Relation between non-alcoholic fatty liver disease and carotid artery intimal media thickness as a surrogate for atherosclerosis: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVE

Non-alcoholic fatty liver disease (NAFLD), characterized by hepatic steatosis without heavy alcohol consumption or other chronic conditions, encompasses a spectrum from non-alcoholic fatty liver to non-alcoholic steatohepatitis leading to cirrhosis. This analysis aimed to investigate the correlation between NAFLD and carotid intimal media thickness (C-IMT), a non-invasive surrogate for atherosclerosis.

METHODOLOGY

Database searches, including PubMed, EMBASE and Cochrane Library, yielded studies up to April 2023. Included were studies exploring the NAFLD-C-IMT relationship in populations aged >18 years. Exclusions comprised non-English papers, those involving animals or pediatric populations and studies lacking control groups.

RESULTS

No statistical significance was noted between mild and moderate NAFLD compared to the control group regarding C-IMT [95% confidence intervals (CI): -0.03, 0.12] and (95% CI: -0.03, 0.21), respectively. There was a statistically significant difference only in the Severe NAFLD group ( P value 0.03). NAFLD with and without metabolic syndrome showed statistically significant differences compared to control regarding C-IMT (95% CI: 0.04, 0.12) and (95% CI: 0.01, 0.07), respectively. Fifty-nine studies were mentioned without classification of NAFLD severity and revealed a high statistically significant difference between NAFLD and controls regarding C-IMT with (95% CI: 0.09, 0.12, P < 0.00001). Stratified analysis according to sex was done in two studies and revealed statistical differences between NAFLD and control regarding C-IMT in both groups.

CONCLUSION

This meta-analysis underscores a significant association between NAFLD and increased C-IMT, emphasizing the importance of assessing C-IMT in NAFLD patients to identify cardiovascular risk and tailor therapeutic interventions for improved patient outcomes.

Dye Chromoendoscopy Outperforms High-Definition White Light Endoscopy in Dysplasia Detection for Patients With Inflammatory Bowel Disease: An Updated Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Whether dye spray chromoendoscopy (DCE) adds value in surveillance colonoscopy with high-definition (HD) scopes remains controversial. This updated meta-analysis compares dysplasia detection using DCE and high-definition white light endoscopy (HD-WLE) in patients with inflammatory bowel disease (IBD) undergoing surveillance colonoscopy.

METHODS

A comprehensive search was performed for randomized controlled trials (RCT) comparing HD-WLE and DCE in patients with IBD. The primary outcome was to compare the proportion of patients with at least 1 dysplastic lesion detected by DCE vs HD-WLE. Odds ratios (OR) and 95% confidence intervals (CI) were pooled using the random-effects model, with I2 > 60% indicating substantial heterogeneity. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to assess the certainty of evidence (CoE).

RESULTS

Six RCT involving 978 patients were analyzed (DCE = 479 vs HD-WLE = 499 patients). DCE detected significantly more patients with dysplasia than HD-WLE (18.8% vs 9.4%), OR 1.94 (95% CI 1.21-3.11, I2 = 28%, P = 0.006, high CoE). This remained significant after excluding 2 RCT published as abstracts. A sensitivity analysis excluding a noninferiority RCT with a single experienced operator eliminated the results' heterogeneity, OR 2.46 (95% CI 1.56-3.90, I2 = 0%). Although high-grade dysplasia detection was numerically higher in the DCE group (2.8% vs 1.1%), the difference was statistically insignificant, OR 2.21 (95% CI 0.64-7.62, I2 = 0%, low CoE).

DISCUSSION

Our updated meta-analysis supports DCE as a superior strategy in overall dysplasia detection in IBD, even with HD scopes. When expertise is available, DCE should be considered for surveillance colonoscopy in patients with high-risk IBD, with the acknowledgment that virtual chromoendoscopy shows equivalence in recent studies. Further multicenter trials with multiple endoscopists with varying expertise levels and longer-term outcome data showing a reduction in cancer or cancer-related death are needed.

Gastrointestinal Variant of Lemierre's Syndrome: A Systematic Review and Comprehensive Analysis of 36 Case Reports

Background

A gastrointestinal (GI) variant of Lemierre's syndrome (LS) involving Fusobacterium species causing pylephlebitis and possibly liver abscesses was recently identified. This systematic review aims to summarize the literature on this variant.

