Gastric Glomus Tumors: The Roles of Endoscopic Ultrasound and Shared Decision-Making.

Gastric glomus tumors (GGTs) are mesenchymal neoplasms with indolent behavior that originate from the subepithelial layers of the stomach and represent up to 1% of all gastric tumors. GGT is detected incidentally during esophagogastroduodenoscopy (EGD) in a proportion of patients. Endoscopic ultrasound (EUS) evaluation of GGT is essential to establish the diagnosis and to differentiate it from gastrointestinal stromal tumors or gastric neuroendocrine tumors. An 80-year-old man who presented for abdominal discomfort was incidentally found to have a gastric antral nodule on EGD. Endoscopic biopsy demonstrated moderately erythematous gastric antral mucosa and a 1.5 cm subepithelial lesion along the greater curvature. An EUS revealed a subepithelial 1.6 cm × 1.3 cm isoechoic, homogenous lesion with small calcifications. Immunohistochemical staining of the fine needle biopsy specimen of the nodule was positive for neoplastic cells, smooth muscle actin, vimentin, patchy muscle-specific actin, and synaptophysin. There were no atypical cytologic features. These findings were consistent with GGT. The patient was not deemed to be a candidate for surgical resection due to advanced age and resolution of his symptoms. A shared decision was made to pursue regular surveillance. EUS is essential for evaluation of GGT. Currently, there are no guideline recommendations for surveillance of GGT detected on routine EGD in asymptomatic individuals. A definitive surgical treatment with partial gastrectomy was favored in previously published literature. For asymptomatic patients with GGT or those with resolution of symptoms, careful surveillance with serial abdominal imaging and EUS may be a reasonable option, especially in older patients with poor surgical candidacy.

Overlapping Hepatotoxicity and Colitis Associated with Immune Checkpoint Inhibitors.

Immune checkpoint inhibitors (ICIs) are monoclonal antibodies that are widely used for the management of many solid-organ and hematologic cancers. These agents work by inhibition of cytotoxic T-lymphocyte-associated antigen-4 (CTLA-4), programmed cell death-1 (PD-1), and PD ligand 1 (PD-L1). Hyperactivation of immune system results in ICI-associated adverse events. Simultaneous hepatotoxicity and colitis associated with ICIs is rare and potentially overlooked, as clinical symptoms are often nonspecific. A 73-year-old man with metastatic squamous cell carcinoma presented six weeks after starting pembrolizumab with abdominal discomfort and diarrhea. Pembrolizumab therapy was held, and supportive therapy with antidiarrheals provided partial relief. After initial workup, ICI-associated hepatitis (ICIH) and ICI-related colitis (ICIC) were diagnosed. Colitis resolution required corticosteroids. This case illustrates the importance of high index of clinical suspensions for gastrointestinal and hepatic adverse events associated with ICIs, which may be overlooked and result in severe complications. While isolated ICIH and ICIC are well known adverse events, overlapping ICIH and ICIC is rare. Prompt recognition, cessation of the inciting agent, and initiation of early supportive therapy are essential. Treatment may require corticosteroids or mycophenolate mofetil.

Non-Alcoholic Fatty Pancreas Disease: The Unsung Disease.

Non-alcoholic fatty pancreas disease (NAFPD) is a relatively new and emerging disease that is increasingly diagnosed yearly, like non-alcoholic fatty liver disease (NAFLD). It is associated especially with metabolic syndrome and obesity. As awareness of pancreatic steatosis and its clinical implications increase, it is diagnosed more frequently. The researchers have explained the clinical importance of NAFPD and the diseases it causes, such as pancreatitis, pancreatic insufficiency, and pancreatic cancer. Although the definitive treatment is not yet established, the primary treatment approach is weight loss since NAFPD is associated with metabolic syndrome as well as obesity. Although pharmacological agents, such as oral hypoglycemic agents, have been investigated in animal experiments, studies on humans have not been conducted. Since the research on NAFPD is still insufficient, it is a subject that needs to be investigated, and further studies are needed to explore its pathophysiology, clinical impact, and its management.

Respiratory Syncytial Virus Associated Hepatitis in Pregnancy.

