Alterations in microbiome associated with acute pancreatitis.

PURPOSE OF REVIEW: This review evaluates the current knowledge of gut microbiome alterations in acute pancreatitis, including those that can increase acute pancreatitis risk or worsen disease severity, and the mechanisms of gut microbiome driven injury in acute pancreatitis. RECENT FINDINGS: Recent observational studies in humans showed the association of gut microbiome changes (decreased gut microbiome diversity, alterations in relative abundances of certain species, and association of unique species with functional pathways) with acute pancreatitis risk and severity. Furthermore, in-vivo studies highlighted the role of gut microbiome in the development and severity of acute pancreatitis using FMT models. The gut barrier integrity, immune cell homeostasis, and microbial metabolites appear to play key roles in acute pancreatitis risk and severity. SUMMARY: Large human cohort studies that assess gut microbiome profile, its metabolites and impact on acute pancreatitis risk and severity will be crucial for development of innovative prediction, prevention and treatment strategies.

Racial and Ethnic Minorities With Acute Pancreatitis Live in Neighborhoods With Higher Social Vulnerability Scores.

OBJECTIVES: The primary objective was to determine differences in Social Vulnerability Index (SVI) scores among minorities (African-Americans and Hispanics) with acute pancreatitis (AP) compared with non-Hispanic whites (NHWs) with AP. The secondary objectives were to determine differences in diet, sulfidogenic bacteria gene copy numbers (gcn) and hydrogen sulfide (H2S) levels between the 2 groups. MATERIALS AND METHODS: Patients with AP were enrolled during hospitalization (n = 54). Patient residential addresses were geocoded, and the Centers for Disease Control and Prevention's SVI scores were appended. Dietary intake and serum H2S levels were determined. Microbial DNAs were isolated from stool, and gcn of sulfidogenic bacteria were determined. RESULTS: Minorities had higher SVI scores compared with NHWs ( P = 0.006). They also had lower consumption of beneficial nutrients such as omega-3 fatty acids [stearidonic ( P = 0.019), and eicosapentaenoic acid ( P = 0.042)], vitamin D ( P = 0.025), and protein from seafood ( P = 0.031). Lastly, minorities had higher pan-dissimilatory sulfite reductase A ( pan-dsrA ) gcn ( P = 0.033) but no significant differences in H2S levels ( P = 0.226). CONCLUSION: Minorities with AP have higher SVI compared with NHWs with AP. Higher SVI scores, lower consumption of beneficial nutrients, and increased gcn of pan-dsrA in minorities with AP suggest that neighborhood vulnerability could be contributing to AP inequities.

The efficacy of Hemospray in managing bleeding related to gastrointestinal tumors: systematic review and meta-analysis.

INTRODUCTION: Gastrointestinal (GI) bleeding stemming from malignant tumors is increasingly recognized, due to advancements in oncology and detection methods. Traditional endoscopic hemostatic techniques have shown variable success rates in managing hemorrhagic GI neoplasms. Hemospray, an emerging endoscopic hemostatic powder, offers promise in treating upper GI bleeding, potentially extending its utility to neoplastic bleeding sites. This meta-analysis aims to evaluate Hemospray's efficacy in managing bleeding related to GI tumors. METHODS: We searched Embase, Scopus, Web of Science, Medline/PubMed, and Cochrane. Inclusion criteria encompassed studies focusing on malignancy-related GI bleeding and interventions utilizing Hemospray. Comparative studies contrasted Hemospray with standard endoscopic treatments (SET), while noncomparative studies assessed Hemospray's efficacy independently. The risk of bias was assessed using appropriate tools, and statistical analyses were performed using Review Manager and open Meta analyst software. RESULTS: We included 19 studies in our meta-analysis. Hemospray demonstrated higher rates of immediate hemostasis compared to SET (odds ratio: 17.14, 95% confidence interval: 4.27-68.86), with consistent outcomes across studies. Rebleeding rates at 14 and 30 days were comparable between Hemospray and SET groups, suggesting similar efficacy in long-term hemostasis. Hemospray showed a significantly lower need for nonendoscopic hemostasis compared to SET (odds ratio: 0.51, 95% confidence interval: 0.30-0.87), indicating a potential reduction in supplementary interventions. Safety assessments revealed no confirmed adverse events directly linked to Hemospray. CONCLUSION: This meta-analysis highlights Hemospray's efficacy in achieving immediate hemostasis in GI tumor-related bleeding, with potential benefits in reducing supplementary interventions and improving patient outcomes. Despite comparable rebleeding rates, Hemospray emerges as a valuable adjunctive therapy in managing malignant GI bleeding.

