The Hong Kong consensus recommendations on the diagnosis and management of pancreatic cystic lesions.

Background: The finding of pancreatic cystic lesions (PCL) on incidental imaging is becoming increasingly common. International studies report a prevalence of 2.2-44.7% depending on the population, imaging modality and indication for imaging, and the prevalence increases with age. Patients with PCL are at risk of developing pancreatic cancer, a disease with a poor prognosis. This publication summarizes recommendations for the diagnosis and management of PCL and post-operative pancreatic exocrine insufficiency (PEI) from a group of local specialists. Methods: Clinical evidence was consolidated from narrative reviews and consensus statements formulated during two online meetings in March 2022. The expert panel included gastroenterologists, hepatobiliary surgeons, oncologists, radiologists, and endocrinologists. Results: Patients with PCL require careful investigation and follow-up due to the risk of malignant transformation of these lesions. They should undergo clinical investigation and pancreas-specific imaging to classify lesions and understand the risk profile of the patient. Where indicated, patients should undergo pancreatectomy to excise PCL. Following pancreatectomy, patients are at risk of PEI, leading to gastrointestinal dysfunction and malnutrition. Therefore, such patients should be monitored for symptoms of PEI, and promptly treated with pancreatic enzyme replacement therapy (PERT). Patients with poor response to PERT may require increases in dose, addition of a proton pump inhibitor, and/or further investigation, including tests for pancreatic function. Patients are also at risk of new-onset diabetes mellitus after pancreatectomy; they should be screened and treated with insulin if indicated. Conclusions: These statements are an accurate summary of our approach to the diagnosis and management of patients with PCL and will be of assistance to clinicians treating these patients in a similar clinical landscape.

Idiopathic mesenteric phlebosclerosis: A rare cause of chronic diarrhea.

We report a 45-year-old healthy Chinese woman who presented with chronic diarrhea and iron deficiency anemia, with colonoscopy showing multiple ulcers from cecum to sigmoid on a background of dark-purple mucosa. She was initially suspected to be suffering from inflammatory bowel disease, but the peculiar colonic biopsy findings and computed tomography (CT) imaging features, together with her habit of using Chinese herbal supplements, supported the rare diagnosis of idiopathic mesenteric phlebosclerosis.

An international, multi-institution survey of the use of EUS in the diagnosis of pancreatic cystic lesions.

BACKGROUND AND OBJECTIVES: Currently, pancreatic cystic lesions (PCLs) are recognized with increasing frequency and have become a more common finding in clinical practice. EUS is challenging in the diagnosis of PCLs and evidence-based decisions are lacking in its application. This study aimed to develop strong recommendations for the use of EUS in the diagnosis of PCLs, based on the experience of experts in the field. METHODS: A survey regarding the practice of EUS in the evaluation of PCLs was drafted by the committee member of the International Society of EUS Task Force (ISEUS-TF). It was disseminated to experts of EUS who were also members of the ISEUS-TF. In some cases, percentage agreement with some statements was calculated; in others, the options with the greatest numbers of responses were summarized. RESULTS: Fifteen questions were extracted and disseminated among 60 experts for the survey. Fifty-three experts completed the survey within the specified time frame. The average volume of EUS cases at the experts' institutions is 988.5 cases per year. CONCLUSION: Despite the limitations of EUS alone in the morphologic diagnosis of PCLs, the results of the survey indicate that EUS-guided fine-needle aspiration is widely expected to become a more valuable method.

Novel use of cap-assisted enteroscopy for detection of colorectal tumor in a patient with incarcerated inguinal hernia.

Multiple reports have documented unsuspected inguinal hernias which result in difficulties during the colonoscopic examinations of patients. In most cases, the colonoscopy can be delayed until a surgical consult has further evaluated the inguinal hernia. This case report documents a patient who required a colonoscopy but surgical intervention for the detected inguinal hernia was not appropriate due to his co-morbid medical conditions. With the use of the combination of an enteroscope fitted with a cap and fluoroscopy, the inguinal hernia was able to be negotiated and the diagnosis of a cecal carcinoma was able to be confirmed.

