Clinical Case Summary

We present the case of a 36-year-old healthy female patient who was admitted to the hospital due to throat pain and foreign body sensation following the accidental ingestion of a fishbone. After undergoing a nasofibroscopy that was unremarkable, a computed tomography (CT) revealed a dense filiform 25mm foreign body in the cervical esophagus, seemingly inside the lumen, without apparent complications. An upper gastrointestinal (GI) endoscopy identified a slightly eroded mucosal protrusion right below the upper esophageal sphincter, although no fishbone was identified. A rigid esophagoscopy was also performed and the foreign body was again not found. A repeated CT showed the object in the exact same location, now apparently being inside the esophageal wall. A multidisciplinary decision (involving Gastroenterology, Otorhinolaryngology [ORL] and General Surgery) was made to attempt the endoscopic removal of the fishbone. An endoscopic ultrasound revealed the presence of echogenic material with acoustic shadow in the second layer (muscularis mucosa) of the esophageal wall, which was mildly thickened, corresponding to the eroded protrusion on endoscopy. After obtaining the patient’s informed consent, an upper GI endoscopy was performed under general anesthesia in the presence of ORL, who would intervene if the fishbone could not be removed endoscopically or in case of procedure complications. Using a distal cap, a DualKnife-J was used to cut the mucosa near the erosion, allowing for the exposure of the embedded fishbone, which was then pulled with forceps. The 25mm fishbone was finally retrieved 12 days after its accidental ingestion.
The increasing experience in endoscopic submucosal dissection and the development of specialized instruments, such as knives, led to the adaptation of the technique to other purposes. Foreign bodies that have become completely embedded in the esophageal wall may now be effectively extracted endoscopically preventing the need for surgery.

References

1- CT scan images evidencing the fishbone in the esophageal wall;
2- Upper GI endoscopy showing the eroded mucosal protrusion;
3- Endoscopic ultrasound showing the fishbone in the second layer of the esophageal wall (still images and videos);
4- Endoscopic removal of the fishbone (still images and videos of the whole procedure)

Introduction

The optimal timing of endoscopy in acute upper gastrointestinal bleeding (AUGIB) management remains debated. We assessed time to endoscopy's impact on rebleeding and mortality based on patient characteristics and pre-endoscopic factors.

Aims & Methods

Data from 3,001 patients with AUGIB undergoing endoscopy within 48 hrs of referral from the prospective multicentre UK 2022 audit were analysed. Patients were categorised into 0-12 hrs, 12-24 hrs, and 24-48 hrs groups based on the time to endoscopy from referral. Regression analyses, adjusting for age, admission status (inpatient vs new admission), vital signs, symptoms, comorbidities, laboratory parameters, red blood cell transfusion, and pre-endoscopic management, assessed the association between endoscopy timing and rebleeding and mortality.

Results

Patients undergoing endoscopy within 0-12 hrs were younger, more likely to be haemodynamically unstable, and had a higher median Glasgow Blatchford Score (GBS) compared to those undergoing endoscopy in the 12-24 and 24-48 hrs groups. Despite a higher proportion receiving endotherapy (41% for the 0-12 hrs group, 28% for the 12-24 hrs group, and 17% for the 24-48 hrs group; p<0.001), the 0-12 hrs group had the highest rates of rebleeding (16%) and mortality (10%), compared to 9% rebleeding and 6% mortality in the 12-24 hrs group, and 7% rebleeding and 5% mortality in the 24-48 hrs group (p<0.001). The median length of stay was longer for the 0-12 hrs and the 24-48 hrs groups at 5 days, compared to 4 days in the 12-24 hrs group (p < 0.001). (see table)

Regression analysis indicated that, compared to the 12–24-hrs group, the 0–12 hrs group had higher odds of rebleeding (OR 1.91, 95% CI 1.38-2.69, p < 0.001), after adjusting for confounding variables. However, the 24–48 hrs group exhibited comparable odds of rebleeding (OR 0.93, 95% CI 0.60-1.45, p < 0.001) compared to the 12–24-hrs group. Regression analysis for mortality showed the 0-12 hrs group had higher odds of mortality compared to the 12-24 hrs group (OR 1.59, 95% CI 1.09-2.34, p = 0.001), while the 24-48 hrs group had similar odds of death (OR 0.74, 95% CI 0.43-1.23, p = 0.001).

