The Natural Course of Pancreatic Cysts in Inflammatory Bowel Disease: Results of a Long-term Follow-up.

OBJECTIVES: The natural course of pancreatic cysts in inflammatory bowel disease (IBD) is unknown. We aim to describe the natural course of pancreatic cysts in IBD and evaluate long-term outcomes. METHODS: A database of patients with abdominal imaging diagnosis of pancreatic cysts (2008-2019) was reviewed. Patients with IBD and pancreatic cysts (study group) and pancreatic cysts without IBD (controls) were selected. Outcomes were measured at 1, 3, 5, and 10 years. Several logistic regression models were used for analysis. RESULTS: Of the 1789 patients evaluated, 1690 had pancreatic cysts without IBD, and 78 had IBD and pancreatic cysts. Majority of cysts were intraductal papillary mucinous neoplasms. Patients with IBD and pancreatic cysts were more likely to be diagnosed with pancreatic cysts at a younger age (P < 0.001) and were more likely to undergo surgical intervention at a younger age (P < 0.001). CONCLUSIONS: This is the first study to evaluate the natural course of pancreatic cysts in IBD patients. Patients with IBD were more likely to have pancreatic cysts detected at a younger age. Despite the early presentation, there were no differences in long-term outcomes. Patients with IBD with pancreatic cysts should be managed similarly to those without IBD.

Pancreatitis After Pancreaticojejunostomy Procedure? A Tale Involving the Tail of the Pancreas.

Recurrent acute pancreatitis (RAP) involving the tail of the pancreas after pancreaticojejunosotomy (PJP) is rare, has very challenging management, and there is minimal literature. We describe a case of idiopathic RAP, complicated with chronic pancreatitis that failed medical and endoscopic management and required PJP. Unfortunately, RAP recurred after PJP, and we describe his clinical course and management.

Do Not Skip the Retroflexion: A Case of Disseminated Anorectal Mucosal Melanoma.

Less than 4% of melanomas are of mucosal origin, with primary anorectal mucosal melanomas comprising a small subset. Mucosal melanomas are often diagnosed at an advanced stage due to delay in patient presentation and obscured tumor origins leading to a more aggressive behavior and less favorable prognosis when compared with cutaneous melanomas. We present a case of metastatic anorectal mucosal melanoma with a negative colonoscopy 1 year earlier.

Epidemiology of Cholangiocarcinoma; United States Incidence and Mortality Trends.

BACKGROUND: Cholangiocarcinoma is an aggressive malignancy with few available studies assessing incidence and mortality. In this study, we aim to investigate trends of incidence and mortality in a large nation-wide epidemiologic study. METHODS: We used SEER 18 database to study cholangiocarcinoma cases in the US during 2000-2015. Incidence and mortality rates of cholangiocarcinoma were calculated by race and were expressed by 1,000,000 person-years. Annual percent change (APC) was calculated using joinpoint regression software. RESULTS: We reviewed 16,189 patients with cholangiocarcinoma, of which 64.4% were intrahepatic. Most patients were whites (78.4%), males (51.3%), and older than 65 years (63%). A total of 13,121 patients died of cholangiocarcinoma during the study period. Cholangiocarcinoma incidence and mortality were 11.977 and 10.295 and were both higher among Asians, males, and individuals older than 65 years. Incidence rates have significantly increased over the study period (APC=5.063%, P<.001), while mortality increased significantly over the study period (APC=5.964%, P<.001), but decreased after 2013 (APC=-25.029, P<.001). CONCLUSION: The incidence and mortality of cholangiocarcinoma were increasing in the study period with significant observed disparities based on race and gender.

Advances in Interventional Endoscopic Ultrasound (EUS): A Technical Review.

Endoscopic ultrasound (EUS) has become the therapeutic intervention of choice for multiple diseases and continues to evolve rapidly. Its increasing use has allowed the development and adaptation of multiple, revolutionary devices and tools. Currently, there is paucity of randomized clinical trials evaluating multiple EUS-guided interventions and the vast majority of published data is heterogenous. However, the available literature on EUS-guided therapeutic interventions continues to expand and demonstrate its safety, efficacy and cost effectiveness in carefully selected patients when performed by expert endosonographers. The future of interventional EUS appears to be bright!

