EUS-guided coil injection therapy in the management of gastric varices: the first U.S. multicenter experience (with video).

BACKGROUND AND AIMS: Despite the significant morbidity associated with gastric variceal bleeding, there is a paucity of high-quality data regarding optimal management. EUS-guided coil injection therapy (EUS-COIL) has recently emerged as a promising endoscopic modality for the treatment of gastric varices (GV), particularly compared with traditional direct endoscopic glue injection. Although there are data on the feasibility and safety of EUS-COIL in the management of GV, these have been limited to select centers with particular expertise. The aim of this study was to report the first U.S. multicenter experience of EUS-COIL for the management of GV. METHODS: This retrospective analysis included patients with bleeding GV or GV at risk of bleeding who underwent EUS-COIL at 10 U.S. tertiary care centers between 2018 and 2022. Baseline patient and procedure-related information was obtained. EUS-COIL entailed the injection of .018 inch or .035 inch hemostatic coils using a 22-gauge or 19-gauge FNA needle. Primary outcomes were technical success (defined as successful deployment of coil into varix under EUS guidance with diminution of Doppler flow), clinical success (defined as cessation of bleeding if present and/or absence of bleeding at 30 days' postintervention), and intraprocedural and postprocedural adverse events. RESULTS: A total of 106 patients were included (mean age 60.4 ± 12.8 years; 41.5% female). The most common etiology of GV was cirrhosis (71.7%), with alcohol being the most common cause (43.4%). Overall, 71.7% presented with acute GV bleeding requiring intensive care unit stay and/or blood transfusion. The most common GV encountered were isolated GV type 1 (60.4%). A mean of 3.8 ± 3 coils were injected with a total mean length of 44.7 ± 46.1 cm. Adjunctive glue or absorbable gelatin sponge was injected in 82% of patients. Technical success and clinical success were 100% and 88.7%, respectively. Intraprocedural adverse events (pulmonary embolism and GV bleeding from FNA needle access) occurred in 2 patients (1.8%), and postprocedural adverse events occurred in 5 (4.7%), of which 3 were mild. Recurrent bleeding was observed in 15 patients (14.1%) at a mean of 32 days. Eighty percent of patients with recurrent bleeding were successfully re-treated with repeat EUS-COIL. No significant differences were observed in outcomes between high-volume (>15 cases) and low-volume (<7 cases) centers. CONCLUSIONS: This U.S. multicenter experience on EUS-COIL for GV confirms high technical and clinical success with low adverse events. No significant differences were seen between high- and low-volume centers. Repeat EUS-COIL seems to be an effective rescue option for patients with recurrent bleeding GV. Further prospective studies should compare this modality versus other interventions commonly used for GV.

A case of duodenal variceal bleeding treated by Doppler-guided endoscopic cyanoacrylate injection.

Video 1.

Incidence of Kidney Stones After Bariatric Surgeries: Comparing Roux-en-Y Gastric Bypass and Sleeve Gastrectomy.

INTRODUCTION/PURPOSE: The two most common procedures performed to treat obesity are Roux-En-Y gastric bypass (RNYGB) and laparoscopic sleeve gastrectomy (LSG). Due to changes in enteric absorption, bariatric surgery increases rates of nephrolithiasis. As population-based data are limited, we aimed to compare the incidence of kidney stones after RNYGB and LSG. MATERIALS AND METHODS: We queried Explorys (Cleveland, OH), a database that aggregated data from 26 healthcare systems. We identified patients who were newly diagnosed with nephrolithiasis 3, 6, and 12 months after their RNYGB or LSG. Additionally, a multivariate analysis was conducted to investigate the association of nephrolithiasis with RNYGB as compared to LSG. This analysis adjusted for other risk factors, including age above 65, male gender, Caucasian race, diabetes mellitus, hypertension, primary hyperparathyroidism, gout, and obesity. RESULTS: From 1999 to 2019, there were 11,480 patients who underwent RNYGB and 22,770 patients who underwent LSG. The incidence of nephrolithiasis in the RNYGB cohort at all three time points was higher than in the LSG cohort (3 months, 7.1% vs. 2.4%; 6 months, 6.6% vs. 2.0%; 1 year, 5.8% vs. 1.4%; P < 0.001). After the multivariate analysis, it was found that, though both RNYGB and LSG were independently associated with the development of nephrolithiasis, the risk of nephrolithiasis was higher in those who underwent RNYGB compared to those who underwent LSG (OR 1.594, 95% CI 1.494 to 1.701, P < 0.001). CONCLUSION: RNYGB is associated with a higher risk of nephrolithiasis when compared to LSG.

