Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic procedure that is crucial for pancreato-biliary diseases and selective cannulation is the most important step. However, even an experienced endoscopist can face cannulation failure in up to 15-30% of cases in the first ERCP when standard methods alone are used.¹ Many studies suggested the various needle knife fistulotomy or papillotomy as an alternative technique in difficult cannulation cases.^2,3 However, needle knife papillotomy (NKP), which is modified technique with needle knife has not been evaluated well.

Aims & Methods

To evaluate the clinical outcomes and adverse events of bile duct cannulation by NKP, we performed a retrospective review on medical records of all ERCP cases in Sheikh Khalfia Specialty Hospital, UAE. For six years, Sphincterotomy (SPT) naïve patients except altered-anatomy cases were enrolled and their procedure times, cannulation success rates, radiation exposures, and adverse events were measured between the procedure time matched two cohort group of SPT only and rescue NKP.

Results

In total 416 ERCP cases, 43 procedure time matched cases were selected among 352 (84.7%) SPT only cohort and 43 cases from 64 rescue NKP cohort. Biliary cannulation was succeeded in all cases (100%) by using SPT cannulation with rescue NKP technique without failure. There was no differences in cumulative radiation doses, cannulation time, and adverse event rates in rescue NKP group compared to SPT only group: Post-ERCP hyperamylasemia/hyperlipasemia (16.5% vs. 34.8%, p=0.080), pancreatitis (3.9% vs. 4.3%, p=0.883), cholangitis (4.7% vs. 4.3%, p=0.695), and no perforation case was noticed in both groups.

Conclusion

The SPT with rescue NKP technique can be used in the difficult biliary cannulation cases during ERCP safely and effectively.

References

(1) Testoni PA , Testoni S , Giussani A .
Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis.
Dig Liver Dis 2011;43:596–603
[2] Testoni PA , Mariani A , Aabakken L , Arvanitakis M , Bories E , Costamagna G,et al.
Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
Endoscopy 2016;4 8:657–6 83 .
[3] Lopes L , Dinis-Ribeiro M , Rolanda C .
Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?
Gastrointest Endosc 2014;80:634–641 .

Introduction

In Crohn’s disease (CD) a symptomatic luminal stricture occurs in up to 20% of patients at the diagnosis and in more than 50% during lifetime (1,2). Endoscopic balloon dilatation (EBD) or surgical procedures are the currently available treatments (3,4). However, a considerable percentage of patients often require further surgery for post-operative CD recurrence (5). A consequent increased burden of short bowel syndrome is warranted. The combination of biological therapy with EBD could potentially reduce this risk.

Aims & Methods

The aim of our study was to evaluate the efficacy of EBD combined with biologic therapy in symptomatic gastrointestinal strictures in CD’s patients. We conducted a retrospective study including consecutive CD patients who underwent EBD for low bowel strictures from December 2015 until November 2022 at our tertiary IBD Center. Clinical strictures recurrence, needs for steroids and for surgery due to CD stenosis relapse were the primary outcomes evaluated during a follow-up period of six and twelve months. Chi-square and univariate statistical analyses were used when appropriate.

Results

A total of 52 patients treated with EBD with an overall number of 55 strictures were included. In the study population, 14 patients (27%) were smoker, the mean age was of 46,8 (18-77) years; the median of disease duration was 9 (0-42) years. Thirty-nine patients (75%) were in active treatment with biologic therapy at the moment of EBD. Twenty-three patients (44%) underwent EBD for anastomotic stricture, 8 (15%) for ileal stricture, 11 (21%) for ileocecal valve stricture, 5 (6%) for anal stricture and 4 (8%) for colic stricture. Three patients (6%) underwent EBD for multifocal bowel stenosis. Twenty-two (42%) patients had increased CRP value, 40 patients (77%) had evidence of moderate or severe endoscopic disease activity and 42 (81%) patients showed ulcerative lesions at stricture site. EBD was performed by 8-10, 12-15 or 15-18 mm dilation balloon. Technical success was reported in 60% of procedures and no adverse events were registered.
After 6 months from EBD, at univariate analysis, active smoke resulted a risk factor for clinical stricture recurrence (OR 10,25; IC 1,350 to 135,4; p value = 0,022) and for subsequent surgery (OR 10,25; IC 1,350 to 135,4; p value = 0,022). Moreover, increased CRP at the time of dilatation resulted a risk factor for need of steroids (OR 14,63; IC 2,69 to 71,50; p value = 0,0006). Concomitant biologic therapy and presence of ulcerative lesions did not show significative correlation with considered outcomes.
After 12 months from EBD, concomitant biologic therapy resulted a protective factor for prevention of surgery (OR 0,061; IC 0,005 to 0,502; p value = 0,0047), while anastomotic strictures were associated with a lower risk of sub-occlusion events than ileal stenosis (OR 0,07; IC 0,005 to 0,651; p value = 0,015). Increased CRP at the time of EBD, ulcerative lesions at the stricture site and active smoke were not significantly correlated with the considered outcome.