Conclusion

The findings suggest a complex relationship between the timing of endoscopy and clinical outcomes in patients with AUGIB. Earlier endoscopy (0-12 hrs) may be associated with a higher risk of rebleeding, mortality and resource utilisation, while later endoscopy (24-48 hrs) may not be associated with increased adverse outcomes, but may lead to a longer hospital stay. Despite the initial severity of illness, early endoscopy may not translate to improved patient outcomes in AUGIB management. These results highlight the need for individualised management when determining the optimal timing of endoscopy in AUGIB.

Introduction

In Japan, more than ten years have passed since direct oral anticoagulants (DOACs) was released in 2011. The differences between DOACs and warfarin (VKA) have gradually become clearer, and many studies have been reported regarding the differences in gastrointestinal bleeding risk ^(1)(2)(3). However, there are few reports that examine the prevalence of gastric mucosal injury or ulcers rather than the risk of bleeding.

Aims & Methods

The aim of this study is to reveal the clinical features about patients with gastric ulcer taking anticoagulants (DOACs or VKA). This study is a retrospective cross-sectional study conducted in a single hospital. Data were extracted from the records of subjects who underwent upper gastrointestinal endoscopy at our department between April 2015 and December 2022. We focused on subjects who took anticoagulants (DOACs or VKA), and compared the prevalence of gastric ulcer between subjects taking DOAC and those taking VKA. Subjects taking anticoagulants were limited to those taking that anticoagulant as the only anti-thrombotic agents. This study was conducted separately for subjects taking antacids (P-CAB or PPI) and those not taking antacids (NO P-CAB, NO PPI and NO H2RA). Statistical analyses were performed by Fisher’s exact test.

Results

Of the 8,602 subjects analyzed, 522 subjects were taking anticoagulants, of which 103 were taking VKA (76 men, 27 women, mean age 73.1±12.0 years) and 297 were taking DOACs (205 men, 92 women, mean age 74.9±8.7 years). Among subjects taking DOACs, 33 subjects received Dabigatran, 93 received Edoxaban, 87 received Rivaroxaban, and 84 received Apixaban. The prevalence of gastric ulcer in subjects taking antacids was 6.7% (4/60) on VKA and 2.9% (5/170) on DOACs (p=0.24). The prevalence of gastric ulcer in subjects not taking antacids was 23.1% (9/39) on VKA and 5.4% (6/111) on DOACs (p=0.004).

Conclusion

Without concomitant use of antacids, subjects taking DOACs had a statistically significantly lower prevalence of gastric ulcers than those taking warfarin. These results suggest that DOACs are gentler on the gastric mucosa and user friendly than warfarin.

References

(1) Miller CS, et al. Clin Gastroenterol Hepatol. 15(11): 1674-1683, 2017
(2) Ray WA, et al. JAMA. 320(21): 2221-2230, 2018
(3) Ingason AB, et al. Ann Intern Med. 174(11): 1493-1502, 2021

Clinical Case Summary

Intestinal failure is a rare condition associated with significant reduction of gut function. Depending on the severity of the loss of gut function and the adaptability of the small intestine, patients may require long-term home parenteral nutrition (HPN) with higher risk to develop complications as intestinal failure-associated liver disease (IFALD). Therapy for IFALD is based on optimization of HPN composition and calories and restoring gut functions by enabling the enteral route; surgical strategies should be considered either by restoration of bowel continuity but their efficacy is not quite clear. Here we present the case of a 60 years old woman with intestinal failure due to short bowel syndrome, who developed IFALD, non-responding to medical therapy but completely resolved after resuming enteral nutrition and surgical approach. Patient was admitted with traumatic mesentery root laceration with rupture of superior mesenteric artery and intestinal infarction with signs of perforation. Small bowel resection and jejunostomy was performed, configuring a short bowel syndrome-type I jejunostomy with tenus “in transitum” to ostomy of 70 cm while 10 cm of ileum with ileocecal valve and entire colon were excluded. Total parenteral nutrition was set up and the patient was discharged without significant biochemical alterations. Two months later blood tests found out elevation of cholestasis and hepatocytonecrosis, suspected for IFALD. Thus HPN composition and medical therapy were optimized, without any laboratory improvement.Thus intestinal recanalization surgery was performed by packing a double ileo-ileal anastomosis preserving the IC valve, restoring intestine continuation with colon for about 80 cm, resulting in SBS type 2, with subsequent complete normalization of blood tests. Although more risky, surgical therapy should be considered a viable strategy for patients with IFALD refractory to conservative therapy.

