Introduction

Biliary pain is a common cause of morbidity both before and after cholecystectomy. Endoscopic ultrasonography (EUS) is sensitive for the diagnosis of biliary pathology and can identify disease that is occult on other imaging modalities. The aim of this study is to determine the diagnostic yield of EUS when performed for biliary pain.

Aims & Methods

This was a retrospective service evaluation of EUS referrals to a regional referral centre in the UK. All local patients who were referred for EUS for suspected biliary pain between January 2015 to December 2019 were included. Demographics, symptoms, liver function tests (LFTs), non-invasive imaging, EUS reports and clinical outcomes were reviewed. Biliary dilatation was defined as greater than 7mm pre-cholecystectomy and greater than 10 mm post-cholecystectomy. A EUS was considered as diagnostic for a cause of biliary pain if findings were identified which explained symptoms. Symptom resolution was defined as no further investigation, review or imaging performed for biliary symptoms in secondary care during the follow-up period. Statistical significance for proportions was calculated using chi-squared tests.

Results

565 patients were included in the study. The median age of the cohort was 55 (range 17-89) years. 161 (28%) patients were male. 241 (43%) patients had previously had a cholecystectomy. The study participants had been extensively investigated with previous imaging which was non-diagnostic; in total the patients had 500 trans-abdominal ultrasound scans, 316 CT scans, 315 MRCPs and 77 previous EUS.
334 (59%) EUS were considered diagnostic. Patients who had previously had a cholecystectomy were less likely to have a diagnostic EUS compared to those who had a gallbladder ((99/241 (41%) vs 235/324 (73%); p<0.01). The diagnostic yield of EUS was higher in patients with abnormal LFTs or a dilated biliary tree and in those with both abnormal LFTs and biliary tree dilatation (table 1).

Positive findings included gallstones (n=92), gallbladder microlithiasis/sludge (n=181), bile duct stones (n=85), bile duct microlithiasis/sludge (n=108), chronic pancreatitis (n=21) and mass lesions (n=4) which were later diagnosed as metastatic renal cell cancer, pancreatic cancer and two ampullary adenomas.
311 patients had a diagnostic EUS with a biliary aetiology for their pain which was amenable to treatment. Symptom resolution occurred in 85/136 (63%) who had ERCP, 21/24 (83%) who had both cholecystectomy and ERCP, 63/94 (67%) who had a cholecystectomy and in 19/57 (33%) who were managed conservatively. Patients with a diagnostic EUS were more likely to have resolution of their symptoms compared to those with no cause identified ((207/334 (62%) vs 81/231 (35%); p<0.05). Median duration of follow-up was 54 months (range 32-81 months).

Conclusion

In our cohort of patients with biliary pain who have been previously investigated, EUS is associated with a high diagnostic yield across all groups, although this yield increases in patients with abnormal LFTs, a dilated biliary tree, or both. A diagnostic EUS leads to biliary intervention in a high proportion of patients, and patients who have EUS-guided intervention appear have a greater chance of becoming symptom free than those without a diagnostic EUS. This supports investigation of patients with suspected biliary pain with EUS, regardless of whether their liver blood tests are abnormal or their bile ducts are dilated.

Clinical Case Summary

Introduction: Rituximab, a monoclonal anti-CD20 antibody, is widely used for treating hematologic malignancies and autoimmune disorders due to its B-cell depleting action. While gastrointestinal side effects like diarrhea are seen in up to 15% of patients, these are typically mild and self-limiting. Severe colitis is a rare but increasingly recognized complication.
Case Description: A 76-year-old diabetic male with a history of ACS (post-PTCA in 2021) presented with 2 months history of generalized abdominal pain, watery diarrhea (6–7 episodes/day), and weight loss. He had a history of follicular lymphoma diagnosed 4 years prior, treated with 6 cycles of CHOP-R followed by rituximab maintenance (375 mg/m² every 3 months). Symptoms began after the 6th maintenance dose.Physical exam revealed mild pallor;abdomen was soft, nontender. Labs showed normocytic anemia and mild neutrophilic leukocytosis. Stool tests were negative for common pathogens, including C. difficile. The patient was planned for a Colonoscopy, which revealed ulcers over the ileocecal valve and rectal erosions. Biopsies showed mixed inflammatory infiltrates, cryptitis, crypt abscesses, and crypt rupture, consistent with severe active ileocolitis. AFB culture and GeneXpert were negative for tuberculosis.The patient was started on oral mesalamine (500 mg TID) along with Rifaximin(400mg) BD for 2 weeks, showing marked clinical improvement.
Discussion: Rituximab-induced colitis is rare and poorly understood. It may result from disruption of mucosal immunoregulation due to B-cell depletion, leading to T-cell-mediated inflammation. Histology may resemble patterns seen in GVHD or autoimmune enteropathy. Most cases resolve with supportive care and discontinuation of the drug; however, some, like this case, may require treatment in the form of 5ASA, or steroids.There is no previous data on the use of rifaximin in such cases. Differentiating drug-induced IBD from primary IBD remains a diagnostic challenge.

