EUS-guided fine-needle liver biopsy in pediatric patients using a modified technique with one-pass, one-actuation wet suction.

BACKGROUND AND AIMS: Liver biopsy (LB) can be a valuable tool to determine the etiology of pediatric liver disease. There is limited data of the role of EUS-LB in children. This study evaluated the efficacy and the safety of a modified technique (M)LB in cases at high risk of bleeding or obese children. In addition, the tissue yield of EUS-(M)LB and percutaneous (PC) approach were compared. METHODS: A retrospective analysis was performed, comparing EUS-(M)LB and PC-LB in children at a tertiary referral center. All consecutive children referred for PC-LB and EUS-LB who had an unexplained liver test abnormality after exclusion of biliary disorders from March-2017 to August-2018 were included. EUS-(M)LB consisted of a one pass wet suction technique using a 19-gauche core needle. A comparison was performed between total specimen length (TSL) and the number of complete portal triads (CPTs). RESULTS: The cohort included 28 EUS-(M)LB and 28 PC-LB pediatric cases. The median (IQR) age was 14.5 years (13.4-16). The median TSL was 8.6 (5.8-9.6) in EUS-(M)LB cases and 7 cm (7-9) in PC-LB cases (P =0.788). The maximum intact specimen was 2.8 cm (EUS-(M)LB) and 1.6 cm (PC-LB) (P =0.009). The mean (SD) number of CPTs per sample was 28.2 (7.3) and 11.6 (2.1), respectively (P =0.001). Adverse events included once case of self-limited abdominal pain in the PC-LB group. CONCLUSION: EUS-(M)LB has the potential to be a safe and effective alternative diagnostic modality when compared to PC-LB, to evaluate children with unexplained liver test abnormalities who undergo EUS to evaluate biliary disorders.

Symptom resolution of bile reflux gastritis after transoral gastric outlet reduction in a patient with Billroth II anastomosis.

Endoscopic transoral outlet reduction (TORe) utilizing a full thickness endoscopic suturing device is a minimally invasive therapeutic option in bariatric surgery patients who have experienced weight gain, but also can be used in patients who underwent Billroth II (B-II) procedure with biliary reflux symptoms.

Practical approach to linear endoscopic ultrasound examination of the gallbladder.

The gallbladder (GB) is a susceptible organ, prone to various pathologies that can be identified using different imaging techniques. Transabdominal ultrasound (TUS) is typically the initial diagnostic method due to its numerous well-established advantages. However, in cases of uncertainty or when a definitive diagnosis cannot be established, computed tomography (CT) or magnetic resonance imaging may be employed to provide more detailed information. Nevertheless, CT scans may sometimes offer inadequate spatial resolution, which can limit the differentiation of GB lesions, particularly when smaller yet clinically relevant abnormalities are involved. Conversely, endoscopic ultrasound (EUS) provides higher frequency compared to TUS, superior spatial resolution, and the option for contrast-enhanced harmonic imaging, enabling a more comprehensive examination. Thus, EUS can serve as a supplementary tool when conventional imaging methods are insufficient. This review will describe the standard EUS examination of the GB, focusing on its endosonographic characteristics in various GB pathologies.

Antireflux band mucosectomy: a novel minimally invasive approach for the treatment of refractory gastroesophageal reflux disease.

Background and Aims: Endoscopic therapies in the treatment of refractory GERD have largely been regarded as inferior as surgical intervention. Procedures such as the transoral endoscopic incisionless fundoplication (TIF), Stretta, and antireflux mucosectomy (ARMS) are less invasive but produce outcomes that are middling to lackluster, with many patients having to continue proton pump therapy without resolution of symptoms. Antireflux band mucosectomy (ARBM), in which the cardia is banded, may provide more effective relief. We present 4 patients with refractory GERD who did not opt for surgical intervention and were successfully treated with the ARBM procedure. Methods: Four patients with GERD refractory to medical therapy underwent ARBM. Three patients had nonerosive esophagitis and 1 patient had erosive esophagitis. Two patients had hiatal hernias ≤2 cm. All underwent preprocedure and postprocedure pH bravo testing as well as follow-up EGD. Results: All cases were completed successfully. All patients underwent a decrease in DeMeester score and acid exposure time. Procedure time ranged from 6 to 15 minutes. There were no adverse events. All patients were taken off proton pump inhibitor (PPI) therapy by 4 weeks postprocedure. Conclusions: Four patients with refractory GERD who declined surgery underwent the ARBM procedure with technical success. All experienced significant decrease to complete resolution of symptoms. All patients were weaned off PPIs by 4 weeks postprocedure.

Assessment of alteration in antiviral plasma concentration across dialysis days: computational and analytical study.

Aim: Protein-bound uremic toxins (PBUTs) may displace drugs from the plasma proteins and render them more liable to clearance. This study aims to investigate the possible interplay between PBUTs and directly acting antivirals (DAAs). Methods: PBUT plasma protein binding was compared to those of paritaprevir (PRT), ombitasivir (OMB) and ritonavir (RTV) in silico to assess the possible competitive displacement. The three drugs were LC-MS/MS determined in seven patients across dialysis and non-dialysis days and results were compared. Results & conclusion: Results showed that the PBUT exhibited a lower binding than DAA reducing the liability of their competitive displacement. This was echoed by an unaltered plasma concentration across dialysis days. Results may indicate that PBUT accumulation may have limited effect on disposition of DAA.

Albuminuria as a predictor of mortality in type II diabetic patients after living-donor liver transplantation.

