Introduction

The post endoscopic retrograde cholangiography induced pancreatitis (PEP) rate among high-risk cohort can reach up to 15%. Precut papillotomy and fistulotomy have been found beneficial in reducing the risk of PEP in usual risk patients for PEP. However, a head-to-head comparison of these 2 techniques as primary modalities of cannulation without attempting standard approach among patients with high risk for PEP is lacking

Aims & Methods

We conducted a randomized controlled trial at a tertiary referral teaching hospital of national importance in North India. Patients undergoing endoscopic retrograde cholangiography (ERC) for various indications were screened and those with a naïve papilla and having high risk features for PEP as per the ESGE guidelines (1 definite or 2 likely risk factors were considered as high risk for PEP) were enrolled. The exclusion criteria were-1- previously sphincterotomised papilla, 2-small flat type of papilla, 3-severe coagulopathy (INR>1.5 and/or platelet count <1 lac/dl), 4-suspected ampullary growth, 5- recent history of pancreatitis/case of chronic pancreatitis, 6-periampullary diverticulum except type III, 7-age <18 or>80 years and 8-not giving informed consent. Patients were randomized in a 1:1 ratio in group A- primary precut papillotomy or group B- primary precut fistulotomy groups. In both the groups cannulation was attempted with the precut technique without giving any trial of standard cannulation. A four hour amylase was sent for all the patients and they were observed for 6 hours after the ERC and discharged if asymptomatic. All the patients were asked to follow up after 48 hours in the out patient department for any missed or delayed presentation of post ERC adverse events. The primary outcome was to compare the PEP rate between the 2 groups. The secondary outcomes were to compare the success rate of biliary cannulation, adverse event rate, cannulation and total procedure time.

Results

Between February 2021 and June 2024 1259 patients undergoing ERC for various indications were screened. After exclusion, 324 patients (162 in each group) were randomized into primary precut papillotomy (group A) or primary precut fistulotomy (group B) groups. The mean age, gender, indications, type of papilla, 4-hour amylase and number of risk factors for PEP among other demographic characteristics were comparable between the 2 groups. The primary outcome (PEP rate) was comparable between the 2 groups (group A-4 versus group B-5, p value- 1.000). All the 9 patients (2.7%) had mild PEP and were managed conservatively. The success rate of biliary cannulation both primary and overall were comparable between the 2 groups. The cannulation (5.4 vs 6.8 min) and total procedure time (22.9 vs 23.4 min) were also comparable between the groups. One patient each in both the groups developed bleeding leading to abandoning of the procedure. None of the patients developed perforation.

Conclusion

Primary precut techniques (papillotomy and fistulotomy) have comparable efficacy and safety and reduce the risk of PEP among high-risk cohort for PEP undergoing ERC and can be used as upfront modalities of cannulation without attempting standard method in situation where we anticipate difficulty and patient has high risk features of PEP.

Clinical Case Summary

An 80-year-old man, with no history of alcohol or tobacco use, presented with a six-month history of oral mucosal erosions, odynophagia, dysphagia, dysphonia, and a significant weight loss. Physical examination revealed an abdominal mass. A CT and MRI showed a normal sized liver with regular contours and a large nodular hepatic lesion suggestive of hepatocellular carcinoma (HCC), along with two small satellite nodules and one large lymphadenopathy at the hepatic hilum. Labs showed elevated -fetoprotein levels of 190 ng/mL. He was referred to Hepatic Oncology and underwent an ultrasound-guided biopsy of the liver lesion, confirming well-differentiated HCC. The patient also developed erythematous-brown scaly plaques on the trunk and limbs. A skin biopsy was performed, and along with clinical and serological findings, confirmed the diagnosis of paraneoplastic pemphigus. High-dose Prednisolone was started and led to partial improvement. Two cycles of IVIG followed, with significant remission of skin lesions. He also began Sorafenib for HCC. After six months, follow-up imaging showed progression of the hepatic lesion, as well as tumor seeding in the thoracic wall along the needle tract of the liver biopsy. Treatment was escalated to Regorafenib, which was discontinued after two months. He died 16 months after diagnosis ,from traumatic brain injury. Paraneoplastic pemphigus is a rare autoimmune disease typically linked to hematologic cancers, with only four cases of associations with HCC described in the literature. This rare combination limits treatment options, particularly immune checkpoint inhibitors. In this case, immunosuppression may have impaired antitumor immunity, contributing to rapid tumor progression and biopsy needle tract dissemination.

