Introduction

Surgery is the only curative treatment option for patients with intrahepatic and perihilar cholangiocarcinoma (CCA) without metastatic disease in lymph nodes (LNs) and beyond. Therefore, pre-operative staging is crucial for appropriate treatment decision-making [1]. Endoscopic ultrasound (EUS) is a promising technique to assess LN preoperatively to find proof of metastatic disease in addition to regular scans [2-5]. Although specific LN characteristics have been recognized as important predictive factors for metastatic disease in hepatobiliary disease in general, inter-observer agreement is suggested to be poor. This study aims to assess interobserver agreement among endosonographers evaluating LN characteristics specifically in intrahepatic cholangiocarcinoma (iCCA) and perihilar cholangiocarcinoma (pCCA).

Aims & Methods

A cross-sectional survey study involving 145 endosonographers from the Netherlands as well as the POELH-trial (NCT05678218) was conducted. Participants reviewed 42 randomly selected de-identified EUS images of LNs in a web-based survey. The primary outcome of this study was to assess the interobserver agreement of LN characteristics among endosonographers. In addition, it was evaluated how concordant endosonographers judged LNs to be malignant. Interobserver agreement was evaluated using Light’s kappa for the following LN characteristics: demarcation, shape, echogenicity, homogeneity, suspicion of malignancy and retrieving tissue. Subgroup analyses were performed for experts vs. non-experts (>1000 vs. <1000 EUS procedures), and experienced vs. non-experienced (15-30 years vs. 0-15 years). Diagnostic accuracy, sensitivity and specificity were determined based on a 2x2 table where presumed suspicious/not suspicious (based on EUS characteristics) was plotted against definite benign/malignant (EUS-fine needle aspiration/biopsy or surgical specimen pathology).

Results

Twenty-four endosonographers (16.6%) completed the survey. Participants showed fair to moderate agreement on EUS features with Light's kappa values of 0.24 for demarcation, 0.45 for shape, 0.38 for echogenicity, 0.52 for homogeneity, 0.36 for suspiciousness and 0.27 for performing FNA/B. Subgroup analyses suggest that experts and experienced endosonographers showed higher agreement on LN characteristics compared to non-experts and non-experienced endosonographers. The overall visual diagnostic accuracy for suspecting malignancy in LNs was 64%, ranging from 45 to 76%.

Conclusion

This study shows a fair to moderate inter-observer agreement of LN characteristics as well as a moderate rate of correct assessment of malignant LNs. among both expert and non-expert endosonographers. These findings support the justification to biopsy all LNs as carried out in the POELH trial (NCT05678218).

References

1. Schulick RD. Criteria of unresectability and the decision-making process. HPB (Oxford). 2008;10(2):122-125.
2. Gleeson FC, Rajan E, Levy MJ, et al. EUS-guided FNA of regional lymph nodes in patients with unresectable hilar cholangiocarcinoma. Gastrointest Endosc. 2008;67(3):438-443.
3. Malikowski T, Levy MJ, Gleeson FC, et al. Endoscopic Ultrasound/Fine Needle Aspiration Is Effective for Lymph Node Staging in Patients With Cholangiocarcinoma. Hepatology. 2019;10.1002/hep.31077.
4. de Jong DM, den Hoed CM, Willemssen FEJA, et al. Impact of EUS in liver transplantation workup for patients with unresectable perihilar cholangiocarcinoma. Gastrointestinal Endoscopy. 2024;99(4):548-556.
5. de Jong DM, van de Vondervoort S, Dwarkasing RS, et al. Endoscopic ultrasound in patients with resectable perihilar cholangiocarcinoma: impact on clinical decision-making. Endosc Int Open. 2023;11(2):E162-E168.

Disclosure

M.J. Bruno serves as a consultant and receives support for industry and investigator-initiated studies from Boston Scientific and Cook Medical and receives support for investigator-initiated studies from Pentax Medical, 3 M, Interscope, and Mylan. The other authors declare that they have no conflicts of interest.

Introduction

Splanchnic vein thrombosis (SVT) is a local complication of acute pancreatitis (AP) that may lead to subsequent complications such as portal hypertension, gastrointestinal bleeding, and mesenteric ischemia.^1,2 Despite its clinical significance, there is limited data in the literature concerning the temporal development and associated risk factors of SVT.

Aims & Methods

Our aim was to understand the time course and risk factors of SVT in the early phase of AP. To identify relevant studies we conducted a systematic search across four major medical databases (Embase, MEDLINE via PubMed, Scopus, and Cochrane Central Register of Controlled Trials) on 27th of October 2022. We included studies that employed appropriate imaging techniques in adult patients with AP, reported SVT data from the early phase of AP, and provided reliable information about the timing of imaging relative to AP symptom onset or hospital admission. We excluded studies that reported data on patients with a recent history of malignant disease or recent surgical procedures. We calculated the proportion of patients affected by SVT with 95% confidence intervals (CI). We conducted subgroup analyses based on diagnostic timing and disease characteristics. To assess the risk of bias we used the Joanna Briggs Institute Critical Appraisal Checklist for Prevalence Studies and the GRADEpro tool to determine the level of evidence. The protocol for this method was registered prospectively in the PROSPERO database, with registration number CRD42022367578.

