Introduction

Recent research has shown that there is considerable interest in studying inflammatory bowel diseases (IBD) due to the potential for dietary interventions to be used as a therapeutic approach for their onset and progression. Evidence suggests that Western-style diets, with high intake of processed foods, food additives, red meat, and animal fat, have been associated with an increased risk of IBD.

Aims & Methods

The purpose of this study is to evaluate the link between an anti-inflammatory exclusion diet and the maintenance of IBD remission, as well as to assess the potential therapeutic advantages of this dietary approach in preserving IBD remission.The inclusion and exclusion criteria were applied to a total of 189 individuals with IBD, with 21 individuals not meeting the criteria. Therefore, 168 eligible patients were enrolled in the study and allocated to either an exclusion diet or a regular diet, based on their personal preference.

Results

A cohort of 84 adult patients with inflammatory bowel disease (IBD) was recruited for the study. The cohort included 47.6% males, with 44 patients having ulcerative colitis (UC) and 40 having Crohn's disease (CD). The intervention group received an exclusion diet consisting of the removal of red and processed meat, fried foods, high-lactose foods, fast food, white bread, sweetened drinks, and vegetable oils rich in omega-6 for a period of 1 year. An equivalent number of IBD patients with similar demographics and disease types formed the control group. The exclusion diet was well tolerated, with 90% of participants adhering to it frequently or always. The study demonstrated that the clinical response was maintained in 80 patients (95.2%) in the intervention group, which was significantly higher than the 72 patients (85.7%) in the control group (p-value=0.036). Although not statistically significant, fecal calprotectin was higher in the control group than in the intervention group at the one-year follow-up interval. Additional information is provided in Table 1.

Conclusion

Patients who adhere to an exclusion diet have the chance of a significantly higher rate of maintenance of clinical remission (95% versus 86% in the control group). A trend toward improvement in inflammation tests was observed in the intervention group, confirming once again that Western-style diet is an important etiological factor in IBD. Therefore, it is recommended that the exclusion, anti-inflammatory diet be presented to all patients diagnosed with IBD as a potential intervention.

Clinical Case Summary

Introduction: Pancreatic involvement in non-Hodgkin lymphomas is rare and often mimics pancreatic adenocarcinoma. We report a case in which endoscopic ultrasound (EUS) was pivotal in establishing the correct diagnosis.
Case Presentation: A 39-year-old male, a chronic smoker, presented with jaundice, anorexia, and fever. Laboratory findings revealed hepatocellular injury and cholestasis (total bilirubin: 15 mg/dL; GGT: 868 U/L; ALP: 679 U/L). CT imaging (Figure 1) demonstrated a large retroperitoneal mass infiltrating both the pancreas and adjacent vascular structures, associated with ascites and omental thickening. EUS (Figure 2) revealed a hypoechoic, poorly defined mass in the head and body of the pancreas (65×55 mm), with evidence of vascular invasion. A fine-needle biopsy (22G) was performed. Endoscopic Retrograde Cholangiopancreatography (ERCP) confirmed malignant duodenal stenosis. Histopathology was consistent with diffuse large B-cell lymphoma (DLBCL). The patient was initiated on R-CHOP chemotherapy (Rituximab, Cyclophosphamide, Hydroxydaunorubicin, Oncovin, Prednisone) after baseline staging. Eight months later, follow-up EUS (Figure 3) showed no residual pancreatic mass.
Discussion: In atypical pancreatic masses—especially in younger patients with systemic symptoms—EUS is essential for tissue acquisition and accurate differential diagnosis. Unlike adenocarcinoma, pancreatic lymphomas respond well to chemotherapy.
Conclusion: Early use of EUS in atypical pancreatic masses can prevent misdiagnosis, reduce time to treatment, and avoid unnecessary surgical interventions.

