What do we know today about drug-induced microscopic colitis? A case of lymphocytic colitis on olmesartan.

Microscopic colitis is part of the differential diagnosis of chronic watery diarrhea. Colonoscopy discloses a normal looking mucosa, therefore its diagnosis is based on histology of colonic biopsies. Two main phenotypes are distinguished: collagenous colitis and lymphocytic colitis. A third entity, incomplete microscopic colitis or unspecified microscopic colitis has been reported in the literature. It affects preferentially women over 60 years of age and its association with certain drugs is increasingly established. In case of suspected drug-induced microscopic colitis, identification of the responsible drug is a key to management. After discontinuation of the suspected drug, the gold standard of treatment is budesonide both for induction and for maintenance in case of clinical relapse, as is often the case after discontinuation. Therapy with immunomodulators, biologics, or surgery is reserved for refractory forms of microscopic colitis after multidisciplinary consultation. Through the clinical case of colitis on olmesartan, we will review the latest recommendations on drug-induced microscopic colitis.

Covid-19: exploring the "new normal" in gastroenterology training.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented disruptions in fellowship training programs worldwide. In gastroenterology, the strain in healthcare service provision and the emphasis on preventing viral transmission has adversely impacted hands-on training opportunities, with trainees facing the constant pressure to meet training requirements under the continuous threat of viral transmission. Emerging evidence highlight the scale of the problem, specifically with regard to endoscopy competence due to cancellation of elective endoscopic procedures, provision of inpatient and outpatient consultative care as well as academic education and the mental well-being of trainees. As such, it has been necessary for trainees, trainers and training programs collectively to adapt to these challenges and incorporate novel and adaptive solutions to circumvent these training barriers. This review aims to summarise data on the global impact of COVID-19 on gastroenterology training and the practical interventions that could be implemented.

Accuracy and other quality indicators of solid pancreatic mass endoscopic ultrasound-guided fine needle aspiration and biopsy in two academic endoscopy centers.

BACKGROUND AND AIMS: Endoscopic ultrasound fine-needle aspiration/biopsy (EUS-FNA/FNB) is highly accurate, but discrepancies between cytological and surgical diagnoses are still observed. We aimed to determine its accuracy and monitor quality indicators in our facilities. PATIENTS AND METHODS: We performed a retrospective review of all cases of pancreatic solid lesions evaluated by EUS-FNA/FNB, between July 2015 and June 2018, in two centers. Cytological and surgical findings were categorized into five groups: benign, malignant, suspect of malignancy, undetermined and insufficient for diagnosis. Final diagnosis was based on surgical diagnosis and, in patients who did not undergo surgery, on clinical outcome after 6 months follow-up. RESULTS: Altogether, 142 patients were included. FNA was the preferred tissue acquisition method (88%), with a predilection for the FNA 22G needle (57%). Cytology was insufficient for diagnosis in 2 cases, therefore a full diagnostic sample was available in 98.6% of the patients (>90%, ESGE target). Fifty-five (38.7%) patients underwent surgery. In term of cancer diagnosis, comparison with final surgical pathology (n=55) revealed 89% true positives, 5.5% true negatives, 3.6% false positives and 1.8% false negatives. When combining surgical diagnosis and clinical outcomes together, EUS-guided sampling sensitivity was 97.4% (92.5-99.5), specificity was 92.3% (74.9-99.1), positive predictive value was 98.2% (93.6- 99.5), negative predictive value was 88.9% (72.3-96.1) and accuracy was 96.4% (91.9-98.8). Post-procedural acute pancreatitis was reported in 2 patients (1.4%). CONCLUSIONS: These results reveal a performance for diagnostic tissue sampling well above the ESGE proposed target standard. Also, the uncommon high specificity illustrates the determining role of the pathologist's final interpretation and diagnosis.

The Belgian national registry on chronic pancreatitis: A prospective multi-centre study covering more than 800 patients in one year.

