The Clinical Significance of Incidental GIT Uptake on PET/CT: Radiologic, Endoscopic, and Pathologic Correlation.

Incidental gastrointestinal tract (GIT) [18F]-Fluorodeoxyglucose (FDG) uptake in positron emission technology/computed tomography (PET/CT) is an unexpected and often complicated finding for clinicians. This retrospective study reviewed 8991 charts of patients who underwent PET/CT: 440 patients had incidental GIT uptake, of which 80 underwent endoscopy. Patient characteristics, imaging parameters, and endoscopic findings were studied. Of the 80 patients, 31 had cancer/pre-cancer lesions (16 carcinomas; 15 pre-malignant polyps). Compared to patients with benign/absent lesions, patients with cancer/pre-cancer lesions were significantly older (p = 0.01), underwent PET/CT for primary evaluation/staging of cancer (p = 0.03), had focal GIT uptake (p = 0.04), and had lower GIT uptake (p = 0.004). Among patients with focal uptake, an SUVmax of 9.2 had the highest sensitivity (0.76) and specificity (0.885) in detecting cancer/pre-cancerous lesions. Lower GIT uptake was most common in the sigmoid colon, and upper GIT uptake was most frequent in the stomach. In a bivariate analysis, predictors of cancer/pre-cancer were older age, PET/CT indicated for primary evaluation, focal uptake, uptake in the lower GIT, and higher SUVmax. Further endoscopic investigation is warranted for patients with incidental GIT uptake, especially in the elderly or those presenting for primary evaluation with PET/CT, with the following findings on imaging: lower GIT uptake, focal uptake, or high SUVmax.

Serial EUS-Guided FNA for the Surveillance of Pancreatic Cysts: A Study of Long-Term Performance of Tumor Markers.

BACKGROUND AND AIM: The natural history of KRAS mutations in mucinous pancreatic cysts (MPCs) over time remains to be fully understood. The aim of this study was to examine the performance of DNA markers and assess changes of KRAS mutations over time. METHODS: Patients who underwent EUS-FNA of pancreatic cysts with at least two separate molecular analysis results were included in the study. We assessed the baseline patient and cyst characteristics, and DNA fluid analysis. The presence of either a KRAS mutation, or a CEA > 192 ng/ml was used as the diagnostic standard for mucinous cysts when surgical pathology was not available. RESULTS: A total of 933 pancreatic cyst fluid samples were collected, including 117 with ≥ 2 FNAs. Examinations were performed over a median of 30 months (range 1-115 months). Forty-three (36%) had a mutant KRAS on the index analysis out of which 26 had a change in their KRAS status to the wild-type. Eighty-one (64%) had a wild-type KRAS on the index analysis out of which 18 had change in their KRAS status to mutant type. There was no significant difference in the index cyst characteristics, presence of symptoms, or main duct involvement based on KRAS status change. Increasing age was associated with a changing KRAS mutation status (p = 0.023). CONCLUSION: KRAS mutations gain and loss in pancreatic cyst fluid appears to occur frequently during long-term surveillance of MPCs. Age appears to be the only predictor for KRAS change over time.

CAD-LT score effectively predicts risk of significant coronary artery disease in liver transplant candidates.

BACKGROUND & AIMS: Patients with cirrhosis and significant coronary artery disease (CAD) are at risk of peri-liver transplantation (LT) cardiac events. The coronary artery disease in liver transplantation (CAD-LT) score and algorithm aim to predict the risk of significant CAD in LT candidates and guide pre-LT cardiac evaluation. METHODS: Patients who underwent pre-LT evaluation at Indiana University (2010-2019) were studied retrospectively. Stress echocardiography (SE) and cardiac catheterization (CATH) reports were reviewed. CATH was performed for predefined CAD risk factors, irrespective of normal SE. Significant CAD was defined as CAD requiring percutaneous or surgical intervention. A multivariate regression model was constructed to assess risk factors. Receiver-operating curve analysis was used to compute a point-based risk score and a stratified testing algorithm. RESULTS: A total of 1,771 pre-LT patients underwent cardiac evaluation, including results from 1,634 SE and 1,266 CATH assessments. Risk-adjusted predictors of significant CAD at CATH were older age (adjusted odds ratio 1.05; 95% CI 1.03-1.08), male sex (1.69; 1.16-2.50), diabetes (1.57; 1.12-2.22), hypertension (1.61; 1.14-2.28), tobacco use (pack years) (1.01; 1.00-1.02), family history of CAD (1.63; 1.16-2.28), and personal history of CAD (6.55; 4.33-9.90). The CAD-LT score stratified significant CAD risk as low (≤2%), intermediate (3% to 9%), and high (≥10%). Among patients who underwent CATH, a risk-based testing algorithm (low: no testing; intermediate: non-invasive testing vs. CATH; high: CATH) would have identified 97% of all significant CAD and potentially avoided unnecessary testing (669 SE [57%] and 561 CATH [44%]). CONCLUSIONS: The CAD-LT score and algorithm (available at www.cad-lt.com) effectively stratify pre-LT risk for significant CAD. This may guide more targeted testing of candidates with fewer tests and faster time to waitlist. LAY SUMMARY: The coronary artery disease in liver transplantation (CAD-LT) score and algorithm effectively stratify patients based on their risk of significant coronary artery disease. The CAD-LT algorithm can be used to guide a more targeted cardiac evaluation prior to liver transplantation.

