Pancreatic Cancer Screening for At-Risk Individuals (Pancreas Scan Study): Yield, Harms, and Outcomes From a Prospective Multicenter Study.

INTRODUCTION: Guidelines endorse pancreatic cancer screening in genetically susceptible individuals. We conducted a prospective, multicenter study to determine yield, harms, and outcomes of pancreatic cancer screening. METHODS: All high-risk individuals undergoing pancreatic cancer screening at 5 centers from 2020 to 2022 were prospectively enrolled. Pancreas findings were designated as low-risk (fatty or chronic pancreatitis-like changes), intermediate-risk (neuroendocrine tumor [NET] <2 cm or branch-duct intraductal papillary mucinous neoplasm [IPMN]), or high-risk lesions (high-grade pancreatic intraepithelial neoplasia/dysplasia, main-duct IPMN, NET >2 cm, or pancreatic cancer). Harms from screening included adverse events during screening or undergoing low-yield pancreatic surgery. Annual screening was performed using endoscopic ultrasound and or magnetic resonance cholangiopancreatography. Annual screening for new-onset diabetes using fasting blood sugar was also performed ( ClinicalTrials.gov : NCT05006131). RESULTS: During the study period, 252 patients underwent pancreatic cancer screening. Mean age was 59.9 years, 69% were female, and 79.4% were White. Common indications were BRCA 1/2 (36.9%), familial pancreatic cancer syndrome kindred (31.7%), ataxia telangiectasia mutated (3.5%), Lynch syndrome (6.7%), Peutz-Jeghers (4.3%), and familial atypical multiple mole melanoma (3.5%). Low-risk lesions were noted in 23.4% and intermediate-risk lesions in 31.7%, almost all of which were branch-duct IPMN without worrisome features. High-risk lesions were noted in 2 patients (0.8%), who were diagnosed with pancreas cancer at stages T2N1M0 and T2N1M1. Prediabetes was noted in 18.2% and new-onset diabetes in 1.7%. Abnormal fasting blood sugar was not associated with pancreatic lesions. There were no adverse events from screening tests, and no patient underwent low-yield pancreatic surgery. DISCUSSION: Pancreatic cancer screening detected high-risk lesions with lower frequency than previously reported. No harms from screening were noted.

Randomized Comparison of 3 High-Level Disinfection and Sterilization Procedures for Duodenoscopes.

BACKGROUND AND AIMS: Duodenoscopes have been implicated in the transmission of multidrug-resistant organisms (MDRO). We compared the frequency of duodenoscope contamination with MDRO or any other bacteria after disinfection or sterilization by 3 different methods. METHODS: We performed a single-center prospective randomized study in which duodenoscopes were randomly reprocessed by standard high-level disinfection (sHLD), double high-level disinfection (dHLD), or standard high-level disinfection followed by ethylene oxide gas sterilization (HLD/ETO). Samples were collected from the elevator mechanism and working channel of each duodenoscope and cultured before use. The primary outcome was the proportion of duodenoscopes with an elevator mechanism or working channel culture showing 1 or more MDRO; secondary outcomes included the frequency of duodenoscope contamination with more than 0 and 10 or more colony-forming units (CFU) of aerobic bacterial growth on either sampling location. RESULTS: After 3 months of enrollment, the study was closed because of the futility; we did not observe sufficient events to evaluate the primary outcome. Among 541 duodenoscope culture events, 516 were included in the final analysis. No duodenoscope culture in any group was positive for MDRO. Bacterial growth of more than 0 CFU was noted in 16.1% duodenoscopes in the sHLD group, 16.0% in the dHLD group, and 22.5% in the HLD/ETO group (P = .21). Bacterial growth or 10 or more CFU was noted in 2.3% of duodenoscopes in the sHLD group, 4.1% in the dHLD group, and 4.2% in the HLD/ETO group (P = .36). MRDOs were cultured from 3.2% of pre-procedure rectal swabs and 2.5% of duodenal aspirates. CONCLUSIONS: In a comparison of duodenoscopes reprocessed by sHLD, dHLD, or HLD/ETO, we found no significant differences between groups for MDRO or bacteria contamination. Enhanced disinfection methods (dHLD or HLD/ETO) did not provide additional protection against contamination. However, insufficient events occurred to assess our primary study end-point. ClinicalTrials.gov no: NCT02611648.

