High volume, low volume, or pills, which way should we go? a review of bowel preparation for colonoscopy.

PURPOSE OF REVIEW: Colorectal cancer (CRC) is the second leading cause of adult cancer-related deaths in the United States. Colonoscopy is the gold standard for CRC screening. Adequate bowel preparation prior to colonoscopy is essential for good visualization, which results in higher polyp detection rates and shorter procedural times. Achieving adequate preparation prior to colonoscopy is accomplished approximately 75% of the time. This review covers current recommendations and recent updates in bowel preparation for colonoscopy. RECENT FINDINGS: Split-dose bowel preparation is recommended, but recent studies show that same day, low-volume preparations are noninferior. Low-volume polyethylene glycol with electrolytes + ascorbic acid can achieve high-quality bowel preparation and 1-day, low-residue diets prior to colonoscopy, particularly prepackaged low-residue diets, can lead to better outcomes. Utilizing visual aids and artificial intelligence in the form of smartphone applications and quality prediction systems can also lead to higher rates of bowel preparation adequacy. SUMMARY: An individualized approach should be used to decide on the best preparation option for patients. Lower volume, same day preparations are available and lead to better patient tolerability and compliance, along with less stringent precolonoscopy diets. Smartphone applications and artificial intelligence will allow us to better educate and guide patients with regards to following preparation instructions.

Artificial Intelligence in Colonoscopy.

PURPOSE OF REVIEW: Artificial intelligence (AI) is a rapidly growing field in gastrointestinal endoscopy, and its potential applications are virtually endless, with studies demonstrating use of AI for early gastric cancer, inflammatory bowel disease, Barrett's esophagus, capsule endoscopy, as well as other areas in gastroenterology. Much of the early studies and applications of AI in gastroenterology have revolved around colonoscopy, particularly with regards to real-time polyp detection and characterization. This review will cover much of the existing data on computer-aided detection (CADe), computer-aided diagnosis (CADx), and briefly discuss some other interesting applications of AI for colonoscopy, while also considering some of the challenges and limitations that exist around the use of AI for colonoscopy. RECENT FINDINGS: Multiple randomized controlled trials have now been published which show a statistically significant improvement when using AI to improve adenoma detection and reduce adenoma miss rates during colonoscopy. There is also a growing pool of literature showing that AI can be helpful for characterizing/diagnosing colorectal polyps in real time. AI has also shown promise in other areas of colonoscopy, including polyp sizing and automated measurement and monitoring of quality metrics during colonoscopy. AI is a promising tool that has the ability to shape the future of gastrointestinal endoscopy, with much of the early data showing significant benefits to use of AI during colonoscopy. However, there remain several challenges that may delay or hamper the widespread use of AI in the field.

Three-Dimensional Evaluation of Skeletal Stability following Surgery-First Orthognathic Approach: Validation of a Simple and Effective Method.

Background The three-dimensional (3D) evaluation of skeletal stability after orthognathic surgery is a time-consuming and complex procedure. The complexity increases further when evaluating the surgery-first orthognathic approach (SFOA). Herein, we propose and validate a simple time-saving method of 3D analysis using a single software, demonstrating high accuracy and repeatability. Methods This retrospective cohort study included 12 patients with skeletal class 3 malocclusion who underwent bimaxillary surgery without any presurgical orthodontics. Computed tomography (CT)/cone-beam CT images of each patient were obtained at three different time points (preoperation [T0], immediately postoperation [T1], and 1 year after surgery [T2]) and reconstructed into 3D images. After automatic surface-based alignment of the three models based on the anterior cranial base, five easily located anatomical landmarks were defined to each model. A set of angular and linear measurements were automatically calculated and used to define the amount of movement (T1-T0) and the amount of relapse (T2-T1). To evaluate the reproducibility, two independent observers processed all the cases, One of them repeated the steps after 2 weeks to assess intraobserver variability. Intraclass correlation coefficients (ICCs) were calculated at a 95% confidence interval. Time required for evaluating each case was recorded. Results Both the intra- and interobserver variability showed high ICC values (more than 0.95) with low measurement variations (mean linear variations: 0.18 mm; mean angular variations: 0.25 degree). Time needed for the evaluation process ranged from 3 to 5 minutes. Conclusion This approach is time-saving, semiautomatic, and easy to learn and can be used to effectively evaluate stability after SFOA.

