Mesenchymal stem cells: A novel treatment option for primary sclerosing cholangitis.

Primary sclerosing cholangitis (PSC) is a progressive liver disease for which there is no effective therapy. Hepatocytes and cholangiocytes from a PSC patient were cocultured with mesenchymal stem cells (MSCs) to assess in vitro change. A single patient with progressive PSC was treated with 150 million MSCs via direct injection into the common bile duct. Coculture of MSCs with cholangiocytes and hepatocytes showed in vitro improvement. Local delivery of MSCs into a single patient with progressive PSC was safe. Radiographic and endoscopic evaluation showed stable distribution of multifocal structuring in the early postoperative period. MSCs may be effective for the treatment of PSC.

Mortality Trends, Outcomes, and Predictors of Portal Vein Thrombosis in Acute Pancreatitis Patients: A Propensity-Matched National Study.

BACKGROUND: Portal vein thrombosis (PVT) is a rare complication of acute pancreatitis (AP) and might be associated with worse outcomes. We aimed to study trends, outcomes, and predictors of PVT in AP patients. METHODS: The National Inpatient Sample database was utilized to identify the adult patients (≥ 18 years) with primary diagnosis of AP from 2004 to 2013 using International Classification of Disease, Ninth Revision. Patients with and without PVT were entered into propensity matching model based on baseline variables. Outcomes were compared between both groups and predictors of PVT in AP were identified. RESULTS: Among the total of 2,389,337 AP cases, 7046 (0.3%) had associated PVT. The overall mortality of AP decreased throughout the study period (p trend ≤ 0.0001), whereas mortality of AP with PVT remained stable (1-5.7%, p trend = 0.3). After propensity matching, AP patients with PVT patients had significantly higher in-hospital mortality (3.3% vs. 1.2%), AKI (13.4% vs. 7.7%), shock (6.9% vs. 2.5%), and need for mechanical ventilation (9.2% vs. 2.5%) along with mean higher cost of hospitalization and length of stay (p < 0.001 for all). Lower age (Odd ratio [OR] 0.99), female (OR 0.75), and gallstone pancreatitis (OR 0.79) were negative predictors, whereas alcoholic pancreatitis (OR 1.51), cirrhosis (OR 2.19), CCI > 2 (OR 1.81), and chronic pancreatitis (OR 2.28) were positive predictors of PVT (p < 0.001 for all) in AP patients. CONCLUSION: PVT in AP is associated with significantly higher risk of death, AKI, shock, and need for mechanical ventilation. Chronic and alcoholic pancreatitis is associated with higher risk of PVT in AP.

Endoscopic ultrasound with combined fine needle aspiration plus biopsy improves diagnostic yield in solid pancreatic masses.

GOALS: Our aim was to compare the diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) versus combined fine needle aspiration and fine needle biopsy (EUS-FNA + FNB) in the evaluation of solid pancreatic masses (SPMs). BACKGROUND: EUS-FNA and EUS-FNB are established methods to diagnose SPMs. No studies have evaluated the efficacy of combination of both (EUS-FNA + FNB). Our senior author (MRS) hypothesized that combining the two techniques by using a single FNB needle improves diagnostic yield and started combination technique in October 2016. STUDY: Patients who underwent EUS for SPMs by MRS during January 2014-September 2019 were included. They were divided into the EUS-FNA group and EUS-FNA + FNB group. EUS-FNA was performed using a 22 or 25 gauge Expect Slimline needle (Boston Scientific, Marlborough, MA) and EUS-FNA + FNB was performed using a single 22 or 25 gauge Shark-core needle (Medtronics, Minneapolis, MN, USA). Our primary outcome was to compare the diagnostic yield in the two groups. RESULTS: Among 105 patients included, 58 were in the EUS-FNA group and 47 were in the EUS-FNA + FNB group. EUS-FNA + FNB group had significantly higher diagnostic yield and required fewer needle passes compared to EUS-FNA group, 95.7% vs. 77.6%, p = .01: and 4 vs. 5, p = .002; respectively. Procedural duration was similar in both groups but the combined technique required less number of needles per procedure. There was no difference in adverse events in the two groups. CONCLUSION: Our study showed that combined EUS-FNA + FNB had higher diagnostic yield compared to EUS-FNA in SPMs along with less number of needle passes and needles required. Further prospective studies are needed to validate these findings and cost-effectiveness of this strategy.

