Endoscopic retrograde cholangiopancreatography using short-type double-balloon enteroscope: Experience in Hong Kong.

OBJECTIVE: To illustrate the efficacy and safety profile of double-balloon enteroscopy (DBE)-assisted endoscopic retrograde cholangiopancreatography (ERCP) using a short enteroscope in patients with surgically altered anatomy. METHODS: A retrospective study was performed to review the endoscopic outcomes of patients undergoing DBE-assisted ERCP for biliary diseases in Tuen Mun and Pok Oi hospitals in Hong Kong SAR, China from December 2015 to December 2020. RESULTS: Altogether 46 DBE-assisted ERCP procedures were performed in 37 patients. The enteroscopic success rate, defined as reaching the papilla or bilioenteric anastomosis, was 95.7% (95% confidence interval [CI] 85.2%-99.5%), which was significantly lower in patients with intact stomach than in those who had a previous gastrectomy (67% vs 100%, P = 0.014). The diagnostic ERCP success rate, defined as performance in an informative cholangiogram, was 84.1% (95% CI 69.9%-93.4%) in cases where it was attempted. Intended biliary therapeutic interventions were successfully performed in 76.1% (95% CI 61.2%-87.4%) of all procedures. Adverse events were reported in six (13.0%) procedures (95% CI 4.9%-26.3%), including the micro-perforation of the intestine in two (4.3%) patients with prior Roux-en-Y gastrectomy, three (6.5%) of acute cholangitis and one (2.2%) of acute pancreatitis. All adverse events were managed successfully using conservative methods except in one case of micro-perforation, which required a laparotomy. CONCLUSIONS: DBE-assisted ERCP using a short enteroscope is a promising technique for managing biliary diseases in patients with surgically altered anatomy. It must be performed to avoid perforation, particularly in patients with a Roux-en-Y reconstruction.

High incidence of hepatocellular carcinoma and cirrhotic complications in patients with psychiatric illness: a territory-wide cohort study.

BACKGROUND: Because of high-risk behaviours, sedentary lifestyle and side effects of medications, psychiatric patients are at risk of viral hepatitis, alcohol-related liver disease and non-alcoholic fatty liver disease. We aimed to study the incidence of hepatocellular carcinoma (HCC) and cirrhotic complications in psychiatric patients. METHODS: We identified consecutive adult patients in all public hospitals and clinics in Hong Kong with psychiatric diagnoses between year 2003 and 2007 using the Clinical Data Analysis and Reporting System, which represents in-patient and out-patient data of approximately 80% of the 7.4-million local population. The patients were followed for liver-related events (HCC and cirrhotic complications) and deaths until December 2017. Age- and sex-standardized incidence ratio (SIR) of HCC in psychiatric patients to the general population was estimated by Poisson model. RESULTS: We included 105,763 psychiatric patients without prior liver-related events in the final analysis. During a median (interquartile range) follow-up of 12.4 (11.0-13.7) years, 1461 (1.4%) patients developed liver-related events; 472 (0.4%) patients developed HCC. Compared with the general population, psychiatric patients had increased incidence of HCC (SIR 1.42, 95% confidence interval [CI] 1.28-1.57, P < 0.001). The SIR was highest in patients with drug-induced (SIR 3.18, 95% CI 2.41-4.11, P < 0.001) and alcohol-induced mental disorders (SIR 2.98, 95% CI 2.30-3.81, P < 0.001), but was also increased in patients with psychotic disorders (SIR 1.39, 95% CI 1.16-1.65, P < 0.001) and mood disorders (SIR 1.16, 95% CI 1.00-1.34, P = 0.047). Liver disease was the fifth most common cause of death in this population, accounting for 595 of 10,614 (5.6%) deaths. Importantly, 569 (38.9%) patients were not known to have liver diseases at the time of liver-related events. The median age at HCC diagnosis (61 [range 26-83] years) was older and the median overall survival (8.0 [95% CI 5.0-10.9] months) after HCC diagnosis was shorter in this cohort of psychiatric patients than other reports from Hong Kong. CONCLUSIONS: HCC, cirrhotic complications, and liver-related deaths are common in psychiatric patients, but liver diseases are often undiagnosed. More efforts are needed to identify liver diseases in the psychiatric population so that treatments and screening for HCC and varices can be provided to patients in need.

A gentleman with anemia and cholestasis.

Primary sclerosing cholangitis is a rare cause of cholestasis caused by progressive inflammation and fibrosis of both intrahepatic and extrahepatic bile ducts leading to multifocal ductal strictures. Herein, we report a case of primary sclerosing cholangitis and inflammatory bowel disease. The concomitant diagnosis of these two diseases is not typical. The management includes the treatment of inflammatory bowel disease and potential complications of primary sclerosing cholangitis, including dominant strictures of bile duct, portal hypertension, gallbladder diseases, cholangiocarcinoma, and colonoscopic surveillance.