Impact of Artificial Intelligence on Colonoscopy Surveillance After Polyp Removal: A Pooled Analysis of Randomized Trials.

BACKGROUND AND AIMS: Artificial intelligence (AI) tools aimed at improving polyp detection have been shown to increase the adenoma detection rate during colonoscopy. However, it is unknown how increased polyp detection rates by AI affect the burden of patient surveillance after polyp removal. METHODS: We conducted a pooled analysis of 9 randomized controlled trials (5 in China, 2 in Italy, 1 in Japan, and 1 in the United States) comparing colonoscopy with or without AI detection aids. The primary outcome was the proportion of patients recommended to undergo intensive surveillance (ie, 3-year interval). We analyzed intervals for AI and non-AI colonoscopies for the U.S. and European recommendations separately. We estimated proportions by calculating relative risks using the Mantel-Haenszel method. RESULTS: A total of 5796 patients (51% male, mean 53 years of age) were included; 2894 underwent AI-assisted colonoscopy and 2902 non-AI colonoscopy. When following U.S. guidelines, the proportion of patients recommended intensive surveillance increased from 8.4% (95% CI, 7.4%-9.5%) in the non-AI group to 11.3% (95% CI, 10.2%-12.6%) in the AI group (absolute difference, 2.9% [95% CI, 1.4%-4.4%]; risk ratio, 1.35 [95% CI, 1.16-1.57]). When following European guidelines, it increased from 6.1% (95% CI, 5.3%-7.0%) to 7.4% (95% CI, 6.5%-8.4%) (absolute difference, 1.3% [95% CI, 0.01%-2.6%]; risk ratio, 1.22 [95% CI, 1.01-1.47]). CONCLUSIONS: The use of AI during colonoscopy increased the proportion of patients requiring intensive colonoscopy surveillance by approximately 35% in the United States and 20% in Europe (absolute increases of 2.9% and 1.3%, respectively). While this may contribute to improved cancer prevention, it significantly adds patient burden and healthcare costs.

Deep Learning Computer-aided Polyp Detection Reduces Adenoma Miss Rate: A United States Multi-center Randomized Tandem Colonoscopy Study (CADeT-CS Trial).

BACKGROUND & AIMS: Artificial intelligence-based computer-aided polyp detection (CADe) systems are intended to address the issue of missed polyps during colonoscopy. The effect of CADe during screening and surveillance colonoscopy has not previously been studied in a United States (U.S.) population. METHODS: We conducted a prospective, multi-center, single-blind randomized tandem colonoscopy study to evaluate a deep-learning based CADe system (EndoScreener, Shanghai Wision AI, China). Patients were enrolled across 4 U.S. academic medical centers from 2019 through 2020. Patients presenting for colorectal cancer screening or surveillance were randomized to CADe colonoscopy first or high-definition white light (HDWL) colonoscopy first, followed immediately by the other procedure in tandem fashion by the same endoscopist. The primary outcome was adenoma miss rate (AMR), and secondary outcomes included sessile serrated lesion (SSL) miss rate and adenomas per colonoscopy (APC). RESULTS: A total of 232 patients entered the study, with 116 patients randomized to undergo CADe colonoscopy first and 116 patients randomized to undergo HDWL colonoscopy first. After the exclusion of 9 patients, the study cohort included 223 patients. AMR was lower in the CADe-first group compared with the HDWL-first group (20.12% [34/169] vs 31.25% [45/144]; odds ratio [OR], 1.8048; 95% confidence interval [CI], 1.0780-3.0217; P = .0247). SSL miss rate was lower in the CADe-first group (7.14% [1/14]) vs the HDWL-first group (42.11% [8/19]; P = .0482). First-pass APC was higher in the CADe-first group (1.19 [standard deviation (SD), 2.03] vs 0.90 [SD, 1.55]; P = .0323). First-pass ADR was 50.44% in the CADe-first group and 43.64 % in the HDWL-first group (P = .3091). CONCLUSION: In this U.S. multicenter tandem colonoscopy randomized controlled trial, we demonstrate a decrease in AMR and SSL miss rate and an increase in first-pass APC with the use of a CADe-system when compared with HDWL colonoscopy alone.