Respiratory syncytial virus (RSV) predominantly affects children and typically manifests as an upper respiratory tract infection. Primary RSV infection in immunosuppressed adults may increase risks of disseminated infection manifesting as RSV hepatitis. A 29-year-old pregnant woman of 10 weeks gestation presented with mild right upper quadrant abdominal pain, intractable nausea, and vomiting, requiring hospitalization. Due to initial lab work showing significantly elevated liver transaminases, she underwent a thorough workup to evaluate for causes of hepatitis. Common viral and autoimmune etiologies of hepatitis were excluded with appropriate serologies. A respiratory viral molecular panel (RVP) was obtained to evaluate for SARS-CoV-2/coronavirus disease 2019 (COVID-19) infection, despite lack of typical respiratory symptoms. No structural pathologies were detected on abdominal imaging with ultrasound and magnetic resonance imaging. No other etiologies for the patient's hepatitis were detected other than RSV infection detected on RVP. The patient's care required close coordination between multiple different subspecialties. Her condition improved due to the early detection of RSV infection and prompt initiation of supportive care. This case highlights the need for providers to consider obtaining an RVP early in workup of hepatitis to evaluate for RSV infection, even when patients have minimal respiratory symptoms. A high index of suspicion is required for early identification of RSV hepatitis as timely supportive care may prevent progression to acute liver failure.

Stem cell therapy: a potential for the perils of pancreatitis.

Acute and chronic pancreatitis carry a significant disease burden and there is no definite treatment that exists for either. They are associated with local and systemic inflammation and lead to numerous complications. Stem cell therapy has been explored for other disease processes and is a topic of research that has gained momentum with regards to implications for acute and chronic pancreatitis. They not only carry the potential to aid in regeneration but also prevent pancreatic injury as well as injury of other organs and hence the resultant complications. Stem cells appear to have immunomodulatory properties and clinical potential as evidenced by numerous studies in animal models. This review article discusses the types of stem cells commonly used and the properties that show promise in the field of pancreatitis.

Prebiotics and Probiotics in Inflammatory Bowel Disease: Where are we now and where are we going?

The incidence, prevalence, and cost of care associated with diagnosis and management of inflammatory bowel disease are on the rise. The role of gut microbiota in the causation of Crohn's disease and ulcerative colitis has not been established yet. Nevertheless, several animal models and human studies point towards the association. Targeting intestinal dysbiosis for remission induction, maintenance, and relapse prevention is an attractive treatment approach with minimal adverse effects. However, the data is still conflicting. The purpose of this article is to provide the most comprehensive and updated review on the utility of prebiotics and probiotics in the management of active Crohn's disease and ulcerative colitis/pouchitis and their role in the remission induction, maintenance, and relapse prevention. A thorough literature review was performed on PubMed, Ovid Medline, and EMBASE using the terms "prebiotics AND ulcerative colitis", "probiotics AND ulcerative colitis", "prebiotics AND Crohn's disease", "probiotics AND Crohn's disease", "probiotics AND acute pouchitis", "probiotics AND chronic pouchitis" and "prebiotics AND pouchitis". Observational studies and clinical trials conducted on humans and published in the English language were included. A total of 71 clinical trials evaluating the utility of prebiotics and probiotics in the management of inflammatory bowel disease were reviewed and the findings were summarized. Most of these studies on probiotics evaluated lactobacillus, De Simone Formulation or Escherichia coli Nissle 1917 and there is some evidence supporting these agents for induction and maintenance of remission in ulcerative colitis and prevention of pouchitis relapse with minimal adverse effects. The efficacy of prebiotics such as fructooligosaccharides and Plantago ovata seeds in ulcerative colitis are inconclusive and the data regarding the utility of prebiotics in pouchitis is limited. The results of the clinical trials for remission induction and maintenance in active Crohn's disease or post-operative relapse with probiotics and prebiotics are inadequate and not very convincing. Prebiotics and probiotics are safe, effective and have great therapeutic potential. However, better designed clinical trials in the multicenter setting with a large sample and long duration of intervention are needed to identify the specific strain or combination of probiotics and prebiotics which will be more beneficial and effective in patients with inflammatory bowel disease.

The efficacy and safety of endoscopic ultrasound-guided liver biopsy versus percutaneous liver biopsy in patients with chronic liver disease: a retrospective single-center study.