Temporal trends of incidence and mortality in Asian-Americans with pancreatic adenocarcinoma: an epidemiological study.

BACKGROUND: Pancreatic cancer is the fourth most common cause of cancer-related deaths in the United States, with an estimated 45,750 deaths in 2019. Mortality outcomes seem to differ based on the ethnicity of the patients, with most studies focusing on the mortality and survival of Caucasians and African Americans. Little attention has been given, however, to Asian-American patients diagnosed with pancreatic adenocarcinoma (PAC). In this study, we aimed to investigate mortality rates in Asian-American patients with PAC. METHODS: The SEER 13 registries (Surveillance, Epidemiology, and End-Results) of the National Cancer Institute were used to study PAC cases during 1992-2015. The incidence and incidence-based mortality rates per 100,000 person-years, and the annual percentage changes were calculated using SEER*stat software and Joinpoint regression software. RESULTS: A total of 5814 PAC cases in Asian-American patients were identified. Most patients were older than 60 years (77.6%) and had metastatic disease (55.8%). The overall incidence of PAC among Asian-Americans was 5.740 per 100,000 person-years (95% confidence interval [CI] 5.592-5.891]. Incidence rates were highest among males and patients older than 60 years. PAC incidence rates among Asian-Americans increased by 1.503% (95%CI 1.051-1.956; P<0.001) per year over the study period. PAC incidence rates increased over the study period for all sex, age, and stage subgroups. PAC incidence-based mortality among Asian-Americans increased by 4.535% (95%CI 3.538-5.541; P<0.001) per year over the study period. CONCLUSION: The incidence of PAC in Asian-Americans, as well as incidence-based mortality rates, are on the rise, irrespective of age, sex or stage subgroup.

Temporal trends of pancreatic ductal adenocarcinoma in young adults in the United States: A Population-Based Study.

INTRODUCTION: Pancreatic Ductal Adenocarcinoma (PDAC) is an uncommon yet fatal malignancy with numerous recent reports detailing a significant increase in the overall incidence lately. However, there is limited literature on recent incidence rates of the disease in young individuals. In this study we evaluate PDAC incidence in the US among young patients. METHODS: Data from 2000 to 2017 was obtained from the Surveillance Epidemiology and End Results 'SEER' database and analyzed using the SEER*stat software. The overall incidence, incidence trends, and survival were calculated. RESULTS: We selected 667 PDAC patients who met our inclusion criteria. We found the incidence of PDAC among young individuals to be 1.016 (95% CI, 0.940-1.096) per 1,000,000 person-years. Incidence rates were stable over the study period. Higher incidence was found among males [1.240 (95% CI, 1.122-1.366)] and blacks [1.226 (95% CI, 0.999-1.490)]. The 5-year relative survival of young patients with PDAC was 6.8%. CONCLUSIONS: Among young adults, pancreatic cancer incidence has been stable over the study duration. However, disparities between subpopulations exist and further studies are warranted to better understand those observed differences.

Revised Marshall Score: A New Approach to Stratifying the Severity of Acute Pancreatitis.

BACKGROUND: Modified Marshall Score is one of the severity scores for acute pancreatitis (AP) and is included in the Revised Atlanta Classification, but given its utilization of a set serum creatinine level (sCr), it may misclassify stable patients with chronic kidney disease (CKD) to a more severe class just due to their elevated sCr. AIMS: Our study aims to evaluate the role of CKD in AP and the possibility of utilizing acute kidney injury (AKI) into developing a new scoring system. METHODS: We retrospectively reviewed the electronic medical records of three hundred consecutive patients who were diagnosed with AP during hospitalization. Multiple demographic variables and clinical course indices were collected. Univariate logistic regression was then applied to predict mortality and ICU admission. Finally, receiver operating curve was utilized to compare original versus New Revised Marshall Score. RESULTS: Two hundred and eight-four (284) patients had a definitive diagnosis of AP. When comparing patients who had AKI on admission to those without AKI, the AKI group showed statistically significant higher mortality rate (5.6% vs. 1.1%, p = 0.04). Finally, we substituted the renal part of Marshall Score with our AKIN and we plotted the New "Revised" Marshall Score, which showed a higher AUROC compared to the original modified version (C-statistics 0.93 vs. 0.89, p < 0.05). CONCLUSION: We found that AKI predicts mortality and outperforms the use of a fixed sCr value alone. The use of our New Revised Marshall Score can accurately classify AP severity, avoiding misclassification of AP severity and providing better patient care.