Incarceration of a colonoscope in an inguinal hernia: Case report and literature review.

Incarceration of an endoscope in an inguinal hernia may occur during the course of routine colonoscopy. The incarceration may occur on insertion or withdrawal and frequently the hernia is not suspected prior to the colonoscopy. Most commonly, a left sided inguinal hernia is involved, however right inguinal hernias may be implicated in subjects with altered anatomy post abdominal surgery. Incarceration of an endoscope in an inguinal hernia has been seldom reported in the literature which is likely to be related to under reporting. A range of techniques have been suggested by various authors over the last four decades to manage this unusual complication of colonoscopy. These techniques include utilizing fluoroscopy, manual external pressure and/or the fitting of a cap onto the tip of the colonoscope to facilitate colonoscopic navigation. The authors present a case report of incarceration of the colonoscope on withdrawal in an unsuspected left inguinal hernia with a review of the literature on the management of this colonoscopic complication. A management strategy is suggested.

The efficacy of cap-assisted colonoscopy in polyp detection and cecal intubation: a meta-analysis of randomized controlled trials.

OBJECTIVES: The role of cap-assisted colonoscopy (CAC) in polyp detection and cecal intubation is unclear. We conducted a meta-analysis to compare the efficacy of CAC vs. standard colonoscopy (SC). METHODS: Publications in English and non-English literatures (OVID, MEDLINE, and EMBASE) and abstracts in major international conferences were searched for controlled trials comparing CAC and SC. Outcome measures included the proportion of patients with polyps or adenomas detected, cecal intubation rate, cecal intubation time, and total colonoscopy time. The statistical heterogeneity of trials was examined and the effects were pooled by random-effects model. The risk of bias was evaluated by the assessment tool from the Cochrane Handbook. Subgroup analyses were performed for possible clinical and methodological heterogeneities. RESULTS: From 2,358 citations, 16 randomized controlled clinical trials were included consisting of 8,991 subjects (CAC: 4,501; SC: 4,490). Mean age of subjects was 61.0 years old and 60% were males. CAC detected a higher proportion of patients with polyp(s) (relative risk (RR): 1.08; 95% confidence interval (CI): 1.00-1.17) and reduced the cecal intubation time (mean difference: -0.64 min; 95% CI: -1.19 to -0.10). Cecal intubation rate (RR: 1.00; 95% CI: 0.99-1.02) and total colonoscopy time (mean difference: -0.97 min; 95% CI: -2.33 to 0.40) were comparable between the two groups. In subgroup analyses, a short cap (≤4 mm) was associated with improved polyp detection, whereas a long cap (≥7 mm) was associated with a shorter cecal intubation time. CONCLUSIONS: CAC demonstrated marginal benefit over SC for polyp detection and shortened the cecal intubation time.

Efficacy of cap-assisted colonoscopy in comparison with regular colonoscopy: a randomized controlled trial.

OBJECTIVES: Colonoscopy cannot be completed in up to 10% of cases. We postulate that cap-assisted colonoscopy (CAC), by fitting a mucosectomy cap to the tip of a colonoscope, could improve the outcome. METHODS: We conducted a prospective randomized controlled trial in two regional endoscopy centers. All colonoscopies were performed by experienced colonoscopists. Patients 18 years or older undergoing their first colonoscopy were recruited. Patients were randomized to the CAC group or to the regular colonoscopy (RC) group. The first successful cecal intubation rate, rescue cecal intubation rate, cecal intubation and total colonoscopy times, and polyp detection rate were compared. RESULTS: One thousand patients were enrolled (mean age 52.6 years, 46% men). There was no statistically significant difference in the first successful cecal intubation rate between CAC and RC groups (96.2% vs. 94.6%, P=0.23). The cecal intubation and total colonoscopy times were shorter in the CAC group than in the RC group (6.0+/-4.0 min vs. 7.2+/-4.8 min, P<0.001; 14.7+/-8.6 min vs. 16.7+/-10.3 min, P=0.001). The adenoma detection rate was significantly lower in the CAC group than in the RC group (30.5% vs. 37.5%, P=0.018), but there was no significant difference in the detection of advanced lesions. In case of failing cecal intubation, use of CAC as a rescue method could achieve a higher success rate than RC (66.7% vs. 21.1%, P=0.003). CONCLUSIONS: Among experienced colonoscopists, CAC did not improve the initial cecal intubation rate and had a lower adenoma detection rate. However, it shortened the cecal intubation time and performed better as a rescue method. Its utilization should be reserved for selected cases, especially when initial cecal intubation fails.