Evidence-Based Cognitive Endoscopy Simulators: Do They Exist? A Systematic Search and Evaluation of Existing Platforms.

BACKGROUND: The development of guidelines by gastroenterology societies increasingly stresses evidence-based endoscopic practice. AIMS: We performed a systematic assessment to determine whether endoscopic video teaching platforms incorporate evidence-based educational strategies and methods in order to disseminate guideline-based endoscopic management strategies. METHODS: Platforms with a video component were systematically identified using the Google search engine, Apple and Android application stores, and searching four major gastroenterology society websites and three known platforms, to identify all relevant platforms. Two video samples from each teaching platform were reviewed independently by two authors and assessed for use of a priori defined principles of evidence-based medicine, as determined by consensus agreement and for the use of simulation. RESULTS: Fourteen platforms were included in the final analysis, and two videos from each were analyzed. One of the 14 platforms used simulation and incorporated evidence-based medicine principles consistently. Nine of the 14 platforms were not transparent in regard to citation. None of the platforms consistently cited the certainty of evidence or explained how evidence was selected. CONCLUSIONS: Education of guideline-based endoscopic management strategies using principles of evidence-based medicine is under-utilized in endoscopic videos. In addition, the use of cognitive simulation is absent in this arena. There is a paucity of evidence-based cognitive endoscopy simulators designed for fellows that incorporate systematic evaluation, and efforts should be made to create this platform.

Intracystic Glucose and Carcinoembryonic Antigen in Differentiating Histologically Confirmed Pancreatic Mucinous Neoplastic Cysts.

INTRODUCTION: Differentiating mucinous neoplastic pancreatic cysts (MNPC) from cysts without malignant potential can be challenging. Guidelines recommend using fluid carcinoembryonic antigen (CEA) to differentiate MNPC; however, its sensitivity and specificity vary widely. Intracystic glucose concentration has shown promise in differentiating MNPC, but data are limited to frozen specimens and cohorts of patients without histologic diagnoses. This study aimed to compare glucose and CEA concentrations in differentiating MNPC using fresh fluid obtained from cysts with confirmatory histologic diagnoses. METHODS: This multicenter cohort study consisted of patients undergoing endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for pancreatic cysts during January 2013-May 2020. Patients were included if the cyst exhibited a histologic diagnosis and if both CEA and glucose were analyzed from fresh fluid. Receiver operating curve (ROC) characteristics were analyzed, and various diagnostic parameters were compared. RESULTS: Ninety-three patients, of whom 59 presented with MNPC, met the eligibility criteria. The area under the receiver operating curve (AUROC) was 0.96 for glucose and 0.81 for CEA (difference 0.145, P = 0.003). A CEA concentration of ≥192 ng/mL had sensitivity of 62.7% and specificity of 88.2% in differentiating MNPC, whereas glucose concentration of ≤25 mg/dL had sensitivity and specificity of 88.1% and 91.2%, respectively. DISCUSSION: Intracystic glucose is superior to CEA concentration for differentiating MNPC when analyzed from freshly obtained fluid of cysts with histologic diagnoses. The advantage of glucose is augmented by its low cost and ease of implementation, and therefore, its widespread adoption should come without barriers. Glucose has supplanted CEA as the best fluid biomarker in differentiating MNPC.

Obesity prevalence in celiac disease in the United States from 2014 to 2018.

Celiac disease (CD) is not commonly associated with obesity; however, many patients are overweight or obese at time of diagnosis. As the number of people in the United States with obesity continues to rise, it is not known if the prevalence of obesity among patients with CD has also increased. This study utilized an electronic health record database incorporating over 360 individual hospitals in the United States (Explorys Incorporated, Cleveland, OH). Adult patients who had an esophagogastroduodenoscopy at least 1 day prior to reporting of CD from the years 2014 to 2018 formed the study population. From 2014 to 2018, 13,410 patients had a diagnosis of CD. The prevalence of obesity was 45,000/100,000 persons in this CD population. Prevalence of class I (BMI 30-34.9), II (BMI 35-39.9), and III (BMI > 40) obesity in patients with CD continued to rise over the 5-year span. Class I obesity had the highest prevalence and Class II the highest prevalence increase when obesity classes were compared. Clinicians should be aware of obesity as a comorbidity of increasing prevalence when providing longitudinal care for patients with CD.

