The Role of Lumen Apposing Metal Stents in the Palliation of Distal Malignant Biliary Distal Obstruction.

Malignant biliary obstruction (DMBO) has been traditionally managed by endoscopic retrograde cholangiopancreatography (ERCP). In the case of ERC failure, percutaneous transhepatic biliary drainage (PT-BD) has been widely utilized as a salvage procedure. However, over the last decade, endoscopic ultrasound-guided biliary drainage (EUS-BD) has gained increasing popularity, especially after the advent of electrocautery-enhanced lumen apposing metal stent devices (EC-LAMSs) which enable a one-step procedure, granting prevention of biliary leakage and minimizing occurrence of adverse events (AEs). In parallel, increasing evidence suggests a possible role of EUS-BD in the management of DMBO as a primary palliative drainage modality. In the current paper, we aim to review all the available evidence on the role of EUS-BD performed with EC-LAMSs and discuss salient technical aspects of this type of procedure.

Transient venous air embolism after ERCP: worrisome or not?

The paper describes the occurrence of a rare complication - portal and systemic venous air embolism - after endoscopic retrograde cholangiopancreatography, related to the endoscopic procedure. It can be associated with the more frequently encountered post-endoscopic retrograde cholangiopancreatography complications pancreatitis or cholangitis. However, it can also be noted with perforation. The presented case suggests that in the clinical context an early abdominal ultrasound examination confirming hepatic portal venous gas and/or systemic venous air embolism could be useful for the diagnosis of post-endoscopic retrograde cholangiopancreatography retroduodenal perforation, and thus highlights the need for a high index of suspicion should this occurrence be noted post-procedurally, in order to ensure the best care of patients.The paper describes the occurrence of a rare complication ­ portal and systemic venous air embolism ­ after endoscopic retrograde cholangiopancreatography, related to the endoscopic procedure. It can be associated with the more frequently encountered post-endoscopic retrograde cholangiopancreatography complications pancreatitis or cholangitis. However, it can also be noted with perforation. The presented case suggests that in the clinical context an early abdominal ultrasound examination confirming hepatic portal venous gas and/or systemic venous air embolism could be useful for the diagnosis of post-endoscopic retrograde cholangiopancreatography retroduodenal perforation, and thus highlights the need for a high index of suspicion should this occurrence be noted post-procedurally, in order to ensure the best care of patients.

Endoscopic management of recurrent tracheoesophageal fistula induced by chronic use of nonsteroidal anti-inflammatory drugs: A case report and review of the literature.

Tracheoesophageal fistula (TEF) is frequently congenital and requires surgical correction. TEF can also occur secondary to malignant esophageal tumors or benign diseases and these cases are managed by endoscopic means, such as closing the defect with metallic stents. Although esophageal injury can occur secondary to nonsteroidal anti-inflammatory drugs (NSAIDs), TEF secondary to chronic NSAIDs use has not been described in the literature. We report the case of a male patient with refractory migraine and chronic use of NSAIDs, with a history of esophageal stenosis presenting with acute-onset total dysphagia. Upper gastrointestinal endoscopy and CT-scan revealed TEF located at 25 cm from the incisors. An esophageal stent was placed endoscopically, and 6 weeks a second stent was placed in a stent-in-stent manner to allow removal of both stents. Endoscopic control after the removal of the stents showed the persistence of the fistula, so a third stent was placed as a rescue therapy. Against medical advice, the patient continued to use OTC painkillers and NSAIDs in large doses. Three months later, he was readmitted with total dysphagia and recent-onset dysphonia. CT scan revealed a new fistula above the already placed stent. A second metallic stent was endoscopically placed through the old stent to close the newly developed fistula. The patient was discharged on the third day with no complications and he remains well at 6 months follow-up. Due to small cases studies, recurrent TEF remains a therapeutic challenge. Endoscopic therapy is usually an effective solution, but complex cases might require multiple treatment sessions.

The diagnostic and prognostic value of serum endocan in patients with cirrhotic cardiomyopathy.

BACKGROUND: We aimed to determine the relationship between endocan and cirrhotic cardiomyopathy. MATERIALS AND METHODS: Patients with liver cirrhosis and no heart disease were included in a prospective observational study with liver disease decompensation and death as primary outcomes. RESULTS: 83 cirrhotic patients were included and 32 had cirrhotic cardiomyopathy. Endocan levels were significantly lower in patients with cirrhotic cardiomyopathy (5.6 vs. 7 ng/mL, p = 0.034). Endocan correlated with severity of cirrhosis, time to decompensation or death from liver disease (OR 4.5 95% CI 1.06-31.1). CONCLUSION: Endocan is a promising biomarker of severity of cirrhosis and may help in the diagnosis of cardiac dysfunction in this population.

