Introduction

Differentiating pancreatic cystic lesions (PCLs) remains a diagnostic challenge. The use of high-definition imaging modalities which detect tumor microvasculature have been described in solid lesions. We aim to evaluate the usefulness of cystic microvasculature when used in combination with cyst fluid biochemistry to differentiate PCLs.

Aims & Methods

We retrospectively analyzed 110 consecutive patients with PCLs from 2 Italian Hospitals who underwent EUS with HFlow and EUS fine needle aspiration to obtain cystic fluid. The accuracy of fluid biomarkers was evaluated against morphological features on radiology and EUS. Gold standard for diagnosis was surgical resection. All cysts fluid cutoff values were assigned from previous literature: CEA>192(ng/ml), CA19.9>37(U/L), amylase>250(U/L), lipase>336(U/L), glucose<50(mg/dl).

Results

Of 110 patients, 65 were diagnosed as mucinous, 41 as non-mucinous neoplasms (4 patients excluded). Fluid analysis alone yielded 76.7% sensitivity, 56.7% specificity, 77.8 positive predictive value (PPV), 55.3 negative predictive value (NPV) and 56% accuracy in diagnosing pancreatic cysts alone. Our composite method yielded 97.3% sensitivity, 77.1% specificity, 90.1% PPV, 93.1% NPV, 73.2% accuracy.

Conclusion

This new composite method which utilizes high-definition microvasculature imaging on EUS is superior to that of the stand-alone analysis of cyst fluid biochemistry. It can be applied to the holistic approach of combining cyst morphology, vascularity, and fluid analysis alongside endoscopist expertise.

References

1. Moris M, Bridges MD, Pooley RA, Raimondo M, et al. Association Between Advances in High- Resolution Cross-Section Imaging Technologies and Increase in Prevalence of Pancreatic Cysts From 2005 to 2014. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2016 Apr;14(4):585-593.e3.
2. de Pretis N, Mukewar S, Aryal-Khanal A, Bi Y, Takahashi N, Chari S. Pancreatic cysts: Diagnostic accuracy and risk of inappropriate resections. Pancreatol Off J Int Assoc Pancreatol IAP Al. 2017 Apr;17(2):267–72.
3. Yamao K, Nakamura T, Suzuki T, Sawaki A, Hara K, Kato T, et al. Endoscopic diagnosis and staging of mucinous cystic neoplasms and intraductal papillary-mucinous tumors. J Hepatobiliary Pancreat Surg. 2003;10(2):142–6.
4. Ahmad NA, Kochman ML, Lewis JD, Ginsberg GG. Can EUS alone differentiate between malignant and benign cystic lesions of the pancreas? Am J Gastroenterol. 2001 Dec;96(12):3295–300.
5. de Jong K, van Hooft JE, Nio CY, Gouma DJ, Dijkgraaf MGW, Bruno MJ, et al. Accuracy of preoperative workup in a prospective series of surgically resected cystic pancreatic lesions. Scand J Gastroenterol. 2012 Sep;47(8–9):1056–63.
6. European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 2018 May;67(5):789–804.

Introduction

Gastroenterology (GE) is a medical discipline that studies all diseases of the digestive system. It comprises several areas of study and offers a large variety of sub-specializations: proctology, interventional endoscopy or even digestive oncology. The decisive elements in the choice of this specialty vary among interns. The aim of our study is to determine the various factors influencing the choice of gastroenterology as a specialty among medical interns.

Aims & Methods

This is a cross-sectional, multicentric, survey-type study, conducted from September 1 to 30, 2023, involving 7 national medical faculties. All medical interns, regardless of sex or age, participated in our study.
An electronic survey with 29 items was created using Google Forms®. It was divided into two parts: the first part contained 13 questions on socio-demographic characteristics and exposure to GE during the academic curriculum, while the second part concerned the factors motivating the choice or not of GE as a specialty.
A statistical analysis using the Fisher’s exact test was performed. P values of <0.05 were considered statistically significant. Data were analyzed using Jamovi (Version 2.3).

