Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most demanding and high-risk endoscopic procedures.
Failures and complications are more common than we realise, they lead to low satisfaction for the patient, high frustration for the endoscopist, higher risks of more instrumentalization in further re-attempts.

Keeping a meticulous updated data logging is fundamental to understand how we perform, what specific factors predict our failures, and identifying areas of improvement, mistakes or learning opportunities.

Aims & Methods

This prospective cohort study was conducted over a 3-year period (September 2020 to January 2024) at a tertiary care centre.
We defined all the adverse events as per ESGE guidelines¹ The 30- mortality was analysed and stratified based on relation to ERCP.
We also identified patients’ factors (Age, sex, frailty, NEWS>4, anticoagulation, antiplatelets, palliative) and technique (First pass cannulation, double wire, precut sphincterotomy, sphincteroplasty). Descriptive statistics, chi-square or t-tests were used to evaluate associations between clinical characteristics and outcomes.

Results

A total of 438 patients underwent ERCP by the single operator during the study period. Procedural success was achieved in 389 cases (88.9%) and in 100% of cases of non-native ampulla. Success rates were lower in malignant cases (80.6%) compared to benign cases (90.05%) with an odds ratio (OR) of 2.21 (CI 1.05–4.63, p = 0.03).
Complications included: Post-ERCP pancreatitis: 12/438 (2.74%) Infections: 4/438 (0.91%) (3 cholangitis, 1 cholecystitis) Perforation: 3/438 (0.68%) and Bleeding: 2/438 (0.45%)
Mortality within 1 month was 17/438 (3.88%) mostly unrelated to the procedure in palliative and frail patients. Procedure-related mortality occurred in 4 cases (0.91%),due to pancreatitis (n=2),perforation (n=1) and sepsis secondary to cholecystitis (n=1).
Of all conscious sedation, only 204 /423 (48.2%) were deemed comfortable. 174/423 (41.1%) had mild discomfort, 32/423 (7.5%) had significant discomfort and 13/423 ( 3.07%) severe or very poor. Female patients demonstrated higher risk of poor tolerance (OR 2.09, CI 1.05–4.18 p = 0.04) but no higher procedural failure.
In difficult cannulation, double-wire succeeded in 19/36(52.8%). When combined with additional techniques after initial failure, success increased to 77.8%. Pre-cut sphincterotomy succeeded only in 13/25( 52%) lower than data published (>75%), thought to be due to learning curve and limited patient tolerance. However, pre-cut helped cannulation in most follow-up ERCPs .
Double wire associated risk of post-ERCP pancreatitis -but exclusively when prophylactic pancreatic duct stent was not placed-OR 3.96 (CI 1.02-15.3) p=0.04. None other AEs were significantly associated with any advanced cannulation techniques.

Conclusion

Overall failure rates and AEs were consistent with published literature. Statistically significant risks of failure included malignant aetiology (OR 2.21) and poor tolerance (OR 2.20). Female sex associated higher intolerance (OR 2.09). Both double-wire and pre-cut sphincterotomy showed failure rates of approximately 50%. Frailty was a significant predictor of 30-day mortality (OR 4.83).

References

1. Dumonceau JM, Kapral C, Aabakken L, Papanikolaou IS, Tringali A, Vanbiervliet G, Beyna T, Dinis-Ribeiro M, Hritz I, Mariani A, Paspatis G, Radaelli F, Lakhtakia S, Veitch AM, van Hooft JE. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2020 Feb;52(2):127-149.
2. Banks PA, BollenTL, Dervenis C et al. Classification of acute pancreatitis– 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102–111
3. Enochsson L., Swahn F., Arnelo U., Nilsson M., Löhr M., Persson G. Nationwide, population-based data from 11,074 ERCP procedures from the Swedish Registry for Gallstone Surgery and ERCP. Gastrointest. Endosc. 2010;72:1175–1184.
4. Spadaccini M, Binda C, Fugazza A, Repici A, Tarantino I, Fabbri C, Cugia L, Anderloni A, On Behalf Of The Interventional Endoscopy Amp Ultra Sound I-Eus Group. Informed Consent for Endoscopic Biliary Drainage: Time for a New Paradigm. Medicina (Kaunas). 2022 Feb 22;58(3):331.
5.Chen J, Wan JH, Wu DY, Shu WQ, Xia L, Lu NH. Assessing Quality of Precut Sphincterotomy in Patients With Difficult Biliary Access: An Updated Meta-analysis of Randomized Controlled Trials. J Clin Gastroenterol. 2018 Aug;52(7):573-578

Introduction

The optimal bowel preparation for small bowel capsule endoscopy (SBCE) has not been standardized.