Trends and risk factors for 30-day readmissions in patients with acute cholangitis: analysis from the national readmission database.

INTRODUCTION: Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. METHODS: We conducted a retrospective cohort study of adult patients admitted with AC from 2010-2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. RESULTS: From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4-1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2-1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0-1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73-0.88) or cholecystectomy (OR 0.54, 95% CI 0.43-0.69). CONCLUSIONS: AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Intestinal metaplasia of the gastric cardia: findings in patients with versus without Barrett's esophagus.

BACKGROUND AND AIMS: There is controversy about finding intestinal metaplasia (IM) of the gastric cardia on biopsy. The most recent American College of Gastroenterology guideline comments that IM cardia is not more common in patients with Barrett's esophagus (BE). It provides limited guidance on whether the cardia should be treated when patients with BE undergo endoscopic eradication therapy (EET) and whether the cardia should undergo biopsy after ablation. The aims of our study were to determine the frequency in the proximal stomach of (1) histologic gastric cardia mucosa and (2) IM cardia. A third aim was to explore the frequency of advanced pathology (dysplasia and adenocarcinoma) in the cardia after patients with BE have undergone EET. METHODS: Consecutive patients undergoing esophagogastroduodenoscopy between January 2008 and December 2014 who had proximal stomach biopsies were included. Patients who had histologically confirmed BE were compared with those without BE. RESULTS: Four hundred sixty-two patients, 289 with BE and 173 without BE, were included. Histologically confirmed cardiac mucosa was found in 81.6% of all patients. This was more frequent in those with versus without BE (86% vs 75%; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.28-3.32; P = .003). IM cardia was more common in the BE group (17% vs 7%; OR, 2.67; 95% CI, 1.38-5.19; P = .004). Advanced pathology was more likely in the patients with BE who had undergone EET. CONCLUSIONS: Cardiac mucosa is present in most patients who undergo endoscopy for upper GI symptoms. IM cardia is more common in patients with BE than those without. Advanced histologic changes in the cardia were seen only in the subgroup of patients with BE who had undergone EET.

Comparison of Small Versus Large Volume Split Dose Preparation for Colonoscopy: A Study of Colonoscopy Outcomes.

BACKGROUND: Split dose bowel preparations (SDP) have superior outcomes for colonoscopy as compared to evening before regimens. However, the association of the actual volume of the SDP to colonoscopy outcome measures has not been well studied. AIMS: Compare adenoma detection rate (ADR), sessile serrated polyp detection rate (SDR), mean bowel cleanse score, and predictors of inadequate exams between small volume SDP and large volume SDP. METHODS: We have conducted a retrospective study in patients undergoing colonoscopy with small volume SDP versus large volume SDP between July 2014 and December 2014. Basic demographics (age, gender and BMI) along with clinical co-morbidities were recorded. Quality of the bowel preparation, ADR and SDR was compared between these groups. Univariate and multivariable logistic regressions were used to assess the determinants of inadequate exams in each group. RESULTS: 1573 patients with split dose preparation were included in this retrospective study. 58.4% (920/1573) patients took small volume SDP. There was no difference in ADR (37.9 vs. 38.8%, p = 0.2); however, SDR was higher for small volume SDP compared to large volume SDP (11.9 vs. 7.9% p = 0.005). There was no difference in the rate of inadequate exams between the two groups (p = 0.7). A history of diabetes and constipation was associated with inadequate exams only in the small volume SDP. CONCLUSIONS: SDR was higher in small volume SDP. There was no difference in rate of inadequate exams between the two groups. A history of diabetes and constipation was associated with inadequate exams only in patients with the small volume SDP.

How to perform direct percutaneous gastrostomy with T-fastener gastropexy using endoscopic guidance.

Demonstration of how to perform direct percutaneous gastrostomy with gastropexy T-fasteners using endoscopic guidance.

Endoscopic management of severe colo-colonic anastomotic stricture.

Video 1A therapeutic approach: endoscopic management of severe colo-colonic anastomotic stricture.

Computed tomography enterography detects intestinal wall changes and effects of treatment in patients with Crohn's disease.