Results

A total of 329 responses were collected: the majority were women 208 (63.2) with a F/M sex ratio of 1.7 and a median age of 27 [25; 28] years. The majority had already completed a GE rotation during their training course n=205 (62.3), of which 90 (44.1) had found it "satisfactory". More than half of the participants n= 178 (54.1) had already considered GE as a future specialty, and this choice was mostly made during GE lectures given in medical school n= 66 (36.9). Among those who had never considered GE, the main reasons were lack of interest in the specialty, the fact that it is a medical specialty, lack of information about GE, potential remuneration, and dissatisfaction with GE rotation during the training course (59.2%, 28.9%, 13.9%, 10.4% and 10% respectively).
Among those who finally opted for GE, the majority were women (70.2% vs. 29.8%, p=0.004). Satisfaction with the GE rotation during the training course had an impact on the final choice: "satisfactory" vs. "mediocre" (43.8% vs. 6.3% p=0.009).
Multivariate analysis showed that early interest in fields such as endoscopy (OR= 4.46, CI95%: 1.44-13.78, p=0.009) or proctology (OR= 4.26, CI95%: 1.01-18.01, p=0.05) increased the chance of choosing GE.

Conclusion

This study showed that there is a gender disparity in the choice of GE as a specialty. The fact that it is a medical discipline may lead men to choose another path. Our study also highlighted the importance of GE training courses during the medical curriculum to motivate interns to join our specialty, as well as the need to spotlight certain areas such as endoscopy or proctology.

Introduction

Patients with ulcerative colitis (UC) report that UC negatively affects their quality of life (QoL), including sexual functioning, satisfaction, and drive.^1,2 These effects are rarely discussed with or by gastroenterologists in clinical practice. The CONFIDE study aims to elucidate the impact of symptoms on the lives of patients with moderate to severe UC in the United States (US), Europe (EU5; France, Germany, Italy, Spain, and UK), and Japan. Data presented here are from the US and EU5.

Aims & Methods

Online, quantitative, cross-sectional surveys were conducted (July–September 2021). Criteria based on previous treatment, steroid use, and/or hospitalization were used to define moderate-to-severe UC. Data collected included patient perspectives on the impact of UC on sexual activity. Sexual activity was not limited to intercourse and included activities such as masturbation.

Results

Surveys were completed by 200 US patients (male [M]=62%, mean age 40 years) and 556 EU5 patients (M=57%, mean age 39 years). Of these, 77% US and 54% EU5 patients were receiving advanced therapy (biologic/novel oral) and 52% and 73% were receiving steroids at the time of survey completion, respectively. Overall, 63% US patients (M=55%, female [F]=77%) and 53% EU5 patients (M=47%, F=60%) reported avoiding or decreasing sexual activity due to UC in the 3 months prior to the survey. Among these patients (US: N=126; EU5: N=292), most frequently reported reasons for avoidance of sexual activity were bowel urgency (BU; 41%), decreased sexual desire (37%), and fear of BU-related accidents (34%) in the US and fear of faecal seepage (37%), fear of BU-related accidents (36%), and BU itself (31%) in EU5. Although reasons for avoiding sexual activity were broadly similar between sexes, higher percentage of male patients from both US and EU5 (US: M=33%, F=24%; EU5: M=42%, F=33%) reported fear of faecal seepage as a factor affecting sexual activity. Conversely, higher percentages of female patients reported perianal pain (M=13%, F=19%) and self-consciousness (M=13%, F=24%) as reasons for avoiding sexual activity in the US and decreased sexual desire (M=16%, F=26%), BU (M=26%, F=36%) and fatigue (M=14%, F=22%) in EU5.

Conclusion

In both US and EU5 populations, >50% patients with moderate-to-severe UC reported avoiding or decreasing sexual activity due to UC, with bowel urgency and bowel urgency-related accidents being among the top three reasons. In addition to other QoL parameters, impact of UC on patients’ sexual health needs to be assessed in routine clinical practice.

