issues. All-synthetic models are easier to prepare and store but not realistic and still need the room for improvement. Hybrid ex vivo model is more widely available and provides various training procedures but still needs special preparation for the porcine tissue.

Silymarin treatment and reduction of liver enzyme levels in non-alcoholic fatty liver disease: a case report.

Non-alcoholic fatty liver disease (NAFLD) is one of the most frequent chronic liver disorders worldwide. It is closely associated with metabolic syndrome components, including type 2 diabetes, hyperlipidaemia and obesity. To date, no effective drug treatment is available for NAFLD but several clinical trials suggested that silymarin, the active milk thistle extract, has well-documented antioxidant and hepatoprotective properties. In this case report, silymarin 140 mg twice daily decreased liver enzyme activity with a good safety profile in a patient with NAFLD and overweight, supporting silymarin as a promising supportive intervention aimed at normalizing liver activity in NAFLD. This article is part of the Current clinical use of silymarin in the treatment of toxic liver diseases: a case series Special Issue: https://www.drugsincontext.com/special_issues/current-clinical-use-of-silymarin-in-the-treatment-of-toxic-liver-diseases-a-case-series.

Contrast-enhanced endoscopic ultrasound for swollen lymph nodes.

Endoscopic ultrasound (EUS) is an important tool for the evaluation of lymphadenopathy, especially in intra-thoracic or intra-abdominal regions. EUS also provides tissue diagnosis via EUS fine-needle aspiration or biopsy. To select the target for biopsy or aspiration, conventional B-mode images are used for the evaluation, but this approach still lacks diagnostic accuracy. Contrast-enhanced EUS has been used to evaluate the vascularity of lesions. Most malignant lymphadenopathy shows heterogenous enhancement or defect of enhancement, while quantitative studies using time-intensity curves in contrast-enhanced harmonic EUS show a rapid decline in enhancement pattern. These findings are useful as an auxiliary method for tissue diagnosis or in cases in which tissue diagnosis is contraindicated.

Three-year evaluation of a novel, nonfluoroscopic, all-artificial model for EUS-guided biliary drainage training for the impact to practice: A prospective observational study (with videos).

Background and Objectives: EUS-guided biliary drainage (EUS-BD) required a dedicated training. We developed and evaluated a nonfluoroscopic, all-artificial training model known as Thai Association for Gastrointestinal Endoscopy Model 2 (TAGE-2) for the training of EUS-guided hepaticogastrostomy (EUS-HGS) and EUS-guided choledochoduodenostomy (EUS-CDS). We hypothesize that trainers and trainees would appreciate the ease of the nonfluoroscopy model and increase their confidence to start their real procedures in humans. Materials and Methods: We prospectively evaluated the TAGE-2 launched in two international EUS hands-on workshops and have followed trainees for 3 years to see long-term outcomes. After completing the training procedure, the participants answered questionnaires to assess their immediate satisfaction of the models in and also the impact of these models on their clinical practice 3 years after the workshop. Results: A total of 28 participants used the EUS-HGS model and 45 participants used the EUS-CDS model. The EUS-HGS model was rated as excellent by 60% of beginners and 40% by experienced and the EUS-CDS model was rated as excellent by 62.5% of beginners and 57.2% of experienced. The majority of trainees (85.7%) have started the EUS-BD procedure in humans without additional training in other models. Conclusion: Our nonfluoroscopic, all-artificial model for EUS-BD training is convenient to be used with good-to-excellent satisfaction scored by the participants in most aspects. It can help the majority of trainees start their procedures in humans without additional training in other models.