BACKGROUND/OBJECTIVES: The epidemiology, natural history, complications, and therapeutic management of chronic pancreatitis (CP) are not well described at the national level. This multi-centre prospective observational study involving eight Belgian hospitals aimed to improve the understanding of these aspects of CP in Belgium. METHODS: All patients with a diagnosis of CP based on imaging were eligible for this study. Data were gathered regarding epidemiology, etiology, CP complications, and treatment modalities. RESULTS: A total of 809 patients were included between 1/9/2014 and 31/8/2015. Most patients (794) were adults ≥16-years old, 74% were male, the median age at symptom onset was 47 (38-57) years, the median disease duration was 7 (3-13) years, and the median Izbicki pain score (IPS) was 96 (0-195). The main etiological risk factors according to the TIGAR-O classification were alcohol and tobacco (67%). Current drinkers had lower body mass index (BMI) (21.4 kg/m2 vs 24.1 kg/m2), higher IPS (110 vs 56), and longer inability to work than non-drinkers. Current smokers had lower BMI (21.5 kg/m2 vs 25 kg/m2) and higher IPS (120 vs 30) than non-smokers. Endocrine insufficiency and/or clinical steatorrhea was recorded in 41% and 36% of patients, respectively. The highest IPS was reported in patients with ongoing endotherapy (166 vs 50 for patients who completed endoscopy). CONCLUSION: This multicentric study on CP patients showed that current alcohol drinking and smoking are associated with pain and malnutrition. Pain scores were higher in patients with ongoing endotherapy, independently of surgery.

Metabolic and nutritional complications of bariatric surgery : a review.

Bariatric surgery is considered as the only effective durable weight-loss therapy and may be curative for obesity-related comorbidities such as diabetes. Nevertheless this surgery is not devoid of potential long-term complications such as dumping syndrome, gastroesophageal reflux disease and nutrient deficiencies. For this reason, preoperative nutritional assessment and rigorous postoperative follow-up with administration of multi-vitamins supplements and assessment of serum levels is recommended for each patient who is undergoing a bariatric surgery. The aim of this review is to identify and treat the metabolic and nutritional complications of bariatric surgery.

Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It provides practical advice on how to achieve successful cannulation and sphincterotomy at minimum risk to the patient. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations 1 ESGE suggests that difficult biliary cannulation is defined by the presence of one or more of the following: more than 5 contacts with the papilla whilst attempting to cannulate; more than 5 minutes spent attempting to cannulate following visualization of the papilla; more than one unintended pancreatic duct cannulation or opacification (low quality evidence, weak recommendation). 2 ESGE recommends the guidewire-assisted technique for primary biliary cannulation, since it reduces the risk of post-ERCP pancreatitis (moderate quality evidence, strong recommendation). 3 ESGE recommends using pancreatic guidewire (PGW)-assisted biliary cannulation in patients where biliary cannulation is difficult and repeated unintentional access to the main pancreatic duct occurs (moderate quality evidence, strong recommendation). ESGE recommends attempting prophylactic pancreatic stenting in all patients with PGW-assisted attempts at biliary cannulation (moderate quality evidence, strong recommendation). 4 ESGE recommends needle-knife fistulotomy as the preferred technique for precutting (moderate quality evidence, strong recommendation). ESGE suggests that precutting should be used only by endoscopists who achieve selective biliary cannulation in more than 80 % of cases using standard cannulation techniques (low quality evidence, weak recommendation). When access to the pancreatic duct is easy to obtain, ESGE suggests placement of a pancreatic stent prior to precutting (moderate quality evidence, weak recommendation). 5 ESGE recommends that in patients with a small papilla that is difficult to cannulate, transpancreatic biliary sphincterotomy should be considered if unintentional insertion of a guidewire into the pancreatic duct occurs (moderate quality evidence, strong recommendation).In patients who have had transpancreatic sphincterotomy, ESGE suggests prophylactic pancreatic stenting (moderate quality evidence, strong recommendation). 6 ESGE recommends that mixed current is used for sphincterotomy rather than pure cut current alone, as there is a decreased risk of mild bleeding with the former (moderate quality evidence, strong recommendation). 7 ESGE suggests endoscopic papillary balloon dilation (EPBD) as an alternative to endoscopic sphincterotomy (EST) for extracting CBD stones < 8 mm in patients without anatomical or clinical contraindications, especially in the presence of coagulopathy or altered anatomy (moderate quality evidence, strong recommendation). 8 ESGE does not recommend routine biliary sphincterotomy for patients undergoing pancreatic sphincterotomy, and suggests that it is reserved for patients in whom there is evidence of coexisting bile duct obstruction or biliary sphincter of Oddi dysfunction (moderate quality evidence, weak recommendation). 9 In patients with periampullary diverticulum (PAD) and difficult cannulation, ESGE suggests that pancreatic duct stent placement followed by precut sphincterotomy or needle-knife fistulotomy are suitable options to achieve cannulation (low quality evidence, weak recommendation).ESGE suggests that EST is safe in patients with PAD. In cases where EST is technically difficult to complete as a result of a PAD, large stone removal can be facilitated by a small EST combined with EPBD or use of EPBD alone (low quality evidence, weak recommendation). 10 For cannulation of the minor papilla, ESGE suggests using wire-guided cannulation, with or without contrast, and sphincterotomy with a pull-type sphincterotome or a needle-knife over a plastic stent (low quality evidence, weak recommendation).When cannulation of the minor papilla is difficult, ESGE suggests secretin injection, which can be preceded by methylene blue spray in the duodenum (low quality evidence, weak recommendation). 11 In patients with choledocholithiasis who are scheduled for elective cholecystectomy, ESGE suggests intraoperative ERCP with laparoendoscopic rendezvous (moderate quality evidence, weak recommendation). ESGE suggests that when biliary cannulation is unsuccessful with a standard retrograde approach, anterograde guidewire insertion either by a percutaneous or endoscopic ultrasound (EUS)-guided approach can be used to achieve biliary access (low quality evidence, weak recommendation). 12 ESGE suggests that in patients with Billroth II gastrectomy ERCP should be performed in referral centers, with the side-viewing endoscope as a first option; forward-viewing endoscopes are the second choice in cases of failure (low quality evidence, weak recommendation). A straight standard ERCP catheter or an inverted sphincterotome, with or without the guidewire, is recommended by ESGE for biliopancreatic cannulation in patients who have undergone Billroth II gastrectomy (low quality evidence, strong recommendation). Endoscopic papillary ballon dilation (EPBD) is suggested as an alternative to sphincterotomy for stone extraction in the setting of patients with Billroth II gastrectomy (low quality evidence, weak recommendation).In patients with complex post-surgical anatomy ESGE suggests referral to a center where device-assisted enteroscopy techniques are available (very low quality evidence, weak recommendation).