Introduction

Optimal timing of endoscopy in patients with acute variceal bleeding (AVB) remains unclear. Studies in patients with peptic ulcer bleeding (PUB) have indicated that urgent endoscopy <6 hours from presentation may be associated with worsened patient outcome. We aimed to analyse the association between timing of endoscopy and mortality in AVB.

Aims & Methods

Prospective multicenter cohort study based on data from the 2022UK Audit on Acute upper gastrointestinal bleeding. The association between timing of endoscopy and in-hospital mortality was evaluated using logistic regression analyses with adjustment for differences in patients’ characteristics and severity of bleeding.

Results

We included 401 AVB patients. Mean age was 58 years, 65% were males, 75% had known cirrhosis at time of presentation, mean Child-Pugh score was 8.2, 31% had other comorbidities, 13% had ongoing bleeding at time of endoscopy, 78% were treated with terlipressin, 75% were treated with antibiotics, and 12.6% died during hospital admission. Mortality rates were 22%, 17%, 11%, and 11% for patients undergoing endoscopy in the periods <6, <12, 6-24 and >24 hours from presentation. Patients undergoing endoscopy < 6 hours had lower blood pressure, higher heart rate, lower haemoglobin, and higher peak-lactate levels than patients undergoing later endoscopy (see table). However, even haemodynamically stable patients with systolic blood pressure above 100mmHg had high mortality rates (16%) when performing urgent endoscopy < 6 hours. When adjusting for differences in patients’ characteristics, and severity of bleeding, we did not find any association between timing of endoscopy and mortality (Odds ratio (95% confidence interval): 1.01 (0.99-1.03); p=0.17).

Table: Patient characteristics in relation to time of endoscopy (n=401)

Conclusion

AVB is associated with significant mortality, in particular in patients undergoing urgent endoscopy <6 hours from presentation, which may be explained by more severe bleeding. When taking differences in patients characteristics and severity of bleeding into consideration, endoscopy within 6-12 hours appears to be associated with similar outcomes to endoscopy undertaken 6-24 hours from presentation, despite less time to patient optimization before endoscopy. Thus, the association between timing of endoscopy and outcome may differ between patients with AVB and patients with PUB.

Disclosure

No conflicts of interest.

Introduction

Difficult pancreatic duct stones, including large and/or impacted pancreatic duct stones, cannot usually be treated by conventional endoscopic retrograde cholangiopancreatography (ERCP). Extracorporeal shock wave lithotripsy (ESWL) and surgery including Frey operation are the main treatment for such difficult pancreatic duct stones. Recently, cholangiopancreatoscopy-assisted lithotripsy using electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) provides an alternative modality for ductal clearance.

Aims & Methods

We aimed to evaluate the clinical outcomes of cholangiopancreatoscopy-assisted lithotripsy and Frey surgery in patients with difficult pancreatic duct stones.
From January, 2018 to December, 2023, a total of 12 (10 male and 2 female) consecutive patients, 51 (38-71) years old, with large and/or impacted pancreatic duct stones undergoing single-operator cholangiopancreatoscopy-assisted lithotripsy using EHL and/or LL, and 14 (10 male and 2 female) consecutive patients, 48 (33-62) years old, undergoing Frey surgery in a medical center were retrospectively analyzed. Clinical outcomes including stone size, lithotripsy and surgery procedures, ductal clearance, complications, and length of hospital stay were evaluated.

Results

In the group of cholangiopancreatoscopy-assisted lithotripsy, 11 (91.7%; 11/12) patients were successfully treated in 19 (median 2; range 1-3) sessions including LL (n=16) and EHL (n=3) to achieve ductal clearance (Clinical success). The technical success rate was 94.7% (18/19). Six (50%; 6/12) patients with pancreatic duct stones were successfully treated at the first session of cholangiopancreatoscopy-assisted lithotripsy. After the procedure, mild pancreatitis occurred in 5 (26.3%; 5/19) patients. The median length of hospital stay was 4 (2-9) days. In the group of Frey surgery, 11 (78.6%; 11/14) patients underwent the surgery successfully. Adverse events after Frey surgery occurred in 3 (21.3%; 3/11) patients, including intra-abdominal abscess, peritonitis and bacteremia, respectively. The median length of hospital stay was 16 (7-58) days.

Conclusion

Cholangiopancreatoscopy-assisted lithotripsy is an effective and safe modality for difficult pancreatic duct stones. Comparing with Frey surgery, cholangiopancreatoscopy-assisted lithotripsy can be an initial therapy.

Disclosure

The authors declare no conflicts of interest.