Ectopic Opening of the Bile Duct Into the Duodenal Bulb: Complications of Biliary Drainage.

Ectopic opening of the common bile duct is a rare anatomic variant that is associated with increased risk of complications such as cholangitis, peptic ulcer disease, and even cholangiocarcinoma. Ectopic opening of the common bile duct into the duodenal bulb is a rare form of ectopic opening of the common bile duct accounting for 0.1%-2.7% of cases of anomalous biliary drainage. Identification of such pathology is important because of its varied presentation and considerable operative and procedural implications. We report a rare case of duodenal bulb opening of the common bile duct in a patient who presented with cholangitis.

Safety and Efficacy of Endoscopic Submucosal Dissection in the Management of Gastric Tube Cancers After Esophagectomy: A Systematic Review.

Esophagectomy is the proposed standard of care for resectable primary esophageal cancers and recurrent lesions in the reconstructed gastric tube (GT); however, it carries significant morbidity and mortality. Endoscopic submucosal dissection (ESD) has established its role in the management of primary esophageal cancers with growing evidence of its safety in resecting recurrent primary lesions in GT. Our study aims to evaluate the safety and efficacy of ESD in the management of recurrent, localized primary esophageal cancers in GT. We searched PubMed, CENTRAL, EMBASE, Scopus, and clinical trial registries from inception to March 2023 for articles evaluating the safety and efficacy of ESD in the management of recurrent cancerous lesions in GT. Our primary outcome was the en bloc resection rate. Secondary outcomes were curative resection rate, complete resection rate, intra-procedural complication rate, post-procedure complication rate, and five-year survival rate. Seven studies with a total of 165 patients undergoing 192 ESDs were included in the review. The pooled en bloc resection rate was 92.5% (95% CI: 87.7-95.6), which was reported in all seven studies. Pooled complete resection rate was 78.9% (95% CI: 64.5-88.5) per three studies, pooled curative resection rate was 73.9% (95% CI: 63.5-82.2) per four studies, and pooled intra-procedural complication rate was 10.2% (95% CI: 1.5-46.3), which was reported in four studies. Only three studies reported a five-year survival rate that was 65.5% (95% CI: 56.0-73.9). ESD is safe and efficacious in the management of GT cancer after esophagectomy.

Diet, Gut Microbiome, and Their End Metabolites Associate With Acute Pancreatitis Risk.

INTRODUCTION: Diet and decreased gut microbiome diversity has been associated with acute pancreatitis (AP) risk. However, differences in dietary intake, gut microbiome, and their impact on microbial end metabolites have not been studied in AP. We aimed to determine differences in (i) dietary intake (ii) gut microbiome diversity and sulfidogenic bacterial abundance, and (iii) serum short-chain fatty acid (SCFA) and hydrogen sulfide (H 2 S) concentrations in AP and control subjects. METHODS: This case-control study recruited 54 AP and 46 control subjects during hospitalization. Clinical and diet data and stool and blood samples were collected. 16S rDNA sequencing was used to determine gut microbiome alpha diversity and composition. Serum SCFA and H 2 S levels were measured. Machine learning (ML) model was used to identify microbial targets associated with AP. RESULTS: AP patients had a decreased intake of vitamin D 3 , whole grains, fish, and beneficial eicosapentaenoic, docosapentaenoic, and docosahexaenoic acids. AP patients also had lower gut microbiome diversity ( P = 0.021) and a higher abundance of sulfidogenic bacteria including Veillonella sp. and Haemophilus sp., which were associated with AP risk. Serum acetate and H 2 S concentrations were significantly higher in the AP group ( P < 0.001 and P = 0.043, respectively). ML model had 96% predictive ability to distinguish AP patients from controls. DISCUSSION: AP patients have decreased beneficial nutrient intake and gut microbiome diversity. An increased abundance of H 2 S-producing genera in the AP and SCFA-producing genera in the control group and predictive ability of ML model to distinguish AP patients indicates that diet, gut microbiota, and their end metabolites play a key role in AP.

Endoscopic ultrasound-guided embolization of refractory splenic pseudoaneurysm.