BACKGROUND & AIMS: The use of computed tomography enterography (CTE) in patients with Crohn's disease has increased. However, there is little data available on how radiologic parameters of active disease change during treatment with infliximab and whether these changes correspond to symptoms, serum biomarkers, or endoscopic appearance. METHODS: We performed a retrospective study of patients with Crohn's disease who had undergone serial CTE imaging while receiving infliximab. Lesions were defined as improved if their enhancement or length decreased without worsening of other parameters. Patients were grouped as responders (all lesions improved), partial responders (some lesions improved), and nonresponders (worsening or no changes in all lesions). Of the 63 patients identified (47% female), the median age was 37.7 years, the median disease duration was 7.6 years, and the median time between initial and first follow-up CTE was 356 days (interquartile range, 215-630). RESULTS: Of 105 lesions, 52 (49.5%) improved, 11 (10.5%) remained unchanged, and 42 (40.0%) worsened. Per patient, 28 (44.4%) were responders, 12 (19.0%) were partial responders, and 23 (36.5%) were nonresponders. The radiologic response had poor-to-fair agreement with symptoms, endoscopic appearance, and levels of C-reactive protein at time of second CTE (κ = 0.26, 0.07, and 0.30 respectively). CONCLUSIONS: Radiologic improvement was observed in 63.4% of patients with Crohn's disease who received infliximab therapy, despite a study design that was likely biased toward nonresponders. Radiologic response was not in good agreement with clinical symptoms, serum biomarkers, or endoscopic appearance; CTE might be used as a complementary approach to identify mural healing or inflammation not detected by other methods.

Prospective blinded comparison of wireless capsule endoscopy and multiphase CT enterography in obscure gastrointestinal bleeding.

PURPOSE: To compare the performance of multiphase computed tomographic (CT) enterography with that of capsule endoscopy in a group of patients with obscure gastrointestinal bleeding (OGIB). MATERIALS AND METHODS: This prospective HIPAA-compliant study was approved by the institutional review board and the institutional conflict of interest committee. All patients provided written informed consent. Two radiologists, blinded to clinical data and results of capsule endoscopy, interpreted images from CT enterography independently, with discordant interpretations resolved by consensus. Results were compared with those from a reference standard (surgery or endoscopy) and clinical follow-up. Sensitivity and 95% confidence intervals were calculated for each modality. RESULTS: Fifty-eight adult patients, referred for the evaluation of OGIB (occult, 25 patients [43%]; overt, 33 patients [57%]), underwent both tests. A small bowel bleeding source was identified in 16 of the 58 patients (28%). The sensitivity of CT enterography was significantly greater than that of capsule endoscopy (88% [14 of 16 patients] vs 38% [six of 16 patients], respectively; P = .008), largely because it depicted more small bowel masses (100% [nine of nine patients] vs 33% [three of nine patients], respectively; P = .03). No additional small bowel tumors were discovered during the follow-up period (range, 5.6-45.9 months; mean, 16.6 months). CONCLUSION: In this referral population, the sensitivity of CT enterography for detecting small bowel bleeding sources and small bowel masses was significantly greater than that of capsule endoscopy. On the basis of these findings, the addition of multiphase CT enterography to the routine diagnostic work-up of patients with OGIB should be considered, particularly in patients with negative findings at capsule endoscopy.

Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

Video 1Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

Appropriate patient selection at abdominal dual-energy CT using 80 kV: relationship between patient size, image noise, and image quality.