What You Need to Know Before Performing Endoscopic Ultrasound-guided Hepaticogastrostomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the primary treatment modality for bile duct obstruction. When ERCP is unsuccessful, percutaneous transhepatic biliary drainage can be an alternative method. Endoscopic ultrasound-guided biliary drainage (EUS-BD) has emerged as a treatment option for biliary obstruction, especially after ERCP failure. EUS-BD offers transluminal intrahepatic and extrahepatic drainage through a transgastric and transduodenal approach. EUS-guided hepaticogastrostomy (EUS-HGS) is an excellent choice for patients with hilar strictures or those with a surgically altered anatomy. The optimal steps in EUS-HGS are case selection, bile duct visualization, puncture-site selection, wire insertion and manipulation, tract dilation, and stent placement. Caution should be taken at each step to prevent complications. Dedicated devices for EUS-HGS have been developed to improve the technical success rate and reduce complications. This technical review focuses on the essential practical points at each step of EUS-HGS.

Endoscopic ultrasound-guided fine-needle aspiration of the left adrenal mass accessed via the gastrostomy tract: A case report with video.

INTRODUCTION AND IMPORTANCE: An adrenal metastasis is uncommon in esophageal cancer. Its diagnosis could be challenging if a percutaneous approach was inaccessible. Moreover, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), a useful adrenal sampling technique, is complicated by the luminal obstruction. CASE PRESENTATION: A patient with esophageal cancer accompanying by adrenal mass and established gastrostomy was described. The EUS-FNA of the adrenal lesion was successfully performed via the dilated gastrostomy tract. Adequate tissue for pathological examination was achieved, and the result indicated metastatic squamous cell carcinoma. Chemotherapy was started accordingly. CLINICAL DISCUSSION: This report described an uncommon event of adrenal metastasis of esophageal primary. Even though it is possible to perform EUS via the gastrostomy tract, performing EUS from an unusual direction might add some difficulty to an endoscopist, considering that EUS involves image pattern recognition in identifying structures. Thus, this technique should be operated by experienced EUS endoscopists. CONCLUSION: Gastrostomy can provide an enteral route for nutrition support in esophageal cancer patients. In addition, it could be an alternative EUS intervention portal when an esophageal stent is not accessible.

Coronavirus disease 2019 gastrointestinal and liver manifestations in adults: A review.

Coronavirus disease 2019 (COVID-19) is an important health problem that has a serious adverse impact on the global economy and healthcare systems. The virus is not only involved in the respiratory system, but also causes other systemic effects as well as several gastrointestinal and liver issues. Evidence has shown direct viral invasion into the gastrointestinal tissue and supporting vascular network, causing various manifestations such as diarrhea, nausea, gastrointestinal bleeding, and abnormal liver function tests. The degree of gastrointestinal injury, especially in terms of liver involvement, is correlated with disease severity. There is no specific treatment for gastrointestinal involvement, and the symptoms can be managed with supportive therapy. Moreover, increased liver decompensation and mortality can be found in COVID-19-infected patients with coexisting liver disease. As the virus can be identified in gastrointestinal contents, endoscopic procedures during the pandemic should be carefully selected and proper protection strategies should be encouraged to prevent viral transmission.

Diagnosis and treatment of the afferent loop syndrome.

Afferent loop syndrome (ALS) is a mechanical complication that arises after gastric surgery with gastrojejunostomy reconstruction. This condition was first described in 1950 by Roux, Pedoussaut, and Marchal to post-gastrectomy patients with bilious vomiting. Acute ALS is associated with complete obstruction and considered a surgical emergency, whereas chronic ALS is mostly related to partial obstruction of the afferent loop. The delay in diagnosis may lead to intestinal ischemia, perforation and can be associated with a high mortality rate up to 60%. Surgery is usually the mainstay treatment of ALS, but endoscopic therapy, including stent placement in malignancy-related, anastomotic stricture dilation, has been evolving over the past recent years.

Diffuse Esophageal Squamous Papillomatosis: A Rare Disease Associated with Acanthosis Nigricans and Tripe Palms.

