Discharge protocol in acute pancreatitis: an international survey and cohort analysis

There are several overlapping clinical practice guidelines in acute pancreatitis (AP), however, none of them contains suggestions on patient discharge. The Hungarian Pancreatic Study Group (HPSG) has recently developed a laboratory data and symptom-based discharge protocol which needs to be validated. (1) A survey was conducted involving all members of the International Association of Pancreatology (IAP) to understand the characteristics of international discharge protocols. (2) We investigated the safety and effectiveness of the HPSG-discharge protocol. According to our international survey, 87.5% (49/56) of the centres had no discharge protocol. Patients discharged based on protocols have a significantly shorter median length of hospitalization (LOH) (7 (5;10) days vs. 8 (5;12) days) p < 0.001), and a lower rate of readmission due to recurrent AP episodes (p = 0.005). There was no difference in median discharge CRP level among the international cohorts (p = 0.586). HPSG-protocol resulted in the shortest LOH (6 (5;9) days) and highest median CRP (35.40 (13.78; 68.40) mg/l). Safety was confirmed by the low rate of readmittance (n = 35; 5%). Discharge protocol is necessary in AP. The discharge protocol used in this study is the first clinically proven protocol. Developing and testifying further protocols are needed to better standardize patients' care.

Fully Covered Metal Stents Safely Facilitate Extraction of Difficult Bile Duct Stones

BACKGROUND

Ten to 15% of the common bile duct (CBD) stones require advanced endoscopic extraction techniques during endoscopic retrograde cholangiopancreatography. The study aimed to evaluate the efficacy and safety of fully covered self-expandable metal stents (FC-SEMS) for facilitating the extraction of difficult bile duct stones.

METHODS

Patients who received FC-SEMS for the extraction of difficult CBD stones were retrospectively reviewed. Group 1 included patients with extrahepatic stones above a distal CBD stricture, Group 2 included patients with intrahepatic stones above a hilar stricture, and Group 3 included patients with complex stone(s) and no biliary stricture. Complete stone clearance rate and complications of FC-SEMS treatment were evaluated.

RESULTS

The study group included 33 procedures on 32 patients (mean age: 55±17, 56.3% male). FC-SEMS was placed as a primary treatment in 15 (45.5%) procedures. Complete stone clearance was achieved in 84.6% of the procedures in Group 1, 100% in Group 2, and 87.5% in Group 3 ( P =0.23). Overall, complete stone clearance was achieved in 30 of the 33 procedures (90.9%). None of the patients developed pancreatitis, cholecystitis, or cholangitis. Stent migration occurred in 4 procedures (12.1%), and all were clinically insignificant.

CONCLUSION

FC-SEMS is effective and safe for facilitating treatment of difficult bile duct stones.

The Classification of Biliary Strictures in Patients With Right-Lobe Liver Transplant Recipients and Its Relation to Traversing the Stricture With a Guidewire

BACKGROUND

Traversing the stricture with a guidewire is a prerequisite for the endoscopic treatment of biliary strictures after living donor liver transplantation. We aimed to evaluate the effect of variations in the biliary anastomosis and strictures on the success of endoscopic treatment and suggest a cholangiographic classification.

METHODS

The 125 strictures among the 104 patients with right-lobe living donor liver transplantation were reviewed. The strictures were classified by the anastomosis pattern according to the number (1, 2, or >2), location (common bile, hepatic, or cystic duct), the angle between the proximal and distal sites of the anastomosis, and the contrast enhancement pattern. The relationship between the success rate of traversing the anastomosis and the classification was evaluated.

RESULTS

Of the 125 biliary strictures, 86 (68.8%) could be passed via endoscopically. Thirty-three strictures were managed either percutaneously (n = 13) or by magnetic compression anastomosis (n = 20). Compared with the round, the triangular (odds ratio [OR], 6.5), the intermediate form (OR, 17.7), and the end-to-side anastomosis (OR, 5.1) were associated with an increased chance of traversing. The contrast enhancement pattern of the strictures and the bile ducts was also related to the successful rate of the endoscopic treatment (P < 0.001). The success rate was higher in the patients with the angle between the proximal and distal sites of the anastomosis approximated was small (0°-30° = 74%, 30°-60° = 69%, 60°-90° = 63%, >90° = 41%).

CONCLUSIONS

The type of biliary anastomoses and stricture affect the success rate of endoscopic treatment. These data may play role in making decision about the type of anastomosis during the surgery.

Hepatitis B reactivation after oral capecitabine treatment in a rectum cancer patient with isolated anti-HBc IgG positivity

INTRODUCTION

Hepatitis B virus (HBV) reactivation in the setting of chemotherapy and immunosuppressive therapy is associated with significant morbidity and mortality. Herein we present a case of HBV reactivation after oral capecitabine treatment in a patient with rectum cancer and isolated anti-HBc IgG positivity.

