Clinical Case Summary

80-year-old female patient was admitted on the emergency room for haematochezia’s without haemodynamic instability (HI). The blood test showed a hemoglobin (Hb) 8.3 gr/dL mean corpuscular volume (MCV) 93.3 fL (baseline Hb 13.1gr/dL). She had personal history of III cranial nerve paresis of microvascular cause and was medicated with acetylsalicylic acid (ASA).
Total colonoscopy with ileoscopy (TCI) without bowel preparation (BP) was performed and diverticular orifices in the sigmoid were identified. Along the way, including in terminal ileum (TI), dark red haematic content and clots were present but without evidence of active bleeding. Next, an upper digestive endoscopy was performed, with no evidence of upper gastrointestinal bleeding.
It was decided to repeat TCI with BP. The day before the exam, during BP, a new episode of haematochezia’s were noticed, this time with HI. Arterial blood test showed metabolic acidosis (lactate 3 mmol/L) and blood tests Hb 5.5gr/dL. After hemodynamic resuscitation, a computed tomography with vascular protocol was performed without identification of active bleeding.
The initial plan was maintained and TCI was performed after BP. A diverticular orifice with active low-debit bleeding was identified at the TI, 3 cm above the ileocecal valve. Combined hemostatic endoscopic therapy (adrenaline + 2 TTS clips) was performed, with bleeding control. The patient has been discharged, on the 6th day of hospitalisation, after restarting ASA. During the follow-up no bleeding recurrence was documented.
We present a rare case of ileal diverticulosis (ID) complicated by lower gastrointestinal bleeding (LGIB) with haemodynamic instability. This is a rare entity with an unusual manifestation, as most patients are asymptomatic. The diagnosis of LGIB in the context of ID is a challenge, both from an imaging and endoscopic point of view, and requires a high index of suspicion. The case has adequate iconographic documentation (photography and video).

References

CT images - after review by 2nd imagiologist - diverticular orificies at sigmoid colon and at the terminal ileum. In the vascular protocol no ative bleeding.
Endoscopic images - present endoscopic images from the first colonoscopy, with blood in all the colon segments and at terminal ileum.
Endoscopic video - active low debit bledding related with terminal ileal diverticulum

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is associated with increased technical difficulty and can potentially contribute to prolonged procedural duration and excess exposure to ionizing radiation.

Aims & Methods

The purpose of the present study was to present descriptive information about fluoroscopy during ERCP from a large reference center and to investigate possible determinants of the radiation dose or fluoroscopy duration during ERCP. We examined a prospectively collected single-center database of adult patients undergoing ERCP between 09/2021 and 12/2023 in a tertiary greek public hospital. Detailed information concerning patient, endoscopist and procedural parameters including ERCP indication, degree of difficulty of ERCP (defined using the Schutz score), types of interventions and fluoroscopy were recorded retrospectively. Non parametric statistical methods were used (Mann–Whitney U-test and Kruskal–Wallis test) for the analysis.

Results

In total, data of 1051 ERCPs were collected at first, while 1028 ERCPs with complete information for fluoroscopy duration and radiation dose were included (mean patient age 72.20 ±14.02years, 49.1% men) in the analysis. The mean procedure time was 34.22 ± 14.9 minutes, carried out by three different endoscopists (n₁=321, 31.4%, n₂=338, 33%, n₃= 363, 35.6%). The majority of ERCPs were performed for treatment of choledocholithiasis (64.5%) and were classified as of intermediate difficulty according to Schutz scoring system [Schutz score 2 (n=523, 53.4%)]. Fluoroscopy was used in 1010 ERCPs (98.2%) and the median fluoroscopy duration was 2.4 minutes (IQR=2.6 min) and the median radiation dose was 1031.6 μGym²(IQR=1237.5 μGym²). ERCPs performed with an indication of biliary tract neoplasm (e.g. cholangiocarcinoma, liver metastases) were associated with prolonged fluoroscopy duration [5.05min (IQR=6.35 min), p=0.008] and increased radiation dose [2372.75 μGym² (IQR=2462.68 μGym²), p=0.003] in comparison to the rest of the indications including choledocholithiasis, pancreatic neoplasm, obstructive jaundice and other indications.ERCP difficulty was also related with increased radiation; ERCPs with Schutz score ≥3 were associated with increased radiation dose and fluoroscopy duration compared with ERCP procedures evaluated as Schutz sore ≤2 [3.3min (IQR=3.9 min) vs. 2.1min (IQR=2.15 min), p<0.001 and 1280.8 μGym² (IQR=1836.8 μGym²) vs. 937.6 μGym² (IQR=820.25 μGym²),p<0.001 respectively]. There was no significant difference of the fluoroscopy duration (p=0.495) and radiation dose (p=0.950) among the three performing endoscopists.