Percutaneous endoscopic jejunostomy in patients with gastroparesis following lung transplantation: feasibility and clinical outcome.

The aim of the present study was to describe success rates, complications, and outcome in patients who underwent percutaneous endoscopic jejunostomy (PEJ) because of gastroparesis due to previous lung transplantation. Between October 2008 and May 2011, 14 attempts at PEJ placement were made in 12 patients in our center. Of the 14 attempts, 11 were successful, giving a technical success rate of 78.6 %. Median duration of followup was8.5 months (2­15 months). No immediate complications were reported. Two severe complications occurred during follow up (one volvulus and one jejunocolic fistula). Jejunal nutrition was well tolerated in most of patients (9 /10). PEJ insertion is a feasible technique, which could help to provide nutritional support for patients with gastroparesis and previous lung transplantation.

Buried bumper syndrome: low incidence and safe endoscopic management.

AIMS: Buried bumper syndrome (BBS) is a rare long-term complication of percutaneous endoscopic gastrostomy (PEG) and consists of a progressive impaction of the inner bumper of the tube in the mucosa of gastric wall. The aim of our study was to report our own experience with BBS, focusing on its incidence and endoscopic management. PATIENTS AND METHODS: Medical records of a large group of 879 patients having undergone PEG insertion (2002-2009) were retrospectively reviewed. All PEG's were followed by our special Nutrition Support Team. Patients presenting with BBS during their follow-up were included in the study. RESULTS: Only eight patients (8/879; 0.9%) developed BBS, which was confirmed during gastroscopy. Median time between PEG insertion and BBS diagnosis was 22.0+/-22.28 months. Five patients underwent successful treatment with: 1) flexible guide wire insertion through the internal orifice of the PEG to define its anatomical settings, 2) cruciform incisions of the gastric mucosa with a needle-knife starting at the center of the mucosal dome covering the internal bumper, and reaching its edges, 3) extrusion and complete extraction of the inner bumper through the gastric tract. No complications were observed. Median hospital stay related to BBS lasted 4.0+/-3.67 days. In two patients with peristomal abscess and deeply migrated bumper surgery was needed. CONCLUSIONS: Cruciform mucosal incisions with needle-knife is a safe endoscopic technique to treat the BBS that could avoid surgery in most of the cases. Preventive measures applied after PEG insertion and continued during the follow-up may result in a distinctly lower prevalence of BBS.

Upper gastrointestinal endoscopic findings in the era of highly active antiretroviral therapy.