BACKGROUND AND AIMS: There is limited literature on endoscopic ultrasound-guided liver biopsy (EUS-LB), a new method of obtaining liver biopsy (LB). METHODS: We conducted a retrospective study of the efficacy and safety of EUS-LB compared to percutaneous liver biopsy (PC-LB) in patients with chronic liver disease at our center between January 2018 and August 2019. RESULTS: Thirty patients underwent EUS-LB and 60 patients underwent PC-LB were identified (median follow-up post-LB was 8 days; interquartile range (IQR), 3-5 days). The median number of portal tracts was significantly higher in the PC-LB group (13 vs. 5; P < 0.0001). A histologic diagnosis was established in 93% of the EUS-LB group, compared to 100% in the PC-LB group (P = 0.841). Patients in EUS-LB group had significantly shorter hospital stay (median time of hospital stay was 3 vs. 4.2 h in the EUS-LB vs. PC-LB group, respectively; P = 0.004) and reported less pain compared to PC-LB group (median pain score was 0 vs. 3.5; P = 0.0009). EUS-LB were performed using a 19-gauge (n = 27) or 22-gauge (n = 3); there was a tendency towards higher number of portal tracts in the 22- vs. the 19-gauge needle group (6 vs. 5; P = 0.501). No patient in either group had significant adverse events such as bleeding or death. CONCLUSION: EUS-LB is safe and is associated with less pain, shorter hospital stay, and high diagnostic yield (93%) compared to PC-LB. Randomized trials are needed to standardize the utility of EUS-LB.

Removal of Esophageal Variceal Bands to Salvage Complete Esophageal Obstruction.

Esophageal varices develop in almost half of the patients with cirrhosis, and variceal hemorrhage constitutes an ominous sign with an increased risk of mortality. Variceal banding is considered an effective and mostly safe measure for primary and secondary prophylaxis. Although adverse events related to banding including dysphagia, stricture formation, bleeding, and ligation-induced ulcers have been described, complete esophageal obstruction is rare, with only 10 reported cases in the literature. Among those cases, 6 were managed conservatively; 1 patient had esophageal intraluminal dissection from an attempt to remove the bands using biopsy forceps but ultimately recovered with conservative management. Three patients developed strictures following removal of the bands, requiring repeated sessions of dilation therapy. We report on a patient who developed absolute dysphagia and complete esophageal obstruction after variceal banding. We successfully used the endoloop cutter hook to release the bands intact and restore luminal integrity.

Epidemiology, determinants, and management of AIDS cholangiopathy: A review.

Diseases of the liver and biliary tree have been described with significant frequency among patients with human immunodeficiency virus (HIV), and its advanced state, acquired immunodeficiency syndrome (AIDS). Through a variety of mechanisms, HIV/AIDS has been shown to affect the hepatic parenchyma and biliary tree, leading to liver inflammation and biliary strictures. One of the potential hepatobiliary complications of this viral infection is AIDS cholangiopathy, a syndrome of biliary obstruction and liver damage due to infection-related strictures of the biliary tract. AIDS cholangiopathy is highly associated with opportunistic infections and advanced immunosuppression in AIDS patients, and due to the increased availability of highly active antiretroviral therapy, is now primarily seen in instances of poor access to anti-retroviral therapy and medication non-compliance. While current published literature describes well the clinical, biochemical, and endoscopic management of AIDS-related cholangiopathy, information on its epidemiology, natural history, and pathology are not as well defined. The objective of this review is to summarize the available literature on AIDS cholangiopathy, emphasizing its epidemiology, course of disease, and determinants, while also revealing an updated approach for its evaluation and management.

Peppered and rare - Gastric and Duodenal Pseudomelanosis: A case series.

Upper Gastrointestinal (GI) pseudomelanosis is an uncommon entity characterized by endoscopic visualization of speckled dark mucosal pigmentation. While described in the rectum and colon, 'melanosis' or more aptly 'pseudomelanosis' is rare in the duodenum and exceedingly rare in the stomach. Five cases of pseudomelanosis were encountered at our department. Four females and one male were diagnosed, with a mean age of 70 years. All patients exhibited duodenal pseudomelanosis, with one demonstrating gastric antral pseudomelanosis as well. Common features among these patients included iron deficiency anemia, hypertension, chronic kidney disease, hydralazine use and iron supplementation. Biopsy specimens stained at least partially positive for iron and stains for calcium and copper were negative. Histochemical analysis revealed the pigment of pseudomelanosis to be mainly iron sulfide, exhibiting unpredictable staining patterns, hypothesized to be secondary to varying sulfur content and iron oxidation. It is visualized as dark deposits in macrophages at the tips of the duodenal villi. Upper GI pseudomelanosis remains a poorly understood finding, weakly associated with chronic kidney disease, diabetes, hypertension, iron supplements and anti-hypertensive medications. While the pathogenesis, clinical and prognostic significance remains unclear, it is thus far considered a benign condition.

