Introduction

ERCP can still represents a challenge for endoscopists. In a variable percentage of cases (about 15%), cannulation of the common bile duct (CBD) is defined as “difficult”. In these cases, various advanced techniques are used to ensure access to the biliary tract. These methods can be summarised as follows: when an accidental cannulation of the pancreatic duct (PD) has occurred, the double guidewire technique (DGW) or the transpancreatic sphincterotomy (TPBS) technique can be performed; when access to the PD has not been achieved, freehand precut (trans papillary or fistulotomy) can be performed.¹
It has been shown that these methods are burdened by higher complication rates (in particular post- ERCP pancreatitis [PEP]) compared to standard cannulation of the CBD.² In particular, TPBS carries a stigma of risk and complexity. The ESGE guidelines propose its use as a second line after failure of DGW technique and only by expert endoscopists.¹ Recent studies have shown a certain distrust among endoscopists towards TPBS.³

Aims & Methods

We conducted a one-year prospective study with the aim of evaluating the efficacy and safety of TPBS in cases of difficult cannulation, comparing it with the DGW technique and trans papillary precut. All patients undergoing ERCP in a secondary centre were enrolled. A total of 169 ERCPs were performed by three endoscopists (two seniors and one junior with experience < 200 ERCPs). The most frequent indication was lithiasis of the CBD (74% of cases). The protocol adopted in case of difficult cannulation was the following: in the case of failed access to the PD, trans papillary precut was attempted. In the case of access to PD, the endoscopist chose at his discretion to perform the DGW technique or TPBS. In the case of PD cannulation, no pancreatic stent placement was performed. Other measures were taken to prevent PEP (rectal indomethacin and intravenous hydration during ERCP). Patients were followed up until discharge and peri- and post-procedural complications were recorded.

Results

The overall cannulation rate for naive papillae was 92.8%. Advanced techniques were used in 19% of the cases to achieve cannulation of the bile duct: 73% were successful. TPBS achieved 100% cannulation of CBP, compared to 66.7% of DWS and 55.6% of pre-cutting, showing a statistically significant better performance (p=0.02). A total of five bleedings, two cholangitis, one cholecystitis and two PEP were recorded. Of all these, only three (respectively one PEP, one bleeding and one cholecystitis) occurred after the above-mentioned advanced CBD cannulation methods were used.

Conclusion

In conclusion, this single-centre prospective observational study, despite its limited sample size, demonstrates that TPBS is a safe and effective method in case of difficult bile duct cannulation when PD cannulation is achieved. In particular TPBS seems to be more efficient than DGW and precut, showing a similar security profile. This technique can also be performed safely by non-expert endoscopists.
Finally, it is important to underline that, despite not placing the pancreatic prosthesis after cannulation of the PD (24 patients) none of them presented PEP.

References

1.Testoni PA, Mariani A, Aabakken L, Arvanitakis M, Bories E, Costamagna G, Devière J, Dinis-Ribeiro M, Dumonceau JM, Giovannini M, Gyokeres T, Hafner M, Halttunen J, Hassan C, Lopes L, Papanikolaou IS, Tham TC, Tringali A, van Hooft J, Williams EJ. Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy. 2016 Jul;48(7):657-83. doi: 10.1055/s-0042-108641. Epub 2016 Jun 14. PMID: 27299638.
2.Fung BM, tea TCTabibian JH. Difficult Biliary Cannulation in Endoscopic Retrograd2 Cholangiopancreatography: Definitions, Risk Factors, and Implications. Eur Med J Hepatol. 2021 Aug;9(1):64-72. Epub 2021 Aug 5. PMID: 34621527; PMCID: PMC8494185.
3.Kouanda A, Bayudan A, Hussain A, Avila P, Kamal F, Hasan MK, Dai SC, Munroe C, Thiruvengadam N, Arain MA. Current state of biliary cannulation techniques during endoscopic retrograde cholangiopancreatography (ERCP): International survey study. Endosc Int Open. 2023 Jun 21;11(6):E588-E598. doi: 10.1055/a-2085-4565. PMID: 37564727; PMCID: PMC10410689.

Introduction

Alternate day oral iron therapy is better than daily oral iron therapy in Iron deficiency anemia (IDA) as it increases the fractional absorption of iron. In Ulcerative colitis (UC) with IDA increased fractional absorption of iron with alternate day iron may not only be better in improvement of anemia but also results in reduced unabsorbed iron delivery to distal bowel and may hence reduce adverse effects.

