Endoscopic treatment of a large intraductal papillary mucinous neoplasm of the bile duct: tips and tricks learned during multiple treatments of a difficult case.

Video 1Endoscopic video demonstrating the ability to gain access to the biliary system using the rigidizing overtube, and subsequent attempted EMR of the neoplastic lesion, followed by successful APC with complete ablation of the neoplasm.

Comparing Patients Diagnosed With Ineffective Esophageal Motility by the Chicago Classification Version 3.0 and Version 4.0 Criteria.

Background: The Chicago Classification version 4.0 (CCv4.0) of ineffective esophageal motility (IEM) is more stringent than the Chicago Classification version 3.0 (CCv3.0) definition. We aimed to compare the clinical and manometric features of patients meeting CCv4.0 IEM criteria (group 1) versus patients meeting CCv3.0 IEM but not CCv4.0 criteria (group 2). Methods: We collected retrospective clinical, manometric, endoscopic, and radiographic data on 174 adults diagnosed with IEM from 2011 to 2019. Complete bolus clearance was defined as evidence of exit of the bolus by impedance measurement at all distal recording sites. Barium studies included barium swallow, modified barium swallow, and barium upper gastrointestinal series studies, and collected data from these reports include abnormal motility and delay in the passage of liquid barium or barium tablet. These data along with other clinical and manometric data were analyzed using comparison and correlation tests. All records were reviewed for repeated studies and the stability of the manometric diagnoses. Results: Most demographic and clinical variables were not different between the groups. A lower mean lower esophageal sphincter pressure was correlated with greater percent of ineffective swallows in group 1 (n = 128) (r = -0.2495, P = 0.0050) and not in group 2. In group 1, increased percent of failed contractions on manometry was associated with increased incomplete bolus clearance (r = 0.3689, P = 0.0001). No such association was observed in group 2. A lower median integrated relaxation pressure was correlated with greater percent of ineffective contractions in group 1 (r = -0.1825, P = 0.0407) and not group 2. Symptom of dysphagia was more prevalent (51.6% versus 69.6%, P = 0.0347) in group 2. Dysphagia was not associated with intrabolus pressure, bolus clearance, barium delay, or weak or failed contractions in either group. In the small number of subjects with repeated studies, a CCv4.0 diagnosis appeared more stable over time. Conclusions: CCv4.0 IEM was associated with worse esophageal function indicated by reduced bolus clearance. Most other features studied did not differ. Symptom presentation cannot predict if patients are likely to have IEM by CCv4.0. Dysphagia was not associated with worse motility, suggesting it may not be primarily dependent on bolus transit.

Endoscopic resection of large Paris 0-Ip pedunculated polyps: video demonstration of recent U.S. Multi-Society Task Force recommendations on resection and removal for general endoscopists.

Video 1Illustration of general principles as well as different techniques that can be used for the ligation and resection of pedunculated polyps.

Proactive Drug Monitoring Is Associated With Higher Persistence to Infliximab and Adalimumab Treatment and Lower Healthcare Utilization Compared With Reactive and Clinical Monitoring.

BACKGROUND: Serum drug-level assays for infliximab (IFX) and adalimumab (ADA) are widely available and are most often obtained reactively, to determine the next steps in patients with loss of response. Studies done thus far on the use of these assays proactively, or during symptom remission, have had mixed results. Here we investigate persistence on therapy and healthcare utilization in patients on 3 drug-level monitoring strategies. METHODS: We conducted a retrospective chart review of 235 patients treated for both Crohn disease and ulcerative colitis on either IFX or ADA. Monitoring strategy was defined as proactive if patients underwent testing at predefined time points regardless of symptoms or signs of disease, reactive if done during relapse, or control if no drug levels were obtained. Groups were compared on persistence on original therapeutic at 1 and 2 years as well as on various measures of healthcare utilization during the 2-year follow-up period. RESULTS: Proactive drug monitoring was associated with a higher likelihood of persistence on therapy at 1 year when compared with the control (odds ratio [OR] = 4.76, 95% confidence interval [CI] = 1.65, 13.67) and reactive groups (OR = 6.10, CI = 2.19, 17.02). Similarly, at 2 years, proactive monitoring was superior to the control (OR = 5.41, CI = 2.26, 12.94) and reactive groups (OR = 4.51, CI = 1.88, 10.80). Proactive monitoring was also associated with lower healthcare utilization across almost all measures related to inflammatory bowel disease. CONCLUSIONS: Proactive drug monitoring increases persistence on IFX and ADA in patients with ulcerative colitis or Crohn disease and decreases overall healthcare utilization in these patients.