References

Figure 1 - retroperitoneal mass infiltrating pancreas and vascular structures
Figure 2 - hypoechoic, poorly defined mass in the head and body of the pancreas
Figure 3 - no residual pancreatic mass

Clinical Case Summary

A 67 old male patient with Hx of DM, HTN, IHD and previous repair of paraumbilical hernial defect. He had history of multiple previous ERCP with difficult stone extraction and stent placement to secure biliary drainage.
He presented with fever and abdominal pain mainly at re-herniated defect at paraumbilical region. By examination we found ulcerated skin over the hernial sac with a small foreign body protruding from it. He was sent for radiology and performed abdominal CT examination which commented on a mispositioned/slipped biliary stent along with CBD dilatation. Initial labs showed elevated TLC and bilirubin. he admitted that he neglected the instructions to make an appointment for stent exchange after 3 months as he was told after the last ERCP 2 years ago.
Surgical consultation was done to inspect the ectopic stent, they removed it and recommended for follow up of the fistulous opening only as the CT didn't show serious injuries or any abdominal free fluid.
The ectopic stent was impacted inside an intestinal loop inside the hernial sac and couldn't take the natural pathway out of the body with the excreta.
When we saw the slipped stent that punctured its own way out through the hernia out of the patient's body, we thought that this strange finding was the only surprise that the patient can give us.
Patient was planned for ERCP to secure biliary drainage.
After cannulation while performing ERCP, the cholangiogram revealed another surprise, The patient had another hidden stent, an internally migrated one.
It was removed by balloon sweeping and another new double pigtail stent was inserted to ensure more stability.
Upon our request we brought the previous ERCP reports to be revised. We found that the last procedure 2 years ago reported a missed stent already and he put a new one. This means that the hernial stent was the older slipped one and kept in place for this whole time till it decided to get out and the newer stent was internally migrated.

Clinical Case Summary

A 45 y/o female patient complained from fatigue and dyspnea, her CBC showed MHA (Hb 6.5 g/dl, MCV 62 fl/cell) with normal WBCs and PLTs and she denied any apparent bleeding or menstrual abnormalities. Upon investigating, her virology profile was negative, she had +ve FOB, low levels of iron (25.6 ug/dl), low ferritin (10.3 ng/ml) and high Reticulocyte count (3.5%). She underwent upper and lower GI endoscopies without significant findings. She received packed RBCs to correct her general condition but the symptoms recurred. Repeated upper and lower endoscopies didn’t show any source of bleeding. Capsule enteroscopy was ordered and showed multiple red spots, dilated vessels and small varices. We thought of angiodysplasia so we ordered CT enterography but the scan couldn’t detect vascular abnormalities in small intestinal wall and showed an aneurismal dilation at portal vein confluence (3x3.7cm) along with dilated both portal vein and splenic vein. The interventional radiology team described the aneurysm as fusiform not saccular, so it wasn’t suitable for coiling and embolization.
Portal vein aneurysm (PVA) was discovered incidentally in this case. The turbulence of the portal blood flow is believed to be causing congestion in the drained intestinal segments. As a result, we found the described spots and dilated vessels in the jejunum. DBE was suggested to apply APC to the telangiectatic spots, but this won’t address the dilated veins that’s why we preferred consulting intervention radiology to deal with both the intestinal lesions and the aneurysm itself as the main cause of this condition, but unfortunately no definitive intestinal lesions were seen in the angiography CT and the aneurysmal anatomy wasn’t suitable for intervention, also endovascular surgical consultation declined the portal vein reconstruction possibilities due to the difficulty and procedural risks. We advised the patient to continue on supportive treatment and blood transfusion when needed.

References

Kurtcehajic, A., Zerem, E., Alibegovic, E., Kunosic, S., Hujdurovic, A. and Fejzic, J.A., 2023. Portal vein aneurysm-etiology, multimodal imaging and current management. World Journal of Clinical Cases, 11(4), p.725.