Aims & Methods

In a randomized, open label trial, from February 2023 to December 2024 patients of UC in remission (Mayo ≤2 OR partial Mayo ≤1 with fecal calprotectin <150mcg/gm for last 3 months) with IDA (ferritin <30mcg/l, transferrin saturation <20%, Hb 8-12 gm/dl) were randomized to every other day 132mg (EOD group) or daily 66mg (OD group) elemental oral iron given as ferrous fumarate for 8 weeks. Primary outcome was the difference in mean change in Hemoglobin (Hb) at 8 weeks. Secondary outcomes were the difference in mean change in RBC indices, iron indices and adverse events at 8 weeks.

Results

54 patients were randomized between both groups. One patient in EOD and 2 in OD group withdrew before treatment initiation. Eleven patients had disease flare on oral iron therapy (5 in EOD and 6 in OD group) p= 0.62 and two patients in EOD group had intolerance requiring oral iron stoppage. Thirty-eight patients completed treatment. The mean change in Hb at 8 weeks in EOD and OD groups was 2.08±1.0gm/dl and 2.09±1.11gm/dl respectively in per protocol analysis (p=0.797). The mean change in serum ferritin, serum iron, transferrin saturation and total iron binding capacity in both the groups is not significant. Disease flare within 6 months prior to oral iron therapy correlated with increased incidence of flare on oral iron therapy. (P=0.04)

Conclusion

Alternate day oral iron is not better than daily oral iron in improving Hb levels, iron indices and with similar incidence of adverse events in patients of UC in remission. A recent flare has increased chances of disease flare with oral iron therapy

Introduction

The peripherally inserted central catheter (PICC-Line) is an essential vascular access method used across various clinical settings. It is particularly indicated in patients requiring prolonged antibiotic therapy, mid-term parenteral nutrition, extended hospitalization with intravenous treatments, or who have poor peripheral venous access. PICC lines are typically delivered in standard lengths (approx. 60 cm) and must be individually trimmed to the correct length prior to insertion. Various approaches exist to estimate the optimal insertion length. While traditional practice relies on clinician experience and anatomical landmarks, this study aims to compare the precision of clinician predictions against those made by a predictive formula developed in a previous retrospective study.

Aims & Methods

To evaluate the accuracy of a previously derived formula for estimating ideal PICC-line length and compare it with estimates made by experienced clinicians.
Patient data on a total of 60 PICC lines was previously retrospectively analyzed to develop a multivariate regression formula. The data of that data set was summarized in 60 individual cases, each to be shown to participants in this study. Participants included both clinicians of varying level of experience in the placement of PICC lines. The participants were asked to estimate the ideal PICC length for each anonimized clinical case. Their estimates were compared to the formula-based ideal lengths using absolute deviation and proximity categories (±2 cm, ±3 cm, ±4 cm).

Results

A total of 264 estimates were recorded from 10 participants. The average deviation from the ideal PICC length was 6.3 cm (range: 2.8–12.5 cm). The proportion of estimates falling within the predefined accuracy margins were:

• ±2 cm: 65 estimates (24.6%) [participant range: 1.7%–45.0%]
• ±3 cm: 97 estimates (36.7%) [range: 3.3%–61.7%]
• ±4 cm: 114 estimates (43.2%) [range: 3.3%–73.3%]

• ±2 cm: 30 out of 60 (50.0%)
• ±3 cm: 49 out of 60 (81.7%), p<0.05
• ±4 cm: 57 out of 60 (95.0%), p<0.05

Conclusion

Clinician estimations of PICC-line length based on experience and anatomical reasoning show considerable variability and are frequently inaccurate. The findings of this study demonstrate that the formula significantly outperforms the average clinician estimate in terms of accuracy. A formula-driven approach, developed from empirical data and integrated into a web-based calculator, provides superior precision and reproducibility. This suggests that routine use of the calculator could improve patient outcomes by minimizing malposition-related complications and unnecessary repositioning. Further validation in larger and more diverse clinical settings is warranted.

