The Role of Real Time Endoscopic Ultrasound Guided Elastography for Targeting EUS-FNA of Suspicious Pancreatic Masses: A Review of the Literature and A Single Center Experience.

BACKGROUND: Endoscopic ultrasound guided elastography is an imaging modality that can be used to evaluate tissue stiffness and to assess solid pancreatic lesions. It can also assist in optimizing the diagnostic yield of endoscopic ultrasound guided fine needle aspiration biopsies. AIMS: To review the literature on solid pancreatic lesions, the use of EUS guided fine needle aspiration and endoscopic ultrasound guided elastography and to present a single center experience using elastography to direct fine needle aspiration biopsies of solid pancreatic lesions. METHODS: We present a review of the literature and a single center experience describing the use of EUS guided elastography in directing fine needle aspiration biopsies of solid pancreatic lesions. RESULTS: Thirteen male veterans with an average age of 62.3 (SD±11.8) years were enrolled in the study. The mean pancreatic mass size on EUS was 5.1×5.2 (SD±4.4×4.5) cm. A total of 13 lesions were identified during elastography. The lesions were most commonly found in the body (n=5), followed by multifocal lesions (n=4), pancreatic head (n=3) and tail (n=1). The seven concerning pancreatic lesions were stratified based on color pattern identified on EUS and EUS-elastography. Three lesions were homogenously blue, and four lesions were heterogeneously blue. The remaining six lesions which were less concerning were predominantly green. Of the three lesions, that were homogenously blue, two were diagnosed as adenocarcinoma (n=2) and chronic pancreatitis (n=1) respectively. Of the four heterogeneously blue lesions two were adenocarcinomas, while the other two represented a large B-cell lymphoma and chronic pancreatitis. Patients whose lesions were characterized as homogenous or heterogeneous green were benign and remained disease free after a median of two years of regular follow up. LIMITATIONS: Relatively small number of patients studied. CONCLUSIONS: In our single center experience we found that the use of real time endoscopic ultrasound guided elastography for targeting fine needle aspiration of suspicious pancreatic lesions may be beneficial as an adjunct modality to complement conventional EUS. Larger prospective studies need to be conducted to evaluate the utility of this modality in targeting pancreatic lesions.

Antibiotics for irritable bowel syndrome: rationale and current evidence.

Irritable bowel syndrome (IBS) is the most common gastrointestinal condition effecting adults in developed countries worldwide. Over the last decade, evidence has emerged suggesting that gut bacteria play a role in the pathophysiology of IBS. While difficult to identify using noninvasive means, one of the most common attributable bacterial concepts in IBS is the small intestinal bacterial overgrowth hypothesis (SIBO). In this article, we review the different mechanisms by which gut flora and, specifically, SIBO may contribute to IBS and the evidence supporting the use of various antibiotic therapies in treating IBS.

SPHINCTEROTOMY ALONE VERSUS SPHINCTEROTOMY AND BILIARY STENT PLACEMENT IN THE TREATMENT OF BILE LEAKS: 10 YEAR EXPERIENCE AT A QUATERNARY HOSPITAL.

BACKGROUND: Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear. OBJECTIVE: The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks. METHODS: We retrospectively analyzed 31 patients with the final ERCP diagnosis of "bile leak". Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP. RESULTS: A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005). CONCLUSION: ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

Use of omental patch and endoscopic closure technique as an alternative to surgery after endoscopic full thickness resection of gastric intestinal stromal tumors: A series of cases.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) originate from interstitial cells of Cajal. GISTs can occur anywhere along the gastrointestinal tract. Large lesions have traditionally been removed surgically. However, with recent innovations in advanced endoscopy, GISTs located within the stomach are now removed endoscopically. We describe a new innovative endoscopic technique to close large and hard to access defects after endoscopic full-thickness resection of gastric GISTs. CASE SUMMARY: We present a series of three patients who were diagnosed with a gastric GIST. All patients underwent full-thickness endoscopic resection. In all cases, for closure of the surgical bed, conventional endoscopic techniques including hemoclips, endoloop and suturing were unsuccessful. We performed a new technique in which we pulled omental fat into the gastric lumen and completely closed the defect using endoscopic devices. All patients performed well post-procedure and computed tomography was carried out one day after the procedures which showed no extravasation of contrast. CONCLUSION: The omental plug technique may be used as an alternative to surgery in selected cases of gastric perforation.