Methods

PubMed, Embase, Scopus, and Cochrane databases were searched up to November, 2nd, 2023 for case reports or case series detailing the GI variant of LS. Data regarding demographics, clinical features, and management were extracted. Descriptive statistics were used for analysis, including means, standard deviations, and percentages.

Results

The cohort included 36 patients (mean age 50.8 years; predominantly men 72%). Positive blood cultures were detected in 88.8% of cases, primarily growing Fusobacterium nucleatum (47.2%) and Fusobacterium necrophorum (33.3%). The GI tract was the primary infection source (58.3%), mostly related to diverticular disease (25%). Common manifestations were fever (86.1%), abdominal pain (72.2%), and leukocytosis (86.1%). Thrombosis involved the portal vein in 77.7%, with isolated portal vein thrombosis (PVT) (44.4%) and PVT extending to the superior mesenteric vein (30.5%). Liver abscesses were detected in 50% of cases, with positive aspirate cultures in 92.3%. Treatment included penicillin/penicillin-lactamase inhibitors alone (17%) and ertapenem alone (17%). Abscess drainage (13/18) resulted in complete/near-complete resolution in 83%. Long-term anticoagulation therapy was given in 75% of cases, commonly using vitamin K antagonists (59.2%). No deaths occurred.

Conclusion

The GI variant of LS should be considered in patients with abdominal pain, fever, leukocytosis, and portal/superior mesenteric vein thrombosis. Identifying Fusobacterium species in blood cultures and liver abscesses further supports the diagnosis. Management involves antibiotic therapy, abscess drainage, and long-term anticoagulation.

Increasing trend of endoscopic drainage utilization for the management of pancreatic pseudocyst: insights from a nationwide database

BACKGROUND/AIMS

The pancreatic pseudocyst (PP) is a type of fluid collection that typically develops as a delayed complication of acute pancreatitis. Drainage is indicated for symptomatic patients and/or associated complications, such as infection and bleeding. Drainage modalities include percutaneous, endoscopic, laparoscopic, and open drainage. This study aimed to assess trends in the utilization of different drainage modalities for treating PP from 2016 to 2020. The trends in mortality, mean length of hospital stay, and mean hospitalization costs were also assessed.

METHODS

The National Inpatient Sample database was used to obtain data. The variables were generated using International Classification of Diseases-10 diagnostic and procedural codes.

RESULTS

Endoscopic drainage was the most commonly used drainage modality in 2018-2020, with an increasing trend over time (385 procedures in 2018 to 515 in 2020; p=0.003). This is associated with a decrease in the use of other drainage modalities. A decrease in the hospitalization cost for PP requiring drainage was also noted (29,318 United States dollar [USD] in 2016 to 18,087 USD in 2020, p<0.001).

CONCLUSION

Endoscopic drainage is becoming the most commonly used modality for the treatment of PP in hospitals located in the US. This new trend is associated with decreasing hospitalization costs.

Etiology, diagnostic modalities, and short-term outcomes of hemoptysis-a retrospective cross-sectional study from a tertiary care center in Qatar

Background

Hemoptysis is a concerning symptom characterized by the expectoration of blood from the respiratory tract, which can range from mild to life-threatening. It can be caused by various underlying conditions. Accurate diagnosis is critical for effective management. The causes of hemoptysis can vary depending on geographic location and the population's composition. In this study, we aimed to examine the etiology, diagnostic methods, and short-term outcomes of hemoptysis in Qatar, focusing on data from Hamad General Hospital (HGH), which serves as a major tertiary care center in the country. Qatar has a diverse and dynamic population, primarily composed of expatriate workers, especially from South Asia. Previous data on hemoptysis in Qatar was collected between 1997 and 2007, when the population was considerably smaller and less diverse. Given the substantial growth in population and diversity since then, this study sought to provide updated information on the causes and outcomes of hemoptysis in the region.

Methods

This is a retrospective single center observational data review from the largest tertiary care center of Qatar, HGH. Patients who presented to HGH from 01/07/2015 to 30/06/2018 with hemoptysis were included in the study. Descriptive and summary statistics were described and analyzed using SPSS version 23.