Conclusion

Our results suggest that in patients with CD undergoing EBD for bowel CD stricture, concomitant biological therapy reduces the risk of surgery for CD stenosis recurrence. Further prospective and controlled studies are underway to confirm these observations.

References

1. Rieder F Managing Intestinal Fibrosis in Patients With Inflammatory Bowel Disease. Gastroenterology & hepatology. 2018. February; 14(2):120–122
2. Yoo JH, Holubar S, Rieder F. Fibrostenotic strictures in Crohn’s disease. Intest Res. 2020;0.
3. Paine E, Shen B. Endoscopic therapy in inflammatory bowel diseases (with videos). Gastrointest Endosc 2013;78:819–35.
4. Hassan C, Zullo A, De Francesco V, Ierardi E, Giustini M, Pitidis A, Taggi F, Winn S, Morini S. Systematic review:
Endoscopic dilatation in Crohn's disease. Aliment Pharmacol Ther. 2007 Dec;26(11-12):1457-64
5. Olaison G, Smedh K, Sjödahl R. Natural course of Crohn’s disease after ileocolic resection: endoscopically visualised ileal ulcers preceding symptoms. Gut 1992;33:331–5.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) is an established endoscopic treatment for common bile duct stones and acute cholangitis. Due to its less invasiveness compared to surgery, it has been accepted as a first choice even for the elderly receiving anticoagulants. However, there is only a limited number of reports of the safety of EST after minimal cessation of anticoagulant based upon the Japan Gastroenterological Endoscopy Society (JGES)guideline.

Aims & Methods

To evaluate the safety, we aimed to clarify the bleeding risk in patients taking anticoagulants in our institute. Patients who underwent ERCP at double institutes from January 2018 to December 2021. Among them, we compared the rate of bleeding after EST and bleeding requiring blood transfusion in anticoagulant patients and non-administrators. Patients taking anticoagulants were allowed to discontinue the direct oral anticoagulant (DOAC) on the day before or the day of ERCP, and those who followed the JGES guideline for warfarin were included.

Results

ERCP was performed in 1616 patients and an analysis of a total of 882 patients of EST including 69 patients taking anticoagulants revealed that there were no significant differences in the bleeding rate although the blood transfusion rate was significantly higher in the DOAC group (2/52 3.9%) and antiplatelet drug combination cases (1/15 6.7%) compared to other cases (5/805 0.6%). Univariate and multivariate analyzes were performed according to background age, sex, hypertension, diabetes mellitus, heart disease, cerebrovascular disease, hemodialysis, platelet count decreased (less than 10x10⁴/μL), and urgency (within 24 hours after consultation). In the univariate analysis for EST bleeding, cerebrovascular disease, hemodialysis, and thrombocytopenia were significant risk factors(p<0.05). As a result of the multivariate analysis of these, only cerebrovascular disease was a significant risk factor (OR=2.11, 95%CI: 1.21-3.68, p=0.0086). In the univariate analysis for blood transfusion, DOAC users, cerebrovascular disease, and hemodialysis patients were significant risk factors(p<0.05). A multivariate analysis that added EST bleeding to these results also found significant risk factors for similar items. DOAC(OR=6.89, 95%CI: 1.06-44.65, p=0.043) and cerebrovascular disease(OR=18.85, 95%CI: 3.01-117.93, p=0.0017), hemodialysis(OR=55.68, 95%CI: 6.51-475.99, p=0.00024) were significant risk factors for severe bleeding requiring blood transfusion.

Conclusion

Although there were no significant differences between the bleeding rates of EST for those taking anticoagulants and those not taking anticoagulants, it was suggested that there is a possibility of serious bleeding requiring blood transfusion in patients receiving anticoagulants, especially DOAC.

