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1.
Artigo em Inglês | MEDLINE | ID: mdl-34890020

RESUMO

Portal hypertensive bleeding is a major complication of portal hypertension (PHT) with high morbidity and mortality. A lot of advances have been made in our understanding of screening, risk stratification, and management strategies for portal hypertensive bleeding including acute variceal bleeding leading to improved overall outcomes in patients with PHT. A number of guidelines on variceal bleeding have been published by various societies in the past few years. The Indian Society of Gastroenterology (ISG) Task Force on Upper Gastrointestinal Bleeding (UGIB) felt that it was necessary to bring out a standard practice guidance document for the use of Indian health care providers especially physicians, gastroenterologists, and hepatologists. For this purpose, an expert group meeting was convened by the ISG Task Force to deliberate on this matter and write a consensus guidance document for Indian practice. The delegates including gastroenterologists, hepatologists, radiologists, and surgeons from different parts of the country participated in the consensus development meeting at Coorg in 2018. A core group was constituted which reviewed all published literature on portal hypertensive UGIB with special reference to the Indian scenario and prepared unambiguous statements on different aspects for voting and consensus in the whole group. This consensus was produced through a modified Delphi process and reflects our current understanding and recommendations for the diagnosis and management of portal hypertensive UGIB in Indians. Intended for use by the health care providers especially gastroenterologists and hepatologists, these consensus statements provide an evidence-based approach to risk stratification, diagnosis, and management of patients with portal hypertensive bleeding.

2.
Artigo em Inglês | MEDLINE | ID: mdl-34914039

RESUMO

INTRODUCTION: Adequate weight loss can lead to reduction in steatosis, inflammation, and fibrosis in patients with obesity and non-alcoholic fatty liver disease (NAFLD). We evaluated the role of endoscopic sleeve gastroplasty (ESG) in patients with obesity and NAFLD. METHODS: In this single-center prospective study, consecutive adult patients with NAFLD who underwent ESG between November 2018 and May 2019 were included. The primary outcome was the impact of ESG on hepatic parameters: change in alanine aminotransferase (ALT), hepatic steatosis index (HSI), NAFLD fibrosis score (NFS), fibrosis-4 index (FIB-4), and aspartate aminotransferase (AST)-to-platelet ratio index (APRI) from baseline to 6 and 12 months. Secondary outcomes included change in glycated hemoglobin (HbA1c), percentage weight loss, and safety. Analysis of variance with repeated measures was used for statistical analysis. RESULTS: A total of 26 patients (mean age [SD] 41.5 [9.58] years; 16 females) with mean (SD) weight of 99.43 (21.89) kg at baseline were included. There was significant improvement in ALT (mean ± SD) from baseline of 59.54 ± 17.02 IU/L to 49.50 ± 11.72 IU/L and 48.42 ± 13.22 IU/L at 6 and 12 months (p = 0.001). Mean (SD) NFS was significantly improved from 0.228 (1.00) at baseline to -0.202 (1.16) and -0.552 (1.08) at 6 and 12 months (p 0.001). Mean (SD) HSI, FIB-4, and APRI scores significantly reduced from baseline to 6 and 12 months (p = 0.001). There was 18.07% total body weight loss at 12 months, with significant improvement in HbA1c. There were no major adverse events. CONCLUSION: ESG is a safe and effective treatment option for patients with NAFLD and obesity causing significant weight loss. Rigorous randomized trials are required to incorporate ESG in NAFLD treatment algorithm.