References

1. Hinterhuber, G., Drach, J., Riedl, E., Böhler, K., Ferenci, P., Wolff, K., & Foedinger, D. (2003). Paraneoplastic pemphigusin associationwith hepatocellular carcinoma. Journal of the American Academy of Dermatology, 49(3), 538–540.
2. Yokokura, H., Demitsu, T., Kakurai, M., Umemoto, N. et al (2006). Paraneoplastic pemphigus mimicking erosive mucosal lichen planus associatedwith primary hepatocellular carcinoma. The Journal of dermatology, 33(12), 842–845.
3. Jang, M., Lee, K., Han, S., Park, J., Lee, J., Suh, K. (2014). Paraneoplastic Pemphigus Associated with Hepatocellular Carcinoma. Korean Journal of Dermatology,34-39.
4. Muramatsu, T., Matsumoto, H., Yamashina, Y., Shirai, T., & Sakamoto, K. (1989). Pemphigus foliaceus associated with acanthosis nigricans-like lesions and hepatocellular carcinoma. International journal of dermatology, 28(7), 462–463.
5. Schaffler-Schaden, D., Birsak, T., Zintl, R., Lorber, B., & Schaffler, G. (2020). Risk of needle tract seeding after coaxial ultrasound-guided percutaneous biopsy for primary and metastatic tumors of the liver: report of a single institution. Abdominal radiology (New York), 45(10), 3301–3306.
7. Decaens, T., Roudot-Thoraval, F., Bresson-Hadni, S., Meyer, C. et al (2006). Role of immunosuppression and tumor differentiation in predicting recurrence after liver transplantation for hepatocellular carcinoma: a multicenter study of 412 patients. World journal of gastroenterology, 12(45), 7319–7325.

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

Surgery is the traditional treatment of traumatic pseudocysts, but with considerable morbidity and mortality. A minimally invasive management of these collections has been increasingly used. Objective: To analyze the outcome following endoscopic treatment of pancreatic pseudocysts caused by abdominal trauma and to study the integrity of the main pancreatic duct (MPD).

Aims & Methods

Patients with pancreatic fluid collections due to abdominal trauma and who underwent endoscopic therapy were studied. All were symptomatic with a persistent collection for more than 6 weeks. Opacification of the MPD allowed characterization according to Takishima Classification (I, II and III) which guided therapy. Endoscopic drainage was divided into: transpapillary (Takishima II and III without bulging), transmural (type I) or combined (type II or III with bulging).

Results

From January 2020 January 2025 51 patients (36 men, mean age of 35.2 years, range - 13.9 years) were identified who developed pancreatic collections after blunt or penetrating abdominal trauma., The average size of the collection was 14.3  5.2 cm. ERP was obtained in 47/51 (90%). Drainage was transmural in 13 (all type I), combined in 24 (type IIa (4), IIb (7) and III (13) and transpapillary in 10 (all type III without bulging). The remaining 4 were drained transmurally. The success of endoscopic treatment was 94% with a recurrence rate of 8%. Stent occlusion occurred in 6%. There were 9 complications, but no procedural-related deaths. Patients with penetrating trauma had more recurrences than those with blunt trauma (p = 0.01). Penetrating trauma conferred a relative risk for development of infection 0.25; (95% 0.07 - 0.88; p = 0.045).

Conclusion

Endoscopic treatment of pancreatic fluid collections that develop after pancreatic trauma is safe and effective and can be considered a first-choice alternative to surgical and/or percutaneous treatment. Pancreatography is useful in determining the best endoscopic approach.

Disclosure

​NO CONFLICT OF INTEREST

Introduction

Autoimmune pancreatitis (AiP) is a rare form of chronic pancreatitis. Studies from Japan and Germany suggest that AiP patients may have a higher incidence of malignancies compared to the general population. However, reliable data in this regard are still lacking.

Aims & Methods

We initiated a retrospective, multicenter observational study within the Pancreas 2000 framework to investigate the incidence of malignancy in AiP Patients.In our global multicenter retrospective observational trial, we are currently collecting data from patients with AiP diagnosed after 2005, including type 1, type 2, and not-otherwise-specified (NOS) AIP, regardless of the diagnostic criteria used. Patients with less than 12 months of follow-up after AIP diagnosis and those with immune checkpoint inhibitor-induced pancreatitis are excluded. Our primary outcome is to determine the occurrence of the first invasive cancer in AiP patients. The secondary outcome is to evaluate the characteristics of AiP patients with distinct pancreatic and/or extrapancreatic cancers and the prevalence of all cancer diagnoses within 12 months prior to AiP diagnosis. The standardized incidence ratio of any first invasive cancer after AiP diagnosis will be compared to age-grouped and gender-matched controls in the general population. The expected number of cancers in the general population will be determined using the Cancer Incidence in Five Continents Volume XI (CI5XI) registry.

Results

We will present the current status of recruitment and preliminary data. To date, 16 centers from Europe and America have entered 321 cases. Ethics submissions have already been applied for in an additional 45 centers across four continents (Europe, Asia, America, and Oceania).

Conclusion

To the best of our knowledge, this is the first global observational trial analyzing the risk of developing cancer in patients with AiP.