Results

A total of 172 patients met the inclusion criteria. Most of the patients were male (74.4%) with a mean age of 37.9±16.4 years. South Asians (43.6%) accounted for the majority followed by Qatari nationals (20.3%). Mild hemoptysis was recorded in 89.5% of patients while only 3.5% had severe hemoptysis. The mean duration of hemoptysis was 1.72±0.72 days. The most common etiology was respiratory infection in 72.6% of the patients followed by tuberculosis (TB) and bronchiectasis 7% each. All patients were managed with observation or antimicrobials except two of the patients with severe hemoptysis who required bronchial artery embolization (BAE). There were no reports of recurrence of hemoptysis or deaths until hospital discharge.

Conclusions

Respiratory infection is the most common cause of hemoptysis at our center. Mild hemoptysis is the major presentation and the majority improved with conservative treatment.

Clinical characteristics and outcomes of autoimmune pancreatitis based on serum immunoglobulin G4 levels: A single-center, retrospective cohort study

Autoimmune pancreatitis (AIP) is a complex, poorly understood disease gaining increasing attention. "Clinical Characteristics and Outcome of AIP Based on Serum IgG4 levels," investigated AIP with a focus on serum immunoglobulin (Ig) G4 levels. The 213 patients with AIP were classified according to serum IgG4 levels: Abnormal (elevated) and normal. Patients with higher IgG4 levels exhibited a more active immune system and increased relapse rates. Beyond IgG4, the IgA levels and age independently contributed to relapse risk, guiding risk assessment and tailored treatments for better outcomes. However, limitations persist, such as no IgA correlation with IgG4 levels, absent data on autoantibody-positive AIP cases critical for Asian diagnostic criteria, and unexplored relapse rates in high serum IgG AIP by subtype. Genetic factors and family histories were not addressed. As the understanding and referral of seronegative AIPs increase, there's a growing need for commercially available, highly sensitive, and specific autoantibodies to aid in diagnosing individuals with low or absent serum IgG4 levels.

Impact of COVID-19 infection on patients admitted with nonvariceal upper gastrointestinal bleeding: an analysis from the National Inpatient Sample

Background

Nonvariceal upper gastrointestinal bleeding (NVUGIB) is a medical emergency that has significant morbidity and mortality. The available data about the impact of COVID-19 infection on mortality in patients with NVUGIB is limited.

Methods

We identified all hospitalizations with a principal diagnosis of NVUGIB in 2020. The baseline characteristics and clinical outcomes of patients with COVID-19 infection were compared to those without COVID-19 infection.

Results

NVUGIB patients with COVID-19 infection had higher mortality (5% vs 2%, P < 0.0001), a longer mean length of stay (6.85 vs 4.48 days, P < 0.0001), and a lower rate of esophagogastroduodenoscopy utilization (40% vs 51%, P < 0.0001) than those without COVID-19 infection. Multivariate logistic regression analysis showed that COVID-19 infection was associated with a higher mortality rate (odds ratio 2.2, 95% confidence interval, 1.4-3.4).

Conclusions

COVID-19 infection is an independent predictor of mortality in adults hospitalized with NVUGIB.

Endoscopic Versus Conservative Therapy for Bleeding Peptic Ulcer with Adherent Clot: A Comprehensive Systematic Review and Meta-Analysis

INTRODUCTION

Peptic ulcers with adherent clots are associated with a high-risk of rebleeding and mortality. However, the optimal management of bleeding ulcers with adherent clots remains unclear. We conducted this systematic review and meta-analysis to compare endoscopic therapy and conservative therapy to manage bleeding ulcers with adherent clots.

METHODS

We systematically searched PubMed, Embase, and Web of Science databases through October 2022 to include all studies comparing the endoscopic and conservative therapeutic approaches for bleeding ulcers with adherent clots. Our primary outcome was rebleeding (overall and 30-day). The secondary outcomes were mortality (overall and 30-day), need for surgery, and length of hospital stay (LOS). The random-effects model was used to calculate the pooled odds ratios (OR) and mean differences (MD) with the corresponding confidence intervals (CI) for proportional and continuous variables, respectively.