Risk prediction rule for advanced neoplasia on screening colonoscopy for average-risk individuals.

BACKGROUND: In resource-limited countries, risk stratification can be used to optimize colorectal cancer screening. Few prospective risk prediction models exist for advanced neoplasia (AN) in true average-risk individuals. AIM: To create and internally validate a risk prediction model for detection of AN in average-risk individuals. METHODS: Prospective study of asymptomatic individuals undergoing first screening colonoscopy. Detailed characteristics including diet, exercise and medications were collected. Multivariate logistic regression was used to elucidate risk factors for AN (adenoma ≥1 cm, villous histology, high-grade dysplasia or carcinoma). The model was validated through bootstrapping, and discrimination and calibration of the model were assessed. RESULTS: 980 consecutive individuals (51% F; 49% M) were enrolled. Adenoma and AN detection rates were 36.6% (F 29%: M 45%; P < 0.001) and 5.1% (F 3.8%; M 6.5%) respectively. On multivariate analysis, predictors of AN [OR (95%CI)] were age [1.036 (1.00-1.07); P = 0.048], BMI [overweight 2.21 (0.98-5.00); obese 3.54 (1.48-8.50); P = 0.018], smoking [< 40 pack-years 2.01 (1.01-4.01); ≥ 40 pack-years 3.96 (1.86-8.42); P = 0.002], and daily red meat consumption [2.02 (0.92-4.42) P = 0.079]. Nomograms of AN risk were developed in terms of risk factors and age separately for normal, overweight and obese individuals. The model had good discrimination and calibration. CONCLUSION: The prevalence of adenoma and AN in average-risk Lebanese individuals is similar to the West. Age, smoking, and BMI are important predictors of AN, with obesity being particularly powerful. Though external validation is needed, this model provides an important platform for improved risk-stratification for screening programs in regions where universal screening is not currently employed.

Bowel Preparation for Colonoscopy in 2020: A Look at the Past, Present, and Future.

PURPOSE OF THIS REVIEW: Colorectal cancer is the third most common cancer in the USA. Colonoscopy is considered the gold standard for colorectal cancer screening and can offer both diagnosis and therapy. The bowel preparation remains a significant barrier for patients who need to undergo colonoscopy and is often cited as the most dreaded aspect of the colonoscopy process. Inadequate bowel preparations still occur in 10-25% of colonoscopies, and this in turn can lead to increased procedural times, lower cecal intubation rates, and shorter interval between colonoscopies. From a quality standpoint, it is imperative that we do what we can to decrease the rate of inadequate bowel preparations. This review will focus on recent data regarding bowel preparation and offers a glimpse into what may be coming in the future. RECENT FINDINGS: Recent advances in the field have been made to improve tolerability of bowel preparations and allow for more adequate colonoscopies. Newer, lower volume, flavored preparations, the use of adjuncts, and using split-dose preparations all can help with tolerability, compliance, and, in turn, preparation quality. Edible bowel preparations may become available in the near future. Early data on the use of artificial intelligence for assessment of preparation quality has been promising. Additionally, utilization of smartphone technology for education prior to the bowel preparation has also been shown to improve the adequacy of bowel preparations. CONCLUSIONS: Ongoing efforts to improve the tolerability and palatability of colonoscopy bowel preparations are important from a quality improvement standpoint to ensure the adequacy of colonoscopy. Incorporating patient-specific factors and comorbidities is also an essential aspect of improving the quality of bowel preparation. Leveraging technology to better communicate with and educate patients on the bowel preparation process is likely to play a larger role in the coming years.