Meet EBE: The Development of an Evidence-Based Endoscopy Simulator.

BACKGROUND AND AIMS: In the digital era of evidence-based medicine, there is a paucity of video endoscopy teaching platforms that use evidence-based medicine principles, or that allow for cognitive simulation of endoscopic management strategies. We created a guideline-based teaching platform for fellows that incorporates these features, and tested it. METHODS: A pilot video module with embedded questions was drafted, and after incorporation of feedback from several attending gastroenterologists, an additional 2 modules were created. The embedded questions were designed to simulate cognitive management decisions as if the viewer were doing the endoscopy procedure in the video. A narrator explained the evidence behind the task being performed, and its certainty based on endoscopic guidelines. Quizzes and surveys were developed and administered to a sample of attendings and fellows who completed the video modules to test efficacy, usability, and likeability. RESULTS: Three video modules, named evidence-based endoscopy (EBE), incorporating low fidelity simulation, and utilizing evidence-based medicine principles, were created. Eight fellows and 10 attendings completed the video modules and all quizzes and surveys. Mean test scores improved from before to after completing the video modules (56% to 92%; mean difference = -35%; 95% confidence interval, 27%-47%). Surveys indicated that the product was viewed favorably by participants, and that there is a strong desire for this type of educational product. CONCLUSIONS: The EBE simulator is a unique, desirable, and effective educational platform based on evidence-based medicine principles that fills a gap in available tools for endoscopy education. Further studies are needed to assess whether EBE can aid in long-term knowledge retention and increase adherence to guideline recommendations.

Post-Liver Transplant Lymphoproliferative Disorder Presenting as Biliary Stricture.

A 63-year-old man with nonalcoholic steatohepatitis cirrhosis who underwent orthotopic liver transplant presented 1 year later with obstructive jaundice because of a biliary stricture. This anastomotic stricture was initially believed to be ischemic, but further investigation revealed malignant biliary obstruction because of encasement of the bile duct by a mass arising from liver segment VII, later determined to be post-transplant lymphoproliferative disorder with widespread metastasis. After reduction of immunosuppression and systemic chemotherapy, he experienced complete remission. This case illustrates the need to consider post-transplantation lymphoproliferative disorder-related biliary stricture in any postorthotopic liver transplantation transplant patient presenting with obstructive jaundice.

Infliximab-Induced Acute Liver Failure in a Patient With Crohn's Disease Requiring Orthotopic Liver Transplantation.

Tumor necrosis factor-alpha inhibitors are not known to have significant liver toxicity; however, a few case reports state otherwise. We report the case of a 25-year-old man with Crohn's disease who was initiated on infliximab. The patient developed severe mixed hepatocellular and cholestatic liver injury that progressed into acute liver failure. Based on clinical history, laboratory findings, and histology, this was presumed because of the development of autoimmune hepatitis secondary to infliximab. He underwent liver transplantation. The mainstay of treatment in this rare condition involves steroid therapy and possible transplantation. Patients must then avoid anti-tumor necrosis factor-alpha therapy for life.

Clothing and shoes of personnel as potential vectors for transfer of health care-associated pathogens to the community.

In an acute care hospital, we demonstrated that the clothing and shoes that physicians and nurses wear home from health care facilities can be contaminated with health care-associated pathogens, particularly methicillin-resistant Staphylococcus aureus. These findings suggest that the clothing and shoes of personnel have the potential to serve as vectors for the transfer of health care-associated pathogens to the community.

Endoscopic Doppler Probe in the Diagnosis and Management of Upper Gastrointestinal Hemorrhage.

Through-the-scope (TTS) endoscopic Doppler ultrasound probe technology is a tool that has garnered interest for the evaluation of variceal and non-variceal bleeding. In previous studies, this technology has been proposed as a more objective method of identifying the bleeding subsurface blood vessel in peptic ulcer hemorrhage. We describe 3 cases where the use of an endoscopic Doppler probe guided the diagnosis and management of upper gastrointestinal (GI) hemorrhage due to causes other than peptic ulcer disease. The first case describes a patient with a duodenal Dieulafoy lesion, while the other 2 cases outline patients with a gastroesophageal varix as the etiology of the bleed.