The Impact of Cannabis Consumption on Mortality, Morbidity, and Cost in Acute Pancreatitis Patients in the United States: A 10-Year Analysis of the National Inpatient Sample.

OBJECTIVES: The aim of this study was to identify the prevalence of cannabis use among all patients admitted with acute pancreatitis (AP) in the United States and to investigate the impact of cannabis use on AP mortality, morbidity, and cost of care. METHODS: The National Inpatient Sample database from 2003 to 2013 was queried for all patients with AP and active exposure to cannabis. Outcomes included in-hospital mortality, length of stay, inflation adjusted charges, acute kidney injury, acute respiratory distress syndrome, and shock. Results were adjusted for age, sex, race, Charlson comorbidity index, median income quartile, and hospital characteristics. RESULTS: More than 2.8 million patients with AP patients were analyzed. Cannabis-exposed (CE) patients' prevalence was 0.3%. Patients exposed to cannabis were younger and mostly males compared with non-cannabis-exposed patients. After adjusting for these factors, the CE group had significantly lower inpatient mortality compared with the noncannabis group (odds ratio, 0.17; 95% confidence interval, 0.06-0.53). Cannabis-exposed patients also had decreased length of stay, inflation-adjusted charges, acute kidney injury, ileus, shock, acute respiratory distress syndrome, and parenteral nutrition requirement. CONCLUSIONS: Cannabis-exposed hospitalized patients with AP had lower age-adjusted, mortality, morbidity, and hospitalization-cost than non-cannabis-exposed patients.

Hypertriglyceridemia-Associated Drug-Induced Acute Pancreatitis.

OBJECTIVES: The aim of our study was to investigate the cases of drug-induced acute pancreatitis (DIAP) with hypertriglyceridemia as the mechanism of injury. METHODS: A MEDLINE search (1963-2018) of the English language literature was performed looking for all human case reports of adults (>18 years old) with hypertriglyceridemia as the mechanism of DIAP. The latest search date was February 28, 2018. Drugs were classified into probability groups based on a classification used by Badalov et al (Clin Gastroenterol Hepatol. 2007;5:648-661). RESULTS: The search revealed a total of 76 cases in 59 published reports. A total of 25 medications were found to be implicated in DIAP secondary to hypertriglyceridemia mechanism. Most of acute pancreatitis cases were mild or moderately severe with favorable outcomes. In 3 cases involving tamoxifen, pagaspargase, and quetiapine, patient death was the outcome. Plasmapheresis was only used in 9 cases in an effort to decrease triglyceride levels. CONCLUSIONS: Hypertriglyceridemia-associated DIAP is a rare phenomenon, and the current systematic review provides a summary of drugs that have been implicated in this phenomenon, which allow physicians to be oriented about this adverse effect when these drugs are used.

Correction to: Endoscopic and surgical management of nonampullary duodenal neoplasms.

This article was updated to correct the author listing for Carlos Roberto Simons-Linares.

Endoscopic and surgical management of nonampullary duodenal neoplasms.