Video 1EUS-guided embolization of splenic arterial pseudoaneurysm refractory to previous percutaneous transcatheter arterial embolizations.

Immunoglobulin G4 associated autoimmune cholangitis and pancreatitis following the administration of nivolumab: A case report.

BACKGROUND: Immune checkpoint inhibitors have significantly improved survivals for an increasing range of malignancies but at the cost of several immune-related adverse events, the management of which can be challenging due to its mimicry of other autoimmune related disorders such as immunoglobulin G4 (IgG4) related disease when the pancreaticobiliary system is affected. Nivolumab, an IgG4 monoclonal antibody, has been associated with cholangitis and pancreatitis, however its association with IgG4 related disease has not been reported to date. CASE SUMMARY: We present a case of immune-related pancreatitis and cholangiopathy in a patient who completed treatment with nivolumab for anal squamous cell carcinoma. Patients IgG4 levels was normal on presentation. She responded to steroids but due to concerns for malignant biliary stricture, she opted for surgery, the pathology of which suggested IgG4 related disease. CONCLUSION: We hypothesize this case of IgG4 related cholangitis and pancreatitis was likely triggered by nivolumab.

Occlusion rate and complications of plastic biliary stent placement in patients undergoing neoadjuvant chemoradiotherapy for pancreatic cancer with malignant biliary obstruction.

GOALS: Determine the stent patency rates, need for additional procedures, and complications of plastic biliary during neoadjuvant chemoradiotherapy. BACKGROUND: Malignant biliary obstruction is a common feature of pancreatic ductal adenocarcinoma and palliative plastic biliary stents are often placed during neoadjuvant chemoradiotherapy before operative resection. RESULTS: Forty-nine patients with resectable or locally advanced pancreatic adenocarcinoma and biliary obstruction had a plastic biliary stent placed endoscopically before receiving neoadjuvant chemoradiotherapy. The median time from stent placement to surgery was 150 days (range 71-227 d). Twenty-two patients (45%) had stents that remained patent throughout the course of neoadjuvant therapy. The remaining 27 patients (55%) required repeat ERCP for stent exchange, a median of 82.5 days after original stent placement (range 14-183 d). Fourteen were owing to abnormal liver enzymes or jaundice and 13 were owing to ascending cholangitis. Seventeen of these patients (63%) required hospitalization for either biliary obstruction or cholangitis. The median duration of hospital stay associated with stent exchange was 3 days (range 2-13 d). CONCLUSIONS: Plastic biliary stents do not maintain patency during the time required for most patients to complete neoadjuvant chemoradiotherapy for pancreatic adenocarcinoma. Initially placing metallic stents to palliate malignant obstruction may be a safer and more cost-effective strategy.

Endoscopic Ultrasound-Guided Biliary Drainage.

Endoscopic ultrasound (EUS)-guided biliary drainage is an emerging technique that combines the advantages of the endoscopic and percutaneous approaches, without the inconveniences and discomfort of an indwelling external catheter. There has been growing interest and experience in EUS-biliary drainage. Several different EUS-guided techniques have been developed to access the obstructed biliary tree from either the stomach or duodenum, according to the location of the stricture, the anatomy of the patient, and the experience of the endoscopist.

Evolving role of the endoscopist in management of gastrointestinal neuroendocrine tumors.

Neuroendocrine tumors (NETs) are uncommon gastrointestinal neoplasms but have been increasingly recognized over the past few decades. Luminal NETs originate from the submucosa of the gastrointestinal tract and careful endoscopic exam is a key for accurate diagnosis. Despite their reputation as indolent tumors with a good prognosis, some NETs may have aggressive features with associated poor long-term survival. Management of NETs requires full understanding of tumor size, depth of invasion, local lymphadenopathy status, and location within the gastrointestinal tract. Staging with endoscopic ultrasound or cross-sectional imaging is important for determining whether endoscopic treatment is feasible. In general, small superficial NETs can be managed by endoscopic mucosal resection and endoscopic submucosal dissection (ESD). In contrast, NETs larger than 2 cm are almost universally treated with surgical resection with lymphadenectomy. For those tumors between 11-20 mm in size, careful evaluation can identify which NETs may be managed with endoscopic resection. The increasing adoption of ESD may improve the results of endoscopic resection for luminal NETs. However, enthusiasm for endoscopic resection must be tempered with respect for the more definitive curative results afforded by surgical treatment with more advanced lesions.