3.
J Gastroenterol Hepatol ; 36(11): 3183-3190, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34269477

RESUMO

BACKGROUND AND AIM: With the advent of video capsule endoscopy (VCE) and device-assisted enteroscopy (DAE), the indication of intraoperative enteroscopy (IOE) has become limited due to reported high morbidity/mortality. Most of the earlier studies on IOE were small/from pre-VCE/DAE era. We aimed to evaluate the impact of IOE in management of small bowel disorders (SBD) in post-VCE/DAE era. METHODS: Patients with SBD undergoing IOE over last 15 years were evaluated retrospectively. Overall diagnostic/therapeutic yield, incremental diagnostic yield over preoperative investigations, and adverse events were noted. We also evaluated the number of cases in which IOE changed the management or guided surgical or endoscopic therapy. Rebleeding and recurrence were evaluated in patients with available follow-up data. RESULTS: A total of 89 patients (59 male, 9-82 years) were included in the study. Overall diagnostic and therapeutic yield were 92.1% and 85.4%, respectively. Common findings of IOE were benign ulcers/strictures (30.1%), vascular lesions (26%), diverticula (15.1%), and tumors (13.7%). A total of 49.4% (44/89), 36% (32/89), and 20.2% (18/89) underwent VCE, DAE, or both, respectively, before IOE. Incremental diagnostic yield over preoperative work-up was 31.5% (28/89), and IOE changed the management in 37.1% (33/89) patients. IOE was used to guide surgery/endotherapy in 39.3% (35/89) patients. Recurrent gastrointestinal bleed occurred in 21.2% (14/66) patients. Morbidity and mortality rates were 20.2% (18/89) and 3.4% (3/89), respectively. CONCLUSIONS: Intraoperative enteroscopy remains an essential technique to evaluate SBD and can detect new and additional lesions even after extensive preoperative evaluation. IOE is useful in guiding therapy in preoperatively identified lesions and can change management in a substantial proportion of patients. Hence, IOE has a definitive role in post-VCE/DAE era in carefully selected patients with SBD.

5.
Ann Gastroenterol ; 34(2): 247-252, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33654367

RESUMO

Background: Acute calculous cholecystitis (ACC) is the most frequent complication of gallstones requiring cholecystectomy. These patients may have coexisting choledocholithiasis. We aimed to evaluate the role of current guidelines for choledocholithiasis in patients with ACC. Methods: In this retrospective study, we included all patients diagnosed with ACC between December 2018 and May 2019. These patients were substratified according to the guidelines of the American and European Societies of Gastrointestinal Endoscopy (ASGE and ESGE) as having high, intermediate, or low likelihood of choledocholithiasis, and the diagnostic performance was measured. Binomial logistic regression analysis was applied to ascertain independent risk factors for choledocholithiasis. Results: A total of 173 patients with ACC, mean age (±standard deviation) 49.89±15.74 years and 60.1% male, were included. Sixty-three (36.4%) had confirmed choledocholithiasis. ASGE high likelihood criteria had sensitivity and specificity of 61.9% (95% confidence interval [CI] 48.8-73.9) and 83.4% (95%CI 75.4-90.0) for predicting choledocholithiasis. ESGE high likelihood criteria had sensitivity and specificity of 49.2% (95%CI 36.4-62.1) and 87.3% (95%CI 79.6-92.9). On logistic regression analysis, an alkaline phosphatase level above the upper limit of normal (P=0.003; odds ratio [OR] 4.26, 95%CI 1.66-10.96) and a dilated common bile duct on ultrasound (P=0.001; OR 9.97, 95%CI 4.65-21.36) were independent positive predictors for choledocholithiasis, while acute biliary pancreatitis was an independent negative predictor (P=0.030; OR 0.36, 95%CI 0.14-0.91). Conclusions: The performance of the ASGE and ESGE guidelines' risk stratification criteria is inadequate in patients with ACC. We suggest the utilization of a separate predictive model for suspected choledocholithiasis in these patients.

6.
J Gastroenterol Hepatol ; 36(8): 2101-2106, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-33445212

RESUMO

BACKGROUND AND AIM: Hemosuccus pancreaticus is considered as one of the rare cause of upper gastrointestinal bleeding. Intermittent nature of bleeding and lack of standardized approach for diagnosis has resulted in significant delay in definitive management. METHODS: We retrospectively analyzed prospectively maintained data of patients with suspected hemosuccus pancreaticus between January 2010 and December 2019. RESULTS: Out of 114 patients, 87 patients were diagnosed with hemosuccus pancreaticus. Mean age was 35.7 ± 11.7 years with 89.7% men. Median duration of bleeding before diagnosis was 10 days, with 40.2%, 10.3%, and 5.7% patients had symptoms beyond 1, 6, and 12 months, respectively. Visceral artery aneurysm was noted in 62% of cases with splenic artery aneurysm (37.9%) being the common source of bleed. Rarer causes noted were superior mesenteric artery aneurysm, pancreatic adenocarcinoma, gastrointestinal stromal tumor, and post-endoscopic retrograde cholangiopancreatography (2.3% each). Santorinirrhage was seen in 3.4% patients. Endoscopic diagnosis was possible in 64.4% of patients, and angiogram localization of bleeding source was noted in 94.2%. A 56.3% of patients underwent conventional angioembolization with 95.9% success and 28.7% underwent surgery, with overall rebleeding rate of 11.5%. CONCLUSIONS: Early diagnosis of hemosuccus pancreaticus avoids prolonged suffering, multiple hospital admissions, and multiple blood transfusions. It is not uncommon in the absence of aneurysm. In cases of high suspicion, repeating the endoscopy with proper technique and proper timing increases the yield. Angioembolization remains the most preferred first line therapeutic approach in majority of cases.