BACKGROUND: Sporadic nonampullary duodenal neoplasms (SNADN) can have malignant potential for which endoscopic and surgical resections are offered. We report combined gastroenterologic and surgical experience for treatment of SNADN, including endoscopic mucosal resection (EMR) and pancreas-preserving partial duodenectomy (PPPD). METHODS: We retrospectively reviewed 121 consecutive patients, who underwent 30 PPPDs and 91 EMRs for mucosal and submucosal SNADN. Decision to undergo EMR or surgical resection was based on expert endoscopist and surgeon discretion including multidisciplinary tumor board review. Main outcomes were recurrence rate of neoplasia and adverse events requiring hospital admission or prolonged care. EMRs were performed with submucosal lifting followed by snare resection. PPPD included total duodenectomy, supra-ampullary PPPD for neoplasms proximal to the ampulla, and infra-ampullary PPPD for lesions distal to the ampulla. Follow-up data were available for 65% of EMR and 73% of surgical patients. RESULTS: Surgically resected neoplasia was larger with more advanced neoplasia and submucosal lesions. En bloc resection was achieved in all surgical resections and in 53% of EMRs. Post-EMR, mucosal and submucosal neoplasia recurred in 32 and 0%, respectively, including five neoplasms (26%) after an initial negative esophagogastroduodenoscopy. All recurrences were treated endoscopically. Complications occurred in 14 endoscopically and eight surgically treated patients, none requiring surgical intervention. CONCLUSIONS: Post-EMR patients had higher recurrence of mucosal neoplasia, whereas submucosal neoplasms, mainly carcinoid, did not recur. Polyp size and positive resection margin were not associated with neoplasia recurrence. Patients with SNADN could benefit from a multidisciplinary approach to stratify the optimal treatment based on local expertise.

Concurrent Diabetic Ketoacidosis in Hypertriglyceridemia-Induced Pancreatitis: How Does It Affect the Clinical Course and Severity Scores?

OBJECTIVES: Concurrent diabetic ketoacidosis (DKA) is highly prevalent in patients with hypertriglyceridemia-induced pancreatitis (HP). Diabetic ketoacidosis could potentially complicate the diagnosis, management, and prognosis of HP. This study aimed to directly compare the clinical course of HP with and without DKA and assess the outcomes of frequently used severity-prediction scores in such population. METHODS: We retrospectively analyzed 140 patients with HP; 37 patients (26.4%) had concurrent DKA. We compared epidemiologic characteristics, initial laboratory values, and clinical courses between the DKA and non-DKA groups. Bedside Index for Severity in Acute Pancreatitis score, Sequential Organ Failure Assessment score, Ranson criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Marshall score were calculated and compared between groups. RESULTS: We observed more acute kidney injury in the DKA group. Patients with DKA more likely required intensive care unit admission, received intravenous insulin, and were discharged on subcutaneous insulin. Ranson criteria and APACHE II score were significantly higher with DKA. CONCLUSIONS: Concurrent DKA does not affect length of stay, in-hospital mortality, and readmission rate in patients with HP. Higher Ranson criteria and APACHE II score likely reflected derangement of clinical parameters secondary to DKA rather than true severity of pancreatitis in such population.

Trends in Hospitalization and Mortality of Venous Thromboembolism in Hospitalized Patients With Colon Cancer and Their Outcomes: US Perspective.

INTRODUCTION: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients with colon cancer. We assessed nationwide population-based trends in rates of hospitalization and mortality from VTE among patients with colon cancer to determine its impact. METHODS: We queried the Nationwide Inpatient Sample (NIS) database entries from 2003 to 2011 to identify patients with colon cancer. Bivariate group comparisons between hospitalized patients with colon cancer with VTE to those without VTE were made. Multivariate logistic regression analysis was used to obtain adjusted odds ratios. The Cochrane-Armitage test for linear trend was used to assess occurrences of VTE and mortality rates among patients with colon cancer. RESULTS: The total number patients with colon cancer was 1,502,743, of which 41,394 (2.75%) had VTE. The median age of the study population was 69 years; 51.5% were women. After adjusting for potential confounders, compared with those without VTE, patients with colon cancer with VTE had significantly higher inpatient mortality (6.26% vs. 5.52%, OR 1.15, P < .001) and greater disability at discharge (OR 1.38, P < .001), but were not associated with longer length of stay (LOS) or cost of hospitalization. From 2003 to 2011, despite an increase in hospitalization rate with VTE in patients with colon cancer, their mortality steadily declined. CONCLUSION: VTE in hospitalized patients with colon cancer is associated with a significantly higher inpatient mortality and greater disability, but not with longer LOS or cost of hospitalization. Furthermore, even though there has been a trend toward more frequent hospitalizations in this patient population, their mortality continues to decline.