References

¹Bulut AE, et al. Turk J Gastroenterol. 2019;30:33-39.
²Jedel S, et al. Inflamm Bowel Dis. 2015;21:923-38.

Disclosure

Simon Travis, Grants: Ferring Pharmaceuticals, AbbVie, Schering-Plough, MSD, Procter & Gamble, Warner Chilcott, International Organization for the Study of IBD, ECCO, UCB, Vifor Pharma, Normal Collision Foundation, Buhlmann, Takeda, Janssen, Pfizer, and Eli Lilly and Company.
Marla C. Dubinsky, Consultancy fees: AbbVie, Arena Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corporation, Eli Lilly and Company, F. Hoffman-La Roche Ltd, Genentech Inc., Gilead Sciences, Janssen, LLC, Pfizer, Prometheus Biosciences, Takeda Pharmaceuticals USA, Inc., and UCB; Stockholder: Trellus Health Inc.; Research support: AbbVie, Janssen, LLC, Pfizer, and Prometheus Biosciences.
Toshifumi Hibi, Consultancy fees/grant/research support/speaker: AbbVie GK, ActivAid, Alfresa Pharma Corporation, Apo Plus Station, Aspen Japan K.K, Bristol-Myers Squibb, Celltrion, EA Pharma, Eli Lilly and Company, Ferring Pharmaceuticals, Gilead Sciences, Janssen, JIMRO, JMDC Inc., Kyorin, Mitsubishi-Tanabe Pharma Corporation, Mochida Pharmaceutical, Nichi-Iko Pharmaceutical, Nippon Kayaku Co. Pfizer, Takeda Pharmaceutical, Zeria Pharmaceutical, and MIYARISAN Pharmaceutical.
David T. Rubin, Grants/contracts: Takeda; Consultancy fees: AbbVie, Altrubio Inc., Allergan, Inc., American College of Gastroenterology, Arena Pharmaceuticals, Athos Therapeutics, Bellatrix Pharmaceuticals, Boehringer Ingelheim International GmbH, Bristol Myers Squibb, Celgene Corp/Syneos, Cornerstones Health, Inc. (non-profit), GalenPharma/Atlantica, Genentech/Roche, Gilead Sciences, GODURN, LLC, InDex Pharmaceuticals, Ironwood Pharmaceuticals, Iterative Scopes, Janssen, Eli Lilly and Company, Materia Prima, Pfizer, Prometheus Biosciences, Reistone Biopharma, Takeda, and Techlab Inc; Stockholder: Altrubio and Datos Health.
Remo Panaccione, Consultancy/speaker fees and/or advisory board member: AbbVie, Amgen, Arena Pharmaceuticals, Bristol-Myers Squibb, Celgene, Eli Lilly and Company, Ferring, Fresenius Kabi, Gilead Sciences, Janssen, Merck, Organon, Pfizer, Roche, Sandoz, Shire, and Takeda; Consultancy fees and/or advisory board member: Alimentiv, AstraZeneca, Biogen, Boehringer Ingelheim, Genentech, Glaxo-Smith Kline, JAMP Bio, Mylan, Novartis, Oppilan Pharma, Pandion Pharma, Progenity, Protagonist Therapeutics, Sublimity Therapeutics; Consultancy fees: Abbott, Celltrion, Cosmos Pharmaceuticals, Eisai, Elan, Galapagos, JAMP Bio, Pendopharm, Satisfai Health, Theravance Biopharma, Trellus, Viatris, and UCB.
Stefan Schreiber, Consultancy and lecture fees: AbbVie, Amgen, Arena Pharmaceuticals, Bristol Myers Squibb, Celltrion, Falk, Ferring Pharmaceuticals, Galapagos/Gilead, Genentech/Roche, Eli Lilly and Company, Janssen, MSD, Pfizer, and Takeda.
Christian Atkinson, Employee: Adelphi Real World; Consultancy: Eli Lilly and Company in connection with this study.
Alison P. Bleakman, Cem Kayhan, Theresa H. Gibble, Christophe Sapin, and Eoin J. Flynn are employees and stockholders of Eli Lilly and Company.