Acanthosis nigricans with tripe palms is one of the skin manifestations of systemic conditions, as well as internal malignancy. There have been reports of this paraneoplastic condition's association with orocutaneous papillomatosis, but investigations into its relationship with diffuse esophageal papillomatosis are scarce. We report a case of acanthosis nigricans with tripe palms that was associated with diffuse esophageal squamous papillomatosis. A 40-year-old Thai woman with underlying systemic lupus erythematosus and secondary Sjögren's syndrome, who was recently diagnosed with acanthosis nigricans and tripe palms was investigated for occult gastrointestinal malignancy. An upper GI endoscopy revealed diffuse squamous papilloma along the entire esophagus and lower GI endoscopy revealed one pedunculated hyperplastic polyp 1 cm in size at the sigmoid colon. Long-term follow-up is needed to reassure these coexisting conditions belonging to benign systemic diseases without hidden malignancy.

When Should We Perform Endoscopic Drainage and Necrosectomy for Walled-Off Necrosis?

Endoscopic drainage and necrosectomy are now accepted treatment approaches for patients with symptomatic walled-off pancreatic necrosis (WON). The current recommendations advocate step-up approaches for the treatment of symptomatic WON. Previous recommendations stipulated that endoscopic intervention should be delayed until more than four weeks after the onset. Recent data on early drainage have been increasing and this option might be considered in well-encapsulated cases, but the percutaneous route is preferred if the drainage is performed within two weeks after onset or in nonencapsulated cases. Recently, additional drainage methods, such as the multiple gateway technique and multiple stent placement, have been developed to open up multiple dead spaces in the WON cavity. Endoscopic necrosectomy could be performed via the transluminal route or percutaneous route after failed initial and additional drainage procedures. The use of novel lumen-apposing stents is a promising treatment option that could reduce the number of steps, the procedure time, and the overall number of necrosectomies.

Duodenal tuberculosis; uncommon cause of gastric outlet obstruction.

Gastrointestinal tuberculosis manifesting as isolated duodenal involvement is uncommon. We present a case of 52 years old man with post-prandial abdominal pain, early satiety and weight loss. Upper endoscopy showed circumferential duodenal stricture adjacent to the ampulla with nodularity, erythema, and ulcerations of the overlying mucosa causing gastric outlet obstruction. Biopsy of duodenal stricture revealed chronic duodenitis and the patient was treated with acid suppression therapy. Endoscopic balloon dilation was also performed with no response. Abdominal computer tomography scan showed multiple enlarged abdominal lymph nodes and subsequent duodenal tissue culture was positive for Mycobacterium tuberculosis. His symptoms and duodenal stricture resolved completely after treatment with anti-tuberculous regimen.

Endoscopic Ultrasound-Guided Vascular Therapy for Portoduodenal Fistula.

Portoenteric fistula is a rare cause of massive upper gastrointestinal bleeding. Most cases can be treated with radiointervention or surgery, but portoenteric fistula is associated with a high mortality. We reported a case of intermittent massive upper gastrointestinal bleeding in a 33-year-old man with cholangiocarcinoma who underwent surgical resection followed by chemoradiation. A portoduodenal fistula due to chronic duodenal ulceration was identified. The bleeding was successfully controlled by endoscopic ultrasound-guided coil placement through the duodenal bulb using the anchoring technique. Follow-up endoscopy and computed tomography scan showed multiple coil placements between a part of the portal vein and the duodenal bulb without any evidence of portal vein thrombosis. There were no complications, and bleeding did not recur during the 8-month follow-up period.

Successful Closure of a Benign Refractory Tracheoesophageal Fistula Using an Over-the-Scope Clip after Failed Esophageal Stent Placement and Surgical Management.

Tracheoesophageal fistulas (TEFs) have traditionally been managed surgically, but the endoscopic approach is widely performed as a less invasive alternative. Different closure techniques have been proposed with inconsistent results. An over-the-scope clip (OTSC) appears to be a reasonable option, but long-term results have not been well defined. We report the long-term outcomes of a complex case of successful closure of a benign refractory TEF using an OTSC after failed surgical management and esophageal stent placement.