Introduction

Esophagogastroduodenoscopy (EGD) is an important diagnostic tool in evaluation of gastrointestinal diseases. Most often the mucosal visibility (MV) is hampered with mucous and air bubbles obscuring the vision and hampering the diagnosis. Simethicone is a proposed defoaming agent. Our aim was to evaluate different defoaming agents, like simethicone alone and in combination with N- Acetyl cysteine (NAC) compared with placebo (Water) to improve total mucosal visibility score.

Aims & Methods

This is a prospective, double-blind, randomized placebo-controlled trial conducted at a tertiary center. The patients were randomized in four groups [A: water alone (W); B: simethicone alone (WPS); C: NAC alone (WPN); and D: simethicone plus NAC (WPSN)]. The solutions were administered 10-30 min before EGD and multiple images were systematically acquired from the stomach (fundus, antrum, proximal and distal body) and duodenum (D1, D2). The images were graded from 1 to 4 (1 being best and 4 worst score) based on endoscopic mucosal visibility score (MVS). The overall MVS ranged from 6 (best) to 24 (worst).

Results

A total of 800 patients (mean age 40.6 years, 68.8% males) were randomized into four groups. Overall, the MVS was lowest in group D (WPSN, 7.58±1.71), followed by group B (WPS, 8.05±2.11), group C (WPN, 10.51±3.14) and group A (W, 11.14±3.49). Overall, MVS was significantly better in group D (WPSN) versus group B (WPS). Overall MV in group C (WPN) was not superior to placebo (group A, W) (p=0.057). In the early (10-20 min) and late endoscopy group (20-30 min), the results remained unchanged. However, MVS were similar between group B (WPS) and group D (WPSN) in the early endoscopy group (8.47±2.45 vs 8.11±2.06, p=0.358). On sub-group analysis according to the timing of endoscopy (10-20 min vs 20-30 min), MVS were significantly better at 20-30 min in group D (WPSN, 7.32±1.46 vs 8.11±2.06, p=0.002) and group B (WPS, 8.47±2.45 vs 7.83±1.89, p=0.043) as compared to 10-20 min sub-group. There was no impact of timing of endoscopy on MVS in other pre-medication groups (W and WPN). There were no adverse events among any of the subgroups.

Table: Sub-group analysis of mucosal visibility scores according to the timing of endoscopy after pre-medication

Conclusion

Pre-medication with combination of simethicone and NAC significantly improves MV when compared to placebo and individual medications alone. The best MV is obtained at 20-30 minutes as compared to 10-20 minutes after pre-medication. If early endoscopy (10-20 min) is contemplated, either simethicone or combination of simethicone and NAC may be used as pre-medication as they provide equivalent MV. NAC alone should be avoided as pre-medication as it has no significant benefit over placebo.

Introduction

It is known that Dual Anti-Platelet Therapy (DAPT) is a risk of gastrointestinal bleeding. Recently, it has been reported that concomitant use of proton pump inhibitor (PPI) can reduce the gastrointestinal bleeding risk ⁽¹⁾. However, it is still unclear how DAPT affects the gastric mucosa. Actually, few reports have examined the relationship between DAPT and gastric mucosal injury ⁽²⁾.

Aims & Methods

The aim of this study is to reveal the difference of gastric mucosal injury between clopidogrel user and prasugrel user in patient receiving DAPT. This is a case-controlled study conducted at our department. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2015 and March 2022. We focused on the subjects taking both low-dose aspirin and P2Y12 receptor antagonist (DAPT). We compared the severity of gastric mucosal injury, between cases using clopidogrel (group C) and prasugrel (group P) individually according to the P2Y12 receptor antagonist used. Severity of gastric mucosal injury was evaluated endoscopically according to the modified LANZA score (MLS) ^{(3, 4)}. Statistical analyses were performed by using Mann–Whitney U test. We evaluated separately for cases with concomitant use of potassium-competitive acid blocker (P-CAB) or PPI (user) and cases without concomitant use of P-CAB, PPI nor histamine H2 receptor antagonist (H2RA) (nonuser).

Results

82 cases out of 6,863 were receiving DAPT. In group C (45 men, 8 women; mean age 72.1 years), average MLS was 0.94±1.66 (user: n=33, score0=22, score1=4, score2=1, score3=2, score4=1, score5=3) and 1.82±1.88 (nonuser: n=17, score0=8, score1=0, score2=1, score3=4, score4=3, score5=1). In group P (21 men, 8 women; mean age 74.3 years), average MLS was 0.23±1.07 (user: n=22, score0=21, score1=0, score2=0, score3=0, score4=0, score5=1) and 0 (nonuser: n=6, score0=6, score1=0, score2=0, score3=0, score4=0, score5=0). There was a statistically significantly difference between group C and group P for both user(p=0.016) and nonuser(p=0.031). These results suggested that regardless of the concomitant use of antacids, prasugrel users had significantly less gastric mucosal injury than clopidogrel users in DAPT.

Conclusion

We found that prasugrel is more user-friendly agent than clopidogrel in terms of gastric mucosal injury in DAPT.