7.
J Gastroenterol Hepatol ; 36(5): 1226-1234, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33000865

RESUMO

BACKGROUND AND AIM: Even though ductal interventions in chronic pancreatitis (CP) are known to improve pain, its impact on diabetes is unclear. In this cohort study, we evaluated the impact of ductal interventions on diabetes in these patients. METHODS: Consecutive patients with CP visiting the pancreas clinic between August 1, 2011, and July 21, 2012, were enrolled and followed until December 2018. Detailed clinical, laboratory, imaging, and treatment data were recorded at enrolment and follow-up. Patients were followed up every 6 months through hospital visit and/or telephonic interview. Risk factors for diabetes were evaluated using logistic regression. The impact of ductal interventions on diabetes was evaluated using Kaplan-Meier survival analyses and Cox proportional hazards. RESULTS: A total of 644 patients were enrolled of which 137 were excluded. Of these, 326 (64.3%) patients had idiopathic CP, and 283 (55.8%) patients underwent ductal intervention. The cumulative incidence of diabetes was 57.9%. Median duration between symptom onset and ductal intervention was similar irrespective of diabetes (2.6 [0.6-6.0] vs 3.0 [1.0-5.5] years; P = 0.69). Alcohol intake and pancreatic ductal calculi were independent risk factors for diabetes (odds ratio [95% confidence interval] of 2.05 (1.18-3.55), P = 0.01, and 2.05 (1.28-3.28), P = 0.003, respectively). Kaplan-Meier analyses revealed that diabetes free interval was significantly longer in patients undergoing ductal interventions, predominantly in those with idiopathic CP with obstructive ductal calculi (hazard ratio [95% confidence interval] 0.39 [0.28-0.55]; P < 0.0001). There were no differences in glycemic status in patients with non-idiopathic CP and those with pre-existing diabetes. CONCLUSION: Early ductal intervention could delay development of diabetes in patients with idiopathic CP with obstructive ductal calculi.


Assuntos
Diabetes Mellitus/etiologia , Diabetes Mellitus/prevenção & controle , Ductos Pancreáticos/cirurgia , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia , Adolescente , Adulto , Estudos de Coortes , Diabetes Mellitus/epidemiologia , Drenagem , Endoscopia do Sistema Digestório , Feminino , Seguimentos , Humanos , Incidência , Modelos Logísticos , Masculino , Dor/etiologia , Dor/cirurgia , Fatores de Risco , Fatores de Tempo , Adulto Jovem
9.
J Clin Gastroenterol ; 55(7): 594-601, 2021 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-32657960

RESUMO

BACKGROUND AND AIMS: Spastic esophageal motility disorders (SEMD) are a rare group of motility disorders including type III achalasia, distal esophageal spasm (DES), and Jackhammer esophagus (JHE). Limited data suggest that per-oral endoscopic myotomy (POEM) may be effective in these disorders. In this study, we aimed to evaluate the long-term outcomes of POEM in SEMD. METHODS: The data of patients with SEMD who underwent POEM (January 2013 to December 2019) were analyzed, retrospectively. The following outcomes were recorded: POEM procedure details, technical and clinical success, adverse events, and gastroesophageal reflux disease (GERD). Clinical success was classified as immediate (<1 y), short-term (1 to 3 y), medium term (3 to 5 y), and long-term (>5 y). RESULTS: A total of 1115 POEM procedures were performed during the study period for achalasia and nonachalasia spastic motility disorders. POEM was performed for SEMD in 74 (6.6%) patients including type III in 53, DES in 11, and JHE in 10 patients. Technical success was achieved in all the patients. The median follow-up for the entire group was 47.5 months (range: 2 to 77 mo). Clinical success at short-term (1 to 3 y) and long-term follow-up (>5 y) was attained in 85.2% and 82.6% patients, respectively. There was no significant difference in the clinical success between type III achalasia and JHE/DES. Mild and moderate adverse events were recorded in 21 (28.4%) cases. GERD was detected in 23 (56.1%) patients with 24-hour pH study. Erosive esophagitis and symptomatic GERD were found in 36 (48.6%) and 16 (21.6%) patients, respectively. CONCLUSIONS: POEM is a safe, effective, and durable treatment modality for spastic motility disorders of the esophagus. However, GERD is found in about half of the patients mandating close monitoring after POEM.