RESULTS

Eleven studies (9 RCTs) with 833 patients (431 received endoscopic therapy vs. 402 received conservative therapy) were included. Overall, endoscopic therapy was associated with lower overall rebleeding (OR 0.41, 95% CI 0.22-0.79, P = 0.007), 30-day rebleeding (OR 0.43, 95% CI 0.21-0.89, P = 0.002), overall mortality (OR 0.47, 95% CI 0.23-0.95, P = 0.04), 30-day mortality (OR 0.43, 95% CI 0.21-0.89, P = 0.002), need for surgery (OR 0.44, 95% CI 0.21-0.95, P = 0.04), and LOS (MD - 3.17 days, 95% CI - 4.14, - 2.19, P < 0.00001). However, subgroup analysis of randomized controlled trials (RCTs) showed no significant difference in overall mortality (OR 0.78, 95% CI 0.24-2.52, P = 0.68) between the two strategies, with numerically lower but statistically non-significant rates of overall rebleeding (7.2% vs. 18.5%, respectively; OR 0.42, 95% CI 0.17-1.05, P = 0.06), statistically lower rate of need for surgery (OR 0.28, 95% CI 0.08-0.96, P = 0.04) with endoscopic therapy compared to conservative therapy.

CONCLUSIONS

Our meta-analysis demonstrates that endoscopic therapy was overall associated with lower rates of rebleeding (overall and 30-day), mortality (overall and 30-day), need for surgery, and LOS, compared to conservative therapy for the management of bleeding ulcers with adherent clots. However, subgroup analysis of RCTs showed that endoscopic therapy was associated with numerically lower but statistically non-significant rates of overall rebleeding and a statistically lower rate of need for surgery compared to conservative therapy with similar overall mortality rates. Combined treatment with thermal therapy and injection therapy was the most effective treatment modality in reducing rebleeding risk. Further large-scale RCTs are needed to validate our findings.

Primary sclerosing cholangitis hospitalizations in the United States: characteristics and predictors of clinical outcomes

Background

Primary sclerosing cholangitis (PSC) is a chronic progressive disease that primarily affects the medium and large biliary ducts.

Methods

This study investigated the baseline characteristics and predictors of clinical outcomes among hospitalized patients with PSC in the US. Using the National Inpatient Sample database from 2018 to 2020, we included adults with a principal diagnosis of PSC.

Results

Our study included 2585 adult hospitalizations. The prevalence of cirrhosis, ulcerative colitis (UC), Crohn's disease (CD), and cholangiocarcinoma among hospitalized PSC patients was 44.5%, 32.3%, 13.15%, and 5.2%, respectively. Over a third of patients (38.1%) underwent endoscopic retrograde cholangiopancreatography (ERCP). UC, CD, cholangiocarcinoma, and autoimmune hepatitis had no impact on mortality, length of stay, or ERCP utilization. Interestingly, individuals of Asian/Pacific Islander ethnicity had higher odds of undergoing ERCP compared to White ethnicity (odds ratio 4.67, 95% confidence interval 1.25-17.4). Conversely, patients with cirrhosis and liver transplant recipients were less likely to undergo ERCP.

Conclusion

This is the first nationwide study to assess the clinical characteristics and outcomes of hospitalized patients with PSC. It highlights various factors associated with increased utilization of ERCP, longer length of stay, and increased inpatient mortality. Further research is warranted to explore these associations.

Clostridioides difficile Infection in COVID-19 Hospitalized Patients: A Nationwide Analysis

Background

Clostridioides difficile infection (CDI) is a significant healthcare-associated infection with implications for patient morbidity, mortality, and healthcare costs. However, the connection between CDI and coronavirus disease 2019 (COVID-19) infection and its influence on patient outcomes remain uncertain. This study aimed to examine the association between CDI and COVID-19, specifically investigating whether CDI worsens outcomes in patients with COVID-19. By utilizing the extensive National Inpatient Sample (NIS) database and analyzing pertinent factors, this research endeavored to enhance our understanding of CDI within the context of COVID-19.

Methods

The NIS database was searched for adult patients hospitalized with a primary diagnosis of COVID-19 infection in 2020. Patients with a secondary diagnosis of CDI were identified and separated into two groups based on CDI status. Baseline characteristics, Charlson Comorbidity Index (CCI), and outcomes were compared between the two groups using Chi-square and t-tests. Multivariate logistic and linear regressions were performed for the identification of independent predictors of CDI and mortality.