Multiorgan Failure Predicts Mortality in Emphysematous Pancreatitis: A Case Report and Systematic Analysis of the Literature.

Emphysematous pancreatitis (EP) is a subtype of acute necrotizing pancreatitis (ANP) characterized by the presence of gas in and around the pancreas. Although investigators have studied prognostic factors in ANP, less is known about EP. We aimed to determine predictors of mortality and identify changes in management strategies for EP. A PubMed search was performed to identify EP cases. Data were gathered about patient demographics, clinical findings, laboratory results, radiological studies, procedures, outcomes, and mortality. Data were analyzed using univariate and multivariate logistic regression analyses. Including a case from our institution, the study cohort included 64 subjects. The overall mortality rate was 32.8% (21/64). On univariate analysis, age (P = 0.019), hypotension (P = 0.007), gas outside the pancreas on computed tomography imaging (P = 0.003), initial surgical evacuation (P = 0.007), and the development of multiorgan failure (P = 0.008) were associated with mortality. On multivariate analysis, only the development of multiorgan failure was found to be an independent predictor of mortality (P = 0.039). The overall mortality rate of 32.8% for EP is similar to the mortality rates published for ANP. The development of multiorgan failure in EP is strongly associated with increased mortality. Percutaneous and endoscopic approaches have been replacing surgical interventions.

An outbreak of pertussis in a hematology-oncology care unit: implications for adult vaccination policy.

A pertussis outbreak in a hematology-oncology care unit involved 10 (8.5%) of 117 employees. The source was an employee who contracted pertussis via a family contact. No screened patients contracted pertussis, likely because of isolation measures. Hospitals should consider employee immunization with acellular vaccine in healthcare settings where pertussis has high rates of morbidity and mortality.

Malignant biliary obstruction: From palliation to treatment.

Malignant obstruction of the bile duct from cholangiocarcinoma, pancreatic adenocarcinoma, or other tumors is a common problem which may cause debilitating symptoms and increase the risk of subsequent surgery. The optimal treatment - including the decision whether to treat prior to resection - depends on the type of malignancy, as well as the stage of disease. Preoperative biliary drainage is generally discouraged due to the risk of infectious complications, though some situations may benefit. Patients who require neoadjuvant therapy will require decompression for the prolonged period until attempted surgical cure. For pancreatic cancer patients, self-expanding metallic stents are superior to plastic stents for achieving lasting decompression without stent occlusion. For cholangiocarcinoma patients, treatment with percutaneous methods or nasobiliary drainage may be superior to endoscopic stent placement, with less risk of infectious complications or failure. For patients of either malignancy who have advanced disease with palliative goals only, the choice of stent for endoscopic decompression depends on estimated survival, with plastic stents favored for survival of < 4 mo. New endoscopic techniques may actually extend stent patency and patient survival for these patients by achieving local control of the obstructing tumor. Both photodynamic therapy and radiofrequency ablation may play a role in extending survival of patients with malignant biliary obstruction.

Celiac Disease Presenting as Profound Diarrhea and Weight Loss - A Celiac Crisis.

BACKGROUND Celiac disease is a hypersensitivity enteropathy that can have various presentations in adults. Rarely, patients can present with severe lab abnormalities, dehydration and weight loss caused by celiac disease - a celiac crisis. CASE REPORT A 46-year-old male with a past medical history significant for diabetes mellitus, type 2 (DM2) and recently treated Bell's Palsy presented to the emergency room complaining of weakness, diarrhea and lightheadedness. On presentation, the patient had a systolic blood pressure (SBP) of 60 mm Hg and a lactic acidosis with pH of 7.28. Infectious etiologies of diarrhea were ruled out. The patient had an EGD which showed erythema of the duodenal bulb. Serum anti-gliadin and anti-TTG IgA were both elevated suggesting Celiac disease. Biopsies showed histopathology consistent with celiac disease. The patient's diarrhea resolved after initiation of a gluten free diet. He gained 25 kilograms after discharge and did not require further hospitalizations for diarrhea. CONCLUSIONS Celiac crisis is a very rare presentation of celiac disease in adults but nonetheless should be considered in patients with marked metabolic derangements in the setting of osmotic diarrhea. Treatment consists of a gluten free diet and may require management with steroids and total parenteral nutrition (TPN).