Baseline Features and Reasons for Nonparticipation in the Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) Study, a Colorectal Cancer Screening Trial.

Importance: The Colonoscopy Versus Fecal Immunochemical Test in Reducing Mortality From Colorectal Cancer (CONFIRM) randomized clinical trial sought to recruit 50 000 adults into a study comparing colorectal cancer (CRC) mortality outcomes after randomization to either an annual fecal immunochemical test (FIT) or colonoscopy. Objective: To (1) describe study participant characteristics and (2) examine who declined participation because of a preference for colonoscopy or stool testing (ie, fecal occult blood test [FOBT]/FIT) and assess that preference's association with geographic and temporal factors. Design, Setting, and Participants: This cross-sectional study within CONFIRM, which completed enrollment through 46 Department of Veterans Affairs medical centers between May 22, 2012, and December 1, 2017, with follow-up planned through 2028, comprised veterans aged 50 to 75 years with an average CRC risk and due for screening. Data were analyzed between March 7 and December 5, 2022. Exposure: Case report forms were used to capture enrolled participant data and reasons for declining participation among otherwise eligible individuals. Main Outcomes and Measures: Descriptive statistics were used to characterize the cohort overall and by intervention. Among individuals declining participation, logistic regression was used to compare preference for FOBT/FIT or colonoscopy by recruitment region and year. Results: A total of 50 126 participants were recruited (mean [SD] age, 59.1 [6.9] years; 46 618 [93.0%] male and 3508 [7.0%] female). The cohort was racially and ethnically diverse, with 748 (1.5%) identifying as Asian, 12 021 (24.0%) as Black, 415 (0.8%) as Native American or Alaska Native, 34 629 (69.1%) as White, and 1877 (3.7%) as other race, including multiracial; and 5734 (11.4%) as having Hispanic ethnicity. Of the 11 109 eligible individuals who declined participation (18.0%), 4824 (43.4%) declined due to a stated preference for a specific screening test, with FOBT/FIT being the most preferred method (2820 [58.5%]) vs colonoscopy (1958 [40.6%]; P < .001) or other screening tests (46 [1.0%] P < .001). Preference for FOBT/FIT was strongest in the West (963 of 1472 [65.4%]) and modest elsewhere, ranging from 199 of 371 (53.6%) in the Northeast to 884 of 1543 (57.3%) in the Midwest (P = .001). Adjusting for region, the preference for FOBT/FIT increased by 19% per recruitment year (odds ratio, 1.19; 95% CI, 1.14-1.25). Conclusions and Relevance: In this cross-sectional analysis of veterans choosing nonenrollment in the CONFIRM study, those who declined participation more often preferred FOBT or FIT over colonoscopy. This preference increased over time and was strongest in the western US and may provide insight into trends in CRC screening preferences.

Comparison Between Intravenous and Intramuscular Octreotide in the Management of Heyde's Syndrome.

Heyde's syndrome is defined as a triad of aortic stenosis, anemia due to angiodysplasia-related bleeding, and von Willebrand syndrome type 2A. It is a rare disease and a diagnostic challenge. Treatment modalities include symptomatic management, blood transfusions, aortic valve replacement, and medications such as octreotide. Here, we report the case of a patient who was resistant to symptomatic management, aortic valve replacement, as well as intravenous octreotide.

The pancreas and COVID-19: a clinical conundrum.

