Indirect comparison of various lumen apposing metal stents for EUS-guided biliary and gallbladder drainage: A systematic review and meta-analysis.

BACKGROUND AND AIMS: Studies assessing endoscopic ultrasound guided biliary drainage (EUS-BD) or gallbladder drainage (EUS-GB) using lumen apposing metal stents (LAMS) have shown variable results based on the type of LAMS. We performed a meta-analysis of the available data. METHODS: Multiple online databases were searched for studies using LAMS (AXIOS or SPAXUS) for EUS-BD and EUS-GB. The outcomes of interest were technical success, clinical success and adverse events. Pooled proportions along with 95% confidence intervals (CI) were calculated. RESULTS: A total of 18 observational studies were included: 11 for AXIOS stent (433 patients with mean age 72 years and 54% males) and 7 for SPAXUS stent (242 patients with mean age 74 years and 50% males). The respective pooled outcomes for AXIOS stent (EUS-BD and EUS-GB) were: technical success (96.2% and 96.2%), clinical success (92.8% and 92.7%), total adverse events (10.1% and 23.6%), and bleeding (3.7% and 4.8%). The respective pooled outcomes for SPAXUS stent (EUS-BD and EUS-GB) were: technical success (93.8% and 95.9%), clinical success (90.1% and 94.2%), total adverse events (12.6% and 9.5%), and bleeding (3.1% and 1.8%). CONCLUSION: AXIOS and SPAXUS stents demonstrate similar pooled technical and clinical success rates. Adverse events occurred in 23.6% patients (AXIOS stent) and 9.5% patients (SPAXUS stent) during EUS-GB.

Sex differences in clinical characteristics and outcomes associated with alcoholic hepatitis.

BACKGROUND: Alcohol-associated liver disease is increasing among females with an earlier onset and more severe disease at lower levels of exposure. However, there is paucity of literature regarding sex differences related to alcoholic hepatitis. METHODS: Hospitalized patients with alcoholic hepatitis were selected from the US Nationwide readmissions database 2019. In this cohort, we evaluated sex differences in baseline comorbidities, alcoholic hepatitis related complications and mortality. A subset of patients with alcoholic hepatitis who were hospitalized between January and June 2019 were identified to study sex differences in 6 month readmission rate, mortality during readmission, and composite of mortality during index hospitalization or readmission. RESULTS: Among 112 790 patients with alcoholic hepatitis, 33.3% were female. Female patients were younger [48 (38-57) vs. 49 (39-58) years; both P  < 0.001] but had higher rates of important medical and mental-health related comorbidities. Compared with males, females had higher rates of hepatic encephalopathy (11.5% vs. 10.1; P  < 0.001), ascites (27.9% vs. 22.5%; P  < 0.001), portal hypertension (18.5% vs. 16.4%; P  < 0.001), cirrhosis (37.3% vs. 31.9%; P  < 0.001), weight loss (19.0% vs. 14.5%; P  < 0.001), hepatorenal syndrome (4.4% vs. 3.8%; P  < 0.001), spontaneous bacterial peritonitis (1.9% vs. 1.7%; P  = 0.026), sepsis (11.1% vs. 9.5%; P  < 0.001), and blood transfusion (12.9% vs. 8.7%; P  < 0.001). Females had a similar in-hospital mortality rate (4.3%) compared to males (4.1%; P  = 0.202; adjusted odds ratio (OR) 1.02, 95% CI (cardiac index) 0.89-1.15; P  = 0.994). In the subset of patients ( N  = 58 688), females had a higher 6-month readmission rate (48.9% vs. 44.9%; adjusted OR 1.12 (1.06-1.18); P  < 0.001), mortality during readmission (4.4% vs. 3.2%; OR 1.23 (1.08-1.40); P  < 0.01), and composite of mortality during index hospitalization or readmission (8.7% vs. 7.2%; OR 1.15 (1.04-1.27); P  < 0.01). CONCLUSION: Compared to their male counterparts, females with alcoholic hepatitis were generally younger but had higher rates of comorbidities, alcoholic hepatitis related complications, rehospitalizations and associated mortality. The greater risks of alcohol-associated liver dysfunction in females indicate the need for more aggressive management.

A Review of Hepatorenal Syndrome.