Conclusion

Increased difficulty of ERCP and the indication of biliary tract neoplasm were related to higher radiation dose and prolonged fluoroscopy duration. These factors could be utilized to predict ERCP procedures related to increased radiation exposure and may contribute to adoption of appropriate radiation reduction methods.

Clinical Case Summary

Placement of self-expandable metal stents (SEMS) is a standard treatment in the palliation of unresectable malignant biliary obstruction, whereas multidisciplinary oncology treatment prolongs patient survival. Consequently, the likelihood of stent-related complications has increased. Distal migration is a rare cause of stent dysfunction and SEMSs are relatively hard to extract after insertion. We present the management of a patient with dislocated SEMS using argon plasma coagulation (APC).
An 88-year-old man with unresectable ampullary cancer and consequential biliary stricture underwent a transpapillary placement of a 6-cm-long, 10-mm diameter uncovered SEMS (uSEMS).
Twelve months later, he presented to our department with vomiting. Given the high index of suspicion for stent dysfunction, a duodenoscopy was performed. Direct endoscopic visualization showed a distal 3-cm-long migration of the uSEMS. The distal end of uSEMS was firmly impacted in the contralateral duodenal wall resulting in reactive tissue ingrowth narrowing both the stent and the duodenal lumen. Significant malignant duodenal obstruction was detected below the dislocated uSEMS.
Subsequently, it was attempted to trim the distal 2 cm of the stent using an axial APC probe (power setting 80W, gas flow 0,8 L/min). The trimmed stent was removed with biopsy forceps. The procedure lasted 20 min, without immediate complications and the patient was discharged within 2 days.
One month after the procedure, the patient was readmitted with recurrent vomiting. Endoscopy revealed duodenal stricture below the papilla of Vater, due to malignant disease progression. Therefore, an 8-cm-long, 20-mm diameter duodenal SEMS placement was performed under simultaneous endoscopic and fluoroscopic control and symptoms were soon relieved.
This case highlights endoscopic APC stent trimming as an efficient procedure, which allows easy, reproducible and well−tolerated management of migrated uSEMS-related complications.

References

Fig. 1. Dislocated uSEMS and reactive tumor ingrowth
Fig. 2. (a) Trimming of the distal end using APC (b) the remaining stent in situ

1. Yokode, M., Matsumori, T., Uza, N., Kuwada, T., Shiokawa, M., Maruno, T., & Seno, H. (2022). Usefulness of a circumferential argon plasma coagulation probe in trimming a dislocated distal biliary metal stent. Endoscopy, 54, E802–E803. https://doi.org/10.1055/a-1816-7903
2. Azevedo, R., Libânio, D., Bastos, P., Dinis Ribeiro, M., & Brandão, C. (2019). Going through the Mesh: Argon Plasma Trimming of a Metal Biliary Stent. GE Portuguese Journal of Gastroenterology, 26(4), 295–297. https://doi.org/10.1159/000493352
3. Ishii, K., Itoi, T., Sofuni, A., Itokawa, F., Tsuchiya, T., Kurihara, T., Tsuji, S., Ikeuchi, N., Umeda, J., Moriyasu, F., & Tsuchida, A. (2011). Endoscopic removal and trimming of distal self-expandable metallic biliary stents. World Journal of Gastroenterology, 17(21), 2652–2657. https://doi.org/10.3748/WJG.V17.I21.2652
McDonald, N. M., & Amateau, S. K. (2022). Jailbreaking a metal biliary stent through a duodenal stent. VideoGIE, 7(6), 226–228. https://doi.org/10.1016/j.vgie.2022.02.002
4. Vanbiervliet, G., Piche, T., Caroli-Bosc, F. X., Dumas, R., Peten, E. P., Huet, P. M., Tran, A., & Demarquay, J. F. (2005). Endoscopic argon plasma trimming of biliary and gastrointestinal metallic stents. Endoscopy, 37(5), 434–438. https://doi.org/10.1055/S-2005-860989

Introduction

Tradipitant is a novel NK-1 receptor antagonist studied in diabetic and idiopathic gastroparesis for short-term relief of nausea. This report presents the pooled analysis from 2 multicenter, randomized, double-blind, placebo-controlled studies (VP-VLY-686-3301 and VP-VLY-686-2301) assessing the efficacy of tradipitant in relieving symptoms of gastroparesis.