A Comparative Study of 22G versus 19G Needles for EUS-Guided Biopsies for Parenchymal Liver Disease: Are Thinner Needles Better?

BACKGROUND AND AIMS: Data on comparative efficacy of various available endoscopic ultrasound-guided liver biopsy (EUS-LB) needles are limited. We sought to compare the performance of a novel Franseen-tip 22G fine-needle biopsy (FNB) device to that of 19G needle platforms for liver parenchyma. METHODS: Consecutive patients referred for EUS and suspected to have hepatic parenchymal disease underwent EUS-LB using different EUS needles and were included in this retrospective study. Two blinded expert liver pathologists independently reviewed and reported on: total number of tissue fragments, length of longest fragment, number of complete and incomplete portal tracts (CPT and IPT), and specimen adequacy. RESULTS: A 22G Franseen-tip needle (A) was used in 30 patients; 19G Tru-Cut needle (B) in 50 patients; 19G reverse beveled non-Tru-Cut needle (C) in 27 patients; and a 19G flexible non-Tru-Cut needle (D) in 28 patients. In the order of needles, A, B, C and D, > 10 tissue fragments were obtained in 100%, 6%, 82%, and 96% samples, the mean number of CPTs was 6.9; 3.0; 7.3; and 16.9, length of longest fragment was 3.8, 4. 7, 3.9, and 8.4 mm, and specimen adequacy was 66.7%, 46%, 82.1%, and 81.5%, respectively. A positive correlation was obtained between number of CPTs and length of longest fragment in samples accrued by 19G needles. CONCLUSION: EUS-LB specimens using 22G Franseen-tip needle appear highly fragmented, leading to inferior specimen adequacy compared to 19G non-Tru-Cut needles. We also report on using length of longest fragment as an additional criterion for specimen adequacy as it positively correlates with number of CPTs standard.

An exclusive fine-needle biopsy approach to sampling solid lesions under EUS guidance: a prospective cohort study.

BACKGROUND: Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) is increasingly utilized to enhance the cytological yield of sampling solid lesions, but its superiority over existing fine-needle aspiration (FNA) platforms has not been clearly demonstrated. The aim of our study was to compare the diagnostic accuracy and procedural outcomes of FNB using a new Franseen-tip needle to that of a traditional FNA in sampling solid lesions under EUS guidance. METHODS: Consecutive patients with solid lesions referred for EUS-FNB sampling were included. Procedure-related outcomes were collected prospectively including patient demographics, number of passes performed, diagnostic sample adequacy, adverse events, and recovery time. The Acquire needle was used to sample all lesions in the study group. Consecutive EUS-FNA procedures performed to sample solid lesions using the Expect needle were utilized as controls. RESULTS: There were 180 patients undergoing EUS-FNB compared to 183 patients undergoing EUS-FNA procedures for solid-lesion sampling. The procedure time was significantly shorter in patients who underwent FNB compared to FNA (mean: 37.4 vs 44.9 minutes, P < 0.001). Significantly fewer passes were performed in the FNB cohort compared to the FNA group (mean: 2.9 vs 3.8, P < 0.001). The cytologic diagnostic yield was significantly higher in the FNB group compared to the FNA group (98.3% vs 90.2%, P = 0.003). No significant difference in the incidence of adverse events was observed between the FNB and FNA groups (1.1% vs 0.5%, P = 0.564). CONCLUSIONS: An FNB-exclusive approach to sampling solid lesions under EUS guidance is safe and feasible, and may result in fewer overall passes, shorter procedure time, and improved diagnostic adequacy. FNB may replace FNA as the primary sampling modality of choice in all solid lesions.

Endoscopic Ultrasound-guided Sampling of Solid Pancreatic Lesions: A Comparative Analysis of 25 Gauge Versus 22 Gauge Core Biopsy Needles.

