Introduction

Risk prediction model for the first-degree relatives (FDRs) of having a potential to develop celiac disease (CeD) is desirable considering that this population is high risk segment. We used a statistical method to develop risk prediction and evaluated the method performance under a wide range of predictor characteristics.

Aims & Methods

Data from 537 CeD cases classified as per ESPGHAN 2012 criteria, and their 1507 FDRs were assessed over a period for 24 months. A total of 222 FDRs were observed positive on baseline screening with serum tTG-IgA. Serology negative FDRs were kept on follow up over a period of 24 months to seek the newly developed FDRs into CeD cases (NDCeD). HLA DQ2/DQ8 genotyping, Interleukin-18 (IL-18) gene polymorphisms and plasma citrulline analysis was also performed in all subjects. Prediction models were made using all predictors and risk prediction scores were calculated using binary logistic regression analysis and ROC analysis was performed to calculate the diagnostic performance of the best fit models and evaluation of model performance criteria was performed.

Results

Diagnostic performance of serum tTG-IgA was significantly better than plasma citrulline in biopsy proven NDCD (DeLong’s Test p=0.038). However, multivariate analysis of diagnostic performance of best fit model from 63 combinations showed citrulline was best predictor (OR=0.92, p=0.04). In the second part of the study, analysis was performed in between symptomatic FDRs (n=690) and oligosymptomatic/silent FDRs (n=64). For the identification of potential CeD over a period of 24 months, risk prediction model based on the combination of tTG-IgA (OR=1.01, p=0.017) and IL-18 polymorphisms (OR=18.37, p=0.005) depicts best prediction.

Conclusion

HLA DQ2/DQ8 showed poor predictor characteristics. Model based on citrulline in immediate diagnosis of the silent and potential CeD was a good model but poor predictor of developing CeD. However, the risk prediction model utilising IL-18 polymorphisms and tTG-IgA had a better performance for the identification of the development of potential CeD.

Introduction

The success rate of endoscopic retrograde cholangiopancreatography (ERCP) is suboptimal in patients with complex surgically altered anatomy (e.g. Roux-en-Y anastomosis, pancreaticoduodenectomy) due to difficulty in advancement of scope to the target site and selective biliopancreatic duct cannulation. Although balloon-assisted enteroscopy can achieve a higher rate of intubation, its clinical application is limited by its small working channel and few compatible accessories.

Aims & Methods

We aimed to explore the feasibility and effectiveness of a novel endoscopic approach in patients with complex surgically altered anatomy.
This is a retrospective study of patients who underwent ERCP with complex surgically altered anatomy at our center with an annual ERCP volume of approximately 3000, between January 2018 and November 2022. The endoscopic procedures were performed by three senior endoscopists who had ERCP experience for at least 5 years. Long colonoscopy (measuring 168cm)-assisted ERCP was adopted as a first-line intervention, and selective biliopancreatic duct cannulation was performed after the target site (native papilla or the surgical anastomosis) was reached. For patients with failed cannulation, a plastic guide tube measuring 250 cm was inserted via the working channel of the colonoscope and its distal end was placed near the target site. The colonoscope was then withdrawn while the guide tube was left in-situ. By following the guide tube, a conventional side-viewing duodenoscope was cautiously advanced to the target site and biliopancreatic duct cannulation re-attempted.

Results

A total of 58 patients were recruited (mean age:56.7 years [standard deviation [SD]:14.4; male:36 [62.1%]]. The reconstruction methods were as follows – Roux-en-Y hepaticojejunostomy:32 (55.2%), Billroth-II gastrectomy with Braun anastomosis:11 (19.0%), pancreaticoduodenectomy:10 (17.2%) and Roux-en Y gastrectomy:5 (8.6%). Common bile duct stone was the most common indication for ERCP (n=30; 51.7%), followed by bilioenteric anastomotic stenosis (n=15; 25.9%), pancreaticojejunal anastomotic stenosis (n=7; 12.1%) and chronic pancreatitis (n=6; 10.3%). 55 (94.8%) of 58 had successful intubation by long colonoscope with a mean procedure time of 57.7minutes (SD:23.4). The mean time to reach target site was 19.1minutes (SD:9.0). The target site could not be identified in two patients and intestinal perforation occurred during endoscopic intubation in one patient. Among those with successful endoscopic intubation, biliopancreatic duct cannulation was achieved in 35 (63.6%) patients. For the remaining 20 patients with initial failure of biliopancreatic duct cannulation, intubation rate by duodenoscope was 100% by tracing the guide tube to target site. The success rate of biliopancreatic duct cannulation by duodenoscope was 85% (17/20) with a mean procedure time of 83.5 minutes (SD:21.1). The mean time to reach target site was 17.0minutes (SD:6.1). Notably, 90% (18/20) had either native papilla or pancreaticojejunostomy, in which selective biliopancreatic duct cannulation is known to be technically difficult with any type of forward-viewing scope due to unfavorable cannulation trajectory. For those with failed cannulation, two had anatomical stricture and one had impacted pancreatic stone.

Conclusion

ERCP by conventional duodenoscope with colonoscopy-assisted pre-placement of guide tube is a feasible, effective and safe alternative for patients with complex surgically altered anatomy in experienced endoscopists.

Introduction

The incidence of caustic ingestion has remained stable in recent years due to its difficult prevention and limited changes in its management.

Aims & Methods

Aims:
1. To explore changes in the epidemiological and clinical characteristics of caustic ingestion over the last decades
2. To identify epidemiological risk factors of adverse outcomes.
Methods: We present data from an observational study that prospectively collected caustic ingestions in our centre since 1995 and included all adult patients whose acute episode was evaluated in the emergency department. Epidemiological data and variables related to the type of ingestion, prognostic risk factors and the adverse outcomes, defined as the need for admission to the intensive care unit, emergency surgery, patient death and oesophageal or gastric stricture development, were analysed; the results were compared for the periods 1995-2009 and 2010-2024.