Aims & Methods

N=342 idiopathic and diabetic gastroparesis patients with delayed gastric emptying, moderate to severe nausea were included in the pooled ITT (Intent-to-Treat) population. Subjects were randomized to 85mg tradipitant twice a day (n=175) or placebo (n=167) and endpoints were assessed at Week 4. Nausea was assessed with the 5-point Gastroparesis Core Symptom Daily Diary (GCSDD). Overall gastroparesis symptom improvement was evaluated with the Patient Global Impression of Change (PGI-C) and Overall Patient Benefit (OPB) scales. Sensitivity analyses were performed to control for confounders.

Results

In a pooled analysis of double-blind subjects in the ITT population of Study 1 and Study 2, tradipitant demonstrated a clinically meaningful and statistically significant improvement in average nausea at week 4 (-1.15 for tradipitant v. -0.85 for placebo, p=0.0138). Significant improvement was seen in the number of nausea free days (20.96% improvement for tradipitant v. 12.52% for placebo, p=0.0085). Tradipitant also showed improvement in other gastroparesis symptoms as measured by the GCSI total score (-0.99 for tradipitant v. -0.76 for placebo, p=0.0265). Responder rates for PGI-C were 79.3% on tradipitant versus 69% on placebo at week 4 (p value = 0.036). For the Overall Patient Benefit, more patients improved on tradipitant versus placebo with 85.3% v. 71.2% at week 4 (p= 0.002). Sensitivity analysis adjusting for drug compliance confirmed the PK population (tradipitant blood levels ≥ 140ng/mL) in the pooled data set (n=284). In the pooled PK Population, tradipitant significantly improved average nausea at week 4 with -1.38 for tradipitant v. -0.85 for placebo (p=0.0001).

Conclusion

Pooling the data provided an opportunity to analyze a much larger data set, increase statistical power, and confirm results and subpopulations from the two separate studies. In the pooled analysis, we observed a clinically meaningful and significant effect on change of nausea severity at week 4. Improvements were also seen across core gastroparesis symptoms and overall measures of gastroparesis.

Disclosure

Study was sponsored by Vanda Pharmaceuticals, Inc. Authors are employees of Vanda Pharmaceuticals, Inc.

Introduction

Peptic ulcer is the most common cause of upper gastrointestinal bleeding (UGB), accounting for about 50 percent of cases. Several scoring systems have been developed for the early and accurate assessment of patients with UGB to predict clinical outcomes, assisting in the management of patients. The Glasgow-Blatchford score (GBS) is currently recommended for risk stratification of UGB in the emergency department, helping triage patients to in-hospital or ambulatory management. GBS includes hemoglobin, urea, heart rate, systolic blood pressure, co-morbidity and symptoms like syncope and melena.

Aims & Methods

Aim: To compare GBS in patients with bleeding peptic ulcer (BPU) infected and non-infected by Helicobacter pylori (HP).
Methods: We conducted a prospective observational study from September 2019 to March 2002, 48 patients with BPU were prospectively evaluated in a tertiary hospital. During emergency endoscopy, two gastric mucosal biopsy samples (one from corpus and one from the antrum) were collected for polymerase chain reaction (PCR) and invasive rapid urease test (RUT). Two hours later, all underwent carbon-13 urea breath test (13C-UBT). Patients were considered HP infected when two or more tests were positive. The clinical data were obtained from the patients´s records immediately before the endoscopy. The Qui-square test and Fisher were used to compare the groups. Written informed consent was obtained from all patients. The study protocol was approved by the local ethical committee.

Results

Mean age was 61.7±17.3 years, 25 (52.1%) presented with melena. Gastric ulcers were the major cause of acute bleeding in 39 (81.3%) and duodenal in 9 (18.8%) patients. Data about blood transfusion (BT), Rockall Score (RS) and presence of blood in the stomach are represented in table 1. GBS was significantly lower in HP positive patients (n=19) compared to HP negative (n=25): 9.1±3.3 e 11.5±3.1, p= 0.0441.

Table 1. Comparison between H.pylori negative and positive groups

* BT: blood transfusion, RS: Rockall score, GBS: Glasgow Blatchford score

Conclusion

H pylori positive patients showed less comorbidities and lower GBS in the BPU scenario. HP negative patients need more severe clinical conditions to bleed than those HP positive. HP is a pathogenic factor by itself, suggesting that GBS might be underestimated in this population. A score using HP presence could be better to predict prognostic in the episode of bleeding peptic ulcer.

References

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