Assuntos
Acalasia Esofágica , Transtornos da Motilidade Esofágica , Miotomia , Cirurgia Endoscópica por Orifício Natural , Acalasia Esofágica/cirurgia , Transtornos da Motilidade Esofágica/cirurgia , Humanos , Espasticidade Muscular , Estudos Retrospectivos , Resultado do Tratamento
10.
Acta Med Indones ; 53(4): 460-464, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-35027494

RESUMO

Biliary strictures diagnosis has become a challenge where benign conditions could mimic a malignant process. Recently, SpyGlass DS overcame the limitations by allowing direct visualization of the biliary tree. A 65 years old Indian patient complaints of jaundice with total and direct bilirubin of 23.3 mg/dL and 16.2 mg/dL, respectively. Liver function test, gamma-glutamyltransferase and CA 19-9 were increased. Transabdominal ultrasound and abdominal CT supported dilatation of common bile duct (CBD) with abrupt narrowing showing periductal enhancement at supra pancreatic level and stricture. Endoscopic ultrasound showed intrahepatic CBD stricture with dilated proximal CBD and sludge ball. Endoscopic retrograde cholangiopancreatography showed mid CBD stricture. Although brush cytology results suggested low grade dysplasia and no definite evidence of malignancy, cholangioscopy using SpyGlass DS found nodularity with abnormal vascularity seen in mid of CBD suggesting malignancy, confirmed with histopathology as cholangiocarcinoma. We reported additional value of SpyGlass DS for detecting cholangiocarcinoma in an indeterminate biliary stricture patient.

11.
Ann Gastroenterol ; 33(5): 473-479, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32879593

RESUMO

Background: Recent advances in endoscopic tools and techniques have allowed the minimally invasive management of iatrogenic gastrointestinal (GI) perforations and bleedings. However, surgery may be required in cases with larger defects and bleeding refractory to conventional endoscopic modalities. The use of over-the-scope clips (OTSC) has been shown to improve the outcomes in these patients compared with conventional treatment modalities. In this study, we evaluated the safety and efficacy of OTSC for different indications in the GI tract. Methods: The data of consecutive patients in whom OTSC was utilized for different indications between February 2017 and October 2019 were analyzed retrospectively. The following outcomes were recorded: technical and clinical success, and adverse events related to the procedure. Results: Thirty-six patients (22 male, mean age 52.673±14.97 years, range 11-72 years) underwent OTSC application. Indications for OTSC were: GI defects (perforation n=13, fistula n=5); esophageal metallic stent fixing n=9; GI bleeding n=8; and neuroendocrine tumor endotherapy n=1. The average size of the defect was 15.88±8.01 mm. The technical and clinical success rates were 88.89% and 83.33%, respectively. There were 4 (11.1%) technical failures: colonic perforations n=2; duodenal ulcer bleeding n=1; and esophageal metal stent fixation n=1. There were 2 (9.5%) adverse events, including 1 partial duodenal obstruction and 1 delayed bleeding. Conclusions: The use of OTSC is safe, easy and effective for various indications in the GI tract. Prospective trials are required to see if the use of OTSC is cost effective as a primary endoscopic treatment method in these cases.