Comparison of EUS and ERCP in the investigation with suspected biliary obstruction caused by choledocholithiasis: a randomized study.

BACKGROUND: EUS may be used to reduce the need of diagnostic ERCP. OBJECTIVE: Our purpose was to investigate the benefits and safety of an EUS-guided versus an ERCP-guided approach in the management of suspected biliary obstructive diseases caused by choledocholithiasis, in whom a US study is not diagnostic. DESIGN: A randomized study. SETTING: A university medical unit. PATIENTS: Patients with clinical, biochemical, or radiologic suspicion of biliary obstruction. INTERVENTIONS: In the EUS group, therapeutic ERCP was performed at the same EUS session if a lesion was found. In the ERCP group, therapeutic treatment was carried out at the discretion of the endoscopist. MAIN OUTCOME MEASUREMENTS: The number of ERCPs avoided, procedure-related complications, and recurrent biliary symptoms on follow-up at 1 year. RESULTS: Thirty-three patients were randomized to EUS and 32 to ERCP. Three patients (9.4%) had failed ERCPs, whereas all EUS procedures were successful. Nine (27.3%) patients in the EUS group were found to have biliary lesions that were all treated by ERCP. In the ERCP group, 7 (22%) patients had biliary lesions detected that were treated in the same session. More patients had serious complications (bleeding, acute pancreatitis, and umbilical abscess) in the ERCP group. One patient in each group had recurrent biliary symptoms during follow-up. With EUS used as a triage tool, diagnostic ERCP and its related complications could be spared in 49 (75.4%) patients. CONCLUSIONS: In patients suspected to have biliary obstructive disease, EUS is a safe and accurate test to select patients for therapeutic ERCP.

Combination of a cyclo-oxygenase-2 inhibitor and a proton-pump inhibitor for prevention of recurrent ulcer bleeding in patients at very high risk: a double-blind, randomised trial.

BACKGROUND: Guidelines on pain management recommend that patients at risk of ulcers receive either a cyclo-oxygenase (COX 2) inhibitor or a non-steroidal anti-inflammatory drug (NSAID) with a proton-pump inhibitor (PPI). These two treatments have similar effectiveness, but they are insufficient for protection of patients at very high risk for ulcer bleeding. We aimed to test the hypothesis that in patients with previous ulcer bleeding induced by non-selective NSAIDs, combined treatment with the COX 2 inhibitor celecoxib and the PPI esomeprazole would be better than celecoxib alone for prevention of recurrent ulcer bleeding. METHODS: 441 consecutively presenting patients who were taking non-selective NSAIDs for arthritis were recruited to our single-centre, prospective, randomised, double-blind trial after admission to hospital with upper-gastrointestinal bleeding. Patients were enrolled after their ulcers had healed and a histological test for Helicobacter pylori was negative. All patients were given 200 mg celecoxib twice daily. 137 patients were randomly assigned to receive 20 mg esomeprazole twice daily (combined-treatment group), and 136 to receive a placebo (control group) for 12 months. The primary endpoint was recurrent ulcer bleeding during treatment or within 1 month of the end of treatment. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00365313. FINDINGS: Combination treatment was more effective than celecoxib alone for prevention of ulcer bleeding in patients at high risk. The 13-month cumulative incidence of the primary endpoint was 0% in the combined-treatment group and 12 (8.9%) in the controls (95% CI difference, 4.1 to 13.7; p=0.0004). The median follow-up was 13 months (range 0.4-13.0). Discontinuation of treatment and the incidence of adverse events were similar in the two treatment groups. INTERPRETATION: Patients at very high risk for recurrent ulcer bleeding who need anti-inflammatory analgesics should receive combination treatment with a COX 2 inhibitor and a PPI. Our findings should encourage guideline committees to review their recommendations for patients at very high risk of recurrent ulcer bleeding.