Results

A total of 1,045,125 COVID-19 hospitalizations were included, of which 4,920 had a secondary diagnosis of CDI. Patients with CDI and COVID-19 were older (mean age 69.9 vs. 64.2 years; P < 0.001), more likely to be female (54.1% vs. 47.1%; P < 0.001) and white (60% vs. 52.4%; P < 0.001). The CDI and COVID-19 group had a longer length of stay (14.1 vs. 7.42 days; P < 0.001), higher total hospital costs ($42,336 vs. $18,974; P < 0.001), and higher inpatient mortality (21.6% vs. 11%; P < 0.001) compared to the COVID-19 group without CDI. Patients in the CDI and COVID-19 group had a higher CCI score (51.7% with a score of 3 or more vs. 27.7%; P < 0.001), indicating a higher comorbidity burden. Multivariate logistic regression analysis revealed CDI was independently associated with increased mortality (odds ratio (OR) 1.37; P = 0.001) and showed that the female gender and several pre-existing comorbidities were associated with a higher likelihood of CDI.

Conclusion

CDI is independently associated with increased mortality in patients admitted with COVID-19 infection. Female gender and several pre-existing comorbidities are independent predictors of CDI in COVID-19 patients.

Choledocholithiasis Can Present with Marked Transaminases Elevation: Systematic Review and Meta-Analysis

BACKGROUND

Extreme transaminase elevation > 1000 international units per liter (IU/L) is typically caused by hepatocellular injury due to ischemia, drugs, or viral infection. Acute choledocholithiasis can also present with marked transaminase elevation mimicking severe hepatocellular injury, contrary to the presumed cholestatic pattern.

METHODS

We searched PubMed/Medline, EMBASE, Cochrane Library, and Google Scholar for studies reporting the proportion of marked elevation of alanine aminotransferase (ALT) or aspartate aminotransferase (AST) > 1000 IU/L in patients with common bile duct (CBD) stones. A proportion meta-analysis with a corresponding 95% confidence interval (CI) was used to pool the proportion of patients with extreme transaminase elevation. I² was used to examine heterogeneity. We used CMA software utilizing a random effect model for statistical analysis.

RESULTS

Three studies (n = 1328 patients) were included in our analysis. The reported frequency of ALT or AST > 1000 IU/L in choledocholithiasis patients ranged between 6 and 9.6%, with pooled frequency of 7.8% (95% CI 5.5-10.8%, I² 61%). The frequency of patients with ALT or AST > 500 IU/L was higher, ranging between 28 and 47%, with pooled frequency of 33.1% (95% CI 25.3-42%, I² 88%).

CONCLUSION

This is the first meta-analysis to study prevalence of severe hepatocellular injury in patients with CBD stones. Results revealed that approximately one-third of patients with choledocholithiasis present with ALT or AST > 500 IU/L. Furthermore, levels > 1000 IU/L are not uncommon. An elaborate work-up for alternative etiologies of severe transaminase elevation is likely unwarranted in cases with clear evidence of choledocholithiasis.

Rhabdomyolysis in the Setting of Severe Hyponatremia: A Case Report

Electrolyte imbalances are common problems among hospitalized patients, and they can have severe consequences. Although rare, severe hyponatremia or low sodium (Na) levels have been associated with the occurrence of rhabdomyolysis. This is a case of a 45-year-old man who presented with confusion and lethargy and was found to have severe hyponatremia with an elevated creatine phosphokinase (CPK) level of 45,440 IU/L. With the administration of normal saline, the Na levels and CPK improved. He was discharged from the hospital in stable clinical condition. This case demonstrates the need for providers to monitor rhabdomyolysis markers in severe hyponatremia, as there is an observed association between the two and the sequelae can be severe.

Lumen-Apposing Metal Stent With and Without Concurrent Double-Pigtail Plastic Stent for Pancreatic Fluid Collections: A Comparative Systematic Review and Meta-Analysis

Background

Lumen-apposing metal stents (LAMSs) are often used to drain pancreatic fluid collections (PFCs). However, adverse events, such as stent obstruction, infection, or bleeding, have been reported. Concurrent double-pigtail plastic stent (DPPS) deployment has been suggested to prevent these adverse events. This meta-analysis aimed to compare the clinical outcomes of LAMS with DPPS vs. LAMS alone in the drainage of PFCs.

Methods

An extensive search was conducted in the literature to include all the eligible studies that compared LAMS with DPPS vs. LAMS alone for drainage of PFCs. Pooled risk ratios (RRs) with the 95% confidence intervals (CIs) were obtained within a random-effect model. The outcomes were technical and clinical success, and overall adverse events, including stent migration and occlusion, bleeding, infection, and perforation.