Introduction

Endoscopic retrograde cholangiopancreatography (ERCP) is a minimally invasive endoscopic procedure that is crucial for pancreato-biliary diseases and selective cannulation is the most important step. However, even an experienced endoscopist can face cannulation failure in up to 15-30% of cases in the first ERCP when standard methods alone are used.¹ Many studies suggested the various needle knife fistulotomy or papillotomy as an alternative technique in difficult cannulation cases.^2,3 However, needle knife papillotomy (NKP), which is modified technique with needle knife has not been evaluated well.

Aims & Methods

To evaluate the clinical outcomes and adverse events of bile duct cannulation by NKP, we performed a retrospective review on medical records of all ERCP cases in Sheikh Khalfia Specialty Hospital, UAE. For six years, Sphincterotomy (SPT) naïve patients except altered-anatomy cases were enrolled and their procedure times, cannulation success rates, radiation exposures, and adverse events were measured between the procedure time matched two cohort group of SPT only and rescue NKP.

Results

In total 416 ERCP cases, 43 procedure time matched cases were selected among 352 (84.7%) SPT only cohort and 43 cases from 64 rescue NKP cohort. Biliary cannulation was succeeded in all cases (100%) by using SPT cannulation with rescue NKP technique without failure. There was no differences in cumulative radiation doses, cannulation time, and adverse event rates in rescue NKP group compared to SPT only group: Post-ERCP hyperamylasemia/hyperlipasemia (16.5% vs. 34.8%, p=0.080), pancreatitis (3.9% vs. 4.3%, p=0.883), cholangitis (4.7% vs. 4.3%, p=0.695), and no perforation case was noticed in both groups.

Conclusion

The SPT with rescue NKP technique can be used in the difficult biliary cannulation cases during ERCP safely and effectively.

References

(1) Testoni PA , Testoni S , Giussani A .
Difficult biliary cannulation during ERCP: how to facilitate biliary access and minimize the risk of post-ERCP pancreatitis.
Dig Liver Dis 2011;43:596–603
[2] Testoni PA , Mariani A , Aabakken L , Arvanitakis M , Bories E , Costamagna G,et al.
Papillary cannulation and sphincterotomy techniques at ERCP: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline.
Endoscopy 2016;4 8:657–6 83 .
[3] Lopes L , Dinis-Ribeiro M , Rolanda C .
Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?
Gastrointest Endosc 2014;80:634–641 .

Introduction

EUS guided cysto- gastrostomy/duodenostomy is well established now as a standard treatment option for symptomatic pancreatic pseudocyst in adult. Pancreatic pseudocyst in children is rare and tend to resolve spontaneously. Pancreatic pseudocyst that persists more than 6 weeks and cause symptoms considered a troublesome and need drainage either surgical, radiological or endoscopic. There are limited data regarding EUS guided cysto-gastrostomy in the childhood age group (2- 12 years). This is due to limited number of cases in this age group, the lack of experienced pediatric gastroenterologist with this technique and relatively large diameter of therapeutic EUS with a rigid tip that may restricts its use in young children.
We assessed the feasibility of EUS guided drainage of symptomatic pancreatic pseudocyst in children as an effective and safe procedure.

Aims & Methods

This is a multi-center retrospective study. We reviewed our data base for all children between the ages of 3 and 12 years underwent EUS guided pancreatic pseudocyst drainage between Oct 2018 and Dec 2022. We assessed preprocedural patient indication (including cause of previous pancreatitis, present complaint, and imaging), procedure technical success, early and delayed procedure related complication and clinical success.