Downregulation of ALAS1 by nicarbazin treatment underlies the reduced synthesis of protoporphyrin IX in shell gland of laying hens.

Shell colour is an important trait for eggs and an understanding of pigment deposition will assist potential management of egg shell colour loss. We demonstrated that nicarbazin feeding down-regulated ALAS1 and reduced protoporphyrin IX (PP IX) in both shell gland and eggshell, indicating the role of nicarbazin in inhibiting the synthesis of PP IX. Additionally, the expression levels of the genes did not show sequential upregulation in the same order of diurnal time-points (TP) during egg formation. The gene SLC25A38, responsible for transporting glycine from cytoplasm to mitochondria, and the gene ALAS1, encoding rate-limiting enzyme (delta-aminolevulinic acid synthase 1), had higher expression at 15 hr, as compared with 2, 5 and 23.5 hrs postoviposition. Interestingly, ABCB6, a gene encoding an enzyme responsible for transporting coproporphyrinogen III, showed higher expression level at 2 and 5 hrs. However, the expression of CPOX that converts coproporphyrinogen III to protoporphyrinogen III, and ABCG2 that transports PP IX out from mitochondria did not alter. Nevertheless, mitochondrial count per cell did not show consistent change in response to time-points postoviposition and nicarbazin feeding. The information obtained in the study sheds light on how nicarbazin disrupts the synthesis of PP IX.

Reference gene selection for the shell gland of laying hens in response to time-points of eggshell formation and nicarbazin.

Ten reference genes were investigated for normalization of gene expression data in the shell gland of laying hens. Analyses performed with geNorm revealed that hypoxanthine phosphoribosyltransferase 1 (HPRT1) and hydroxymethylbilane synthase (HMBS) were the two most stable reference genes in response to post-oviposition time alone (POT) or with nicarbazin treatment (POT+N) of laying hens. NormFinder analyses showed that the two most stable reference genes in response to POT and POT+N were 18S ribosomal RNA (18S rRNA), ribosomal protein L4 (RPL4) and HMBS, RPL4, respectively. BestKeeper analyses showed that 18S rRNA, RPL4 and HPRT1, HMBS were the two most stable reference genes for POT, and POT+N, respectively. Of the ten reference genes, all except B2M showed geNorm M <0.5, suggesting that they were stably expressed in the shell gland tissue. Consensus from these three programs suggested HPRT1 and HMBS could be used as the two most stable reference genes in the present study. Expression analyses of four candidate target genes with the two most and the two least stable genes showed that a combination of stable reference genes leads to more discriminable quantification of expression levels of target genes, while the least stable genes failed to do so. Therefore, HMBS and HPRT1 are recommended as the two most stable reference genes for the normalization of gene expression data at different stages of eggshell formation in brown-egg laying hens. Available statistical programs for reference gene ranking should include more robust analysis capability to analyse the gene expression data generated from factorial design experiments.

Colon Cancer Screening - Is It Time Yet?