The development of acute kidney injury (AKI) is one of the most frequent complications in patients with cirrhosis. AKI due to volume depletion is the most common etiology and hepatorenal syndrome (HRS) is the second most common cause of AKI in these patients. HRS is the extreme form of kidney injury in patients with cirrhosis, which is caused due to a reduction in renal blood flow unresponsive to volume expansion. The literature involving HRS is rapidly evolving and newer tests and updated definitions have been proposed which allows timely identification and treatment. Here, we will discuss the definition, pathophysiology, prevention, diagnosis, and treatment of HRS.

Retrospective analysis of complications related to endoscopic retrograde cholangio-pancreatography in patients with cirrhosis vs patients without cirrhosis.

BACKGROUND: There is minimal objective data regarding adverse events related to endoscopic retrograde cholangio-pancreatography (ERCP) in patients with cirrhosis compared to those without cirrhosis and even fewer data comparing complications among cirrhosis patients based on severity of cirrhosis. AIM: To determine if patients with cirrhosis are at increased risk of adverse events related to ERCP: mainly pancreatitis, bleeding, perforation, cholangitis, and mortality; And to see if higher Child-Pugh (CP) score and Model for End-Stage Liver Disease (MELD) score are associated with higher post-ERCP complications. METHODS: We performed a retrospective analysis of 692 patients who underwent ERCP and analyzed the impact of cirrhosis etiology, gender, type of sedation used during procedure, interventions performed, and co-morbidities on the rate of complications in cirrhosis patients as compared to non-cirrhosis patients. RESULTS: Overall complications were higher in those with cirrhosis as compared to those without cirrhosis (P = 0.015 at significance level of 0.05). CP class, especially CP class C, was shown to be associated with a significantly higher rate of ERCP complications as compared to CP class A and CP class B (P = 0.010 at significance level of 0.05). CONCLUSION: The results of our study reaffirm that liver cirrhosis has an impact on the occurrence of complications during ERCP. Our study shows that CP class seems to be more reliable as compared to MELD score in predicting complications of ERCP in cirrhosis patients.

Impact of early cholecystectomy on the readmission rate in patients with acute gallstone cholangitis: a retrospective single-centre study.

BACKGROUND AND AIMS: The pathogenesis of acute cholangitis (AC) occurs with biliary obstruction followed by bacterial growth in the bile duct. The leading cause of AC is obstructing gallstones. There have been conflicting theories about the optimal timing for cholecystectomy following AC. The aim of this study is to assess the impact of early cholecystectomy on the 30-day readmission rate, 30-day mortality, 90-day readmission rate and the length of hospital stay. METHODS: This retrospective study was performed between January 2015 and January 2021 in a high-volume tertiary referral teaching hospital. Included patients were 18 years or older with a definitive diagnosis of acute gallstone cholangitis who underwent endoscopic retrograde cholangiopancreatography (ERCP) with complete clearance of the bile duct as an index procedure. We divided the patients into two groups: patients who underwent ERCP alone and those who underwent ERCP with laparoscopic cholecystectomy (LC) on the same admission (ERCP+LC). Data were extracted from electronic medical records. The primary endpoint of the study was the 30-day readmission rate. RESULTS: A total of 114 patients with AC met the inclusion criteria of the study. The ERCP+LC group had significantly lower rates of 30-day readmission (2.2% vs 42.6%, p<0.001), 90-day readmission (2.2% vs 30.9%, p<0.001) and 30-day mortality (2.2% vs 16.2%, p=0.017) when compared with the ERCP group. In a multivariate logistic regression analysis, patients in the ERCP+LC group had 90% lower odds of 30-day readmission compared with patients who did not undergo LC during admission (OR=0.1, 95% CI (0.032 to 0.313), p<0.001). CONCLUSION: Performing LC on same day admission was associated with a decrease in 30-day and 90-day readmission rate as well as 30-day mortality.

Multiple myeloma presenting as plasmacytoma causing obstructive jaundice.

Jaundice, weight loss, and anorexia are common symptoms that raise concern for pancreatic malignancy. Although the most common form of pancreatic malignancy is pancreatic adenocarcinoma, not all pancreatic malignancies are exocrine in origin. Pancreatic plasmacytomas are plasma cell tumors that can lead to similar presentations. Plasmacytomas are classified as either intra- or extramedullary, depending on their location; intramedullary plasmacytomas are more common than extramedullary plasmacytomas. Here, we present a case of pancreatic plasmacytoma in association with advanced multiple myeloma diagnosed using endoscopic ultrasonography-guided fine-needle aspiration.

Rare Case of Leukemoid Reaction in a Patient With Severe Alcoholic Hepatitis.