12.
Endosc Int Open ; 8(7): E834-E839, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32676535

RESUMO

Background and study aims Impact of intravenous fluid administration on prophylaxis against post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) has not been rigorously evaluated among patients at high-risk for PEP. Patients and methods Effect of volume and type of fluid administered on PEP incidence was studied through a secondary analysis of high-risk patients who underwent endoscopic retrograde cholangopancreatography (ERCP) as a part of a randomized controlled trial in which all patients received rectal indomethacin. Periprocedural fluid was defined as fluid infused during and after ERCP. Results A total 960 patients were randomized during the trial, of whom 476 (49.6 %) received periprocedural fluids (mean volume = 1245 mL [±â€Š629]). There was a trend towards a lower incidence of PEP in patients who received periprocedural fluid vs. those who did not (5.2 % vs. 8.0 %, P  = 0.079). Among those receiving fluids, those who did not develop PEP received a higher mean volume of fluid vs. who developed PEP (1012 ±â€Š725 mL vs. 752 ±â€Š783 mL, P  = 0.036). Among 174 patients (37 %) who received LR, patients who did not develop PEP received a higher mean volume of LR vs. those who developed PEP (570 ±â€Š559 mL vs. 329 ±â€Š356 mL, P  = 0.006). Length of hospital stay decreased as the volume of periprocedural volume administration increased (r = 0.16, P  < 0.001). Conclusion Higher fluid volume and lactated Ringer's use during the periprocedural period was associated with a decreased risk of PEP and length of hospital stay beyond rectal indomethacin in high risk patients.

13.
Trials ; 21(1): 338, 2020 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-32299454

RESUMO

BACKGROUND: Pain is the primary symptom of chronic pancreatitis (CP) and remains a considerable therapeutic challenge. In patients with obstruction of the pancreatic duct, including stones and strictures, endoscopic treatment with or without preceding extracorporeal shock wave lithotripsy (ESWL) has been used for pancreatic duct decompression. The rationale for these procedures is based on the assumption that obstruction of the pancreatic duct leads to ductal hypertension and pain. However, clinical pain symptoms correlate poorly with pancreatic duct morphology, and the evidence for pancreatic duct decompression as an effective treatment for pain is based on case series and comparison between different procedures. No randomized, prospective, sham-controlled trials are currently available. The SCHOKE (Extracorporeal Shock Wave Lithotripsy and Endotherapy for Pain in Chronic Pancreatitis) trial is a randomized, sham-controlled trial designed to determine if pancreatic duct decompression is an effective treatment for pain in patients with CP. METHODS: The SCHOKE trial is a randomized, single-blind, parallel-group, sham-controlled trial designed to evaluate the effect of combined ESWL and endoscopic treatment for pain in patients with CP. In total, 106 adult patients with painful CP and pancreatic duct obstruction will be randomized to combined ESWL and subsequent endoscopic treatment or corresponding sham procedures. The primary outcome is pain relief during the 3-month postrandomization period as documented in a pain diary. Secondary outcomes include quality of life and functional scores, patient global impression of change, change in use of analgesics, frequency of hospitalization, and complications. Standard follow-up is at 3 and 6 months after randomization. In an experimental substudy, quantitative sensory testing obtained before and after intervention will be used to obtain information on central pain processing and to develop models for prediction of treatment outcome. DISCUSSION: The SCHOKE trial investigates if pancreatic duct decompression, obtained by combined ESWL and endoscopic treatment, is effective for pain treatment in patients with CP. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03966781. Registered on May 25, 2019. Protocol date and version identifier: March 1, 2020; version 3.0. SPONSOR: Rupjyoti Talukdar, Department of Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India.


Assuntos
Dor Abdominal/complicações , Dor Abdominal/cirurgia , Colangiopancreatografia Retrógrada Endoscópica/métodos , Cálculos Biliares/complicações , Cálculos Biliares/cirurgia , Litotripsia/métodos , Pancreatite Crônica/complicações , Pancreatite Crônica/cirurgia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia Combinada , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Método Simples-Cego , Resultado do Tratamento , Adulto Jovem
14.
Endoscopy ; 52(8): 643-651, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32208499