An atypical type I gastric neuroendocrine tumor.

BACKGROUND: Gastric neuroendocrine tumors (GI-NETs) are rare lesions, usually discovered incidentally during endoscopy. Based on their pathology, there are 4 types of GI-NETs. Type I are multiple small polypoid lesions with central ulceration located in the gastric body or the fundus, associated with atrophic gastritis usually noninvasive and very rarely metastatic. We report on a rare case of a gastric NET arising from the muscularis propria layer of the pyloric ring. CASE REPORT: We present the case of a 65-year old woman with a history of alcoholic cirrhosis, investigated for melena. Upper endoscopy revealed a 30 mm submucosal pedunculated polypoid lesion located on the pylorus protruding in the duodenum, with normal overlying mucosa, fundic gastric atrophy and multiple small polyps at this level, with no active bleeding. CT scan did not reveal any distant metastases. An ultrasound endoscopy was performed, and a round hypoechoic heterogeneous solitary mass, evolving from the pyloric muscle was described. Considering a 30-mm tumor evolving from the gastric muscle layer in the absence of local invasion and with no distant metastases we decided against an endoscopical resection and we referred the patient to surgery. A laparoscopic wedge resection was performed. The pathology report described a 30/25 mm welldifferentiated neuroendocrine tumor invasive in the muscularis mucosa (pT3). CONCLUSIONS: Usually, type I neuroendocrine tumors are located in the body or the fundus of the stomach without submucosal invasion. The interesting feature in our case was that the tumor originated from the pylorus, making it an atypical presentation for a neuroendocrine tumor.

Is the use of AGILE patency capsule prior to videocapsule endoscopy useful in all patients with spondyloarthritis?

BACKGROUND AND AIMS: As already known, spondyloarthritis patients present a striking resemblance in intestinal inflammation with early Crohn's disease. Moreover, the frequent use of nonsteroidal anti-inflammatory drugs is an important part of their treatment. Both conditions could lead to intestinal stenoses. Therefore we proposed to investigate the usefulness of the patency capsule test in patients with spondyloarthritis. MATERIAL AND METHODS: 64 consecutive patients (33 males; mean age 38 ± 11 years) that fulfilled the AMOR criteria for seronegative spondyloarthropathy (59.4% ankylosing spondylitis) lacking symptoms or signs of intestinal stenosis were enrolled and submitted to an AGILE™ capsule patency test followed by a video capsule endoscopy (PillCam SB2™), as part of a protocol investigating the presence of intestinal inflammatory lesions. After reviewing the VCE recordings, the Lewis score (of small bowel inflammatory involvement) was computed. RESULTS: In only 5 patients (7.8%) of the study group, the luminal patency test was negative. However, there was no retention of the videocapsule in any of the patients. From the 59 patients with a positive patency test, 3 patients presented single small bowel stenoses (two with ulcerated overlying inflamed mucosa, one cicatricial), all being traversed by the videocapsule along the length of the recording. None of the patients with a negative test had bowel stenoses. There was no correlation between the patency test and the Lewis score, the C reactive protein value, diagnosis of inflammatory bowel disease, or the family history of spondyloarthritis, psoriasis or inflammatory bowel disease. CONCLUSION: The AGILE patency capsule does not seem to be a useful tool for all patients with spondyloarthritis prior to small bowel videocapsule endoscopy (ClinicalTrial.gov ID NCT 00768950).

The Impact of Hypoxaemia on the Outcome in Liver Cirrhosis.

BACKGROUND AND AIMS: Prognostic factors for poor evolution are critical in the setting of limited access to liver transplantation for patients with cirrhosis. We aimed to investigate the impact of hypoxaemia on the outcome in cirrhosis and the evolution of arterial oxygen tension during long-term follow-up in these patients. METHODS: Consecutive cirrhotic patients were prospectively enroled and followed-up in our tertiary referral center. Clinical features, biological tests, arterial blood gases, NT-proBNP levels, pulse oximetry measurements, 12-lead ECG, and transthoracic contrast echocardiography were documented on enrolment. The main outcomes were death and decompensation due to liver disease. RESULTS: 87 cirrhotic patients were included in the analysis and followed-up for a mean of 16 months. At enrolment, 27 (31%) patients were hypoxaemic, 19 had hepatopulmonary syndrome (HPS), but only 6 of those who were sampled at follow-up had persistent hypoxaemia. During the study period, 22 patients died of liver-related complications. Nine of them (41%) were hypoxaemic on enrolment but none had severe hypoxaemia. Hypoxaemia present at enrollment was not a risk factor for death (p=0.29) or decompensation of liver disease (p=0.7). A higher MELD score at baseline or increase during follow-up was a risk factor for death (p=0.02) and correlated with the presence of hypoxaemia. Normalization of the arterial oxygen levels was accompanied by a significant decrease in NT-proBNP (83 pg/ml vs 0 pg/mL, p=0.023). CONCLUSION: Mild and moderate hypoxaemia was frequent in our patients but was not associated with adverse outcome in cirrhosis. Repeated arterial blood gas sampling is advisable, especially in patients diagnosed with hepatopulmonary syndrome.