Alcoholic hepatitis results from excessive alcohol consumption in patients with or without underlying chronic liver disease. Leukemoid reactions have been associated with poor outcomes in severe alcoholic hepatitis. There are only a handful of reported cases describing this relationship, and the striking similarity in these cases was a high short-term mortality rate. We believe that these patients represent a unique subgroup of patients with alcoholic hepatitis and that leukemoid reaction is a poor prognostic indicator in this condition. Here, we describe a case of 55-year-old male with severe alcoholic hepatitis with superimposed candida esophagitis who was found to have leukemoid reaction during diagnostic workup.

Double pylorus in cirrhosis.

Double pylorus is an uncommon clinical condition that can be acquired or congenital. Most acquired cases arise as a complication of peptic ulcer disease and less commonly from other conditions such as gastric malignancy. We present a case of double pylorus in a cirrhotic patient diagnosed during surveillance endoscopy for esophageal varices.

Emphysematous Gastritis: A Real Indication for Emergent Surgical Intervention?

Emphysematous gastritis is a rare disease with gastric inflammation and intramural gas formation due to gas-forming microorganisms. It is diagnosed based on clinical presentation and imaging findings of gas in the gastric wall. Computed tomography is the preferred imaging modality. Early diagnosis and management are important since emphysematous gastritis is associated with high rates of morbidity and mortality. We present a case of emphysematous gastritis, which was successfully managed conservatively through early diagnosis and prompt treatment.

Wide-area transepithelial sampling in adjunct to forceps biopsy increases the absolute detection rates of Barrett's oesophagus and oesophageal dysplasia: a meta-analysis and systematic review.

BACKGROUND: Wide-area transepithelial sampling (WATS) is a new technique that uses an abrasive brush to obtain samples from a larger surface area of the oesophagus. Studies have shown promising results that WATS in adjunct to forceps biopsy (FB) increases the detection rate of Barrett's oesophagus (BE) as well as oesophageal dysplasia (ED). We conducted a systematic review and meta-analysis to compare the detection rates of BE and ED between FB and WATS in adjunct to FB. METHODS: A Literature search was done using electronic databases, including PubMed, Embase, Scopus, Cochrane and CINAHL from inception to 26 April 2020. A meta-analysis comparing detection rates of WATS in adjunct to FB versus FB using the random-effects model was done using RevMan V.5.3. RESULTS: Pooled data from 20 392 endoscopies across 11 studies showed an absolute increase in detection of 16% (95% CI 0.10% to 0.22%, p<0.00001). A relative increase of 1.62 was seen in detection rates of BE (95% CI 1.28 to 2.05, p<0.0001) when WATS was used with FB with the number needed to test (NNT) of 6.1 patients. For ED, a 2% absolute increase (95% CI 0.01 to 0.03, p=0.001) in additional diagnostic yield from WATS. A relative increase of 2.05 was seen in the detection rate of ED (95% CI 1.42 to 2.98, p=0.0001) yielding an NNT of 50 patients. CONCLUSION: Our study shows that WATS, as an adjunct to FB, improves both the absolute detection rate and relative detection rate of both BE and ED as compared to FB alone.

Novelty in the gut: a systematic review and meta-analysis of the gastrointestinal manifestations of COVID-19.

BACKGROUND: The COVID-19 epidemic has affected over 2.6 million people across 210 countries. Recent studies have shown that patients with COVID-19 experience relevant gastrointestinal (GI) symptoms. We aimed to perform a systematic review and meta-analysis on the GI symptoms of COVID-19. METHODS: A literature search was conducted via electronic databases, including PubMed, Embase, Scopus, and Google Scholar, from inception until 20 March 2020. Data were extracted from relevant studies. A systematic review of GI symptoms and a meta-analysis comparing symptoms in severe and non-severe patients was performed using RevMan V.5.3. RESULTS: Pooled data from 2477 patients with a reverse transcription-PCR-positive COVID-19 infection across 17 studies were analysed. Our study revealed that diarrhoea (7.8%) followed by nausea and/or vomiting (5.5 %) were the most common GI symptoms. We performed a meta-analysis comparing the odds of having GI symptoms in severe versus non-severe COVID-19-positive patients. 4 studies for nausea and/or vomiting, 5 studies for diarrhoea and 3 studies for abdominal pain were used for the analyses. There was no significant difference in the incidence of diarrhoea (OR=1.32, 95% CI 0.8 to 2.18, Z=1.07, p=0.28, I2=17%) or nausea and/or vomiting (OR=0.96, 95% CI 0.42 to 2.19, Z=0.10, p=0.92, I2=55%) between either group. However, there was seven times higher odds of having abdominal pain in patients with severe illness when compared with non-severe patients (OR=7.17, 95% CI 1.95 to 26.34, Z=2.97, p=0.003, I2=0%). CONCLUSION: Our study has reiterated that GI symptoms are an important clinical feature of COVID-19. Patients with severe disease are more likely to have abdominal pain as compared with patients with non-severe disease.