Aims & Methods

Compare the rate of complete examinations, quality of bowel preparation, diagnostic yield and tolerability, using three protocols for intestinal preparation for SBCE.
A prospective, multicentre, randomized clinical trial including consecutive patients submitted to SBCE was conducted. All patients were instructed to comply with a clear liquid diet and 12-hour fasting before the exam. After ingesting water and 100 mg of simethicone and swallowing the capsule, once it reached the small bowel, patients ingested a booster, randomized into one of three protocols: 1) 1 liter of polyethylene glycol (PEG), 2) 1 liter of PEG and ascorbic acid, 3) 1 liter of water. The patients’ bowel preparation was evaluated with SB-CLEAR. Each patient responded to a questionnaire about their tolerability.

Results

A total of 261 patients were included, 96 patients (36.8%) in protocol 1, 93 (35.6%) in protocol 2 and 72 (27.6%) in protocol 3. The rate of complete examinations, adequate bowel preparation and diagnostic yield were comparable among the groups (p=0.655, p=0.193 and p=0.589, respectively). The overall SB-CLEAR score was similar among the protocols (p=0.236). Although the preparation of the third tertile had a lower score using protocol 3 (protocol 1: 2.5±0.1 vs 2: 2.6±0.1 vs 3: 2.3±0.1, p=0.021), it did not compromise the mucosal visualization, maintaining a mean score above 2 and similar diagnostic yield among the protocols (p=0.850). The patients’ reported tolerability was higher in protocol 3 (protocol 1: 2.8±0.1 vs 2: 3.0±0.2 vs 3: 0.6±0.1, p<0.001).

Conclusion

Using 1 liter of water as a booster in SBCE was better tolerated and associated with comparable rates of complete examinations, adequate bowel preparation and diagnostic yield versus PEG with or without ascorbic acid.

Introduction

During the COVID-19 pandemic the British Society of Gastroenterology (BSG) introduced interim guidelines supporting a non-biopsy pathway for the diagnosis of coeliac disease. These guidelines reflect the current recommendations of the American Gastroenterological Association (AGA). According to these guidelines, symptomatic or high risk adults with anti-Tissue transglutaminase (TTG) IgA titres ≥10× the upper limit of normal (ULN) and a positive endomysial antibody (EMA) on a repeat sample can be diagnosed without endoscopy and referred directly to a specialist coeliac clinic. Patients who do not meet these criteria should be referred for a gastroscopy (OGD) with biopsy for the confirmation of coeliac, prior to starting a gluten free diet.

Aims & Methods

To assess whether general practitioners (GPs) in the community appropriately referred patients with suspected coeliac disease in line with the AGA and BSG interim non-biopsy diagnostic criteria.
A retrospective review was conducted of all new patients referred to the Coeliac clinic in Galway university hospital between January 2023 and December 2024. Data regarding TTG level at diagnosis, EMA result, and compliance with the diagnostic pathway outlined above was collected for each new referral. This data was collected via Evolve - the hospital's electronic based patient record system.

Results

• There were 119 “new” referrals to our Coeliac Service between January 2023 and December 2024. Of these, 44 cases were known coeliac who were referred by primary care for re-engagement with the clinic, 18 were referred from secondary or tertiary care including GI surgery, Dermatology, Paediatrics, etc. 4 coincidental diagnoses (i.e. OGD performed for indications other than coeliac disease), and 5 outliers (i.e. with incomplete data or incorrectly referred to coeliac clinic) leaving 48 new coeliac cases referred from primary care.
• 18 of these referrals met the non-biopsy criteria for diagnosis (TTG ≥100 + positive EMA)
  • Within this cohort 66% (n=12) were incorrectly referred directly for an OGD which may have delayed the diagnosis of coeliac disease while the remaining 33% (n=6) were correctly referred for direct review at the coeliac clinic.
• The remaining 29 patients all had TTG values less that 10x ULN. 48% (n=14) of these patients were incorrectly referred to clinic prior to endoscopy and of greater concern, 45% (n=13) were recommended by their primary care physician to start a gluten free diet prior to any review or endoscopic procedure.
• Overall, only 44% (n=21) of referrals were compliant with the AGA/BSG guidance.