PURPOSE: Diabetes mellitus (DM) increases the risk of morbidity and mortality after liver resection. Albuminuria is associated with a higher risk for all-cause and cardiovascular mortality. This study evaluated albuminuria as a predictor of the outcome of living donor liver transplantation (LDLT) in patients with pre-existing DM. METHODS: This retrospective study involved 103 type II diabetic patients with end-stage liver disease who received LDLT. Preoperative spot urine albumin: creatinine ratio was used to determine the degree of albuminuria. The primary outcome measure was the impact of urinary albumin excretion on the 3-year mortality rate after LDLT in this diabetic cohort. RESULTS: Hepatitis C virus infection was the main cause of cirrhosis. Albuminuria was detected in 41 patients (39.8%); 15 had macroalbuminuria, while 26 had microalbuminuria. Patients with microalbuminuria were significantly older than those with macroalbuminuria and normal albumin in urine. After 3 years, twenty-four patients (23.3%) died within 3 years after LT. Myocardial infarction was the leading cause of death (25%). Albuminuria was an independent factor affecting 3-year mortality with an odds ratio of 5.17 (95% CI: 1.86-14.35). CONCLUSION: Preoperative albuminuria is an independent factor affecting mortality within 3 years after LDLT in type II diabetic patients. Myocardial infarction was the leading cause of death in 25% of cases, followed by hepatocellular carcinoma recurrence, sepsis, and graft failure.KEY MESSAGESDiabetes mellitus (DM) increases the risk of morbidity and mortality after liver resection.Albuminuria is associated with a higher risk for all-cause and cardiovascular mortality.Preoperative albuminuria is a significant predictor of mortality within 3 years after LDLT in diabetic patients.

Successful removal of a giant esophageal lipoma with hybrid endoscopic submucosal dissection.

Video 1Endoscopic submucosal dissection of a giant esophageal lipoma.

Development and Validation of a New LC-MS/MS Analytical Method for Direct-Acting Antivirals and Its Application in End-Stage Renal Disease Patients.

BACKGROUND AND OBJECTIVE: The effectiveness of direct-acting antivirals (DAAs) is not well established in end-stage renal disease (ESRD) patients. Assessment of the plasma concentrations may support understanding of their therapeutic outcomes in this population. The aim of this study is to develop a direct, yet matrix-effect tolerant, analytical method for determining DAAs in the plasma of ESRD patients while maintaining a moderate cost per sample and with an improved analyte extraction recovery. METHODS: In this study, a liquid chromatography-tandem mass spectrometric (LC-MS/MS) method was developed for the analysis of ombitasvir (OMB), paritaprevir (PRT) and ritonavir (RIT) in plasma. Sample preparation was performed using the liquid-liquid extraction (LLE) method. Isocratic separation was performed using a mixture of methanol and 10 mM ammonium acetate (79:21, v/v) followed by MS/MS detection. The method was validated and applied to determine DAAs in the plasma of ESRD patients (n = 7). RESULTS: The developed method was linear (r2 > 0.995), accurate (89.4 ± 7.8 to 108.3 ± 3.0) and precise (% CV 0.9-15.0) and showed improved recovery (> 80) over previously published ones in the range 5-250, 30-1,500, 20-1,000 ng/mL for OMB, PRT and RIT, respectively. Relative matrix effect was absent, and the method accurately determined the three DAAs in real-life samples (n = 7). CONCLUSIONS: An efficient analytical method for the determination of DAAs is presented. The method overcomes the potential analytical response fluctuation in ESRD. The developed method show improved extraction recoveries and is suitable for routine application in developing economies where hepatitis C virus is most prevalent.

Alopecia Universalis Associated with Ulcerative Colitis and The Role of Azathioprine.

Skin manifestations can herald, co-exist, or follow the evolution of inflammatory bowel disease (IBD). We report a middle-aged man with recent onset alopecia universalis and a history of intermittent diarrheal attacks for 6 years. Colonscopy and biopsy sampling confirmed ulcerative colitis. Regrowth of hair was achieved by treating the patient with azathioprine and mesalamine. Clinicians have to be aware that a multitude of skin manifestations with history of diarrhea can be an extraintestinal manifestation of IBD such as ulcerative colitis and this warrants further investigation.

EUS-guided fine-needle liver biopsy in pediatric patients using a modified technique with one-pass, one-actuation wet suction

Background and aims: liver biopsy (LB) can be a valuabletool to determine the etiology of pediatric liver disease.There is limited data on the role of EUS-LB in children. Thisstudy evaluated the efficacy and safety of a modified technique —(M)LB— in cases at high risk of bleeding or in obesechildren. In addition, the tissue yield of EUS-(M)LB and thepercutaneous (PC) approach were compared.Methods: a retrospective analysis was performed comparing EUS-(M)LB and PC-LB in children at a tertiary referral center. All consecutive children referred for PC-LB andEUS-LB who had an unexplained liver test abnormality afterexclusion of biliary disorders from March 2017 to August2018 were included. EUS-(M)LB consisted of a one pass wetsuction technique using a 19-gauge core needle. A comparison was performed between total specimen length (TSL)and number of complete portal triads (CPTs).Results: the cohort included 28 EUS-(M)LB and 28 PC-LBpediatric cases. Median (IQR) age was 14.5 years (13.4-16). Median TSL was 8.6 (5.8-9.6) in EUS-(M)LB cases and7 cm (7-9) in PC-LB cases (p = 0.788). The maximum intactspecimen was 2.8 cm (EUS-(M)LB) and 1.6 cm (PC-LB) (p= 0.009). The mean (SD) number of CPTs per sample was28.2 (7.3) and 11.6 (2.1), respectively (p = 0.001). Adverseevents included one case of self-limited abdominal pain inthe PC-LB group.Conclusion: EUS-(M)LB has the potential to be a safe andeffective alternative diagnostic modality, when compared toPC-LB, to evaluate children with unexplained liver test abnormalities who undergo EUS to evaluate biliary disorders. (AU)