Results

A total of 582 episodes of caustic ingestion were included, 305 during the first period and 277 during the second.
Epidemiological characteristics and type of ingestion were overall similar in both periods, as were the clinical, analytical, endoscopic and radiologic indicators of severity.
Adverse outcomes were also similar in the two time periods, both in the short term (comparable frequency of intensive care unit admission, need for surgery and death) and in the long term (stricture development).
The main risk groups for severe ingestions were patients older than 45 years (OR 4.3; 95%CI: 2.3-7.9) and psychiatric comorbidity (OR 5.2; 95%CI: 3.0-9.1), especially depressive syndrome (OR 7.2; 95%CI: 4.2-12.4).
Recurrent ingestions were more frequent in men (OR 1.9; 95%CI: 1.0-3.5) and psychiatric illness (OR 7.6; 95%CI: 3.5-16.5), mainly personality disorder (OR 11.0; 95%CI: 5.5-21.9).

	1995-2009	2010-2024	p value
Women	164 (53,8)	133 (48,0)	0,192
Age	44 (30)	50 (30)	0,193
Voluntary intake	154 (50,5)	121 (44,0)	0,139
pH of caustic Strong acid Weak acid Weak alkali Strong alkali	50 (16,9) 17 (5,8) 215 (72,9) 13 (4,4)	40 (14,7) 25 (9,2) 200 (73,3) 8 (2,9)	0,318
Psychiatric illness Depression Bipolar disorder Personality disorder Psychotic disorder Alcohol/toxic substances consumption	155 (50,8) 112 (36,7) 5 (1,6) 28 (9,2) 16 (5,2) 23 (7,5)	119 (43,0) 75 (27,1) 11 (4,0) 20 (7,2) 13 (4,7) 26 (9,4)	0,007 0,016 0,143 0,479 0,908 0,515
Intensive care unit admission	40 (13,1)	29 (10,5)	0,391
Emergency surgery	8 (2,6)	10 (3,6)	0,655
Death	15 (4,9)	19 (6,9)	0,412
Stricture formation	11 (5,1)	8 (3,7)	0,624

Conclusion

No relevant changes were identified in the epidemiological and clinical characteristics of caustic ingestions over the last decades, nor in their evolution. The most vulnerable groups to prioritise prevention measures would be patients with psychiatric cormobility.

Introduction

Biliary complications are estimated to occur in 5-32% of patients undergoing liver transplantation (LT) and are an important source of morbimortality, with mortality and retransplantation rates up to 20% and 13%, respectively. Their early recognition and multidisciplinary management are critical in improving outcomes.

Aims & Methods

Our aim was to evaluate post LT biliary complications, their endoscopic management, and clinical outcomes.
We conducted a retrospective study of a prospectively maintained database of LT adult patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) at a transplantation center between July 2020 - December 2022. Demographic, clinical, surgical, and endoscopic data were collected and analyzed in Stata®V17 (p<0,05). The outcomes assessed were ERCP’s technical success, procedure-related complications, complete resolution of the biliary complication, need for surgical reintervention, and mortality.

Results

We performed 166 ERCPs in 64 patients (2,6±1,3 ERCPs/patient), 86% males, mean-aged 56±11 years. The median interval between LT and first ERCP was 10 [2;46] months. The most frequent indications for ERCP were radiological documentation of biliary stenosis (BS) (33%) and cholangitis (27%). All patients had prophylactic antibiotic treatment and rectal indomethacin.
The most common biliary complication was anastomotic BS (75%), followed by bile leakage (14%), non-anastomotic BS (5%) and choledocholithiasis without BS (5%). 56% of anastomotic BS presented in the first year, whereas all the non-anastomotic BS were diagnosed after the first year. The bile leaks were detected from the fourth week following LT, 67% were high-output leaks and 67% associated with a BS.
Biliary cannulation ± sphincterotomy was achieved in 100% of the procedures, with a 97% technical success rate (4 BS were not traversed by the guidewire and 1 high output leakage was considered not amenable to endoscopic treatment). We performed dilation in 28% of the procedures, plastic stent placement in 62% (mean number of 2±1 stents with a total caliber of 15±6Fr per procedure) and fully covered self-expandable metal stent in 5% of the cases.
There were 4.8% procedure-related complications (4 intraprocedural bleedings treated endoscopically, 2 post-ERCP cholangitis, 1 mild pancreatitis and 1 delayed bleeding requiring blood transfusion), with no associated deaths.
Median follow-up was 10 [4;21] months. From the initial 64 patients, 16 patients are still under treatment, 4 were retransplanted for unrelated reasons, 3 died of other causes and 1 abandoned follow-up.
Our clinical success rate was 77.5% (31/40), achieving complete endoscopic resolution of the biliary complication within 3,2±1,3 ERCPs during a median of 196 days of treatment. Success rates per diagnosis were 100% in isolated choledocholithiasis, 79% in anastomotic BS, 67% in bile leaks and 50% in non-anastomotic BS.
Among the 9 patients with treatment failure (22.5%), 5 had presented with cholangitis, 3 of whom with multiple liver abscesses. Seven underwent surgical reintervention and 4 died of complications related to the post-LT biliary condition (mortality rate: 4/40, 10%). We did not find statistically significant associations of age, number of index surgeries, T tube placement, and indication for ERCP with clinical failure in multivariable logistic regression analysis.

Conclusion

The endoscopic management of biliary complications after LT had a high success rate in our patients, with few associated complications and an important contribution to decreasing the need for surgical reinterventions.

References

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