Acute bleeding after argon plasma coagulation for weight regain after gastric bypass: A case report.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) is the most commonly performed surgical procedure used to treat obesity worldwide. Despite satisfactory results in terms of weight loss, over time many patients experience weight regain. There are many factors that contribute to weight regain after RYGB, including the diameter of the gastric-jejunal anastomosis (GJA). One of the most commonly performed endoscopic procedures for weight regain after RYGB is argon plasma coagulation (APC). We report a case of hematemesis after outlet revision with APC. We highlight several treatment modalities that can be used to treat this complication. CASE SUMMARY: A 45-year-old female with a history of weight regain after RYGB was referred for possible endoscopic treatment for weight regain. On endoscopic evaluation, the diameter of the GJA was 22 mm. Due to the dilated GJA, treatment with APC was performed. Several months later she reported a return of poor satiety and an increased appetite. A repeat endoscopy was then performed. The GJA was approximately 15 mm and was incompetent. APC was performed. One day post procedure she had four episodes of hematemesis. An endoscopy was performed and a large ulcer with a visible arterial vessel was visualized at the GJA. Coagulation was attempted using a Coagrasper and after initial contact with the vessel, the vessel started oozing. Due to fibrosis and the depth of ulceration in the area, clips and repeat APC could not be used. Therefore, an attempt to inject epinephrine injection was made. However, persistent oozing was noted. As a result, hemostatic powder was applied to the region of the bleeding vessel. Subsequently, no more bleeding was observed. On follow-up, the patient remained hemodynamically stable and a second look endoscopy was not performed. The patient was discharged three days later. CONCLUSION: APC revision of the GJA is known to be a relatively safe and effective strategy to manage weight regain post RYGB. Anastomotic site bleeding is an infrequent and potentially life-threatening complication associated with this therapy. Endoscopic management is the first line therapy used to achieve hemostasis in these cases.

The Utility of Endoscopic Ultrasound in Patients with Isolated Elevations in Serum Amylase and/or Lipase.

BACKGROUND/AIMS: The aim of this study was to describe the diagnostic yield of endoscopic ultrasound (EUS) in patients with isolated elevated levels of amylase and/or lipase. METHODS: A retrospective chart review was conducted at a large academic medical center from 2000 to 2016. Patients were selected based on having elevated amylase, lipase, or both, but without a diagnosis of pancreatitis or known pancreatobiliary disease. Patients were excluded if they had abnormal liver function tests or abnormal imaging of the pancreas. RESULTS: Of 299 EUS procedures performed, 38 met inclusion criteria. Symptoms were present in 31 patients, most frequently abdominal pain (87%). In 20 patients (53%), initial EUS most commonly found chronic pancreatitis (n=7; 18%), sludge (5; 13%), or new diagnosis of pancreas divisum (3; 8%). In the asymptomatic patients (7), 3 had a finding on EUS, most importantly sludge (2), stone (1), and pancreas divisum (1). No patients were diagnosed with a mass or pancreatic cyst. During the follow up period, 6 patients (22%) had cholecystectomy. CONCLUSION: In our study of patients with isolated elevations in amylase and/or lipase without acute pancreatitis who underwent EUS, approximately 50% had a pancreatobiliary finding, most commonly chronic pancreatitis or biliary sludge.

Celiac Plexus Block and Neurolysis: A Review.

Pain is often associated with chronic pancreatitis and pancreatic cancer. Often times opioids are used to treat pain; however, the use of opioids is frequently difficult. Endoscopic ultrasound-guided celiac plexus block and celiac plexus nuerolysis are safe and effective modalities used to alleviate pain. Celiac plexus block is a transient interruption of the plexus by local anesthetic, while celiac plexus neurolysis is prolonged interruption of the transmission of pain from the celiac plexus using chemical ablation. Celiac plexus block is generally performed in the unilateral position, while celiac plexus neurolysis is performed in the unilateral or bilateral position.