BACKGROUND: The current literature suggests that there has been a decrease in opportunistic diseases among HIV-infected patients since the widespread introduction of highly active antiretroviral therapy (HAART) in 1995. OBJECTIVES: The aim of the study was to investigate the impact of HAART and CD4 lymphocyte count on diseases of the upper gastrointestinal (UGI) tract, digestive symptoms, and endoscopic and histological observations. METHODS: A review of 706 HIV-infected patients who underwent GI endoscopy was undertaken. The cohort was divided into three groups: group 1 (G1), pre-HAART, consisting of 239 patients who underwent endoscopy between January 1991 and December 1994; group 2 (G2), early HAART, consisting of 238 patients who underwent endoscopy between January 1999 and December 2002; and group 3 (G3), recent HAART, consisting of 229 patients who underwent endoscopy between January 2005 and December 2008. Parameters studied included age, gender, opportunistic chemoprophylaxis, antiretroviral therapies, CD4 cell counts, symptoms, observations at the first UGI endoscopy and histology. RESULTS: When G1, G2 and G3 were compared, significant increases were seen over time in the following parameters: the percentage of women, the mean CD4 cell count, and the frequencies of reflux symptoms, gastroesophageal reflux disease (GERD), inflammatory gastropathy, gastric ulcer and Helicobacter pylori (HP) infection. Significant decreases were seen in the frequencies of the administration of anti-opportunistic infection prophylaxis, odynophagia/dysphagia, acute/chronic diarrhoea, candida oesophagitis, nonspecific oesophageal ulcer and Kaposi sarcoma. No significant change was observed in the other parameters, i.e. digestive bleeding, duodenal ulcer and inflammatory duodenopathy. CONCLUSION: These results suggest a correlation between the improvement of immunity as a result of more efficient antiviral therapy and the decrease in the frequency of digestive diseases in AIDS, mainly opportunistic pathologies. However, HP infection, reflux symptoms and GERD have increased in the HAART era.

Lessons from a 20 year experience of Home Parenteral Nutrition in adult patients.

BACKGROUND: Home Parenteral Nutrition (HPN) is a method commonly used in patients with Chronic Intestinal Failure (CII) related to benign or malignant diseases. We report the experience from a 20 year programme of HPN in a single academic centre. METHODS: In this study, we have reviewed characteristics and outcome of a group of patients enrolled in a HPN program between 1987 and 2007. Focus was given to the prevalence and severity of cholestasis in these patients as well as on their oral food behaviour. RESULTS: In 20 years, 125 patients were included in a HPN programme; 65 patients had benign diseases (BD) and 60 advanced cancer (AC). Short bowel was the most common indications in patients with BD. Almost 40% of patients with BD were weaned off HPN. Median survival was excellent in BD patients and extremely short in AC. Death related to HPN was very rare. Cholestasis has been observed in 84% of patients but it was mild to moderate in the majority of cases. Hyperphagia was observed in 50% of the patients with BD on long-term HPN. CONCLUSIONS: This study confirms that HPN is the first line therapy in CII due to BD. Patients with AC should be carefully selected. Cholestasis is frequent but mostly without clinical impact. Half of the patients with CII due to BD become hyperphagic allowing to reduction of parenteral intake. The role of a multidisciplinary nutrition support team is essential for optimizing HPN.

Nutrition in care homes and home care: recommendations - a summary based on the report approved by the Council of Europe.

Undernutrition in home care and care home settings has been acknowledged as a situation with various causes and significant consequences on both an individual and social level. A review article exposing this problem has been recently published. Consequently, scientific experts and other stakeholders were involved in formulating recommendations to tackle undernutrition and sensitize political authorities. The forum held in Brussels and its proceedings were considered as a baseline to interview stakeholders involved in care homes and home care in order to propose solutions on different levels. A full report including guidelines was sent and accepted by the Council of Europe, and can be used as a basis for implementing strategies on a national and international level. A multidisciplinary approach is important to successfully tackle malnutrition on multiple levels: the patients, the health care workers (medical and non-medical), the public, policy makers and society stakeholders. Awareness for patients and caregivers is important; this can be obtained by information and appropriate training. Care home management and kitchen staff activities can be modified in order to promote nutrition. Policy makers should create legal frameworks to confront malnutrition as being a public health concern. Undernutrition in home care and care home settings is a considerable problem and confrontation involves a multidisciplinary approach.

Intraductal optical coherence tomography during endoscopic retrograde cholangiopancreatography for investigation of biliary strictures.