Barrett's esophagus: best practices for treatment and post-treatment surveillance.

Barrett's esophagus (BE) is a premalignant condition that increases the risk of esophageal adenocarcinoma (EAC). Significantly more common in the Western world, risk factors include increased age, male sex, white race, gastro-esophageal reflux disease (GERD), central obesity, and cigarette smoking. The rates of progression to cancer depend on the grade of Barrett's dysplasia. Screening for BE is recommended in patients with GERD and additional risk factors. Endoscopic surveillance of patients with BE likely improves overall outcomes. Advanced endoscopic imaging can help increase the efficiency of current endoscopic surveillance. Endoscopic therapy is safe and effective for the treatment of dysplastic BE and intramucosal EAC, but ongoing surveillance following treatment is necessary. This review will cover screening, surveillance, advanced imaging, chemoprevention, endoscopic treatment, and post-treatment surveillance of BE.

Esophageal Adenocarcinoma: Screening, Surveillance, and Management.

Esophageal adenocarcinoma (EAC) is a growing problem with a rapidly rising incidence. Risk factors include gastroesophageal reflux disease, central obesity, and smoking. The prognosis of EAC remains poor because it is usually diagnosed late, and many efforts have been made to improve prevention, early detection, and treatment. Acid suppression, nonsteroidal antiinflammatory drugs (NSAIDs), and statins may play a role in chemoprevention. Screening for Barrett's esophagus (BE), the only known precursor lesion of EAC, is indicated for individuals with increased risk. Endoscopic surveillance of patients with BE likely improves overall outcomes. Endoscopic ablation and resection is highly effective for treating dysplastic BE and early EAC, whereas esophagectomy is indicated for patients with locally advanced disease. This review covers epidemiology, staging, screening, and prevention of EAC as well as endoscopic and surgical management.

Challenging the dogma: a randomized trial of standard vs. half-dose concomitant nonbismuth quadruple therapy for Helicobacter pylori infection.

BACKGROUND: Current treatment of Helicobacter pylori consists of three or four drugs for 7-14 days with important associated cost and adverse events. AIMS: This study compared efficacy and safety of standard dose vs. half-dose concomitant nonbismuth quadruple therapy (NBQT) for 7 days. The standard dose consisted of twice daily rabeprazole 20 mg, amoxicillin 1 g, metronidazole 500 mg, and clarithromycin 500 mg. METHODS: This was a prospective randomized trial. (14)C-urea breath test was performed ≥4 weeks after treatment and ≥2 weeks off acid suppressive therapy. Compliance and adverse events were monitored during treatment. RESULTS: A total of 200 consecutive treatment-naïve patients were enrolled. Baseline characteristics were similar between groups, with 15.5% of subjects reporting prior macrolide use. Eradication occurred in 78% (95% CI 68.6-85.7%) in both groups on intention-to-treat analysis. Per-protocol rates were 82.1 vs. 83.9% for standard-dose patients vs. half-dose patients, respectively (p = NS). Adverse events (only mild) were reported in 57 vs. 41% of standard-dose patients vs. half-dose patients (p = 0.024), with metallic taste and nausea notably less frequent in the latter (36 vs. 12% and 18 vs. 7%, respectively; p < 0.05 for both). Overall, eradication failed in 38.7% of prior macrolide users vs. 18.9% without such exposure (p = 0.019). On multivariate logistic regression, prior macrolide exposure was the only factor associated with failed eradication (OR 2.60, 95% CI 1.06-6.39; p = 0.038). Treatment was cheaper with the half-dose regimen. INTERPRETATION: A 50% reduction in antibiotic dosage does not diminish efficacy of concomitant nonbismuth quadruple therapy but leads to significant reduction in cost and adverse events. Seven-day concomitant NBQT is suboptimal for H. pylori independent of prior macrolide exposure.

Recurrence of a pancreatic cystic lymphangioma after diagnosis and complete drainage by endoscopic ultrasound with fine-needle aspiration.