Dieulafoy's lesion: a case series study.

AIM: Dieulafoy's lesion (DL) accounts for 1-5.8% of cases of acute upper gastrointestinal bleeding (GIB). Its mortality is high, approaching 20%, despite recent advances in endoscopic therapy. We aimed to report our experience in the treatment of DL. METHODS: A retrospective case study of all patients with DL between January 1993 and January 2003 was done. Characteristics, treatment methods, success rates and 30-d mortality of the patients were analyzed. RESULTS: Thirty-six patients were noted to have DL in the study period. Thirty-three records were available for assessment in which 35 DL were identified. The median age of the patients was 67 years with male to female ratio of 5.6:1. Significant comorbidities existed in 69% of the patients. Eighty-nine percent of the DL was found at first endoscopy, three DL at laparotomy. Significant coexistent endoscopic findings existed in 23%. Hemostasis was achieved in 88% by using adrenaline injection, or in combination with heater probe application at first endoscopy. Four cases had re-bleeding, all were successfully treated endoscopically. The 30-d mortality rate was 23%. CONCLUSION: Successful endoscopic hemostasis could be achieved in 100% of cases of DL. The overall mortality may still remain high, mainly due to the comorbidities and age of these patients.

Long-term outcome of Helicobacter pylori-negative idiopathic bleeding ulcers: a prospective cohort study.

BACKGROUND & AIMS: Helicobacter pylori-negative idiopathic ulcers are increasingly recognized. The secular trend and long-term outcome of this condition are unknown. METHODS: We prospectively studied consecutive patients with bleeding gastroduodenal ulcers from January to December 2000. The incidence and etiology of ulcers during this period were compared with that between September 1997 and August 1998. H. pylori-negative idiopathic ulcers were defined as negative tests for H. pylori, no exposure to analgesics within 4 weeks, and absence of other risk factors for ulcers. After the ulcers had healed, patients with H. pylori-negative idiopathic ulcers and patients with H. pylori ulcers who received eradication therapy were followed up for 12 months without anti-ulcer drugs. RESULTS: Six hundred thirty-eight patients had bleeding ulcers: 213 (33.4%) were H. pylori ulcers, and 120 (18.8%) were H. pylori-negative idiopathic ulcers (vs 480 [50.3%] H. pylori ulcers and 40 [4.2%] H. pylori-negative idiopathic ulcers in 1997-1998; P < .001). H. pylori-negative idiopathic ulcers accounted for 16.1% of patients who were admitted for bleeding and 42.4% of patients who bled while in the hospital (P < .0001); 28.3% of patients with H. pylori-negative idiopathic ulcers had histologic evidence of past H. pylori infection. The probability of recurrent ulcer complications in 12 months was 13.4% (95% CI: 7.3%-19.5%) in patients with H. pylori-negative idiopathic ulcers and 2.5% (95% CI: 0.4%-4.6%) in patients with H. pylori ulcers who received eradication therapy (P = .0002). CONCLUSIONS: The incidence of H. pylori-negative idiopathic bleeding ulcers is rising. These ulcers are prone to recurrent complications.

A randomized, controlled trial of combination therapy for chronic hepatitis B: comparing pegylated interferon-alpha2b and lamivudine with lamivudine alone.