Transaminitis is an indicator of mortality in patients with COVID-19: A retrospective cohort study.

BACKGROUND: Since its discovery in Wuhan, China in December of 2019, the novel coronavirus has progressed to become one of the worst pandemics seen in the last 100 years. Recently, there has been an increased interest in the hepatic manifestations of coronavirus disease 19 (COVID-19). AIM: To describe the demographic and clinical characteristics of COVID-19 positive patients and study the association between transaminitis and all-cause mortality. METHODS: This is a descriptive retrospective cohort study of 130 consecutive patients with a positive COVID PCR test admitted between March 16, 2020 to May 14, 2020 at a tertiary care University-based medical center. The Wilcoxon-rank sum test and paired t-test were used for comparing non-parametric and parametric continuous variables respectively and a multivariable logistic regression models to study the association between transaminitis and mortality using SAS version 9.4 (SAS Institute, Cary, NC, United States). RESULTS: Out of the 130 patients, 73 (56%) patients were found to have transaminitis and 57 (44%) did not. When compared to patients without transaminitis, the transaminitis group was found to have a higher median body mass index (30.2 kg/m2 vs 27.3 kg/m2, P = 0.04). In the multivariate analysis those with transaminitis were found to have 3.4 times higher odds of dying as compared to those without transaminitis adjusting for gender, the Age-adjusted Charlson Comorbidity Index and admission to the intensive care unit (P = 0.03). CONCLUSION: Our study showed that transaminitis on admission was associated with severe clinical outcomes such as admission to the intensive care unit, need for mechanical ventilation, and mortality.

Treatment of metastatic carcinoma to the hip with CT-guided percutaneous acetabuloplasty: report of four cases.

Percutaneous acetabuloplasty (PA) is a promising treatment for painful metastatic lesions of the acetabulum. Four patients were treated with injection of the bone cement polymethylmethacrylate directly into the lesion. After the procedure, all four patients had improvement or relief of their pain and were able to resume weight-bearing activities. The procedure was well tolerated by each patient without morbidity. PA appears to be a reasonable palliative procedure for painful and fragile hips associated with metastatic bone disease.

Smaller and deeper lesions increase the number of acquired scan series in computed tomography-guided lung biopsy.

PURPOSE: To determine factors influencing the number of acquired scan series and subsequently the radiation dose and time during computed tomography (CT)-guided lung biopsies. MATERIALS AND METHODS: This Health Insurance Portability and Accountability Act-compliant, institutional review board-approved, retrospective study reviewed 50 consecutive procedures. Each procedure was separated into the following steps: trajectory planning, needle placement, needle insertion (extrapulmonary and intrapulmonary), and sampling and follow-up. The number of scan series, time, and radiation dose were calculated for each procedure and its steps. The effects of patient characteristics (age, sex, history of surgery that violated the pleura), procedure characteristics (needle-pleural angle, patient position), and lesion characteristics (size, depth, lobar location) on the number of scan series for the procedure and each step were evaluated using stepwise linear regression. The overall diagnostic accuracy, pneumothorax rate, and chest tube insertion rate were also calculated. RESULTS: The mean number of total CT scans was 21, the mean effective dose was 14 mSv, and the mean entrance skin dose was 249 mGy. On average, trajectory planning and needle insertion contributed most to the number of scan series (18.5% and 52.9%, respectively). For trajectory planning, a smaller lesion size and shallower needle-pleural angle were associated with an increased number of scans (R(2)=0.200, P=0.005). During needle insertion, smaller lesions were associated with increased scanning (R(2)=0.296, P<0.001), with both smaller and deeper lesions associated with an increased number of scans during the intrapulmonary component (R(2)=0.372, P<0.001). For the entire procedure, smaller lesions were associated with an increased number of scans (R(2)=0.12, P=0.01). CONCLUSION: Lesions that are smaller or deeper in the lung result in a higher number of CT scans, resulting in increased radiation dose and procedure time, with most of these performed during the needle insertion step.