CONTEXT: Lymphangiomas are uncommon benign neoplasms that result from a blockage of the lymphatic system. Pancreatic cystic lymphangiomas are extremely rare. Pancreatic cystic lymphangiomas have been classically diagnosed on histopathologic examination following surgical excision, but recent reports have demonstrated successful diagnosis using endoscopic ultrasound with fine-needle aspiration (EUS-FNA). Data on the natural history of these lesions following drainage via EUS-FNA are lacking. We present a case of successful initial diagnosis and drainage of a pancreatic cystic lymphangioma using EUS-FNA, with unfortunate recurrence of the lesion four months later. CASE REPORT: A 50-year-old female was evaluated for epigastric abdominal pain and nausea. CT scan revealed a 4 cm retroperitoneal cystic lesion. EUS-FNA was performed with complete drainage of the lesion using a 22-gauge needle. Twenty-five mL of chylous white fluid was obtained with laboratory analysis consistent with a pancreatic cystic lymphangioma. The patient was symptom-free for 4 months following drainage, but eventually had symptoms again with a CT scan confirming recurrence. CONCLUSIONS: While EUS-FNA is effective for the diagnosis of pancreatic cystic lymphangiomas, its role in the management of these lesions is questionable. Temporary relief of symptoms can be achieved after EUS-guided drainage, but recurrence is a concern. Definitive cure likely requires complete surgical excision.

CYP2C19 genetic polymorphism, rabeprazole and esomeprazole have no effect on the antiplatelet action of clopidogrel.

The aim of this study is to investigate the effect of CYP2C19 polymorphism and cotherapy with rabeprazole or esomeprazole on the antiplatelet effect of clopidogrel. Patients receiving clopidogrel 75 mg ± rabeprazole or esomeprazole underwent genotyping for CYP2C19*2 and CYP2C19*3, and vasodilator-stimulated phosphoprotein testing to measure platelet reactivity index (PRI). Two hundred thirty-nine consecutive patients were enrolled as follows: 92 clopidogrel (C group), 94 clopidogrel + rabeprazole (CR), and 53 clopidogrel + esomeprazole (CE). Forty-five patients had loss of function (LOF) polymorphism (43 heterozygous; 2 homozygous mutant for CYP2C19*2). The mean PRI was 20.7% ± 21.9% in the C group, 19.1% ± 20.9% in the CR group, and 24.5% ± 22.9% in the CE group (P = NS). High on-treatment platelet reactivity (HPR), defined as PRI >50%, was observed in 12 (13.0%), 13 (13.8%), and 10 (18.9%) patients on C, CR, and CE, respectively (P = NS). HPR was similar in rapid metabolizers between groups. On multivariate logistic regression, neither CYP2C19 LOF alleles nor proton pump inhibitor cotherapy were associated with HPR. The use of proton pump inhibitors was indicated in 30.6% of recipients. As a conclusion, CYP2C19*2 LOF allele and the use of esomeprazole or rabeprazole have no effect on the action of clopidogrel.

Proton pump inhibitors have no measurable effect on calcium and bone metabolism in healthy young males: a prospective matched controlled study.

OBJECTIVES: Proton pump inhibitors (PPIs) are associated with an increased risk of bone fractures. This study sought to evaluate the effect of PPIs on biochemical markers of calcium and bone metabolism. METHODS: Prospective matched controlled study involving healthy adult males (age 18-50years) suffering from frequent heartburn. Patients received standard-dose PPI for 12weeks and were matched by age with healthy controls. Blood studies were taken at 0, 1 and 3months for biochemical markers of mineral and bone metabolism. Two-way (time and PPI treatment) repeated measures analysis of variance (RM-ANOVA) and multiple linear regression were used for analysis. RESULTS: A total of 58 participants (29 per group) completed the study. Mean age of participants was 33.2±7.5years. Baseline characteristics and biomarkers were similar for both groups except for higher BMI (28.6 vs. 25.6kg/m(2), p=0.008) and serum C-terminal cross linked telopeptides of type I collagen [CrossLaps, (300 vs. 228pg/ml, p=0.028)] in the PPI group. There was no difference in parathormone (PTH), ionized calcium, vitamin D, osteocalcin and CrossLaps between the PPI and control subjects (all non-significant; 2-way RM-ANOVA). Multiple linear regression modeling showed no effect of PPIs on any of the studied calcium or bone metabolism biomarkers. CONCLUSION: PPI intake for 12weeks has no measurable effect on calcium or bone metabolism in healthy young males.