RESUMO

BACKGROUND: Gastroesophageal reflux disease (GERD) is an important concern after peroral endoscopic myotomy (POEM). However, there are limited data on the risk factors for post-POEM GERD and its responsiveness to proton pump inhibitors (PPIs). In this study, we aimed to analyze the variables affecting the occurrence of GERD and its response to PPI therapy. METHODS: Consecutive patients with idiopathic achalasia who underwent POEM (December 2016 to January 2018) were evaluated for GERD using 24-hour pH impedance, esophagogastroduodenoscopy (EGD), and symptoms. Multivariate analysis was performed to identify the variables affecting the incidence of post-POEM GERD. RESULTS: A total of 209 patients with esophageal motility disorders, including 194 patients with non-sigmoid achalasia, underwent POEM during the study period. Comprehensive evaluation of GERD was completed on 167 patients (86.1 %): 47.3 % women with a mean (standard deviation) age of 41 (14.42) years and body mass index of 22.2 (3.89) kg/m2; the majority (70.7 %) were treatment naïve. A high DeMeester score (> 14.72), reflux esophagitis, and symptomatic GERD were identified in 47.9 %, 41.9 %, and 29.3 % of patients, respectively. On logistic regression analysis, type of achalasia, technique of POEM (anterior vs. posterior), pre- or post-POEM esophageal manometry variables, and patient characteristics were not associated with post-POEM GERD. Erosive esophagitis responded to PPI therapy in the majority of patients (81.4 %). CONCLUSION: The incidence of GERD is high after POEM. Most of the reflux esophagitis is mild and responsive to PPI therapy. There are no procedural or patient-related variables that appear to affect the incidence of post-POEM GERD.


Assuntos
Acalasia Esofágica , Esofagite Péptica , Refluxo Gastroesofágico , Miotomia , Adulto , Acalasia Esofágica/cirurgia , Esofagite Péptica/epidemiologia , Esofagite Péptica/etiologia , Feminino , Refluxo Gastroesofágico/tratamento farmacológico , Refluxo Gastroesofágico/epidemiologia , Refluxo Gastroesofágico/etiologia , Humanos , Masculino , Miotomia/efeitos adversos , Inibidores da Bomba de Prótons/efeitos adversos , Resultado do Tratamento
15.
Case Rep Gastroenterol ; 14(1): 48-55, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32095124

RESUMO

Achalasia cardia is an esophageal myenteric plexus disorder characterized by absence of or incomplete lower esophageal sphincter relaxation and esophageal aperistalsis; Heller's myotomy is the main treatment of choice due to a lower failure rate. Recently, peroral endoscopic myotomy (POEM) has been reported as an alternative treatment for achalasia due to persistent symptoms after Heller's myotomy. An Indian male, aged 18 years, was admitted to the hospital due to dysphagia which had started more than 3 years ago. He also complained of occasional regurgitation and retrosternal pain with Eckardt score 6. Heller's myotomy was performed 2 years ago. Barium swallow showed achalasia cardia and upper gastrointestinal endoscopy found liquid residue and resistance at the gastroesophageal junction. Esophageal manometry is concluded as achalasia cardia type II with a median integrated relaxation pressure (IRP) of 25.6 mm Hg. He underwent POEM; with the help of a submucosal tunnel, an extension of up to 1 cm beyond the gastroesophageal junction could be achieved with a posterior orientation of myotomy. There were no adverse events after the POEM procedure. He was treated with a soft diet for 10 days and other supportive treatments. Following POEM, barium swallow showed a significant improvement and esophageal manometry exhibited that the basal lower esophageal sphincter pressure was normal with complete relaxation on swallowing and normal median IRP. The post-procedure Eckardt score was 0. We reported an achalasia patient who received POEM after unsuccessful Heller's myotomy and showed clinical improvement.

16.
Endoscopy ; 52(7): 569-573, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32106321

RESUMO

BACKGROUND: Recent guidelines from the European Society of Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) recommend risk stratification according to liver function test (LFT) and abdominal ultrasound in patients with suspected choledocholithiasis. We evaluated and validated the clinical utility of these new risk stratification criteria for choledocholithiasis. METHODS: We retrospectively analyzed prospectively maintained data of patients with suspected choledocholithiasis between January 2016 and December 2018 in patients undergoing cholecystectomy. Patients with common bile duct stricture, cirrhosis, and portal biliopathy were excluded. After LFT and ultrasound, all patients were stratified according to ESGE and ASGE criteria into high, intermediate, and low likelihood of choledocholithiasis. RESULTS: 1042 patients were analyzed. Using ESGE guidelines, 213 patients (20.4 %) met high likelihood criteria, 637 (61.1 %) met intermediate, and 192 (18.4 %) met low likelihood criteria. Using ASGE guidelines, 230 (22.1 %), 678 (65.1 %), and 134 (12.9 %) met high, intermediate, and low likelihood criteria, respectively. Specificity and positive predictive value (PPV) of ASGE high likelihood criteria were 96.87 % (95 % confidence interval [CI] 95.37 - 97.98) and 89.57 % (95 %CI 85.20 - 92.75) for choledocholithiasis compared with 98.96 % (95 %CI 97.95 - 99.55) and 96.24 % (95 %CI 92.76 - 98.09), respectively, for ESGE criteria. ASGE classified 17 (7.4 %) additional patients as high likelihood compared with ESGE, only one of whom had choledocholithiasis. ASGE classified 58 (8.6 %) additional patients as intermediate, none of whom had choledocholithiasis. CONCLUSION: This study validates the clinical utility of new ESGE and ASGE criteria for predicting choledocholithiasis. ESGE risk stratification appears more specific than ASGE.