References

There is limited evidence in the literature establishing a definitive association between rituximab therapy and the onset of colitis. However, emerging hypotheses suggest that rituximab-induced depletion of peripheral CD19+ B cells and colonic CD20+ lymphoid aggregates may disrupt mucosal immune homeostasis, thereby contributing to structural alterations in the intestinal architecture and promoting inflammation.
The role of the gut microbiota in the pathogenesis and persistence of mucosal inflammation in inflammatory bowel disease (IBD) provides a rationale for the therapeutic use of antibiotics in selected cases. While systemic antibiotics such as ciprofloxacin and metronidazole have demonstrated clinical efficacy in IBD management, their utility may be limited in drug-induced colitis due to the potential for systemic adverse effects.
In contrast, rifaximin, a non-systemic, presents a favorable safety profile and has shown promise as a therapeutic option in both idiopathic and drug-induced enterocolitis. Its targeted antimicrobial activity within the gastrointestinal tract, combined with minimal systemic exposure, renders it an attractive alternative. However, further prospective, randomized studies are warranted to substantiate its efficacy and long-term safety in this context.

Introduction

Acute upper gastrointestinal (UGI) bleeding is a common medical emergency among the elderly. There is limited data on the management and outcomes of non-variceal UGI bleeding in the elderly in India.

Aims & Methods

We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute non-variceal UGI bleeding. All elderly patients (≥ 60 years of age) who presented with acute UGI bleed and were admitted for the same from 2021 to 2022 were retrospectively analysed. Baseline characteristics, blood transfusions before and after endoscopy, endoscopic diagnosis and therapy, AIMS65 score, complete Rockall score, and outcomes such as in-hospital re-bleeding and mortality were recorded.

Results

Of the 399 patients who had acute non-variceal UGI bleed, 309 patients aged <60 years were excluded. Of the 90 patients studied, the mean age of presentation was 69.8 ± 7.35 years, with 81.1% males. The most common presentation was melena (30%). Forty-one (45.5%) patients had a history of antiplatelet and anticoagulant use. The most common endoscopic finding was gastric ulcer (54.4%), followed by duodenal ulcer (22.2%), gastroesophageal junction ulcer (7.7%), Mallory-Weiss tear (6.6%), duodenal diverticular bleed (2.2%). The majority of ulcers were Forrest III (43.3%), followed by Forrest IIa (23.3%) and IIc (18.3%). Around 65% of patients with non-variceal UGI bleeds did not require endotherapy. Dual endotherapy was done in 25.5.5% of patients. Triple endotherapy was done in two patients. AIMS65 score was 1 in 50% of patients and 2 in 24.5% of patients. The majority (81.1%) of patients had a complete Rockall score of 3-7, indicating a moderate risk of re-bleeding and mortality. All the 90 patients were discharged without any mortality.

Conclusion

Our study showed that gastric ulcer was the most common cause of acute non-variceal UGI bleeding in the elderly, and melena was the most common presentation. Early endoscopic therapy may reduce blood transfusion requirements, in-hospital re-bleeding, and mortality.

Introduction

Aspiration Pneumonia is a well described complication of upper digestive endoscopy. However, limited data are available on incidence, risk factors and clinical consequences of post- Endoscopic retrograde cholangiopancreatography (ERCP) aspiration pneumonia (pEP).

Aims & Methods

All consecutive ERCPs performed under anesthesiologist-administered sedation at the Endoscopy Unit of the University of Verona between April 1st 2022 and August 31st 2024 were retrospectively evaluated. Demographical, clinical and endoscopic data were collected.