BACKGROUND: Conventional interferon and lamivudine monotherapy are unsatisfactory in treating hepatitis B virus (HBV) infection. OBJECTIVE: To evaluate the efficacy and safety of pegylated interferon-alpha2b and lamivudine combination therapy for chronic hepatitis B. DESIGN: Randomized, controlled, open-label trial. SETTING: Outpatient clinic in a referral center. PARTICIPANTS: 100 treatment-naive patients with hepatitis B e antigen (HBeAg)-positive chronic hepatitis B and moderately elevated alanine aminotransferase levels. MEASUREMENT: The primary end point was sustained virologic response (HBeAg seroconversion and HBV DNA level < 500,000 copies/mL) at 24 weeks after cessation of treatment. INTERVENTION: A staggered regimen of combination therapy with pegylated interferon-alpha2b (1.5 microg/kg of body weight per week; maximum, 100 microg) given for 32 weeks plus lamivudine (100 mg daily) given for 52 weeks versus lamivudine (100 mg daily) monotherapy given for 52 weeks. Of the 100 participants, 96% completed treatment and 80% completed post-treatment follow-up. RESULTS: The rate of sustained virologic response was 36% for the combination treatment group and 14% for the lamivudine monotherapy group (absolute difference, 22 percentage points [95% CI, 6 to 38 percentage points]). End-of-treatment outcomes showed that, compared with monotherapy, patients receiving combination therapy more often had virologic response (60% vs. 28% [absolute difference, 32 percentage points (CI, 14 to 50 percentage points)]); had more substantial reductions of HBV DNA (3.91 log10 copies/mL vs. 2.83 log10 copies/mL); and less often had lamivudine-resistant mutants (21% vs. 40%). The percentages of patients with normalization of alanine aminotransferase levels and histologic improvement did not differ. Adverse effects, such as transient influenza-like symptoms, alopecia, and local erythematous reactions, were more common with combination therapy. LIMITATIONS: This study lacked a double-blind design and was conducted at 1 institution. Because of the staggered pegylated interferon-lamivudine regimen, patients assigned to combination therapy received treatment for 8 weeks longer than those assigned to monotherapy. CONCLUSIONS: In patients with HBeAg-positive chronic hepatitis B, staggered combination treatment with pegylated interferon-alpha2b and lamivudine may lead to a higher rate of virologic response than lamivudine monotherapy.

Premedication with orally administered midazolam in adults undergoing diagnostic upper endoscopy: a double-blind placebo-controlled randomized trial.

BACKGROUND: A double-blind placebo-controlled randomized trial was conducted to investigate the safety and the efficacy of orally administered midazolam as premedication for patients undergoing elective EGD. METHODS: A total of 130 patients were randomized to receive either 7.5 mg of midazolam orally (n = 65) or a placebo (n = 65) as premedication. Outcomes measures included the anxiety score (visual analog scale) during EGD, overall tolerance, extent of amnesia, overall satisfaction, patient willingness to repeat the procedure, recovery time, and hemodynamic changes after medication. RESULTS: The median (interquartile range) anxiety score during the procedure in the midazolam group was significantly lower than that in the control group (2.0 [0-4.9] vs. 3.8 [2.1-7.95], p < 0.001). A significantly greater number of patients in the midazolam group graded overall tolerance as "excellent or good" (70.8% vs. 49.2%, p = 0.012) and reported a partial to complete amnesia response (52.3% vs. 32.3%, p = 0.02) when compared with the control group. Patients in the midazolam group were more willing to repeat the procedure if necessary (89.2% vs. 69.2%, p = 0.005). The median (interquartile range) recovery time was significantly longer in the midazolam group than in the control group (5 [5-15] minutes vs. 5 [5-10] minutes, p = 0.014). There were no statistically significant differences in satisfaction score and hemodynamic changes between groups. CONCLUSIONS: Premedication by oral administration of midazolam is a safe and an effective method of sedation that significantly reduces anxiety and improves overall tolerance for patients undergoing EGD.

Cyanosis in a compulsive urine drinker.

An 18-year-old gentleman with a habit of compulsive urine drinking was admitted because of repeated vomiting and was noted to be cyanotic. His oxygen saturation was 84% on pulse oximeter but arterial blood gas was normal. He was subsequently confirmed to have methemoglobinemia. He was successfully treated with methylene blue followed by behavioral therapy for his compulsive urine drinking and there was no recurrence of methaemoglobinaemia.