Assuntos
Coledocolitíase , Colangiopancreatografia Retrógrada Endoscópica , Colecistectomia , Coledocolitíase/diagnóstico por imagem , Coledocolitíase/cirurgia , Endoscopia Gastrointestinal , Humanos , Estudos Retrospectivos , Estados Unidos
17.
J Clin Exp Hepatol ; 9(5): 554-560, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31695244

RESUMO

Background and aim: Endoscopic retrograde cholangiopancreatography (ERCP) is treatment modality of choice for management of pancreatobiliary disorders. However, safety of ERCP in the patients with cirrhosis is not adequately studied. This study was aimed to evaluate adverse events in the patients with cirrhosis undergoing ERCP and the predictors of adverse events and mortality. Methods: The present study was a retrospective analysis of patients with cirrhosis who underwent ERCP from January 2012 to December 2016. Binary logistic regression analysis was performed to ascertain the risk factors for adverse events and mortality at 1 month. Results: A total of 261 patients underwent ERCP (80.8% men, mean age 53.49 ± 12.6years). There were 36 (16.1%) overall adverse events in patients undergoing ERCP for biliary indication, whereas no adverse event in pancreatic indication. On univariate analysis, ascites, encephalopathy, high Child-Pugh-Turcotte (CTP) and model for end-stage liver disease (MELD) score, and creatinine levels were significantly associated; however, on multivariable analysis, CTP class C (p value 0.033; odds ratio [OR] 3.5, 95% confidence interval [CI] 1.1-11.5) and MELD > 18 (p value 0.004; OR 5.6, 95% CI 1.7-17.9) were independent risk factors for adverse events. There were 19 (8.5%) mortalities. On univariate analysis, presence of ascites, encephalopathy, cholangitis, biliary sphincterotomy, high CTP, low albumin, and high creatinine were significantly associated, whereas, on multivariable analysis, presence of cholangitis (p 0.017; OR 3.8, 95% CI 1.3-11.4) was associated increased mortality. Conclusion: Although endoscopic sphincterotomy might be safe for the patients with cirrhosis undergoing ERCP; advanced liver cirrhosis may be independent risk factor for post-ERCP adverse events. Cholangitis at admission is an independent risk factor for mortality.

18.
Pancreatology ; 19(7): 916-921, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31447280

RESUMO

INTRODUCTION: The primary aim of this study was to evaluate efficacy, safety and short-term pain relief after ESWL for large pancreatic calculi in over 5000 patients at a single center. METHODS: This is a retrospective analysis of prospectively collected data. Patients with painful calculi >5 mm, located in the head, neck and body region in the MPD, who were not amenable for extraction by the standard procedure of endoscopic pancreatic sphincterotomy were subjected to ESWL using a third generation dual focus lithotripter. Patients were followed up at 6 months for outcome evaluation. RESULTS: A total of 5124 patients (66% males) were subjected to ESWL. Majority of stones (79.2%) were radiopaque. Single calculi were seen in 3851 (75.1%).The majority of stones were located in head region of MPD in 2824 (55.1%) patients. 4386 (85.5%) patients required 3 or less sessions for fragmentation and complete stone clearance was achieved in 3722 (72.6%). EPS was performed in 5022 (98%) while PD stenting was required in 3536 (69%) patients. Of the 4280 patients followed up for 6 months, 3529 (82.6%) patients were pain free. Another 512 (11.9%) patients had significant reduction in VAS score. In 229 (5.3%) there was no decrease in pain intensity. Minor and self-limiting complications were reported in 1153 (22.5%). DISCUSSION: Our study confirms the safety and efficacy and short-term pain relief of ESWL for large calculi in the MPD. In properly selected patients, this should be offered as the first line of therapy for all large MPD calculi not amenable to the standard techniques of stone extraction.