Results

One-thousand-one-hundred-forty consecutive ERCPs were included. Main indication was malignant biliary stricture and patient’s mean age was 68±13.9 years. Overall incidence of pEP was 2.7%. American Society of Anesthesiologists (ASA) score, presence of active cholangitis before ERCP and performance of endoscopic ultrasound (EUS) and ERCP in the same sedation session were significantly associated to higher risk of pEP at both univariable and multivariable analysis. pEP was an independent risk factor for post-ERCP 30-days-mortality and for prolonged hospital stay.

Conclusion

pEP is a relatively frequent adverse event after ERCP. In patent with high ASA score, active cholangitis and scheduled EUS and ERCP in the same sedation session, preventive medical and/or anesthesiological strategies might be considered. Additional prospective studies are needed to confirm these data.

References

Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Complications of ERCP: a prospective study.
ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.
Unrecognised aspiration pneumonitis during enteroscopy: two case report.
Efficecay and safety of therapeutic endoscopic retrograde cholangiopancreatography in patients with native papillae with a performance status score of 3 or 4: a single-center retrospective study.
A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administred sedation.
Increased ERCP-related adverse event from premature urgent ERCP following symptom onset in acute biliary pancreatitis with cholangitis.
Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.
Deep sedation without intubation for ERCP is appropriate in healthier, non-obese patients.
Comparative efficacy and safety of anesthetic and sedative regimens for endoscopic retrograde cholangiopancreatography: a network meta-analysis.
International consensus recommendations for difficult biliary access.
Intraprocedural quality in endosocpic retrograde cholangiopancreatography: e meta-analysis.
Criteria for difficult biliary cannulation: start to count.
Safety and efficacy of therapeutic endoscopic retrograde cholangiopancreatography for patients over 90 years of age.
Risk factors for post-endoscopic retrograde cholangiopancreatography complications in very elderly patients aged 90 years or older-no additional risk.

Disclosure

I have no conflict of interest

Introduction

Acute pancreatitis (AP) is one of the most common gastroenterological diseases requiring admission to the hospital. The main etiological factors of AP are gallstones and excessive alcohol consumption, but rarer causes, such as hypercalcemia, should keep on mind. Only few cases are reported in the literature, and the severity of hypercalcaemia-induced acute pancreatitis is not known.

Aims & Methods

We aim to assess the occurrence and severity of hypercalcaemia-induced AP and compare it with the clinical characteristics of AP caused by other etiological factors. We collected patients from the Hungarian Acute Pancreatitis Registry, Hungarian GOULASH study and the Europe-wide EASY study, who had AP and had a serum calcium level above 2.6 mmol/l. Patients were divided into three groups: hypercalcemia-induced AP, where no other etiology than hypercalcemia were present, mixed etiology group, where both hypercalcemia and other etiologies were revealed and the control group with normal serum calcium level. Propensity score matching adjusted by age, sex, diabetes, lipid disorder, previous pancreatic disease was made and several outcome parameters were analyzed during the statistical analysis. Hypercalcemic cases were divided into 3 subgroups based on the level of serum calcium: mild (2.6< >3.0 mmol/l), moderate (3.0 < >3.5 mmol/l) or severe hypercalcemia (>3.5 mmol/l).

Results

1.02% of our AP patients (19/1867) had clear hypercalcemic etiology and 3.75 % (70/1867) of the patients had mixed etiology, 1778 patients were in the control group. There was no difference in the mean ages of the patients in the three groups (57.3± 16.3 and 56.1 ± 20.1 vs. 55.1 ± 14.6 years). Severe AP was significantly more frequent in patients with hypercalcemia-induced AP compared to the control group [21.05% (4/19) vs 6.13% (109/1778); odds ratio: 4.08 (95% CI, 1.08-15.38)]. Renal failure was more frequent in hypercalcemic etiology compared to AP patients with normal serum calcium level [27.27% (3/11) vs 5.35% (95/1776); odds ratio: 6.63, (95% CI, 1.36-32.35)]. There was no significant difference in CRP, amylase, lipase, WBC, creatinine, length of hospital stay, mortality, intensive care admission, the presence of pancreatic necrosis, pseudocysts, and other organ failure between the hypercalcemic or mixed etiology and the control groups. There was no significant difference in the severity of AP between the mixed etiology and normal serum calcium groups. The outcome of acute pancreatitis was not influenced by the severity of hypercalcemia within the hypercalcemic group.

Conclusion

Hypercalcemia-induced AP has a higher risk for developing into severe AP and renal failure compared to other etiology.