Introduction

Acute pancreatitis (AP) can pose challenges in diagnosing its underlying cause, with 10-30% of cases remaining elusive despite thorough clinical, biological, and morphological assessments. Echo-endoscopy (EUS) is particularly effective in exploring the bilio-pancreatic region. Our study aims to assess the role of EUS in elucidating the etiology of unexplained AP.

Aims & Methods

We performed a retrospective descriptive study at a university hospital's gastroenterology department between January 2018 and December 2023. It involved 118 patients diagnosed with AP, whose etiology was either suspected or remained undetermined after an initial radiobiological assessment (US, CT scan and MRI). These patients underwent EUS as part of their diagnostic evaluation.

Results

The average age of our patients was 55 ± 16 years, with a predominance of females (73.7%) and a male-to-female sex ratio of 0.35. 32.2% of patients had undergone cholecystectomy. 94.1% were admitted for their first episode of AP, while 5.9% had experienced at least one previous episode. Jaundice was observed in 29.7% of cases, and liver tests abnormalities were noted in 38.5%. Following initial radiological evaluation (ultrasonography, CT scan, MRCP), 53.4% of patients had biliary duct dilatation without visible obstruction, 33.9% had no dilatation, and 12.7% had diagnostic uncertainty. The diagnostic yield of EUS was 83%: micro lithiasis of the main bile duct accounted for 75.4% of cases, tumor-related causes for 4.2%, IPMN in 2 cases, biliopancreatic junction anomaly in 1 case, and Pancreas Divisum in 1 case. EUS findings were normal in 17% of cases.

Conclusion

EUS shows promise in elucidating the etiology of unexplained AP, boasting a high diagnostic yield in exploring the bilio-pancreatic region. Integrating EUS into diagnostic protocols could enhance the management of patients with AP, particularly in cases where initial investigations are inconclusive.

Clinical Case Summary

Small bowel bleeding can pose a diagnostic and therapeutic challenge.
We present an interesting case involving the use of different endoscopic modalities in jejunal diverticular bleeding. A 66-year-old male with gout and intermittent Naproxen use presented to the Emergency Department with melena. Oesophagogastroduodenoscopy (OGD) and colonoscopy did not reveal any source of bleeding. A Computed Tomography Mesenteric Angiography scan showed evidence of recent hemorrhage within the small bowel loops without active blush seen. Subsequent video capsule endoscopy (VCE) revealed blood pooling in the distal small bowel. He underwent a retrograde double balloon enteroscopy showing only coffee-ground stains in the distal jejunum. Further review of VCE images showed another small ‘dark spot’ in the proximal jejunum. Thus, he underwent an antegrade motorised spiral enteroscopy (MSE) which showed fresh blood clots in the proximal jejunum with multiple large diverticula. Active bleeding was identified from one of the diverticula but difficulty was encountered in manoeuvring the MSE into the jejunal diverticulum. The MSE was switched to a cap-fitted paediatric colonoscope which made it easier to advance into the proximal jejunal diverticulum to address the pulsating vessel. Hemostasis was achieved with adrenaline injection and application of hemostatic clips.
MSE can locate pathology that lies coaxial to the axis of the scope but it can be difficult to reach the culprit lesion due to its off axis location and acute angulation within the diverticulum. Push enteroscopy or balloon-assisted enteroscopy (BAE) maintains its benefit of having a more flexible shaft/tip and can safely enter a jejunal diverticulum for hemostasis even if located off axis compared to MSE. Although MSE represents an innovation, conventional push enteroscopy or BAE still remains an important tool in the endoscopic armamentarium.

References

Illustrative material

1. VCE image with ‘dark spot’
2. Endoscopic image of large diverticulum
3. Hemostasis was achieved with adrenaline injection and application of hemostatic clips
   

Introduction

Digestive hemorrhage is a frequent complication in advanced chronic kidney disease. Patients with end-stage renal disease (ESRD) are more likely to have gastrointestinal (GI) problems, including digestive bleeding of high or low origin.

Aims & Methods

The aim of our work is to study the particularities of HD in CKD patients.
This is a monocentric prospective analytical study over a period of 28 months: April 2020 to August 2022, including patients with HD with CKD at the dialysis stage or not, including renal transplant patients.
In order to be able to compare patients with ESRD with patients without ESRD, a control group of patients admitted for HD who had a GI endoscopy during the study period and with normal renal function were identified and grouped. In this group of patients, we took into account age, sex, indications, GI endoscopy results and ICU stay.
We also assessed all-cause mortality between the groups of CKD patients with HD versus the control group.

Results

A total of 378 patients underwent digestive exploration for HD. In this population, 46 (12.16%) patients with CKD were compared with 332 patients without RI.
70% (n=32) of the patients with RI were on chronic hemodialysis, 26% (n=12) had a GFR<60ml/min/1.73m2 but were managed without the aid of dialysis or transplantation, and 4% (n=2) patients were renal transplant recipients.
The most common etiologies in CKD patients were ulcer disease 65.2% (n=30); vascular ectasia 28.2% (n=13), gastritis 26% (n=12), esophagitis 10.8% (n=5); and tumors in 8.6% (n=4).
After statistical analysis patients with CKD had:
A higher risk of hemodynamic instability 69.5% (n=32) compared to the control group 11.14% (n=37) with p=0.002,
A higher rate of recurrence 26% (n=12) CKD patients compared to 9.6% (n=32) of the control group with a p=0.00.
A higher mortality rate 4.34% (n=2) in CKD patients compared to the control group 1.2% (n=4) with p=0.00.