Results

Five studies involving 281 patients with PFCs (137 received LAMS plus DPPS vs. 144 received LAMS alone) were included. LAMS plus DPPS group was associated with comparable technical success (RR: 1.01, 95% CI: 0.97 - 1.04, P = 0.70) and clinical success (RR: 1.01, 95% CI: 0.88 - 1.17). Lower trends of overall adverse events (RR: 0.64, 95% CI: 0.32 - 1.29), stent occlusion (RR: 0.63, 95% CI: 0.27 - 1.49), infection (RR: 0.50, 95% CI: 0.15 - 1.64), and perforation (RR: 0.42, 95% CI: 0.06 - 2.78) were observed in LAMS with DPPS group compared to LAMS alone but without a statistical significance. Stent migration (RR: 1.29, 95% CI: 0.50 - 3.34) and bleeding (RR: 0.65, 95% CI: 0.25 - 1.72) were similar between the two groups.

Conclusions

Deployment of DPPS across LAMS for drainage of PFCs has no significant impact on efficacy or safety outcomes. Randomized, controlled trials are necessary to confirm our study results, especially in walled-off pancreatic necrosis.

Transjugular Intrahepatic Portosystemic Shunt With or Without Gastroesophageal Variceal Embolization for the Prevention of Variceal Rebleeding: A Systematic Review and Meta-Analysis

Background

The role of variceal embolization (VE) during transjugular intrahepatic portosystemic shunt (TIPS) creation for preventing gastroesophageal variceal rebleeding remains controversial. Therefore, we performed a meta-analysis to compare the incidence of variceal rebleeding, shunt dysfunction, encephalopathy, and death between patients treated with TIPS alone and those treated with TIPS in combination with VE.

Methods

We performed a literature search using PubMed, EMBASE, Scopus, and Cochrane databases for all studies comparing the incidence of complications between TIPS alone and TIPS with VE. The primary outcome was variceal rebleeding. Secondary outcomes include shunt dysfunction, encephalopathy, and death. Subgroup analysis was performed based on the type of stent (covered vs. bare metal). The random-effects model was used to calculate the relative risk (RR) with the corresponding 95% confidence intervals (CIs) of outcome. A P value < 0.05 was considered statistically significant.

Results

Eleven studies with a total of 1,075 patients were included (597: TIPS alone and 478: TIPS plus VE). Compared to the TIPS alone, the TIPS with VE had a significantly lower incidence of variceal rebleeding (RR: 0.59, 95% CI: 0.43 - 0.81, P = 0.001). Subgroup analysis revealed similar results in covered stents (RR: 0.56, 95% CI: 0.36 - 0.86, P = 0.008) but there was no significant difference between the two groups in the subgroup analysis of bare stents and combined stents. There was no significant difference in the risk of encephalopathy (RR: 0.84, 95% CI: 0.66 - 1.06, P = 0.13), shunt dysfunction (RR: 0.88, 95% CI: 0.64 - 1.19, P = 0.40), and death (RR: 0.87, 95% CI: 0.65 - 1.17, P = 0.34). There were similarly no differences in these secondary outcomes between groups when stratified according to type of stent.

Conclusions

Adding VE to TIPS reduced the incidence of variceal rebleeding in patients with cirrhosis. However, the benefit was observed with covered stents only. Further large-scale randomized controlled trials are warranted to validate our findings.

Endoscopic ultrasound guided access procedures following surgery

EUS-guided therapeutic procedures have emerged in the recent years as a minimally invasive option for the management of complex hepatobiliary disorders. Gastrointestinal surgeries, e.g., pancreaticoduodenectomy, Roux-en-Y Gastric Bypass, Roux-en-Y hepaticojejunostomy, and partial gastrectomy with different reconstructions are commonly performed for a wide range of indications that include tumour resections and weight loss. Conventional endoscopic procedures are challenging in those patients due to inaccessible or unreachable ampulla. Patients with surgically altered anatomy are good candidates for EUS-guided access procedures that have shown good technical and clinical success rates. This category of procedures includes EUS-guided biliary drainage, EUS-guided pancreatic drainage, EUS-directed transgastric ERCP (EDGE) and EUS-guided Gastroenterostomy. Studies have shown that these procedures have comparable or better results than traditional endoscopic, interventional radiology-guided and surgical procedures. This article discusses the indications, technique and outcome of the different EUS-guided access procedures in patients with surgically altered anatomy.