BACKGROUND: Pancreatic mass sampling has historically been performed by endoscopic ultrasound-guided fine needle aspiration (EUS-FNA). However, its sensitivity has been reported to be within a wide range, which limits its reliability. Fine needle biopsy (FNB) has been shown to have superior diagnostic performance and is increasingly replacing fine needle aspiration. In FNA, 25 gauge (G) needles appear to outperform 22G. Data comparing these sizes in FNB platforms is limited. We aimed to prospectively compare the performance of 22G and 25G Franseen-tip core biopsy needles in the sampling of solid pancreatic lesions. PATIENTS AND METHODS: Patients who underwent EUS-FNB of pancreatic lesions at the Indiana University Hospital using 2 needle sizes: 25G (Study group) and 22G (Control group) using the Acquire needle (Boston Scientific Co., Natick, MA, USA) were enrolled. Needle choice was left to the discretion of the endosonographer. Tissue specimens were evaluated onsite, and underwent touch and smear and cellblock preparation. Specimens were independently evaluated by 2 expert cytopathologists blinded to diagnosis. Cytopathologists assessed cytological yield (on smears) and histological yield (on cellblock) using a validated scoring system reached by a consensus among our cytopathologists as we have previously published. RESULTS: A total of 75 patients (42 males, median=65 years) underwent EUS-FNB during the study period (2017-2018): 50 using 25G and 25 using 22G needle. Diagnostic yield was numerically higher in 25G (98% vs. 88%, p=0.105). Number of passes for smears were similar, however the 25G group required additional passes for cell-block (1.6 vs. 0.4, p=0.001). 25G was used more frequently for pancreatic head and uncinate process sampling (70% vs. 52%, p=0.126). Four patients had self-limited adverse events in the 22G group, but none in the 25G group. CONCLUSION: We report no difference in the diagnostic yield between 25G FNB vs. 22G sampling device with Franseen style tip, however, the 25G needle use was associated with the need of additional passes to collect a sufficient cell block.

Intragastric balloon treatment of obesity: Long-term results and patient satisfaction.

BACKGROUND/AIMS: Intragastric balloon (IGB) treatment of obesity is a minimally invasive outpatient procedure that has been shown to help weight loss in some patients. The aim of this study is to analyze the long-term results regarding the effectiveness, tolerability, and patient satisfaction in a cohort of patients undergoing the IGB insertion. MATERIALS AND METHODS: Using a retrospective cohort study design, patients who had their IGB inserted/removed between the years 2009 and 2016 were contacted by phone and asked to answer a short questionnaire. The baseline characteristics, pre- and post- IGB weight, as well as their current weight were recorded. Different parameters of satisfaction were noted in addition to whether patients resorted to alternative weight-reduction measures. RESULTS: Ninety-nine eligible patients were contacted, and 65 consented to the study. The average weight loss achieved at the end of the treatment period (3 to 10 months) was approximately a 12% decrease from the baseline. Only 39% of patients were satisfied with the procedure, and less than 50% were satisfied with the weight loss achieved. When assessing the long-term follow-up, years after the IGB removal (3.3±1.76 years), the vast majority of patients (78.7%) regained weight or resorted to further bariatric measures. CONCLUSION: IGB leads to weight loss among most patients, but it does not appear to fulfill patients' expectations. Further, the initial weight loss is not sustainable over time.

Dexlansoprazole is Effective in Relieving Heartburn during the Fasting Month of Ramadan.

BACKGROUND AND AIMS: Proton pump inhibitors are effective at reducing heartburn. No studies have evaluated their efficacy in Ramadan. Dexlansoprazole has a unique active formulation independent of time-of-day dosing or food. The aim is to investigate the efficacy of dexlansoprazole 60 mg during Ramadan in patients with symptomatic heartburn. METHODS: Subjects recruited using poster, radio, and SMS advertisements completed a diary using a mobile-friendly application and received daily SMS reminders. Dexlansoprazole was started on day 8 for 3 weeks. No placebo arm was used in this trial. Primary endpoint was relief of heartburn expressed as mean 24-h free heartburn percentage (24FH%) per weekly period. RESULTS: A total of 32 patients were enrolled. During week 1, only 1 person (3.1%) was heartburn-free and mean 24FH% was 41.1 ± 24.8%. On dexlansoprazole, mean 24FH% rose to 63.4 ± 23.8 and 81.6 ± 24.5% in weeks 2 and 4, respectively (p < 0.001 for both). Median 24FH% increased from 35.7% in week 1 to 71.4 and 85.7% in weeks 2 and 4, respectively. Mean Gastroesophageal Reflux Disease Questionnaire (GERDQ) scores decreased from 10.0 ± 3.2 in week 1 to 6.53 ± 2.2 in week 2 (p < 0.001) and 5.87 ± 2.1 in week 4 (p < 0.001). Mean heartburn severity score decreased from 2.5 ± 1.0 to 1.7 ± 0.8 (p = 0.001). Early response was higher in patients with GERDQ scores ≥8 (p = 0.012). CONCLUSION: Dexlansoprazole is effective in the treatment of heartburn during Ramadan. Clinicaltrials.gov number: NCT03079050.