Assuntos
Cálculos/terapia , Litotripsia , Pancreatopatias/terapia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
19.
J Pediatr Gastroenterol Nutr ; 69(1): 116-119, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31058778

RESUMO

OBJECTIVES: Disconnected pancreatic duct syndrome (DPDS) is frequently encountered in cases with walled off necrosis (WON). The impact of DPDS on the outcomes of pancreatic fluid collections (PFCs) is not well known. In this study, we aim to evaluate the incidence of DPDS and its clinical impact on the outcomes of endoscopic ultrasound (EUS)-guided drainage of PFC in children. METHODS: All children with symptomatic WON who underwent EUS-guided drainage using metal stents were included in the study. At 4 weeks, pancreatic ductal anatomy was evaluated, and metal stents removed. All the children were followed at regular intervals and evaluated for the recurrence of PFC and the development of new-onset diabetes. RESULTS: A total of 32 children (28 boys, median age 15 years) underwent EUS-guided drainage of WON. Resolution of WON was documented in all children at 4 weeks. Pancreatic ductal anatomy using magnetic resonance retrograde cholangiopancreatography and endoscopic retrograde pancreatography was available in 30 (93.7%) children. Of these, DPDS was documented in 25 (83.3%) children including proximal disconnection in 12 and distal disconnection in 13 children. Recurrent PFC and new-onset diabetes were found in 5 (20%) and 2 (8%) children with DPDS, respectively. Of the 5 recurrences of PFC, endoscopic reintervention was required in 3 children. CONCLUSIONS: Majority of the children with DPDS do not develop a symptomatic recurrence of PFC after the removal of cystogastric stents. DPDS may be a risk factor for the development of new-onset diabetes. However, future prospective studies are needed.


Assuntos
Drenagem/métodos , Necrose/cirurgia , Pancreatopatias/cirurgia , Ductos Pancreáticos/cirurgia , Adolescente , Criança , Endoscopia do Sistema Digestório/métodos , Feminino , Humanos , Masculino , Necrose/etiologia , Pancreatopatias/complicações , Ductos Pancreáticos/diagnóstico por imagem , Estudos Prospectivos , Stents , Ultrassonografia de Intervenção/métodos
20.
Am J Gastroenterol ; 114(2): 339-347, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30730860

RESUMO

INTRODUCTION: Rectal indomethacin and topical spray of epinephrine have separately shown efficacy in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis (PEP) in randomized controlled trials. We hypothesized that the combination of indomethacin and topical spray of epinephrine on the duodenal papillae would further reduce PEP than when indomethacin was used alone. METHODS: We conducted a comparative effectiveness, multicenter, double-blinded, randomized trial of rectal indomethacin alone vs a combination of rectal indomethacin and topical spray of epinephrine for the prevention of PEP in high-risk patients. The primary outcome was the incidence of PEP and the secondary outcome was the severity of PEP. A 2-tailed Fisher's exact test was used to analyze the difference in the proportion of patients with PEP in the indomethacin alone vs the combination group. RESULTS: A total of 960 patients (mean age 52.33 ± 14.96 years; 551 [57.4%] females) were randomized and 959 completed follow-up. The baseline demographic and clinical characteristics were similar between the 2 groups. Women <50 years of age (25.4%) and difficult cannulation (84.9%) were the most common PEP risk factors. The incidence of PEP was 6.4% in the indomethacin alone group (n = 482) compared to 6.7% in the combination group (n = 477; P = 0.87). Severe PEP was found in 5 (12%) and 7 (16%) patients in the indomethacin alone and combination groups, respectively (P = 0.88). The overall mortality was 0.6%, which was unrelated to the primary outcome. CONCLUSIONS: The combination of rectal indomethacin and topical spray of epinephrine does not reduce the incidence of PEP compared to rectal indomethacin alone in high-risk patients; https://clinicaltrials.gov/ct2/show/NCT02116309.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica , Inibidores de Ciclo-Oxigenase/uso terapêutico , Epinefrina/uso terapêutico , Indometacina/uso terapêutico , Pancreatite/prevenção & controle , Complicações Pós-Operatórias/prevenção & controle , Vasoconstritores/uso terapêutico , Administração Retal , Administração Tópica , Adulto , Idoso , Método Duplo-Cego , Quimioterapia Combinada , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Risco
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