BACKGROUND AND STUDY AIMS: Optical coherence tomography (OCT) uses infrared light reflectance to produce high-resolution cross-sectional tissue images. The aim of this study was to demonstrate the feasibility of biliary intraductal OCT during endoscopic retrograde cholangiopancreatography (ERCP) and to assess the potential of the method to detect malignant biliary strictures. PATIENTS AND METHODS: Thirty-seven patients with biliary strictures were studied during therapeutic ERCP. Malignant strictures were defined as those that demonstrated malignant cells in brushing and/or biopsy specimens, and/or endoscopic ultrasound-guided fine-needle aspiration and/or surgery. Strictures that did not have malignant cells in resected specimens and were without clinical/radiological evidence of disease progression for at least a 12-month follow-up period were considered as benign. Two OCT criteria for malignancy were considered: unrecognizable layer architecture; and presence of large, nonreflective areas compatible with tumor vessels. Sensitivity and specificity for brushings/biopsies as well as OCT criteria were calculated. RESULTS: Nineteen patients had malignant and 16 had benign strictures. In two patients, OCT assessment could not be performed due to tight strictures. Malignancy was confirmed by biliary brushings/biopsies in 12/19 (63 %) patients. OCT revealed that two malignancy criteria were encountered in 10/19 (53 %) and at least one criterion in 15/19 (79 %) patients with malignant strictures. No patient with benign stricture met both criteria and 5/16 met one criterion (31 %). Combining brushings/biopsy with the observation of at least one OCT criterion resulted in the diagnosis of malignancy in 16/19 (84 %) patients. CONCLUSIONS: OCT may improve the sensitivity and diagnostic accuracy of biliary brushings/biopsies alone.

Nutrition in care homes and home care: how to implement adequate strategies (report of the Brussels Forum (22-23 November 2007)).

BACKGROUND & AIMS: Undernutrition in home care and care home settings is an unrecognized problem with significant consequences. The present work was edited after a forum concerning nutrition in these settings was held in Brussels in order to tackle the problem. METHODS: Various aspects of the question were addressed with the participation of scientific experts. The proceedings of the forum were edited and completed by a review of previously published material. RESULTS: Prevalence of undernutrition in home care and care home settings varies between 15% and 65%. Causes of undernutrition are various: medical, social, environmental, organizational and financial. Lack of alertness of individuals, their relatives and health-care professionals play an important role. Undernutrition enhances the risk of infection, hospitalization, mortality and alter the quality of life. Moreover, undernutrition related-disease is an economic burden in most countries. Nutritional assessment should be part of routine global management. Nutritional support combined with physical training and an improved ambiance during meals is mandatory. Awareness, information and collaboration with all the stakeholders should facilitate implementation of nutritional strategies. CONCLUSIONS: Undernutrition in home care and care home settings is a considerable problem and measures should be taken to prevent and treat it.

Pancreatic ductal system obstruction and acute recurrent pancreatitis.

Acute recurrent pancreatitis is a clinical entity largely associated with pancreatic ductal obstruction. This latter includes congenital variants, of which pancreas divisum is the most frequent but also controversial, chronic pancreatitis, tumors of the pancreaticobiliary junction and sphincter of Oddi dysfunction. This review summarizes current knowledge about diagnostic work-up and therapy of these conditions.

Efficacy of the combination of long-acting release octreotide and tamoxifen in patients with advanced hepatocellular carcinoma: a randomised multicentre phase III study.

To assess the efficacy of the combination of long-acting release (LAR) octreotide and tamoxifen (TMX) for the treatment of advanced hepatocellular carcinoma (HCC). A total of 109 patients with advanced HCC were randomised to receive octreotide LAR combined with TMX (n=56) (experimental treatment group) or TMX alone (n=53; control group). The clinical, biological and tumoural parameters were recorded every 3 months until death. Primary end point was patient survival; secondary end points were the impact of therapy on tumour response, quality of life and variceal bleeding episodes. Univariate and multivariate analyses were performed for assessment of specific prognostic factors. The median survival was 3 months (95% CI 1.4-4.6) for the experimental treatment group and 6 months (CI 95% 2-10) for the control group (P=0.609). There was no difference in terms of alpha-foetoprotein (alpha-FP) decrease, tumour regression, improvement of quality of life and prevention of variceal bleeding between the two groups. Variables associated with a better survival in the multivariate analysis were: presence of cirrhosis, alpha-FP level <400 ng ml(-1) and Okuda stage I. The combination of octreotide LAR and TMX does not influence survival, tumour progression or quality of life in patients with advanced HCC.