The Natural History of Incidental Colonic Diverticulosis on Screening Colonoscopy.

Background: The natural history of colonic diverticulosis is unclear. Methods: Patients with incidental diverticulosis identified in a previous prospective cross-sectional screening colonoscopy study were evaluated retrospectively for clinic or hospital visit(s) for diverticular disease (DD= acute diverticulitis or diverticular bleeding) using review of electronic health records and patient phone interview. Results: 826 patients were included in the screening colonoscopy study. Three were excluded for prior DD. In all, 224 patients (27.2%; mean age 62.3 ± 8.2) had incidental diverticulosis distributed in the left colon (67.4%), right colon (5.8%), or both (22.8%). Up-to-date information was available on 194 patients. Of those, 144 (74.2%) could be reached for detailed interview and constituted the study population. Over a mean follow-up of 7.0 ± 1.7 years, DD developed in 6 out of 144 patients (4.2%) (4 acute cases of diverticulitis, 1 probable case of diverticular bleeding, and 1 acute case of diverticulitis and diverticular bleeding). Two patients were hospitalized, and none required surgery. The time to event was 5.1 ± 1.6 years and the incidence rate was 5.9 per 1000 patient-years. On multivariate analysis, none of the variables collected at baseline colonoscopy including age, gender, obesity, exercise, fiber intake, alcohol use, constipation, or use of NSAIDs were associated with DD. Conclusion: The natural history of incidental diverticulosis on screening colonoscopy was highly favorable in this well-defined prospectively identified cohort. The common scenario of incidental diverticulosis at screening colonoscopy makes this information clinically relevant and valuable to physicians and patients alike.

Preoperative biliary drainage for malignant biliary obstruction: results from a national database.

BACKGROUND: The impact of preoperative biliary drainage (PBD) on postoperative morbidity and mortality in patients with malignant biliary obstruction is still unclear. We examined short-term surgical outcomes among drained and non-drained patients. METHODS: Patients who underwent surgical resection for their malignancies with biliary obstruction were identified using the American College of Surgeons National Surgical Quality Improvement Program Participant Use Files from 2014 to 2015. Mortality and morbidity were compared among patients who had PBD to those who did not undergo biliary drainage prior to surgery. RESULTS: A total of 2,306 patients were included; of these 1,803 (77.8%) had PBD. The postoperative mortality was 3.0% and 2.2% among direct surgery (DS) group and PBD group, respectively (P = 0.3). Postoperative complications were higher in the PBD group compared to the DS group (27.1% vs. 19.5%; P = 0.0005). Patients in the PBD group had higher risk of sepsis (13.5% vs. 7.2%; P = 0.0001), wound infections (16.5% vs. 10.9%; P = 0.002) and pancreatic fistula (17.5% vs. 12.4%; P = 0.006) compared to the DS group. CONCLUSION: Preoperative biliary drainage is associated with increased risk of sepsis and wound infections, but does not impact the postoperative mortality of patients undergoing PBD.

Predictors of bile tree pathology in patients presenting with gallbladder disease.

BACKGROUND: Patients with gallstone disease can present with elevated liver function tests (LFTs). It is often challenging to differentiate those with a common bile duct (CBD) stone from those without a CBD stone on the basis of the LFTs levels. In this study, we aim to evaluate the predictors of a CBD stones among patients presenting with symptomatic gallbladder disease and elevated LFTs. PATIENTS AND METHODS: We retrospectively examined all patients who had undergone a cholecystectomy between January 2010 and December 2015. Patients with symptomatic cholelithiasis and increased LFTs were included. Patient characteristics, imaging findings, lab findings, endoscopic interventions, and operative report were recorded and evaluated. The diagnosis of CBD stones was made on the basis of ERCP and IOC findings. RESULTS: We included 354 patients in the final analysis. Of these, 113 (32%) had confirmed choledocholithiasis. The prevalence of CBD stones among biliary colic, acute cholecystitis, and pancreatitis patients was 47, 25, and 26%, respectively. γ-Glutamyl transferase and direct bilirubin had the highest sensitivities for CBD stones among these patients (83 vs. 79%). In the setting of biliary colic, total bilirubin was highly predictive of CBD stones with a positive predictive value of 85%. In the setting of acute cholecystitis, elevated LFTs were even less significant in predicting stones, with a positive predictive value of less than 40% for most. CONCLUSION: Although γ-glutamyl transferase and bilirubin levels showed a relatively higher sensitivity for CBDS compared with the other LFTs, these were not reliable enough because of high false-positive as well as false-negative values, especially in patients presenting with acute cholecystitis.