Conclusion

GI bleeding in advanced chronic kidney disease is more severe it is accompanied by a higher risk of recurrence of ICU stay and mortality, hence the interest of prompt management and close monitoring. The main causes are peptic ulcer and vascular ectasia.

Introduction

H.pylori infection is common in developing countries leading to of high prevalences of peptic ulcers and gastric cancer. However, the diagnostic tests such as rapid urease test or urease breath test requires facilities and patients need to go to medical sites, which raise a more and more need for non-invasive and convenient tests appropriate to community.

Aims & Methods

A cross-sectional study was conducted at the Institute of Gastroenterology and Hepatology, Hanoi, Vietnam to compare the H.pylori determination results of the qualitative detection of 2 antibodies specific to FliD and CagA with the rapid urease test and urease breath test in Vietnamese patients with upper gastrointestinal symptoms. Patients over 18 years old with upper GI symptoms and no prior history of treated peptic ulcers or H.pylori eradication were invited to participate in the study. Patients were indicated with upper GI endoscopy and three methods to diagnose H.pylori infection: Rapid Urease Test (RUT), Urease Breath Test (UBT), and qualitative detection of 2 antibodies specific to FliD and CagA (Pylori Duotect). Pylori Duotect is considered positive if either antibody for FliD and CagA are positive. The parameters for evaluating the diagnostic accuracy of Pylori Duotect include sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). Patients are considered H.pylori positive if both RUT and UBT are positive.

Results

From December 1, 2023, to April 20, 2024, 189 patients were recruited for the research. The mean age were 45.8 years old (min-max: 18-76 years old), 40.7% were female. The most common symptom of patients was epigastric pain (46.6%). There were 172 patients (91%) with gastritis, 27 patients (14.3%) with gastric ulcers and 16 (8.5%) with duodenal ulcers. Using the Pylori Duotect test, 50.8% of the patients were positive, in which 39.6% were positive with FliD and 86.5% were positive with CagA. Based on RUT and UBT results, 31.2% of patients were diagnosed with H. pylori infection. Pylori DuoTect’s sensitivity, specificity, PPV, and NPV were 81.4%, 63.8%, 50.5%, and 88.3%, respectively.

Conclusion

The Pylori DuoTect test had low sensitivity and specificity in diagnosis H. pylori infection in patients with upper gastrointestinal symptoms.

Introduction

There have been advances in endoscopic hemostasis in acute gastrointestinal bleeding, from the conventional injection of submucosal solutions of dilute epinephrine to the application of thermal energy and, more recently, mechanical hemostasis (1,2). There has been the development of non-contact hemostasis in the form of an endoscopically applied hemostatic powder spray. When applied, these inert compounds absorb water, which concentrates clotting factors on the surface of the particles, thus initiating the clotting cascade. These compounds enhance clot formation, and the coagulum sloughs off after 24 to 72 hours. The primary objective of the study is to evaluate the safety of the Resolv® Endoscopic Hemostat System. The secondary objective is to evaluate the efficacy of the use of the Resolv© Endoscopic Hemostat System in the control of non-variceal GI bleed.

Aims & Methods

This is a single-center, prospective, open-label, single-arm study (CTRI/2021/12/038478) to evaluate the safety and efficacy of a novel plant-based polysaccharide Hemostasis’ Resolv© Endoscopic Hemostat System, from July 2022 to February 2023, in achieving acute hemostasis in adult subjects diagnosed with non-variceal upper gastrointestinal bleeding. Clinically known or confirmed GI bleeding—nonvariceal UGIB with bleeding severity of Forrest 1b, such as post-EMR, ESD, or tumour bleed—underwent standard endoscopy. Patients were evaluated for the proportion of subjects with AE or SAE within 72 hours after hemostat application, the proportion of subjects with device-related SAE within 30 days of the procedure, the proportion of subject mortality within 30 days of the procedure (all-cause) [Primary endpoints], the proportion of subjects with acute procedural hemostasis (index endoscopy), the proportion of subjects with recurrent bleeding within 72 hours of the index procedure/ application, and the need for surgery or an alternative hemostat for failure to achieve hemostasis within 72 hours [Secondary endpoints]. Blood sugars were closely monitored pre- and post-procedure, due to concerns regarding its effect on RBS since the powder is a plant-based polysaccharide.

Results

Sixty patients (M: F- 42/18, Age: 54.7±13.9) underwent the procedure and were considered for analysis. The device was used in the following indications: post-polypectomy (n = 34), peptic ulcer bleed (n = 12), malignant tumour bleed (n = 6), biopsy bleed (n=5), congestive gastropathy bleed (n=2), post-EMR bleed (n = 1). The technical success rate was 100%. Within 72 hours of use, there were no adverse events or side effects related to the device, and there was no mortality (all-cause) secondary to device use (Primary endpoints). The index endoscopy hemostasis was 100%. Within 72 hours of hemostasis, n=1 patients had a rebleeding (malignant ulcer bleed), which was controlled using Argon plasma coagulation (Secondary endpoints). The mean RBS was 150.3 mg/dl in 18 of 60 (30%) diabetic patients. The mean RBS 2 hours and 4 hours post-procedure was 130 and 131 mg/dl.

Conclusion

Resolv® Endoscopic Hemostat System is a safe and highly efficacious device for achieving acute hemostasis in adult subjects diagnosed with non-variceal upper gastrointestinal bleeding.

References

1. Lau JYW, Yu Y, Tang RSY, et al. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. N Engl J Med 2020;382:1299-308
2. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107:345-60; quiz 61.