With the progression of the COVID-19 pandemic, the classic manifestations of COVID-19 (e.g., persistent fever, dry cough, pneumonia, and acute respiratory distress syndrome in the severe disease) have expanded to include less common complications of the extrapulmonary organs. Recent evidence has shown that COVID-19 patients with concomitant presence of GI symptoms are at higher risk of developing severe disease and have poor clinical outcomes. Recently, multiple SARS-CoV-2-induced acute pancreatitis (AP) cases have been reported. This literature review aims to provide an insight into SARS-CoV-2-directed invasion of the pancreas. We will also review the currently available literature on the clinical effects of SARS-CoV-2, including AP and mild elevation of lipase levels in patients with COVID-19. In addition, we will discuss plausible mechanisms that underly SARS-CoV-2-induced pancreatitis.

Gastric Schwannoma In a Patient Undergoing Sleeve Gastrectomy: Uncommon Gastric Tumor Discovered Incidentally During a Common Gastric Procedure.

BACKGROUND Obesity is a major global health issue associated with significant co-morbidities. Regarding its treatment, the use of bariatric procedures is increasing due to their efficacy in weight reduction and improved management of the associated medical conditions. Although comprehensive preoperative evaluation is essential, routine upper endoscopy is controversial. CASE REPORT We present the case of a 27-year-old woman with a history of morbid obesity, hypertension, and diabetes mellitus. She had multiple unsuccessful attempts at lifestyle modification for weight reduction. Accordingly, she was scheduled for sleeve gastrectomy. However, the operation was canceled due to the incidental intra-operative finding of a gastric mass. She was diagnosed as having gastric schwannoma, which is considered a rare gastrointestinal neoplasm. CONCLUSIONS Comprehensive preoperative evaluation of patients undergoing bariatric procedures is essential. The present case is a good example of the value of upper endoscopy in the evaluation of patients, including those who are asymptomatic.

Fibrous ring formation in cirrhotics treated with band ligation.

BACKGROUND/AIMS: We observed that the formation of a fibrous ring following variceal eradication appeared to be associated with less variceal recurrence. We aimed to evaluate this formally. METHODOLOGY: Twenty-one cirrhotic patients with a fibrous ring formation in the esophagus after eradication of varices (FR group) were compared with 21 controls of similar age, gender and liver function but without ring formation after eradication in terms of variceal recurrence, portal hypertension related bleeding and survival. RESULTS: Both groups were similar with regard to baseline demographic and clinical data. During a mean follow-up period of 28.8+/-18.3 (SD) months, variceal recurrence occurred in 2 (9.5%) patients in the FR group compared to 10 (47.6%) in the control group (p=0.005). Cox regression model revealed a significant difference in probability of variceal recurrence between the two groups (p=0.006). In the FR group 1 patient bled and 3 died vs. 2 and 6 patients in the control group respectively. The differences between the groups in relation to bleeding and death were not statistically significant. CONCLUSIONS: In cirrhotic patients undergoing band ligation for eradication of esophageal varices, the formation of a fibrous ring is followed by a lower variceal recurrence rate.

Endoscopic Ultrasound-Guided Vascular Interventions: From Diagnosis to Treatment.

The development of endoscopic ultrasound was driven by the need to develop less invasive alternatives to surgical and radiologic interventions for a wide variety of gastrointestinal conditions. During the past decade, there has been a very rapid growth in the clinical role and capabilities of endoscopic ultrasound-guided therapeutic interventions. Endoscopic ultrasound offers both real-time imaging and access to structures within and adjacent to the gastrointestinal tract. The proximity of the gastrointestinal system to vascular structures throughout the abdomen and the mediastinum allows for endoscopic ultrasound-guided vascular access and therapy. The recent development of endoscopic ultrasound-guided vascular interventions has relied both on finding new applications for standard endoscopic accessories and on commandeering tools originally developed for use in interventional radiology. This article provides a review of the literature regarding the current state of endoscopic ultrasound for the management of variceal and nonvariceal bleeding, portal vein angiography and pressure measurements, intrahepatic portosystemic shunts, endoscopic ultrasound-guided fine-needle aspiration for portal vein sampling, drug administration and embolization as well as endoscopic ultrasound-guided cardiac access and treatment.