Alcohol consumption is a risk factor for colonic diverticulosis.

BACKGROUND AND AIM: The exact factors predisposing to colonic diverticulosis other than age are unknown. METHODS: Cross-sectional study of asymptomatic subjects undergoing screening colonoscopy. A detailed dietary and social questionnaire was completed on all participants. A worldwide review of the literature was performed to further investigate any association between identified risk factors and diverticulosis. RESULTS: Seven hundred forty-six consecutive individuals were enrolled (mean age, 61.1±8.3 y; female: male=0.98). Overall, the prevalence of diverticulosis was 32.8% (95% CI, 29.5-36.2). Diverticula were left-sided, right-sided, or both in 71.5%, 5.8%, and 22.7% of affected subjects, respectively. On univariate analysis, age, sex, adenomatous polyps, advanced neoplasia (adenoma≥1 cm, villous histology, or cancer), aspirin, and alcohol use were significantly associated with diverticulosis. Diet, body mass index, physical activity, and bowel habits were not associated with the disease. On multivariate analysis, increasing age (P<0.001), advanced neoplasia (P=0.021), and alcohol consumption (P<0.001) were significantly associated with diverticulosis. The adjusted odds ratio for diverticulosis in alcohol users was 1.91 (1.36 to 2.69), with increasing prevalence with higher alcohol consumption (P-value for trend=0.001). When the prevalence of diverticulosis reported from 18 countries was analyzed against alcohol use, there was a strong correlation with national per-capita alcohol consumption rates (Pearson correlation coefficient r=0.68; P=0.002). CONCLUSIONS: Alcohol use is a significant risk factor for colonic diverticulosis and may offer a partial explanation for the existing East-West paradox in disease prevalence and phenotype. Further studies are needed to investigate this association and its putative pathophysiological mechanisms.

A randomized trial of standard-dose versus half-dose rabeprazole, clarithromycin, and amoxicillin in the treatment of Helicobacter pylori infection.

OBJECTIVES: To evaluate the efficacy and safety of a standard-dose versus half-dose 10-day triple regimen for the eradication of Helicobacter pylori infection. METHODS: A total of 115 consecutive patients with documented infection were enrolled in this open-label trial. Group A (standard dose) received rabeprazole (20 mg), amoxicillin (1 g), and clarithromycin (500 mg), all twice daily for 10 days. Group B (half dose) received rabeprazole (10 mg), amoxicillin (500 mg), and clarithromycin (250 mg), all twice daily for 10 days. (14)C urea breath tests were performed a minimum of 4 weeks after treatment and a minimum of 2 weeks off any acid-suppressive therapy. Compliance and adverse effects were evaluated throughout the treatment period. RESULTS: A total of 115 patients were enrolled (59 women and 56 men; mean age 47.1±14.0 years). Eradication occurred in 45 of 58 patients [77.6%; 95% confidence interval (CI): 66.9-88.3%] in the standard-dose group versus 44 of 57 in the half-dose group (77.2%; 95% CI: 66.3-88.1%) on an intent-to-treat (ITT) analysis (P=1.00). Per protocol eradication rates were 45 of 57 (78.9%; 95% CI: 68.4-85.9%) and 44 of 54 (81.5%; 95% CI: 71.1-91.8%), respectively (P=0.81). The number of patients reporting any adverse effect was significantly higher in the standard-dose group (64.9 vs. 40.4%; P=0.014). The cost of treatment was significantly less in patients receiving the half-dose regimen (ITT analysis; P<0.05). The number needed to harm to suffer one additional failure in the half-dose over the standard-dose arm was 250 (ITT analysis). CONCLUSION: A half-dose 10-day regimen of rabeprazole, amoxicillin, and clarithromycin is equally effective but cheaper and better tolerated than its standard-dose regimen in the treatment of Helicobacter pylori. Eradication rates of both regimens are, however, suboptimal compared with accepted standards.

