Endoscopic therapy for Barrett's high grade dysplasia and intramucosal esophageal cancer is effective in community clinical practice by advanced endoscopists following multidisciplinary approach.

Barrett's esophagus with high-grade dysplasia (BEHGD) and intramucosal esophageal adenocarcinoma (IMC) can be treated by radiofrequency ablation (RFA) and endoscopic mucosal resection (EMR). Efficacy of RFA and EMR in academic medical centers has been demonstrated in previous studies. However, the clinical effectiveness of this approach in community clinical practice is not fully established.All patients with biopsy-proven BEHGD and IMC (T1a), who were treated endoscopically between 2007 and 2014, were prospectively enrolled. Treatment algorithms were determined by consensus opinion after presentation at gastrointestinal tumor board. Patients underwent EMR and/or RFA until eradication-of-dysplasia and complete remission of intestinal metaplasia (CRIM) was achieved. Patients were then enrolled in an endoscopic surveillance program.A total of 60 patients underwent endoscopic therapy for BEHGD (32) or IMC (28). Median length BE was 4 cm. Forty-six patients had EMR. Median treatment interval was nine months. Median follow-up was 33 months (Interquartile range: 16-50). Fifty-five (92%) patients achieved eradication-of-dysplasia and 52(87%) CRIM. One patient with BEHGD did not achieve any benefit six months into treatment. Nine (15%) patients relapsed after CRIM with nondysplastic-BE (6), BE with low-grade dysplasia (1), and BEHGD (2). After retreatment, eradication-of-intestinal metaplasia was achieved in five patients. BE length was a negative predictor for achieving CRIM (OR 0.81; P = 0.04). There were no procedure-related severe complications. Eleven patients with prior EMR developed symptomatic strictures, which were all successfully dilated.Endoscopic management of BEHGD and IMC can be safely and effectively performed in a community clinical practice similarly to high-volume academic medical centers when performed by advanced endoscopists following multidisciplinary approach.

Intraprocedural quality in endoscopic retrograde cholangiopancreatography: a meta-analysis.

OBJECTIVES: In 2006, the American College of Gastroenterology (ACG)/the American Society for Gastrointestinal Endoscopy (ASGE) Taskforce on Quality in Endoscopy published quality indicators for the major gastrointestinal procedures. Our primary aim was to use the published literature to assess current endoscopic retrograde cholangiopancreatography (ERCP) intraprocedural performance and compare it to the targets set by the ACG/ASGE taskforce. Our secondary aim was to determine whether performance varies across different health-care settings (academic and community), study designs (prospective and retrospective), and trainee participation. METHODS: A PubMed and EMBASE literature search from 1/1/2006 to 2/1/2013 was conducted. Articles were selected based on title, abstract, full text, and reporting of success rates for the intraprocedural quality indicators. Success rates, represented as numerical proportions, were collected from each study. For each success rate, a standard error and a 95% confidence interval (CI) was calculated. A random-effects meta-analysis model was used to weight each study, and a cumulative, weighted success rate (or effect size) for each indicator was determined. Random-effects meta-regression was then used to examine the impact of study setting, design, and trainee involvement on each quality indicator. RESULTS: A total of 8,005 articles were initially retrieved. Following the application of predefined criteria, 52 articles remained. The cumulative, weighted bile duct cannulation success rate was 89.3% (95% CI 0.866-0.919); pancreatic duct cannulation was 85.0% (95% CI 0.813-0.886); precut utilization rate was 10.5% (95% CI 0.087-0.123); common bile duct stone extraction rate was 88.3% (95% CI 0.825-0.941); and the rate of successful biliary stenting below the common bile duct bifurcation was 97.5% (95% CI 0.967-0.984). Subgroup analysis with meta-regression showed no statistically significant differences between academic and community settings, prospective and retrospective study designs, and trainee participation on success across bile duct cannulation, precut utilization, and common bile duct stone extraction (insufficient observations/variance for pancreatic duct cannulation and biliary stent placement). CONCLUSIONS: ERCP intraprocedural quality is in good standing. On the basis of this analysis, the two targets that could be potentially revised are precut utilization and biliary stenting. This analysis was confined to the published literature and therefore, in general, reflects the ERCP performance of institutions, primarily academic, that are conducting clinical research. Thus, it is difficult to generalize this performance assessment to the broader ERCP community as a whole.

Peritoneal fluid bilirubin to serum bilirubin ratio for the diagnosis of bile leaks in orthotopic liver transplant recipients.