The month of March is dedicated to Colon Cancer Awareness. Worldwide, colorectal cancer (CRC) incidence has been on the rise. It is currently the third most common cancer in men (746,000 cases, 10.0% of the total) and the second in women (614,000 cases, 9.2% of the total).1 Arecent meta-analysis reported a 61% risk reduction in CRC incidence with colonoscopy.2 Unlike screening programs for breast and prostate cancers, not only has CRC screening reduced mortality from colon cancer and detected early CRC, it has also decreased the incidence of CRC through detection and removal of pre-cancerous lesions. Studies have shown that screening for colorectal cancer provided 152 to 313 life-years-gained (LYG) per 1000 forty-year-old individuals.3 Anumber of modalities exist for CRC screening, which can broadly be categorized into stool-based tests and direct visualization tests. Stool-based tests include fecal occult blood testing (FOBT), fecal immunochemical testing (FIT) and stool DNAtesting. Direct visualization tests include endoscopic procedures such as colonoscopy and flexible sigmoidoscopy; and radiographic tests such as CT colonography, which has largely replaced air contrast barium enemas.4 The only reported population-based data for CRC in Pakistan comes from Bhurgri et al. in 2011.5It described Pakistan as a low risk region with an age standardized incidence rate (ASR) world per 100,000 of 7.1 in males and 5.2 in females, but with a much younger age and advanced stage at diagnosis. The ratio for individuals diagnosed with CRC under the age of 40, as oppose to over 40 years, was 3:1, which is much higher than the international average. Noteworthy as well, is an increase in incidence especially among men, noted between the study periods of 1995-1997 and 1997-2002. It ranks 7th in incidence among males, and 8th among females, with tobacco related malignancies topping the list.6 There has since been additional cross-sectional data from Pakistan echoing these findings of a younger age and advanced disease at presentation.7 Speaking from a public health perspective, Pakistan, while still battling communicable diseases, is now seeing an increasing incidence of non-communicable diseases population-based screening programs for CRC were not justified in most developing countries, citing low reported incidence and low resource health authorities; but that in limited regions with an ageing population and a shift to Western lifestyle, organized screening strategies needed to be developed. This can well be extrapolated to large urban centers in Pakistan. In a resource poor, conservative country like Pakistan, with poor health literacy, there exist many barriers to CRC screening which were summed up very articulately by Ahmed F in 2013. Quite appropriately, areas identified for further pursuit included, among others, the training of gastroenterologists, especially female ones, less expensive and more culturally acceptable screening options, and cost-effectiveness analyses. The recipe for any cancer screening program to be successful, begins with epidemiological data to document disease burden. There has not been any population-based cancer registry to report incidence data for the past few years. There is also no centralized cancer registry to effectively unify and coordinate data from across the country. Furthermore, even with a cancer registry there is no mandated reporting of malignancies from a health policy standpoint, as exists in the more developed world. The last population-based data we have for CRC was for cases reported until 2002, and there was already an increase in incidence noted in less than a decade, starting in 1995.5 Health awareness is another important factor. There is no data from Pakistan regarding patient or physician awareness regarding colon cancer. If one is to extrapolate, a cross-sectional study on breast cancer awareness, for which Pakistan demonstrates one of the highest incidences worldwide,6 reported that a mammogram had been performed in only 4.9 % of women in the cohort, while 61.5 % of the remainder had never even heard about it.7 It is also unclear if we have the infrastructure including endoscopy centers and adequate numbers of gastroenterologists to service the population at large. FOBTis available and cheap, but there is no data regarding the availability of FITor stool DNAtesting. In the absence of health insurance, it will certainly be a challenge to make CRC screening widely accessible. At what point does a disease warrant attention? While we may not have the luxury or the immediate necessity to introduce mass population-based CRC screening, we can certainly start with individual screening in populations who are at high risk of colorectal cancer due to family history and have adequate access to healthcare. There should be a concerted drive to revitalize cancer registration in order to guide health policy and to have an effective national cancer control program. Awareness programs are also needed to be established for the public and, specifically, for physicians as well.

Dual Infection with Hepatitis B and Epstein-Barr Virus Presenting with Severe Jaundice, Coagulopathy, and Hepatitis B Virus Chronicity Outcome.

BACKGROUND Hepatitis B virus (HBV) has been reported as a coinfection with hepatitis C virus (HCV), hepatitis D virus (HDV), cytomegalovirus (CMV), and human immunodeficiency virus (HIV). CASE REPORT A 34-year-old female presented to our clinic with epigastric pain and severe acute hepatitis manifested as jaundice associated with hyperbilirubinemia, elevated transaminases, and coagulopathy. The patient was diagnosed with acute HBV with Epstein-Barr virus (EBV) coinfection leading to subsequent chronic hepatitis B. CONCLUSIONS To our knowledge, this patient case is the first reported case of HBV and EBV coinfection reported in the literature. HBV and EBV coinfection may cause severe acute hepatitis with HBV chronicity.

Effect of production system and flock age on eggshell and egg internal quality measurements.