Disclosure

none

Clinical Case Summary

Whipple’s disease (WD), caused by Tropheryma whipplei, is a rare, multisystemic infection with a wide spectrum of clinical presentations. It may manifest acutely with nonspecific symptoms such as diarrhea, abdominal pain, fever, and fatigue, or present chronically. Diagnosis can be challenging due to its diverse manifestations, including cardiac, pulmonary, and neurological involvement. We describe a case of a 54-year-old male with a background of peroneal nerve dysfunction, admitted for progressive epigastric pain, nausea, vomiting, altered bowel habits, and recent mood changes. A comprehensive diagnostic evaluation was undertaken, including blood tests, abdominal ultrasound, computed tomography, and upper gastrointestinal endoscopy with biopsy. Diagnostic investigations revealed elevated cholestatic and pancreatic enzymes, raised CRP and ferritin levels, esophagitis, and distal duodenal swelling obstructing endoscope passage with inflammation around the ampulla of Vater. There were features of chronic pancreatitis with calcifications, pseudocysts (up to 27 mm), dilated Wirsung’s duct, and enlarged crescent lymph nodes. Histopathology showed extensive macrophage infiltration, and PAS staining was suggestive of T. whipplei infection. The patient was successfully treated with Ceftriaxone 2g orally daily for 30 days, followed by Trimethoprim/Sulfamethoxazole 960mg twice daily for one year. This case highlights an atypical presentation of WD, manifesting as upper gastrointestinal obstruction and recurrent acute pancreatitis, probably due to duodenal and ampullary inflammation impairing bile flow. It underscores the importance of considering WD in the differential diagnosis of complex and unexplained gastrointestinal symptoms. Presentations involving upper gastrointestinal obstruction and pancreatitis are rare. Early identification through intestinal biopsy and appropriate antimicrobial therapy is critical to avoid irreversible complications and improve outcomes.

References

Illustrative material:
1. Upper gastrointestinal endoscopy: view of the descending duodenum
2. Abdominal CT scan
3. Pathological findings: PAS staining

Clinical Case Summary

For decompensated advanced chronic liver disease (dACLD) individuals, the onset of refractory ascites (RA) represents a dramatic event (6-month survival rate < 50%). In this setting, a relevant proportion of RA patients develop Hepatorenal Syndrome-Acute Kidney Injury (HRS-AKI) with limited therapeutic and survival chances.
An 81-year-old female dACLD RA patient was admitted to our department to receive large-volume paracentesis (LVP). Eradicated HCV infection, type II diabetes, and chronic obstructive pulmonary disease were her comorbidities.
The AKI onset imposed the intravenous (i.v.) human albumin (HA) (1 g/kg/die) administration, followed by the proper dosage of terlipressin (for HRS-AKI) within the first 72 hours (h), subsequently discontinued due to the persistence of anuria and the worsening of respiratory failure.
To simultaneously address uremic symptoms and facilitate ascites drainage, a Tenckhoff catheter was placed, and peritoneal dialysis (PD) started with a single icodextrin dwell, resulting in the removal of 14 L of ascites and an improvement in AKI within the subsequent 72h. After one week, she was discharged, receiving a specific PD schedule. After the readmission due to the difficulties in administering i.v. HA, we proposed administering HA via the intraperitoneal route, creating an HA-enriched PD (PD+HA) home-performable schedule by adding two vials of 100 ml of HA 20% to 800 ml of icodextrin solution (40 g in 1000 ml/die; lasting: 12 hours; frequency: every other day) (Figure 1).
The patient has been performing this PD schedule for 12 months (~0.5 L of ascites is discharged every other day before performing PD+HA dwell). During the follow-up, no PD-related complications (e.g., peritonitis) and liver-related events requiring hospitalization have been observed.
We report the first successful use of PD+HA, highlighting the cruciality of a multidisciplinary (hepatologists-nephrologists) approach in the management of dACLD-RA HRS-AKI patients.

References

1. Moreau, R.; Delègue, P.; Pessione, F.; Hillaire, S.; Durand, F.; Lebrec, D.; Valla, D.-C. Clinical Characteristics and Outcome of Patients with Cirrhosis and Refractory Ascites. Liver Int 2004, 24, 457–464, doi:10.1111/j.1478-3231.2004.0991.x.
2. Moore, K.P.; Wong, F.; Gines, P.; Bernardi, M.; Ochs, A.; Salerno, F.; Angeli, P.; Porayko, M.; Moreau, R.; Garcia-Tsao, G.; et al. The Management of Ascites in Cirrhosis: Report on the Consensus Conference of the International Ascites Club. Hepatology 2003, 38, 258–266, doi:10.1053/jhep.2003.50315.
3. Nadim, M.K.; Kellum, J.A.; Forni, L.; Francoz, C.; Asrani, S.K.; Ostermann, M.; Allegretti, A.S.; Neyra, J.A.; Olson, J.C.; Piano, S.; et al. Acute Kidney Injury in Patients with Cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) Joint Multidisciplinary Consensus Meeting. J Hepatol 2024, 81, 163–183, doi:10.1016/j.jhep.2024.03.031
4. Brown, E.A.; Blake, P.G.; Boudville, N.; Davies, S.; de Arteaga, J.; Dong, J.; Finkelstein, F.; Foo, M.; Hurst, H.; Johnson, D.W.; et al. International Society for Peritoneal Dialysis Practice Recommendations: Prescribing High-Quality Goal-Directed Peritoneal Dialysis. Perit Dial Int 2020, 40, 244–253, doi:10.1177/0896860819895364.