Results

Data from 14 eligible studies and 1,951 patients was pooled; the proportion of patients with SVT in the early phase of AP (within 11 days after symptom onset or 5 days after hospital admission) was 0.13 (CI 0.07-0.23). The occurrence was lowest 0-3 days after symptom onset at 0.06 (CI 0.03-0.1), it increased to 0.23 (CI 0.16-0.31) between 3-11 days. Disease factors influencing SVT occurrence were severity (mild: 0.14 (CI 0.04-0.39), moderate: 0.23 (CI 0.09-0.47), severe: 0.31 (CI 0.15-0.54), p=0.21), etiology (alcoholic 0.31 (CI 0.13-0.58), biliary 0.12 (CI 0.04-0.3), p=0.03), and pancreatic necrosis (absent 0.10 (CI 0.04-0.25), under 30% 0.25 (CI 0.1-0.5), over 30% 0.55 (CI 0.29-0.78), p= 0.01).

Conclusion

One in eight patients develops SVT in the early phase of AP. Alcoholic etiology and pancreatic necrosis increase the risk of SVT. In addition, this risk seems to increase with the duration of AP; therefore, looking for and diagnosing SVT with imaging is important in the management of AP.

References

1. Nawacki L, Matykiewicz J, Stochmal E, Gluszek S. Splanchnic Vein Thrombosis in Acute Pancreatitis and Its Consequences. Clin Appl Thromb Hemost. 2021;27.
2. Valeriani E, Riva N, Di Nisio M, Ageno W. Splanchnic Vein Thrombosis: Current Perspectives. Vascular Health and Risk Management. 2019;15.

Introduction

Non-variceal upper gastrointestinal bleeding (NVUGI) represents a significant gastrointestinal disorder with elevated mortality rates (1). Non-steroidal anti-inflammatory drugs (NSAIDs) have been firmly established as a risk factor for NVUGI, yet their precise impact on clinical outcomes remains insufficiently defined (2,3). Conversely, proton pump inhibitors (PPIs) have shown efficacy in reducing the incidence of NVUGI associated with NSAIDs. However, the extent of their influence on the clinical outcomes of NVUGI remains inadequately substantiated. Therefore, it is necessary to study the impact of these drugs on the clinical outcomes of patients with NVUGI.

Aims & Methods

The primary objective of our study is to compare the outcomes of NVUGI patients using NSAIDs with or without PPIs against those who did not use either medication. We conducted a retrospective analysis at a Spanish tertiary hospital, encompassing NVUGI cases from 2013 to 2022. NVUGI was defined as hematemesis or melena accompanied by a two-point decrease in hemoglobin or hemodynamic instability. Key clinical outcomes included the necessity for intervention (endoscopic, radiological, or surgical) and in-hospital mortality. Additionally, we compared baseline characteristics and pertinent clinical results such as rebleeding and delayed cardiovascular events. Statistical analysis was performed using SPSS.

Results

​A total of 1200 cases were included, with 6.6% undergoing concomitant treatment with PPIs and NSAIDs, and 15.7% utilizing NSAIDs alone. Patients who took NSAIDs alone were younger (57 years vs. 66 in both other groups) and had a lower rate of comorbidities. Table 1 presents risk scores and outcome comparisons among the three groups. Statistical differences were observed, revealing lower acute mortality (9.6% vs. 7 vs. 2.8%, p=0.011) and reduced need for intervention (74% vs. 69.6 vs. 57.8%, p<0.001) in the group using NSAIDs alone. In multivariate analysis, MAP(ASH) > 2 (OR: 8, CI: 3-21, p<0.001) and ASA > 2 (OR: 4.4, CI: 1.7-11.4, p:0.002) emerged as independent risk factors for acute mortality, with an elevated MAP(ASH) score (OR: 8.8, CI: 5.9-13, p<0.001) being the sole independent factor explaining the need for intervention.

Conclusion

Patients abstaining from NSAIDs or those concurrently undergoing PPI therapy exhibited a higher incidence of intervention or acute mortality compared to those solely using NSAIDs. Through multivariate analysis, our study indicates that bleeding severity and baseline comorbidities, expressed by elevated MAP(ASH) scores and ASA classification, are pivotal factors influencing the clinical outcomes of NVUGI. In summary, the use of NSAIDs or PPIs to safeguard against gastrointestinal lesions induced by these drugs did not demonstrate a discernible impact on the short-term outcomes of patients with non-variceal upper gastrointestinal bleeding.

References

1. Lakatos L, Gonczi L, Lontai L, Izbeki F, Patai A, Racz I, et al. Incidence, predictive factors, clinical characteristics and outcome of non-variceal upper gastrointestinal bleeding – a prospective population-based study from hungary. Journal of Gastrointestinal and Liver Diseases. 2021 Sep 1;30(3):327–33.
2. Durak MB, Şimşek C, Yüksel İ. Clinical Outcomes of Older Patients with Non-Variceal Upper Gastrointestinal Bleeding Taking Anti-Thrombotic or Non-Steroidal Anti-Inflammatory Agents. Turkish Journal of Gastroenterology. 2023 Sep 1;34(9):918–24.
3. Åhsberg K, Höglund P, Kim WH, Von Holstein CS. Impact of aspirin, NSAIDs, warfarin, corticosteroids and SSRIs on the site and outcome of non-variceal upper and lower gastrointestinal bleeding. Scand J Gastroenterol. 2010 Dec;45(12):1404–15.