PURPOSE: To determine the computed tomographic (CT) detector configuration, patient size, and image noise limitations that will result in acceptable image quality of 80-kV images obtained at abdominal dual-energy CT. MATERIALS AND METHODS: The Institutional Review Board approved this HIPAA-compliant retrospective study from archival material from patients consenting to the use of medical records for research purposes. A retrospective review of contrast material-enhanced abdominal dual-energy CT scans in 116 consecutive patients was performed. Three gastrointestinal radiologists noted detector configuration and graded image quality and artifacts at specified levels-midliver, midpancreas, midkidneys, and terminal ileum-by using two five-point scales. In addition, an organ-specific enhancement-to-noise ratio and background noise were measured in each patient. Patient size was measured by using the longest linear dimension at the level of interest, weight, lean body weight, body mass index, and body surface area. Detector configuration, patient sizes, and image noise levels that resulted in unacceptable image quality and artifact rankings (score of 4 or higher) were determined by using multivariate logistic regression. RESULTS: A 14 × 1.2-mm detector configuration resulted in fewer images with unacceptable quality than did the 64 × 0.6-mm configuration at all anatomic levels (P = .004, .01, and .02 for liver, pancreas, and kidneys, respectively). Image acceptability for the kidneys and ileum was significantly greater than that for the liver for all readers and detector configurations (P < .001). For the 14 × 1.2-mm detector configuration, patient longest linear dimensions yielding acceptable image quality across readers ranged from 34.9 to 35.8 cm at the four anatomic levels. CONCLUSION: An 80-kV abdominal CT can be performed with appropriate diagnostic quality in a substantial percentage of the population, but it is not recommended beyond the described patient size for each anatomic level. The 14 × 1.2-mm detector configuration should be preferred.

Bedside quantification of dead-space fraction using routine clinical data in patients with acute lung injury: secondary analysis of two prospective trials.

INTRODUCTION: Dead-space fraction (Vd/Vt) has been shown to be a powerful predictor of mortality in acute lung injury (ALI) patients. The measurement of Vd/Vt is based on the analysis of expired CO2 which is not a part of standard practice thus limiting widespread clinical application of this method. The objective of this study was to determine prognostic value of Vd/Vt estimated from routinely collected pulmonary variables. METHODS: Secondary analysis of the original data from two prospective studies of ALI patients. Estimated Vd/Vt was calculated using the rearranged alveolar gas equation: Vd/Vt=1-[(0.86×VCO2est)/(VE×PaCO2)] where VCO2est is the estimated CO2 production calculated from the Harris Benedict equation, minute ventilation (VE) is obtained from the ventilator rate and expired tidal volume and PaCO2 from arterial gas analysis. Logistic regression models were created to determine the prognostic value of estimated Vd/Vt. RESULTS: One hundred and nine patients in Mayo Clinic validation cohort and 1896 patients in ARDS-net cohort demonstrated an increase in percent mortality for every 10% increase in Vd/Vt in a dose response fashion. After adjustment for non-pulmonary and pulmonary prognostic variables, both day 1 (adjusted odds ratio-OR = 1.07, 95%CI 1.03 to 1.13) and day 3 (OR = 1.12, 95% CI 1.06 to 1.18) estimated dead-space fraction predicted hospital mortality. CONCLUSIONS: Elevated estimated Vd/Vt predicts mortality in ALI patients in a dose response manner. A modified alveolar gas equation may be of clinical value for a rapid bedside estimation of Vd/Vt, utilizing routinely collected clinical data.

Kinetics of Gallbladder Emptying During Cholecystokinin Cholescintigraphy as an Indicator of In Vivo Hormonal Sensitivity.

Cholecystokinin cholescintigraphy is used clinically to quantify gallbladder ejection fraction as an indicator of functional gallbladder disorder. It can also provide the opportunity to quantify an individual's responsiveness to the physiologic stimulant of gallbladder contraction, cholecystokinin, which is a major regulator of appetite and postprandial satiety. Methods: In the current work, we use cholecystokinin cholescintigraphy to quantify the kinetics of gallbladder emptying, including average and peak rates, in response to a standard cholecystokinin infusion. Results: We demonstrated that patients with no gallstones or biliary obstruction who empty their gallbladders completely in response to cholecystokinin, having an ejection fraction greater than 80%, exhibit a broad range of sensitivity to this hormone. Three distinct kinetic profiles were observed, with those most sensitive to cholecystokinin achieving the earliest peak and the fastest rate of gallbladder emptying, whereas those least sensitive to cholecystokinin have the latest peak and the slowest rate of emptying. Conclusion: Patients can have abnormal cholecystokinin stimulus-activity coupling as an effect of endogenous negative allosteric modulation by membrane cholesterol. This was predicted in ex vivo studies but has not, to our knowledge, previously been demonstrated in vivo. This type of kinetic analysis provides a tool to quantify cholecystokinin responsiveness in patients and identify patients who might benefit from a drug that would positively modulate cholecystokinin action to improve their appetite regulation and to better control their weight.