Prophylaxis with ertapenem in patients with obstructive jaundice undergoing endoscopic retrograde cholangiopancreatography: safety, efficacy, and biliary penetration.

BACKGROUND: Cholangitis and biliary sepsis are rare but serious complications of endoscopic retrograde cholangiopancreatography (ERCP). The aim of this study is to investigate the safety, efficacy, and biliary penetration of ertapenem, a newer carbapenem with a long half-life and broad-spectrum antimicrobial activity, for ERCP prophylaxis. METHODS: Patients with obstructive jaundice without cholangitis received a single dose of ertapenem equal to 1 gram intravenously prior to ERCP. A 2-3 mL bile sample was collected after cannulation and prior to contrast injection. Patients were observed for 72 hours for cholangitis or drug-related adverse events. Biliary ertapenem levels were measured using high-performance liquid chromatography (HPLC). RESULTS: Twenty-eight patients (ages 18-87 years, M/F ratio 1:1) were enrolled. Seven had no cholestasis and were included to study ertapenem penetration in unobstructed biliary trees. Cannulation was achieved in all patients. One patient (3.6%) with persistent intrahepatic stones developed cholangitis. No drug-related adverse events were noted. The mean time from ertapenem administration to bile collection was 60 ± 24 minutes. There was a significant negative correlation between serum bilirubin and biliary ertapenem levels (r = -0.542, P = 0.003) with the highest level (6.25 µg/mL) noted in unobstructed biliary systems. CONCLUSION: Ertapenem appears to be a safe and effective prophylaxis in patients with obstructive jaundice undergoing ERCP despite a limited biliary penetration in patients with high-grade obstruction.

Duration of pain is correlated with elevation in liver function tests in patients with symptomatic choledocholithiasis.

BACKGROUND & AIMS: We assessed the temporal relationship between abdominal pain and elevation in liver function tests (LFTs) in patients with acute symptomatic choledocholithiasis. METHODS: Retrospective study of patients that presented within 12 hours of pain onset and were subsequently found to have choledocholithiasis. RESULTS: We identified 40 patients with complete medical records. Levels of aspartate and alanine aminotransferases (AST and ALT) correlated with duration of pain (Pearson correlation, r = 0.633 and 0.622 respectively, P < .001 for both); the correlation was not as strong for γ-glutamyl transpeptidase (GGT) (r = 0.326, P = .046) and was not significant for alkaline phosphatase or bilirubin. This temporal association was stronger in patients that had undergone cholecystectomy versus those with intact gallbladders (for ALT, r = 0.603 vs r = 0.311, respectively). Eighteen patients, evaluated within 6 hours of pain, had normal or minimal alterations in LFTs; transabdominal ultrasound was abnormal in 6 (sensitivity 33.3%). All had repeat LFTs within 24 hours (mean 10.3 ± 6.9 hours later) and large increases in ALT and aspartate aminotransferase levels (mean 10.5- and 6.8-fold respectively; P < .01 for both), intermediate increases in glutamyl transpeptidase levels, (mean 4-fold, P < .05), and no changes in alkaline phosphatase levels. This significant increase in LFTs was the only indication of biliary pathology before endoscopy in 11/18 patients. CONCLUSIONS: Increasing duration of pain is associated with increasing LFTs (particularly transaminases) in patients with acute symptomatic choledocholithiasis. Patients with normal LFTs and ultrasound upon presentation should have repeat LFTs if biliary pain is suspected. The absence of significant biochemical abnormalities within the first 24 hours makes the diagnosis of symptomatic choledocholithiasis unlikely.