Introduction

Solid-pseudopapillary neoplasm (SPN) is a rare tumor of low malignancy that occurs predominantly in young females. Imaging of SPN is often described as a well-defined and heterogeneous tumor with calcifications or cysts, otherwise small size SPN often shows a homogeneously solid tumor. However, the differential diagnosis between SPN and other cystic tumors is often difficult due to the variety of imaging findings. In this report, we describe the clinical features and preoperative diagnosis of SPN we experienced at our hospital.

Aims & Methods

We studied 18 cases of SPN that were pathologically diagnosed by surgical resection at our hospital between 1997 and 2022.

Results

There were 12 female and 6 male patients, with a median age of 39.5 years (range: 9-67) and a median tumor size of 23 mm (range: 9-66). The tumor location was in the pancreatic head in 4 cases, body in 6 cases, and tail in 8 cases. The median follow-up period was 89.5 months (range: 8-265), and recurrence-free survival was achieved in all cases during the follow-up period. The tumors were incidentally detected in 15 cases during health check-ups (mainly by ultrasonography) or other medical examinations, while the other 3 cases were detected due to subjective symptoms that were thought to be caused by SPN. SPN could be diagnosed by contrast-enhanced CT in 10 of 18 cases (56%) and by EUS in 7 of 12 cases (58%). Contrast-enhanced CT showed enhancing mass in 10 cases, cystic component in 9 cases (50%), and calcification in 8 cases (44%). Among the 8 cases in which SPN could not be diagnosed by contrast-enhanced CT, EUS was performed in 7 cases, and we could diagnose SPN in 2 cases. Both cases had small lesions of less than 13 mm without cystic components, which made the differentiation from other tumors difficult on contrast-enhanced CT, however EUS showed well-circumscribed, well-defined, and homogeneously hypoechogenic tumors. MRI was performed in 12 cases, and could diagnose SPN in 5 cases, but MRI did not improve the diagnostic accuracy compared to contrast-enhanced CT. The diagnostic accuracy of EUS-guided fine needle aspiration (EUS-FNA) was 89% (8/9 cases). There were 5 cases in which SPN could not be diagnosed preoperatively. Among them, 3 cases had small tumor sizes (12-16 mm), and 4 cases lacked calcification, making it difficult to differentiate them from neuroendocrine tumors or solid-cystic neoplasms.

Conclusion

Most cases of SPN are detected incidentally, and regular abdominal ultrasonography during medical check-ups is important for early detection. Diagnosis can be more difficult in cases with small tumor diameter, and no cystic component or calcification. However adding EUS to contrast-enhanced CT imaging may improve accuracy. Furthermore, EUS-FNA contributes to preoperative diagnosis with a high diagnostic accuracy.

Introduction

Proton pump inhibitors (PPIs) are frequently used in daily clinical practice, but often without a valid indication. Strategies to identify inappropriate PPI use are widely available, although the true challenge is to discontinue PPIs in these patients without developing rebound symptoms. There is therefore a need for a tool to guide patients during this process.

Aims & Methods

We aimed to evaluate the effect of a smartphone app that provides an individualized educational approach as a tool to achieve sustained PPI discontinuation. This multicenter randomized controlled trial included adult patients on daily PPI for at least four weeks without chronic PPI indication from the outpatient clinics of Internal Medicine, Gastroenterology, Rheumatology and Nephrology in two community hospitals and one university hospital in the Netherlands. Patients were excluded in case they could not understand the study (procedures) or in case of a limited life span. Patients were randomly assigned to either the smartphone app providing timely information on PPI discontinuation (intervention group) or usual care which consisted of patients receiving a brochure explaining how to stop PPI and manage symptoms providing all information at once (control group). Primary endpoint was the discontinuation rate at 2-months follow-up, defined as self-declared intake of a maximum of one tablet in the previous 14 days. Patient recruitment has ended and we anticipate final results in August 2023. We now only present preliminary numerical data.

Results

Preliminary follow up results are based on 129 (2-months) and 99 (4-months) of 165 included patients (median age 55 y/o [IQR 46-64 y/o], 61 males [47%]). More patients succeeded to discontinue PPI use at 2-months follow-up in the intervention group: 54/62 (87%) vs. 44/67 (66%). This was also seen after 4-months follow-up: 44/55 (80%) patients in the intervention group vs. 41/61 (67%) patients in the control group.

Conclusion

A smartphone app intervention providing timely guidance in discontinuing inappropriate PPI use seems to be an effective tool to improve the discontinuation rate of inappropriate PPI use compared with a one-time information folder. These preliminary data suggest that patients are able to successfully discontinue inappropriate use of medication without the time-consuming support of a healthcare worker. (Clinical trial registration number: NCT05348252).