BACKGROUND: A peritoneal fluid-to-serum bilirubin ratio (FSBR) of >5 has been shown to be accurate for the detection of bile leaks in post-cholecystectomy and trauma patients; however, there are no studies evaluating the accuracy of this threshold ratio in orthotopic liver transplant (OLT) recipients. METHODS: We performed a nested case-control analysis to determine the optimal FSBR threshold for diagnosing bile leaks in OLT recipients and the relationship between FSBR and likelihood of bile leak. Adult OLT patients undergoing ERCP for suspected bile leak were divided into 2 groups: those with cholangiographic evidence of a bile leak and those without evidence of leak. Of 57 included patients, 37 were found to have a bile leak on cholangiogram (64.9 %). RESULTS: We found a relationship between higher FSBR and the presence of a bile leak (OR 2.84, 95 % CI 1.37-5.88, p = 0.005). A FSBR of >3.25 produced the optimal sensitivity and specificity for identifying bile leaks in OLT recipients (area under ROC curve 0.8865, sensitivity 72.97 %, specificity 95.00 %). CONCLUSIONS: We conclude FSBR is an easily accessible, moderately accurate test to diagnose bile leaks in liver transplant recipients. This test can inform clinical decision-making with regard to the utilization of ERCP in lower suspicion transplant recipients with a suspected bile leak.

Clinical yield of diagnostic endoscopic retrograde cholangiopancreatography in orthotopic liver transplant recipients with suspected biliary complications.

Diagnostic endoscopic retrograde cholangiopancreatography (D-ERCP) is commonly performed for the evaluation of biliary complications after orthotopic liver transplantation (OLT). This practice is contrary to the national trend of reserving endoscopic retrograde cholangiopancreatography (ERCP) for therapeutic purposes. Our aim was to evaluate the clinical yield and complications of D-ERCP in OLT recipients. In this retrospective study, 165 OLT recipients who underwent ERCP between January 2006 and December 2010 at the University of Michigan were divided into 2 groups: (1) a therapeutic endoscopic retrograde cholangiopancreatography (T-ERCP) group (if they met prespecified criteria that suggested a high likelihood of endoscopic intervention) and (2) a D-ERCP group (if there was clinical suspicion of biliary disease but they did not meet any criteria). The 2 groups were compared with respect to the proportion of subjects undergoing high-yield ERCP, which was defined as a procedure resulting in a clinically important intervention that modified the disease course. 66.3% of the D-ERCP procedures were classified as high-yield, whereas 90.1% of the T-ERCP procedures were (P < 0.001). Serious complications were infrequent in both groups. A survey of practitioners caring for OLT recipients suggested that the rate of high-yield D-ERCP seen in this study is congruent with what is considered acceptable in clinical practice. In conclusion, although T-ERCP is more likely to reveal a pathological process requiring an intervention, D-ERCP appears to be an acceptable clinical strategy for OLT recipients because of the high likelihood of a high-yield study and the low rate of serious complications.

Do clinical characteristics predict the presence of small bowel angioectasias on capsule endoscopy?

BACKGROUND AND AIMS: Angioectasias (AVMs) are the most common vascular anomaly of the gastrointestinal (GI) tract, and these lesions are often associated with obscure gastrointestinal bleeding (OGIB). It is unknown if the presence of upper and/or lower gastrointestinal AVMs are predictive of small bowel AVMs. The aims of this study are to define the small bowel segmental distribution of AVMs and to identify the factors predicting the presence of small bowel AVMs among a cohort of patients with a known history of AVMs in the upper and/or lower GI tracts who are undergoing capsule endoscopy (CE) for OGIB. METHODS: We performed a retrospective cohort analysis of 1,125 patients undergoing CE at our institution between 11/1/2001 and 8/31/2007. Inclusion criteria were: (1) complete esophagoduodenoscopy (EGD), CE, and colonoscopy, (2) OGIB indication for CE, and (3) history of ≥ 1 AVM on EGD and/or colonoscopy that was previously treated in the past or deemed not to be a clinically significant source of bleeding. Exclusion criteria were: (1) history of radiation therapy to the GI tract, and (2) presence of a congenital or systemic disease associated with GI AVMs. Data were extracted on: (1) age; (2) gender; (3) presence of diabetes, (4) presence of hypertension, (5) presence of aortic stenosis, (6) history of non-steroidal anti-inflammatory therapy, (7) history of anticoagulant therapy, (8) hemoglobin, platelet, and INR values prior to CE; (9) baseline serum creatinine; and (10) presence and GI tract segmental location of AVMs. Multivariate logistic regression was used to identify independent predictors of small bowel AVMs. RESULTS: 1,125 patients underwent EGD, CE, and colonoscopy. One hundred and fourteen patients had a history of ≥ 1 AVM on EGD and/or colonoscopy and met inclusion and exclusion criteria. The mean age was 69 years, and 63% of patients were women. 37% of patients were found to have ≥ 1 jejunal AVM and 15% were found to have ≥ 1 ileal AVM. In multivariate analysis, age ≥ 65 (OR 2.62, P = 0.05) and the presence of AVMs on EGD (OR 4.61, P = 0.02) were predictive of jejunal AVMs. AVMs on colonoscopy alone were not predictive of jejunal or ileal AVMs. No factors were found to predict the presence of ileal AVMs. CONCLUSIONS: Patients with AVMs on EGD have an increased risk of jejunal AVMs on CE, particularly if they are elderly. Future studies should validate these findings in a prospective cohort.