References

(1) Luo X, et al. Efficacy and safety of concomitant use of proton pump inhibitors with aspirin-clopidogrel dual antiplatelet therapy in coronary heart disease: A systematic review and meta-analysis. Front Pharmacol. 13:1021584. 2023
(2) Shimada Y, et al. Comparison of degree of gastric mucosal injury between patients who are receiving dual antiplatelet therapy or single antiplatelet therapy. Diagnostics. 29: 2364. 2022
(3) Lanza FL, et al. Endoscopic comparison of cimetidine and sucralfate for prevention of naproxen-induced acute gastroduodenal injury. Effect of scoring method. Dig Dis Sci. 35: 1494–1499. 1990
(4) Naito Y, et al. Prevention of indomethacin-induced gastric mucosal injury in Helicobacter pylori-negative healthy volunteers: a comparison study rebamipide vs famotidine. J Clin Biochem Nutr. 43: 34–40. 2008

Introduction

Combined Biliary (BO) and Gastric Outlet Obstruction (GOO) represent a challenging clinical scenario. Previous retrospective experiences have demonstrated shorter Dysfunction-Free survival (DFS) of EUS-guided Choledochoduodenostomy (EUS-CDS) versus EUS-Hepaticogastrostomy (EUS-HGS) in this scenario, but no prospective evidence is available.

Aims & Methods

All consecutive patients treated for double obstruction between 2021-2023 were eligible for inclusion upon receiving EUS-guided Gastroenterostomy (EUS-GE) for GOO and either EUS-CDS or EUS-HGS for BO according to endoscopist preference. DFS prospective surveillance started from the day the 2 procedures coexisted. Efficacy and safety were evaluated, with biliary dysfunctions as primary outcome and DFS using Kaplan-Meier estimates (with log-rank test) as primary measure.

Results

Twenty patients (75% with pancreatic cancer, 50% with metastatic disease) with EUS-GE were included (7 EUS-CDS and 13 EUS-HGS). No significant difference was detected at baseline. Technical success was 100% in both groups. EUS-CDS versus EUS-HGS showed similar clinical success (100% vs. 92.3%, p= 0.5), a higher rate of post-procedural adverse events (42.9% vs. 7.7%, p= 0.067, mostly related to severe/fatal cholangitis in the EUS-CDS group) and a higher rate of biliary dysfunctions during follow-up (57.1% vs. 16.7%, p= 0.074).
DFS was significantly shorter in the EUS-CDS group (39 [12-66] vs. 267 [192-344] days, p=0.0043), with a 30-days probability of DFS of 53.6% vs. 100%, HR = 7.4 [1.1-52.3].

Conclusion

In this prospective comparison of patients with malignant double obstruction undergoing EUS-GE, treating jaundice with EUS-CDS versus EUS-HGS resulted in reduced probability of survival without biliary events, with detection of severe/fatal cholangitis.

Disclosure

GV reports travel grants from Pentax Medical, Boston Scientific and Euromedical, and lecture fees by Boston Scientific.
All the other authors ​declare no conflict of interest.

Introduction

Suspected foreign body ingestion and food bolus impaction are common indications for urgent esophagogastroduodenoscopy. Nevertheless, most of the ingested foreign bodies (80 to 90%) pass spontaneously throughout the gastrointestinal tract. In 2022, the Decision-To-Scope (DTS) Score was developed, revealing an excellent accuracy in predicting foreign bodies in the esophagus.

Aims & Methods

Our aim was to prospectively evaluate the diagnostic accuracy of the DTS-Score.
We have prospectively included consecutive patients admitted for suspected foreign body in the upper gastrointestinal tract, for a 6-month period. Previously to endoscopic evaluation, the DTS-score - time since ingestion < 6 hours (+1pt); absence of any meal since the suspected ingestion (+2pts); dysphagia (+3pts); odynophagia (+1pt) and drooling (+4pts) - was applied in each patient. The maximal possible value was 11 points, with a DTS-Score ≥5 being considered to assign a high probability of endoscopic confirmation of the foreign body.

Results

Final sample included 47 patients, from which 26 (55.3%) were females, with a mean age of 60±16 years. From these, most (n=42; 91.5%) were evaluated for accidental ingestion of food-related foreign bodies (fish or chicken bones) or suspected food bolus impaction. A DTS-Score ≥5 was calculated in 11 (23.4%) of the patients, with an esophageal foreign body being confirmed in 12 (25.5%) of them. DTS-score presented an excellent accuracy in predicting the endoscopic confirmation of a foreign body in the esophagus (AUC=0.94; 95%CI 0.85-1.00; p<0.001). The originally defined cut-off (DTS-Score ≥5) presented a specificity of 97.1%, a sensitivity of 83.3%, a positive predictive value of 90.9% and a negative predictive value of 94.4%.

Conclusion

When prospectively applied, the DTS-score demonstrated an excellent acuity in stratifying the probability of endoscopic confirmation of a suspected foreign body in the esophagus. This tool may be included in future clinical algorithms for suspected foreign bodies ingestion.