Endoscopic Full-Thickness Defects and Closure Techniques.

PURPOSE OF REVIEW: Gastrointestinal transmural defects are defined as total rupture of the gastrointestinal wall and can be divided into three main categories: perforations, leaks, and fistulas. Due to an increase in the number of therapeutic endoscopic procedures including full-thickness resections and the increase incidence of complications related to bariatric surgeries, there has been an increase in the number of transmural defects seen in clinical practice and the number of non-invasive endoscopic treatment procedures used to treat these defects. RECENT FINDINGS: The variety of endoscopic approaches and devices, including closure techniques using clips, endoloop, and endoscopic sutures; covering techniques such as the cardiac septal occluder device, luminal stents, and tissue sealants; and drainage techniques including endoscopic vacuum therapy, pigtail, and septotomy with balloon dilation are transforming endoscopy as the first-line approach for therapy of these conditions. In this review, we describe the various transmural defects and the endoscopic techniques and devices used in their closure.

Endoscopic Management of Foreign Bodies in the Gastrointestinal Tract: A Review of the Literature.

Foreign body ingestion is a common diagnosis that presents in emergency departments throughout the world. Distinct foreign bodies predispose to particular locations of impaction in the gastrointestinal tract, commonly meat boluses in the esophagus above a preexisting esophageal stricture or ring in adults and coins in children. Several other groups are at high risk of foreign body impaction, mentally handicapped individuals or those with psychiatric illness, abusers of drugs or alcohol, and the geriatric population. Patients with foreign body ingestion typically present with odynophagia, dysphagia, sensation of having an object stuck, chest pain, and nausea/vomiting. The majority of foreign bodies pass through the digestive system spontaneously without causing any harm, symptoms, or necessitating any further intervention. A well-documented clinical history and thorough physical exam is critical in making the diagnosis, if additional modalities are needed, a CT scan and diagnostic endoscopy are generally the preferred modalities. Various tools can be used to remove foreign bodies, and endoscopic treatment is safe and effective if performed by a skilled endoscopist.

Esfincterotomia isolada versus esfincterotomia associada a passagem de prótese biliar no tratamento de fístulas biliares: 10 anos de experiência de um hospital quaternário / Sphincterotomy alone versus sphincterotomy and biliary stent placement in the treatment of bile leaks: 10 year experience at a quaternary hospital

ABSTRACT BACKGROUND: Hepatobiliary surgery and hepatic trauma are frequent causes of bile leaks and this feared complication can be safely managed by endoscopic retrograde cholangiopancreatography (ERCP). The approach consists of sphincterotomy alone, biliary stenting or a combination of the two but the optimal form remains unclear. OBJECTIVE: The aim of this study is to compare sphincterotomy alone versus sphincterotomy plus biliary stent placement in the treatment of post-surgical and traumatic bile leaks. METHODS: We retrospectively analyzed 31 patients with the final ERCP diagnosis of "bile leak". Data collected included patient demographics, etiology of the leak and the procedure details. The treatment techniques were divided into two groups: sphincterotomy alone vs. sphincterotomy plus biliary stenting. We evaluated the volume of the abdominal surgical drain before and after each procedure and the number of days needed until cessation of drainage post ERCP. RESULTS: A total of 31 patients (18 men and 3 women; mean age, 51 years) with bile leaks were evaluated. Laparoscopic cholecystectomy was the etiology of the leak in 14 (45%) cases, followed by conventional cholecystectomy in 9 (29%) patients, hepatic trauma in 5 (16%) patients, and hepatectomy secondary to neoplasia in 3 (9.7%) patients. The most frequent location of the leaks was the cystic duct stump with 12 (38.6%) cases, followed by hepatic common duct in 10 (32%) cases, common bile duct in 7 (22%) cases and the liver bed in 2 (6.5%) cases. 71% of the patients were treated with sphincterotomy plus biliary stenting, and 29% with sphincterotomy alone. There was significant difference between the volume drained before and after both procedures (P<0.05). However, when comparing sphincterotomy alone and sphincterotomy plus biliary stenting, regarding the volume drained and the days needed to cessation of drainage, there was no statistical difference in both cases (P>0.005). CONCLUSION: ERCP remains the first line treatment for bile leaks with no difference between sphincterotomy alone vs sphincterotomy plus stent placement.