Mind the Gap: Successful Endoscopic Closure of a Large Gastric Sleeve Leak Using an Endoscopic Stent and Over-the-Scope Clips.

Laparoscopic sleeve gastrectomy (LSG) is gaining popularity for the treatment of morbid obesity. It is regarded as a simple, low-cost procedure achieving significant weight loss within a short period of time. LSG is considered a safe procedure with a relatively low complication rate. The complications encountered nevertheless can result in significant morbidity and may even be lethal. The most significant complications are staple-line bleeding, stricture, and staple-line leak. The purpose of this paper is to present a case of a 31-year-old patient complicated by a 3.06 cm staple-line leak 10 days after LSG. Review of the current literature regarding this complication as well as outline of a strategy for the management of large post-LSG gastric leaks is suggested.

Azathioprine discontinuation earlier than 6 months in Crohn's disease patients started on anti-TNF therapy is associated with loss of response and the need for anti-TNF dose escalation.

OBJECTIVES: A high proportion of Crohn's disease (CD) patients lose response to antitumor necrosis factor (anti-TNF) and therapy needs to be intensified. We aimed to prospectively determine the predictors and frequency of anti-TNF loss of response and therefore the need for dose escalation and de-escalation in CD patients treated with infliximab or adalimumab. METHODS: All patients were anti-TNF naive while concomitant azathioprine was administered for 6 months. In patients initially responding to anti-TNF and subsequently losing clinical response after the first 14 weeks of therapy, dose escalation was scheduled. During the follow-up period and after 1 year of intensified administration, anti-TNF was de-escalated in patients in remission. RESULTS: A total of 161 patients were started on infliximab (n=96) or adalimumab (n=65); however, 29 patients (18.0%) did not respond to therapy and were excluded from further analysis. From the remaining 132 patients (infliximab=77, adalimumab=55), 31 (23.5%) needed a dose escalation for maintenance of remission during a median 28-month follow-up period. Factors associated with loss of response and therefore the need for anti-TNF dose escalation were azathioprine discontinuation earlier than 6 months and smoking. Most patients achieved clinical remission (n=25, 80.6%) without other interventions and among these, 16 patients (64%) were successfully de-escalated to the standard maintenance infliximab or adalimumab dose schedule after 1 year of intensified anti-TNF administration. CONCLUSION: Azathioprine discontinuation earlier than 6 months and smoking in CD patients started on anti-TNF therapy is associated with loss of response and the need for anti-TNF dose escalation.

When to use antibiotics in the cirrhotic patient? The evidence base.

Bacterial infections are very common in advanced cirrhosis and are a leading cause of death of these patients. Early and appropriate empirical antibiotic treatment of infection is essential in determining patient's outcome. A strategy of careful restriction of prophylactic antibiotics to the high-risk populations could contribute to the reduction of multidrug resistant bacteria. This article reviews and reports the current knowledge in the use of antibiotics in the cirrhotic patient.

Refractory GERD: increased body mass index is associated with persisting acid exposure but not hypersensitive esophagus or functional heartburn.

OBJECTIVE: To compare the incidence of persistent abnormal acid exposure, hypersensitive esophagus (HE), and functional heartburn (FH) in obese/overweight and normal-weight patients referred for impedance-pH monitoring, because of persisting gastroesophageal reflux disease (GERD) symptoms despite therapy with proton pump inhibitors (PPIs). ΜETHODS: Patients with normal endoscopy and typical GERD symptoms, despite PPI therapy twice daily, underwent 24-h impedance-pH monitoring while on therapy. Distal esophageal acid exposure (% time pH<4) was measured and reflux episodes were classified into acid or nonacid. A positive symptom index was defined when at least 50% of symptom events were preceded by reflux episodes. Patients were categorized as those with persistent abnormal acid exposure, those with HE, and those with FH. The incidence of persistent abnormal acid exposure, HE, and FH between overweight/obese patients (BMI≥25 kg/m) and normal-weight patients (BMI<25 kg/m) was subsequently evaluated. RESULTS: A total of 246 patients (women: 158, men: 88, increased BMI: 151, normal BMI: 95, mean age 55, range 18-75 years) were included. Persistent abnormal acid exposure was found in 39 patients (increased BMI: 31, normal BMI: 8), HE in 77 patients (increased BMI: 43, normal BMI: 34), and FH in 118 patients (increased BMI: 69, normal BMI: 49). When comparing BMI among all three groups, patients with increased BMI were more likely to have acid reflux than HE or FH (P=0.03). CONCLUSION: In patients with GERD symptoms refractory to double-dose PPI therapy, those with increased BMI are more likely to have persistent abnormal acid exposure than HE or FH.

Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis.

BACKGROUND-AIM: The aim of this study is to identify the long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS: Seven patients with chronic refractory pouchitis diagnosed by clinical, endoscopic and histological criteria received infliximab 5 mg/kg at 0, 2, and 6 weeks and thereafter every 2 months for 1 year. Three patients had fistulae (1 pouch-bladder, 2 perianal) and 4 extraintestinal manifestations (2 erythema nodosum, 2 arthralgiae). All patients were refractory to antibiotics and 3 to azathioprine. Crohn's disease was excluded after re-evaluation of the history and small bowel examination with enteroclysis or capsule endoscopy. Clinical response was classified as complete, partial and no response. Fistulae closure was classified as complete, partial and no closure. The pouchitis disease activity index (PDAI) was used as an outcome measure. All patients were followed up for 3 years after discontinuation of infliximab therapy. RESULTS: After 1 year of infliximab administration 5 patients had complete clinical response, 1 partial clinical response and 1 no response, while 2 out of the 3 patients with fistulae had a complete closure. The median PDAI dropped from 11 (baseline) (range, 10-14) to 5 (range, 3-8). Extraintestinal manifestations were in complete remission too. Three years after completion of therapy, all patients with complete clinical response at one year remained in remission. CONCLUSIONS: One year infliximab administration is associated with a long term benefit in patients with chronic refractory pouchitis following IPAA for UC.

Noninvasive markers of fibrosis and inflammation in clinical practice: prospective comparison with liver biopsy.

BACKGROUND: The efficiency of transient elastography for the assessment of liver fibrosis has been evaluated mainly in patients with chronic hepatitis C and chronic hepatitis B, with few studies with nonviral chronic liver disease (CLD) such as autoimmune hepatitis, alcoholic liver disease and nonalcoholic steatohepatitis. In this study, we examined the value of transient elastography in a number of groups in comparison with the Fibrotest/Actitest (FT/AT), using the liver biopsy (LB) as the reference standard. METHODS: An unselected and consecutive group of 65 patients had an LB either as part of an initial diagnosis or of a follow-up assessment, and in addition had a transient elastography measurement [Fibroscan (FS)] and serum blood tests FT/AT performed before the LB. The group consisted of patients diagnosed with a variety of CLD: chronic hepatitis C (n=27), chronic hepatitis B (n=8), alcoholic liver disease (n=14), autoimmune hepatitis (n=13) and nonalcoholic steatohepatitis (n=4). RESULTS: FS optimal cutoff values were 9.70 kPa for F at least 2, 13.00 kPa for F at least 3, and 16.00 kPa for F=4. The areas under the receiver operating characteristic curve of FS and FT for F at least 2 were 0.88 versus 0.78 in the viral CLD group and 0.81 versus 0.70 in the nonviral CLD group and 0.87 versus 0.80 in all patients. The areas under the receiver operating characteristic curve for A at least 2 in all patients was 0.83. The optimal cutoff for A at least 2 was 0.50. CONCLUSION: FT/AT is a reliable method for predicting significant liver fibrosis and necroinflammation in both viral and nonviral CLD patients with a value measurement comparable with that of the FS.