Results

EUS guided cysto-gastrostomy was performed in nine children (six were males and 3 were females). The median age of the included children was 8 years (ranging from 3: 12 years) and the median Weight was 26.4 kg (ranging from 14.5: 37 kg). The cause of previous pancreatitis was blunt trauma in 4 cases, post chemotherapy for ALL in 3 cases and two were biliary cause. We had 100% clinical success with deployment of short double pigtail plastic stent (10Fr x 5 or 7 cm) through created fistula between the gastric lumen and cyst (the fistula was done by using 6 fr cystotome over guidewire and was dilated using mechanical dilator in 5 cases and 6:8 mm balloon in 4 cases). All patients resolved completely from pre- procedure symptoms and eight patients had complete cyst resolution after one month. One case has marked regression from 9.5 cm to less than 2 cm, this case also did trans-papillary drainage for pancreatic duct disruption. No post procedure complications were observed, only mild pancreatitis managed conservatively for 3 days in the child underwent concomitant trans-papillary drainage.

Conclusion

EUS guided cysto- gastrostomy for childhood population with symptomatic pseudocyst appeared to be feasible, effective, and safe procedure using therapeutic endoscopic ultrasound. Larger number of cases needed to support this procedure as a standard treatment option for these cases.

Introduction

Lactose malabsorption (LM) is a common digestive disorder. The hydrogen breath test (HBT) is currently the non-invasive gold standard in diagnosing LM and lactose intolerance (LI), which is defined only in case of developing symptoms directly related to lactose ingestion in subjects with LM. (Misselwitz et al. 2019) The analysis of methane values in air samples may increase the accuracy of the test by including subjects “non hydrogen producers”. (De Geyter et al. 2021)

Aims & Methods

The aim of this study is to describe the relationship between pre-test clinical features, symptoms reported during lactose challenge and the result of the HBT in adults. In this prospective study we included a consecutive series of adult patients who underwent a HBT during a 5-month period. Air samples were taken every 30 minutes for 4 hours after the ingestion of a charge of 25 g of lactose. Symptoms reported in the previous 15 days (abdominal pain, bloating, diarrhoea, flatulence) and those experienced after lactose ingestion were assessed using a standard questionnaire establishing their presence or absence, and relative severity using 0-10 scale. The results were considered positive when a H₂ peak exceeded 20 parts per million (ppm) above the baseline or in case CH₄ excretion reached 10 ppm above the baseline, for experimental purpose. LI was defined by at least one symptom experienced during the test in subjects with LM.

Results

68 patients were included in the study and 40 of them (59%) were positive at the HBT. 52 (76%) developed at least one symptom while LI was diagnosed in 34 patients of them (65%). Only 40% of patients who referred pre-test symptoms had LM and none of the four symptoms was associated with LM or LI. A positive trend was found between abdominal bloating after lactose ingestion and a positive HBT (p 0.08). This association was statistically significant (73% vs 43%, p 0.02), with a positive trend also for flatulence (p 0.08) (Table), implementing diagnostic test with values of exhaled methane, finding 10 more intolerant patients. Considering the variation of symptoms (new or worsening of symptoms after lactose ingestion), the worsening of bloating was significantly more frequent in subjects with positive HBT compared to those with a negative test (40% vs 14%, p 0.03) and predictive of LI (PPV= 80%). Diarrhoea was the most predictive symptom of LI (PPV up to 88%). An association between the number of symptoms experienced during the test and LM was confirmed, while we didn’t find the same relationship with pre-test symptoms. (Beyerlein et al. 2008)

Conclusion

Symptoms reported before HBT seems to be non-related to LI. This may lead to arbitrary dietary exclusion of dairy products with consequences on bone health (Infante and Tormo 2000) and suggest that the causal role of lactose should be confirmed by HBT. In adult, the development ex-novo or the exacerbation of abdominal bloating and diarrhoea during the test, in subjects with LM, seems to be the most predictive of LI. Furthermore, the increase of the number of symptoms complained makes the diagnosis of LI more likely. On these basis, a domestic screening with 25 g of lactose (500 ml of milk) to establish whether the patient really needs the execution of breath test should be explored.

References

Beyerlein et al. 2008
De Geyter et al. 2021
Infante and Tormo 2000
Misselwitz et al. 2019