Alcohol use and cigarette smoking as risk factors for post-endoscopic retrograde cholangiopancreatography pancreatitis.

BACKGROUND & AIMS: Alcohol use and cigarette smoking are associated with various pancreatic diseases, but it is not known whether they associate with post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP). We performed a retrospective case-control study to determine if these activities increase the risk of PEP. METHODS: We identified 7638 patients who had undergone ERCP in the University of Michigan Health System and applied exclusion criteria to identify 123 with PEP. We randomly selected 308 age- and sex-stratified controls (2.5-fold case sample); after applying exclusion criteria 248 remained. In a masked fashion, we collected data for alcohol use, cigarette smoking, and 5 internal control variables: suspected sphincter of Oddi dysfunction (SOD), pancreatic sphincterotomy, moderate/difficult cannulation, 2 or more pancreatic injections, and pancreatic stent placement. RESULTS: The univariate model showed an increased frequency of PEP in current drinkers (P < .001), former drinkers (P < .001), and former smokers (P < .001), as well as patients who were suspected of having SOD (P < .001), had undergone pancreatic sphincterotomy (P < .001), had a moderate/difficult cannulation (P = .001), and/or had 2 or more pancreatic injections (P = .007). The frequency of PEP was reduced in current smokers (P < .001). The multivariate model showed that the only independent significant predictors of PEP were current drinking (odds ratio [OR], 4.70; 95% confidence interval [CI], 2.60-8.50; P < .0001), former cigarette smoking (OR, 3.29; 95% CI, 1.28-8.44; P < .013), suspected SOD (OR, 3.69; 95% CI, 1.94-7.02; P < .001), and pancreatic sphincterotomy (OR, 5.91; 95% CI, 2.04-17.14; P = .001). CONCLUSIONS: Current alcohol use and potentially former cigarette smoking are new risk factors for PEP. It is important to consider these variables in designing PEP prevention trials.

Post-sphincterotomy bleeding: fully-covered metal stents for hemostasis.

BACKGROUND/OBJECTIVES: In endoscopic retrograde cholangiopancreatography, post-sphincterotomy bleeding (PSB) is a common complication of biliary sphincterotomy. Recently, the temporary placement of fully-covered metal stents (FCMS) into the biliary tree in order to achieve a tamponade effect has been described as an additional therapeutic option for PSB. The aim of this article is to review the literature on FCMS for hemostasis in PSB and update the treatment algorithm for this complication. METHODS: A PubMed literature search was conducted using the search terms post-sphincterotomy, bleeding, and stent. 33 articles were reviewed, along with their references, and four were found to describe the use of FCMS for hemostasis in PSB. RESULTS: A total of 21 patient cases were described in the four articles. All patients received FCMS for PSB hemostasis following the application and subsequent failure of traditional therapies (conventional pharmacologic injection, thermal or electrocoagulation, and mechanical therapy (balloon tamponade or endoclip)). Successful hemostasis was achieved in all patients through FCMS placement. No major complications were observed.    CONCLUSION: These 21 cases demonstrate that FCMS are a viable therapeutic option for PSB.  It is reasonable to consider stent placement for patients in which traditional interventions fail in order to avoid the need for angiographic or surgical hemostasis.

Advances in managing acute pancreatitis.

This review highlights advances in acute pancreatitis (AP) made in the past year. We focus on clinical aspects of AP - severe disease especially - and risk stratification tools to guide the clinical care of patients. Most patients with AP have mild disease that requires a diagnostic evaluation, self-limited supportive care, and a short hospital stay. In patients with potentially severe AP, it is important for clinicians to use available risk-stratifying tools to identify high-risk patients and initiate timely interventions such as aggressive fluid resuscitation, close monitoring, early initiation of enteral nutrition, and appropriate use of endoscopic retrograde cholangio-pancreatography. This approach decreases morbidity and possibly mortality and is supported by evidence drawn from recent clinical guidelines, historical literature, and the highest quality studies published in the last year.

A case of vanishing bile duct syndrome and IBD secondary to Hodgkin's lymphoma.

BACKGROUND: A 39-year-old man presented with a 2-month history of abdominal pain, jaundice, non-bloody diarrhea, weakness, and weight loss. Initial evaluation revealed intrahepatic ductopenia consistent with vanishing bile duct syndrome and IBD, type unclassified. Although treatment with budesonide improved his symptoms, they worsened several months later. On repeat evaluation, he was found to have extensive lymphadenopathy and an elevated white blood cell count. INVESTIGATIONS: Physical examination, laboratory investigations, abdominal ultrasound, CT scans, magnetic resonance cholangiopancreatography, endoscopic retrograde cholangiopancreatography, colonoscopies with biopsies, hepatic biopsy, axillary lymph node biopsy. DIAGNOSIS: Hodgkin's lymphoma with secondary vanishing bile duct syndrome and IBD, type unclassified. MANAGEMENT: The initial symptoms were managed with budesonide, but following recurrence, the patient's underlying lymphoma was treated with nitrogen mustard and dexamethasone.