Clinical Case Summary

Case report: A 47-year-old woman presented with persistent abdominal bloating, cytolysis and hyperalkaline phosphatase. The patient was underweight. Over 10 years, pancreatic hyperamylasemia (>900 U/l), thrombocytopenia and anemia with low iron and folate levels are observed. Medical history - one spontaneous abortion, 2 children conceived by in vitro fertilization. Viral, autoimmune and genetic liver diseases, autoimmune thrombocytopenia, macroamylasemia, Helicobacter pylori and Giardia lamblia infection were excluded. Immunoglobulins and calprotectin were normal. Serological tests for Celiac disease (CD) detected a positive result only for antigliadin Ig G. Abdominal tomography scan did not detect pathological changes. Duodenoscopy revealed flattening of the intestinal villi suggestive of CD. Duodenal biopsy determined a morphological picture characteristic of CD: type 3c/B2 according to the Marsh-Oberhuber criteria. It was recommended a gluten-free diet, iron and folate therapy. At repeated check-up after 3 months, the patient's condition showed significant improvement, and no changes were detected in the laboratory tests.
Discussion: CD can be diagnosed at any age and can present with a wide range of associated or isolated clinical manifestations. Evaluation of the causes of various biological abnormalities may lead to the diagnosis of CD. The presented case highlights atypical clinical presentations that can be associated with CD. Despite the evolution of serological test performances, there are significant problems regarding the diagnosis in atypical conditions, especially in the patient with intestinal atrophy. In such situations, the intestinal biopsy remains the gold standard diagnosis for CD.
Conclusion: The non-classical clinical presentation of CD is becoming increasingly common in the daily practice of the physician, which requires an awareness of its many clinical faces with atypical forms.

References

- 2 illustrative materials with fragments of biopsy from duodenal mucosa (A - complete villous atrophy, stage 3c according to Marsh-Oberhuber, cryptic hyperplasia by numeral growth and depth of the glandular layer. B - m​arked lymphocytic infiltrate within the lamina propria, minor eosinophilia, hyperplastic crypts, slightly distorted architecture, complete villous atrophy).
- 4 illustrative materials from duodenoscopy

Disclosure

None to declare.

Clinical Case Summary

Diseases damaging the enteric mucosa cause malabsorption that may trigger neurologic symptoms, both by immune-related processes and impaired absorption of essential vitamins.
Celiac disease (CD) is found in patients presented with nonhereditary ataxia. In these patients, abnormalities referred to as “gluten ataxia”, are probably the result of immunologic damage to the CNS and peripheral nerves.
B1 is an essential vitamin which its deficiency has broad clinical spectrum; thus, its diagnosis is challenging, and a sensitized clinician is needed to prompt identification. The encephalopathic form of adult thiamine deficiency is called Wernicke-Korsakoff syndrome.
A 40-y/o/w, G4P2, suffered from severe hyperemesis gravidarum resistant to antiemetics during trimester 1.
On 13^th week of pregnancy, she went to the ER, d/t confusion & extensive weakness. Her lab tests showed severe electrolytes deficiencies with transaminitis and elevated CPK levels. She was diagnosed with rhabdomyolysis secondary to her continuous vomiting. On her neurological examination psychomotor slowness and ataxia were found. Thus, Wernicke encephalopathy was suspected and her B1 level was tested and found low: 12 ug/L. She was hospitalized in the ICU to get electrolytes replacement and intravenous thiamine. To confirm the diagnosis, brain MRI was performed and demonstrated a classic picture of Wernicke encephalopathy (1).
6m later she gave birth, but her neurological deficits got worse. TTG level was tested and found positive. Gastroscopy showed duodenal scalloping (2) and Marsh 3C on biopsy (3). She started GFD and neurological rehabilitation. On repeated anamnesis she had abdominal pain before the pregnancy, but her investigation was negative.
This case illustrates a rare herald of CD and increases the awareness of possible manifestation of B1 def.
Points to discuss:

1. Two-hit theory of B1 def. (hyperemesis gravidarum and CD)
2. Neurologic manifestation of CD & B1 def.
3. Vitamins’ malabsorption in CD

References

1. Brain MRI with classic picture of Wernicke encephalopathy
2. Endoscopic picture of duodenal scalloping
3. H&E staining that demonstrates Marsh 3C in duodenal biopsy

Introduction

Anastomotic leaks and fistulae following upper gastrointestinal (GI) surgery remain a serious clinical challenge, carrying high morbidity and mortality. Endoscopic vacuum therapy (EVT) has emerged as a promising minimally invasive treatment option for managing these complications. This study aimed to assess the efficacy and safety of EVT for postoperative anastomotic leaks in a high-volume tertiary referral center.

Aims & Methods

We conducted a retrospective analysis of all patients treated with EVT for anastomotic leakage following upper GI surgery between January 2022 and January 2025. The primary outcome was EVT success, defined as complete leak closure confirmed through both endoscopic and radiologic assessment. Secondary outcomes included procedure-related adverse events and all-cause mortality.