RESUMO CONTEXTO: Cirurgia hepatobiliar e trauma hepático são causas frequentes de fístulas biliares, e esta temida complicação pode ser manejada de forma segura através da colangiopancreatografia retrógrada endoscópica (CPRE). O procedimento consiste em esfincterotomia isolada, passagem de prótese biliar ou combinação das duas técnicas, porém a forma ideal permanece incerta. OBJETIVO: O objetivo desse estudo é comparar a realização de esfincterotomia isolada versus locação de prótese biliar no tratamento de fístulas pós-cirúrgicas e traumáticas. MÉTODOS: Foram analisados de forma retrospectiva 31 CPREs com diagnóstico final de "fístula biliar". A informação colhida incluía dados demográficos dos pacientes, etiologia das fístulas e detalhes dos procedimentos. As técnicas de tratamentos foram divididas em dois grupos: esfincterotomia isolada vs esfincterotomia associada a locação de prótese biliar. Foram analisados os volumes dos drenos abdominais cirúrgicos antes e depois de cada procedimento e o número de dias necessários para que ocorresse cessação da drenagem pelo dreno abdominal cirúrgico após a CPRE. RESULTADOS: Um total de 31 pacientes (18 homens e 3 mulheres; idade média de 51 anos) com fístulas biliares foram avaliados. Colecistectomia laparoscópica foi a etiologia da fístula em 14 (45%) casos, seguida de colecistectomia convenvional em 9 (29%) pacientes, trauma hepático em 5 (16%) pacientes, e hepatectomia secundária a neoplasia em 3 (9,7%) pacientes. As localizações mais frequentes das fístulas foram: coto do ducto císticos com 12 (38,6%) casos, seguido de ducto hepático comum em 10 (32%) casos, ducto colédoco em 7 (22%) cases e leito hepático em 2 (6,5%) casos. 71% dos pacientes foram tratados com esfincterotomia associada a passagem de prótese biliar e 29% com esfincterotomia isolada. Houve diferença estatística em relação ao volume drenado antes e depois de ambos os procedimentos (P<0,05). Entretanto, quando comparada esfincterotomia isolada e esfincterotomia associada a passagem de prótese biliar, em relação ao volume drenado e ao número de dias necessários para cessação da drenagem, não houve diferença estatística em ambos os casos (P>0,005). CONCLUSÃO: A CPRE permanece como tratamento de primeira linha no tratamento de fístulas biliares, sem diferença entra a esfincterotomia isolada versus esfincterotomia associada a passagem de prótese biliar.

Gastrointestinal bacterial overgrowth: pathogenesis and clinical significance.

Small intestinal bacterial overgrowth (SIBO) is defined as the presence of an abnormally high number of coliform bacteria in the small bowel. It is associated with a broad range of predisposing small intestinal motility disorders and with surgical procedures that result in bowel stasis. The most common symptoms associated with SIBO include diarrhea, flatulence, abdominal pain and bloating. Quantitative culture of small bowel contents and a variety of indirect tests have been used over the years in an attempt to facilitate the diagnosis of SIBO. The indirect tests include breath tests and biochemical tests based on bacterial metabolism of a variety of substrates. Unfortunately, there is no single valid test for SIBO, and the accuracy of all current tests remains limited due to the failure of culture to be a gold standard and the lack of standardization of the normal bowel flora in the small intestine. Currently, the ideal approach to treat SIBO is to treat the underlying disease, eradicate overgrowth, and address nutritional deficiencies that may be associated with the development of SIBO.