Clinical Case Summary

Bouveret syndrome is a rare type of ileus caused by the impaction of large gallstones that pass through a cholecystoenteric fistula in the duodenum.Although endoscopic treatment is preferable over surgery for patients with Bouveret,1 some difficulties in endoscopic procedures must be overcome.2 Herein, we describe the usefulness of combined endoscopic procedures of electrohydraulic lithotripsy (EHL) and new technique by using the guide wire as a snare (Figure1).72 years old female patient known chronic liver disease and splenomegaly came to the emergency department by progressive abdominal pain, persistent vomiting, and weight loss two months ago. Upper Endoscopy was arranged next day and showed hugely dilated stomach with remnant food (signs of Gastric outlet obstruction) down to large stone at second part of duodenum totally obstructing lumen and a fistulous opening. MRCP was done and revealed: dilated Common Bile Duct about 10 mm down to its lower with extensive air in the biliary tree, dilated IHBRs with extensive pneumobilia, collapsed thick-walled gall bladder with air inside and large 35x55 mm impacted stone in the second part of the duodenum. An attempt using Biliary Electrohydraulic lithotripsy (EHL) was done, EHL over 3 hours was with minimal effect as the stone was hard and decreased the stone size to about 4 cm but it is still lodged in the angle, and we couldn’t grasp it by snare.We used Boston scientific guidewire 0.035 to create an open snare which overlapped the stone in its place then gradually pulled to the stomach. Over another 4 hours we used EHL and Lithotripsy stone extractor to destroy the stone into small fragments less than 1 cm.The stone was destroyed. The duodenum was reevaluated and circumferential ulcerations was noted with complete healing of fistula. The patient started oral intake 24 hours after the procedure with no abdominal pain or vomiting. Long term follow up of the patient showed marked weight gain with no adverse effects.

References

1. Cappell MS, Davis M. Characterization of Bouveret’s syndrome: A comprehensive review of 128 cases. A m J G a s t r o e n t e r o l 2006;
101: 2139–46.
2. Caldwell KM, Lee SJ, Leggett PL, Bajwa KS, Mehta SS, Shah SK. Bouveret syndrome: Current management strategies. C l i n E x p
69–75.

Introduction

Lumen-apposing metal stents have increasingly been used for acute cholecystitis cases where surgery is not an option. However, endoscopic ultrasound gallbladder drainage (EUS-GBD) is rarely performed in cases where surgery can be safely planned. One reason for this is the large size of the fistula and the spread of inflammation to the cystic duct, which makes surgery difficult. Preoperative EUS-GBD has the potential to reduce hospital stay, alleviate pain, and eliminate the need for external drainage tube management when compared to percutaneous drainage. To address these challenges, we developed a novel drainage kit specifically for EUS-GBD. This kit includes an anchor to fix the gallbladder and gastric walls and a thin drainage tube that allows one-step insertion and washing. This kit is believed to help create a smaller fistula, prevent the spread of inflammation to the cystic duct, and facilitate subsequent surgery. Here, we present the preliminary results of an exploratory clinical study using this novel kit as a first-in-human case.

Aims & Methods

The aim of this study was to evaluate the clinical outcomes of preoperative EUS-GBD using a novel drainage kit.
Between April 2024 and January 2025, EUS-GBD was performed using the novel drainage kit in six cases of acute cholecystitis. These patients were eligible for elective surgery but ineligible for emergency surgery. There were five female patients with a mean age of 70.0 years (range: 55 to 88 years). The mean time from symptom onset to treatment was 2.7 days (range: 1 to 5 days). All patients had gallstones. All cases have undergone laparoscopic cholecystectomy (LapC) at a mean of 36.8 days (range: 32 to 43 days) after EUS-GBD. The technical success rate, clinical success rate, adverse event rate, mean hospital stay, and conversion rate to open surgery were evaluated.

Results

The technical success rate was 100%, and the clinical success rate was also 100%. No adverse events or open surgery occurred. The mean hospital stay after EUS-GBD was 5.3 days (range: 5 to 6 days), and the mean hospital stay after LapC was 5.3 days (range: 5 to 6 days).

Conclusion

Preoperative EUS-GBD using the novel drainage kit was feasible and safe.

Disclosure

Stock ownership: KOEDA Inc.