Results

Twenty-four patients were included (79.2% male; mean age: 64 ± 12 years). Of these, 16 patients underwent oesophagectomy and 8 total gastrectomy; only two surgeries were performed for benign conditions. EVT achieved leak closure in 20 patients (87%). One patient died due to hemorrhagic shock from a hepatic artery pseudoaneurysm, unrelated to EVT.
Among successful cases, the mean duration of EVT was 30 ± 19 days, with a median of four sponge exchanges (IQR = 5). Median hospital stay was 52 days (IQR = 41). EVT failure occurred in three patients, all of whom had cancer-related surgeries and defect sizes exceeding 30 mm. In these cases, adjunctive endoscopic treatment with self-expanding metallic stents led to successful leak closure.
A larger defect size was associated with a lower likelihood of closure (p = 0.067), suggesting a trend toward reduced efficacy in extensive leaks. Importantly, no EVT-related complications were observed throughout the study period.

Conclusion

EVT demonstrated a high success rate (87%) and an excellent safety profile for managing postoperative anastomotic leaks following upper GI surgery. Larger leak sizes showed a trend toward lower closure rates, highlighting the importance of early diagnosis and timely initiation of EVT when defects are smaller. Given its effectiveness and minimal risk, EVT should be considered a first-line endoscopic treatment for anastomotic leaks. Further studies are warranted to refine treatment protocols and establish standardized indications based on leak characteristics.

References

1. de Moura DTH, et al. Role of endoscopic vacuum therapy in the management of gastrointestinal transmural defects. World JGastrointestEndosc. 2019 May 16;
2. Mastoridis S, et al. Endoscopic vacuum therapy (EVT) in the management of oesophageal perforations and post-operative leaks. Minim Invasive TherAllied Technol. 2022 Mar;
3. Livingstone I, et al. Current Status of Endoscopic Vacuum Therapy in the Management of Esophageal Perforations and Post-Operative Leaks. Clin Endosc. 2021 Nov;
4. Panneerselvam K,et al. Endoscopic vacuum therapy for treatment of spontaneous and iatrogenic upper gastrointestinal defects. Clin Endosc. 2023 Nov.

Clinical Case Summary

Background: AL (amyloid light chain) amyloidosis is a rare systemic disorder affecting the heart, kidneys, nervous system, and gastrointestinal (GI) tract. GI involvement typically presents with malabsorption or dysmotility from mucosal amyloid deposition. We describe an unusual case presenting as small bowel obstruction (SBO), initially attributed to adhesions.
Case presentation: An 84-year-old man with a history of radical cystoprostatectomy and ileal conduit for urothelial carcinoma presented with recurrent SBO over three months. The initial suspicion was that of adhesive obstruction due to the surgical history. He underwent laparotomy with adhesiolysis and small bowel resection, but the symptoms persisted with high nasogastric output and ongoing obstruction. Histology from the first resected segment did not reveal any specific pathology.
A contrast follow-through study showed dilated small bowel loops with a transition point. Computed Tomography (CT) of the abdomen and pelvis revealed proximal jejunal dilation and segmental circumferential wall thickening.
Antegrade double-balloon enteroscopy (DBE) was performed and it revealed a tumor-like nodular stricture in the jejunum, 68 cm from the incisors. Biopsies showed Congo red-positive amyloid with birefringence and lambda-restricted plasma cells. Repeat surgical resection confirmed amyloid at both margins.
Bone marrow aspirate showed a lambda-restricted plasma cell population (0.5%). Mass spectrometry confirmed AL amyloidosis (lambda type).Positron Emission Tomography-CT (PET-CT) revealed Fluorodeoxyglucose uptake in the right paracolic peritoneum. Cardiac MRI ruled out cardiac involvement.
The patient received 8 cycles of bortezomib-cyclophosphamide-dexamethasone (VCD). Interval PET-CTs showed resolution and he remained well on maintenance bortezomib 16 months post-treatment initiation.
Conclusion: This case illustrates an unusual AL amyloidosis presentation, with a focal tumor-like jejunal stricture, causing SBO.

References

We plan to include endoscopic, radiological, and pathological visuals in the final poster. This includes:

1. Double-balloon enteroscopy (DBE) image showing a jejunal nodular lesion;
2. Congo red-stained histology demonstrating apple-green birefringence under polarized light;
3. Computed tomography (CT) showing proximal jejunal dilation and segmental mural thickening;
4. Initial and follow-up PET-CT scans showing fluorodeoxyglucose (FDG) uptake and treatment response;
5. Bone marrow aspirate results with flow cytometry and immunofixation confirming a lambda-restricted plasma cell population.

• Kwon JH et al. An Unusual Cause of Acute Intestinal Pseudo-Obstruction. Case Rep Gastroenterol. 2019;13(3):507–512. [PMC6873005]
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