Usefulness of virtual chromoendoscopy in the evaluation of subtle small bowel ulcerative lesions by endoscopists with no experience in videocapsule.

BACKGROUND AND STUDY AIMS: In videocapsule endoscopy examination (VCE), subtle variations in mucosal hue or pattern such as those seen in ulcerations can be difficult to detect, depending on the experience of the reader. Our aim was to test whether virtual chromoendoscopy (VC) techniques, designed to enhance the contrast between the lesion and the normal mucosa, could improve the characterization of ulcerative mucosal lesions. PATIENTS AND METHODS: Fifteen trainees or young gastroenterologists with no experience in VCE were randomly assigned to evaluate 250 true ulcerative and 100 false ulcerative, difficult-to-interpret small bowel lesions, initially as white light images (WLI) and then, in a second round, with the addition of one VC setting or again as WLI, labeling them as real lesions or artifacts. RESULTS: On the overall image evaluation, an improvement in lesion characterization was observed by adding any chromoendoscopy setting, especially Blue mode and FICE 1, with increases in accuracy of 13 % [95 %CI 0.8, 25.3] and 7.1 % [95 %CI - 17.0, 31.3], respectively. However, when only false ulcerative images were considered, with the same presets (Blue mode and FICE 1), there was a loss in accuracy of 10.7 % [95 %CI - 10.9, 32.3] and 7.3 % [95 %CI - 1.3, 16.0], respectively. The interobserver agreement was poor for both readings. CONCLUSIONS: VC helps beginner VCE readers correctly categorize difficult-to-interpret small bowel mucosal ulcerative lesions. However, false lesions tend to be misinterpreted as true ulcerative with the same presets. Therefore care is advised in using VC especially under poor bowel preparation.

Antibiotic Prophylaxis Prior to Elective ERCP Does Not Alter Cholangitis Rates or Shorten Hospital Stay: Results of an Observational Prospective Study of 138 Consecutive ERCPS.

OBJECTIVES: The role of prophylactic antibiotherapy prior to elective endoscopic retrograde cholangiopancreatography (ERCP) is unclear. We aimed to determine whether patients receiving systemic antibiotics prior to ERCP had lower morbidity and mortality rates as well as shorter hospitalization compared to patients who did not receive antibiotic prophylaxis. MATERIALS AND METHODS: We conducted a prospective study of all patients undergoing ERCP in our unit. Antibiotic use, postERCP cholangitis rates, 30-day mortality and hospital stay were studied. Also, bacteriological examination of bile aspirates from these patients was conducted and antibiotic susceptibility was determined for the isolated pathogens. OUTCOMES: One hundred-thirty eight consecutive ERCPs conducted in our unit in a 9 month period were included. Cholangitis developed in 3 (4.6%) cases in the antibiotics groups and 3 (4%) cases in the control group (p=0.8). Hospital stay did not differ significantly between the two study groups (p=0.58). There was only one procedure-related death which was the result of postERCP pancreatitis in a patient with severe associated illnesses. Bile aspirates showed bacterial growth in 75% of the cases where bile was obtained, with E. coli being the most frequently isolated microorganism. No differences in bacteriological profiles were noted between the two study groups. CONCLUSION: There seems to be no influence on patient-related outcome of antibiotic prophylaxis prior to elective ERCP.

Functional dyspepsia today.

Functional dyspepsia (FD) is a disorder presenting with symptoms such as postprandial fullness, early satiety or epigastric pain. Although there is a 10 to 30% reported prevalence worldwide, there is currently no clear explanation of the pathophysiology behind this condition. Motility disorders, visceral hypersensitivity, acid disorders, Helicobacter pylori infection or psychosocial factors have all been reported to play a part in the pathophysiology of FD. The diagnosis of FD is one of exclusion, based on the Rome III criteria. The main therapeutic modalities include lifestyle changes, eradicating Helicobacter pylori infection and treatment with either proton pump inhibitors, prokinetics or antidepressants.