Egg quality was measured in eggs from different flocks that were reared together and then allocated to different production systems. Eggs were processed for measurements of eggshell and egg internal quality variables, scoring of ultrastructural mammillary layer features, completeness of cuticle cover, and protoporphyrin IX (PP IX) quantification. There was a significant main effect (P < 0.05) of production system on shell reflectivity, egg weight, and egg internal quality and significant effects of flock age on most measurements. The mammillary layer ultrastructural variables showed no clear relationship with production system and flock age. However, there was a significant interaction between production system and flock age for mammillary cap, early and late fusions. Cuticle cover ([Formula: see text]), was significantly higher in barn eggs (19.20), followed by free range (17.57), and cage eggs (15.99). Completeness of cuticle cover was significantly higher in eggs from the 44 week old flock than for 64 week and 73 week old flocks. For eggshells with cuticle intact, there was a significant main effect of both production system and flock age, and significant interaction between the two, for shell reflectivity, L*a*b* values and amount of PP IX. For PP IX, when this difference was calculated for the cuticle alone, there were no statistically significant differences. In 1 g of shell with and without cuticle, there was more PP IX in cage eggs (9.49 × 10-8, 7.90 × 10-8 mM) followed by free range (8.24 × 10-8, 6.90 × 10-8 mM), and barn eggs (8.64 × 10-8, 7.28 × 10-8 mM). Similar trends were recorded for the amount of PP IX in 1 g of cuticle, but the difference was not statistically significant. The amount of PP IX decreased significantly with increasing flock age. Comparing the cage and barn production systems at 68 week of flock age, there was no difference for the amount of PP IX in shell with or without cuticle, or in the cuticle alone. Eggs from the cage production system were darker in color and contained more PP IX mainly within the calcareous part of the shell. For the barn production system, the completeness of cuticle cover was higher and egg weight generally lower.

Infectious bronchitis virus and brown shell colour: Australian strains of infectious bronchitis virus affect brown eggshell colour in commercial laying hens differently.

The aim of the current study was to assess any effect of wild and vaccine Australian infectious bronchitis virus (IBV) strains on shell colour in brown-shelled eggs. In Experiment 1, eggs were collected from day 1 to day 13 post-inoculation (p.i.) from unvaccinated laying hens challenged with IBV wild strains T and N1/88 and from a negative control group of hens. In Experiment 2, eggs were collected from 2 to 22 days p.i. from unvaccinated and vaccinated laying hens challenged with either a wild or a vaccine strain of IBV. In Experiment 1, there was a significant effect (P < 0.05) of day p.i. and of viral strain on shell reflectivity, L* and protoporphyrin IX (PP IX) in eggshells, with and without cuticle. The mean PP IX/g of shell with and without cuticle was significantly higher on day 1 p.i. compared to day 7, after which PP IX increased with day p.i. In Experiment 2, shell reflectivity and L* increased and PP IX decreased with increased day p.i. until day 12. Shell reflectivity and L* decreased slightly after day 12 and increased again towards day 22. Shell reflectivity, L* and PP IX were not significantly different for eggshells from unvaccinated and vaccinated laying hens in the intact eggshell, but were significantly different in shells from which cuticle had been removed. In conclusion, the IBV strains reduced the intensity of brown shell colour to different extents with a lower amount of PP IX in eggshells.

Minimizing Radiation Exposure During ERCP by Avoiding Live or Continuous Fluoroscopy.

GOALS: The aim of this study was to assess the cumulative radiation exposure incurred by patients when using single-frame fluoroscopy. BACKGROUND: Single-frame fluoroscopy is a technique that can be used instead of pulsed fluoroscopy or continuous live fluoroscopy to minimize radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP). STUDY: We retrospectively reviewed ERCPs performed at our academic medical center. We recorded fluoroscopy time (FT, minutes), total radiation dose (mGy), dose area product (DAP, Gy cm²), and effective dose (ED, mSv). ERCP degree of difficulty was graded based on procedure complexity level. RESULTS: There were 400 ERCP procedures performed on 210 patients, 32 ERCPs were unsuccessful. The mean FT for all procedures was 1.57 minutes (median, 1.2 min); the mean FT for complexity score 1 procedures (0.78 min) was significantly shorter than for all other procedures (P<0.0001). The mean total radiation dose delivered for all procedures was 23.02 mGy (median, 14.95 mGy). The total radiation dose for complexity score 1 procedures (13.15 mGy) was significantly lower than for all other complexity scores (P<0.0001). The mean total DAP was 3.62 Gy cm² and the mean ED was 0.94 mSv. Procedure complexity score 1 DAP (2.1 Gy cm²) and ED (0.55 mSv) were significantly lower than for all other procedures (P<0.0001 for both). There was no statistically significant difference in these parameters when comparing successful and unsuccessful procedures. CONCLUSIONS: Successful ERCP can be performed using single-frame fluoroscopy only. Our results demonstrate lower radiation exposure using this technique than what is reported in the literature.