Conclusion

There is a notable gap in adherence to AGA and BSG non-biopsy coeliac diagnostic guidance in community settings. Half of patients eligible for a non-biopsy diagnosis underwent unnecessary endoscopy, and the majority of ineligible patients were commenced on a gluten free diet prior to, or without, referral for endoscopy. Further GP education is warranted to align referral practices with evidence-based pathways. Dedicated streamlined referral pathways for coeliac disease should ensure a timely diagnosis without mandatory endoscopy in those fulfilling the criteria for a non-biopsy diagnosis and facilitate a timely endoscopy prior to gluten elimination in those who require histological diagnosis.

References

Husby, S., Murray, J.A. and Katzka, D.A. (2019) ‘AGA clinical practice update on diagnosis and monitoring of celiac disease—changing utility of serology and histologic measures: Expert review’, Gastroenterology, 156(4), pp. 885–889. doi:10.1053/j.gastro.2018.12.010.
Tashtoush, L.B. et al. (2021) ‘Letter: The BSG covid‐19 interim coeliac disease guidance no‐biopsy approach is safe in adults’, Alimentary Pharmacology &amp; Therapeutics, 54(8), pp. 1090–1092. doi:10.1111/apt.16553.

Disclosure

No conflict of interest

Introduction

The risk of colorectal advanced adenomas (CAAs) and colorectal cancer (CRC) in siblings aged ≤ 50 years of patients diagnosed with early-onset CAAs (E-CAAs), defined as having CAA at or below the age of 50 years​, is poorly understood.

Aims & Methods

This study aimed to compare the risks of adenomas, CAA, and CRC in siblings aged ≤ 50 years of patients diagnosed with E-CAA to those in individuals aged ≤ 50 without such a family history.
This case-control study was conducted at a tertiary hospital in Vietnam. The participants included 96 cases who were siblings aged ≤ 50 years of patients diagnosed with E-CAA. Controls were randomly selected from consecutive patients aged ≤ 50 years who did not have siblings diagnosed with E-CAA. The absence of a family history of CAA in the control group was confirmed through comprehensive history taking. ​The controls were matched to cases in a 2:1 ratio for age (±3 years), sex, and smoking status. Individuals with alarming features of CRC or a family history of CRC were excluded. All the participants underwent standard bowel preparation and colonoscopy.

Results

The mean age was similar between cases (40.9 ± 6.0 years) and controls (41.1 ± 6.0 years). Except for the indications for colonoscopy, there were no significant differences in the baseline demographics between the two groups. A higher risk of CAA was documented in cases compared with controls (odds ratio [OR] = 6.33; 95% confidence interval [CI], 1.43–43.8; P = 0.018). This increased risk of CAA was more pronounced among male participants (OR = 13.7; 95% CI, 1.23–262; P = 0.006). Higher risks of colorectal adenomas (OR = 2.43; 95% CI, 1.27–4.67; P = 0.009) and colorectal neoplasia (OR = 2.23; 95% CI, 1.24–4.40; P = 0.011) were also found in cases compared with controls. CRC was found in one case and two controls.

Conclusion

Siblings aged ≤ 50 years of patients diagnosed with E-CAA have an increased risk of adenomas, CAA, and colorectal neoplasia. CRC screening should be initiated early in high-risk individuals.

Table 1. Risk of Colorectal Neoplasia among Siblings of Patients Diagnosed with Advanced Adenomas (n = 288)

References

Ng SC, Lau JY, Chan FK, et al. Risk of Advanced Adenomas in Siblings of Individuals With Advanced Adenomas: A Cross-Sectional Study. Gastroenterology. 2016;150(3):608-e17.
Cottet V, Pariente A, Nalet B, et al. Colonoscopic screening of first-degree relatives of patients with large adenomas: increased risk of colorectal tumors. Gastroenterology. 2007;133(4):1086-1092.