CASE REPORT

A 57-year-old man was consulted from the oncology clinic because of increased serum liver tests after chemotherapy. He underwent surgery for early-stage rectal cancer and received adjuvant chemotherapy with oral capecitabine. After cessation of chemotherapy, his laboratory tests revealed severe liver dysfunction. HBV markers showed positivity for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc). HBV DNA level was markedly elevated.

MANAGEMENT AND OUTCOME

A review of medical records revealed that, before chemotherapy, the patient was positive for anti-HBc IgG but negative for HBsAg, and serum aminotransferases were within the normal limits. A diagnosis of HBV-related hepatitis due to capecitabine use was made, and the patient was put on tenofovir treatment. Six months later, HBV DNA decreased, and liver function tests were normalized.

DISCUSSION

To the best of our knowledge, this is the first case report describing HBV reactivation after chemotherapy with capecitabine for rectal cancer in a patient with isolated anti-HBc IgG positivity. Our case shows that HBV reactivation may develop in a low-risk patient with a low degree of immunosuppression.

Comparison of Tenofovir Disoproxil Fumarate and Entecavir in the Prophylaxis of HBV Reactivation

INTRODUCTION

Current guidelines recommend starting antiviral prophylaxis to prevent hepatitis B virus (HBV) reactivation in patients receiving immunosuppressive treatments (IST). The aim of this study was to compare the efficacy of entecavir (ETV) and tenofovir disoproxil fumarate (TDF) for prophylaxis.

METHODS

Patients, who were HBsAg and/or anti-HBc IgG positive and scheduled to receive IST for oncologic and hematologic diseases, were enrolled into the study. Those who were already receiving an antiviral treatment for HBV or had an associated HIV, hepatitis C, D were excluded. The remaining patients with a prophylaxis indication according to the AGA guideline were randomized to receive either ETV (0.5 mg/day) or TDF (245 mg/day). Prophylaxis was continued for 6-12 months after completion of IST. Patients were followed up for 1 year after completion of prophylaxis. The HBV reactivation rates and side effects of the drugs were compared.

RESULTS

The study group included 120 patients. There was no significant difference between the demographic data, viral serologic parameters and reactivation risk profiles of the ETV (n = 60) and TDF (n = 60) groups. Forty-one patients in the ETV and 36 in the TDF group completed the antiviral prophylaxis, and no HBV reactivation was observed. HBV reactivation was observed in 4 of 37 patients (10.8%) in the ETV group and 5 of 35 (14.3%) patients in the TDF group (including one with flare) during the follow-up after completion of prophylaxis. Ten patients in the ETV group (16.7%) and 14 patients (23.3%) in the TDF group experienced side effects (p = 0.77). One patient in the TDF group had to switch to ETV due to severe itchy, maculopapular rash-like lesions.

CONCLUSIONS

ETV and TDF had a similar efficacy in the prophylaxis of HBV reactivation in patients undergoing IST, with none of the patients experiencing reactivation.

A Simple Method for Endoscopic Treatment of Large Gastric Phytobezoars: "Hand-Made Bezoaratome"

BACKGROUND

Large gastric phytobezoars are generally resistant to standard chemical or endoscopic treatments. We presented our experience of an alternative endoscopic method using a hand-made tool called a "hand-made bezoaratome" for the treatment of large gastric phytobezoars.

METHODS

Patients who consulted or who were diagnosed with gastric bezoars at an education and research hospital between January 2015 and December 2018 were prospectively included in the study. Patients with phytobezoars of 50 mm and larger were included in the study. Patients with trichobezoars, lactobezoars, pharmacobezoars, under 18 years of age, and pregnant women were excluded. A 0.25 mm diameter guidewire and a mechanical lithotripter sheath were used to prepare the "hand-made bezoaratome." After the first procedure, patients were advised to consume 2500 mL of Coca Cola® or the same amount of pineapple juice per day, until the next procedure. Endoscopic procedures were performed at 5-day intervals until complete reabsorption of the bezoar was achieved. Patients were followed up for 6 weeks.

RESULTS

The study group included 37 (21 males, mean age: 57.6 ± 12.5 years) patients. The median size of the phytobezoars was 71 mm (50-90). The median endoscopic procedure time was 853 s (380-1940 s). The success rate for endoscopic fragmentation was found to be 100%. No major complications occurred during the endoscopic procedures, but 1 patient (2.7%) required surgery for ileus due to an obstruction at the distal part of the jejunum, 61 h after the second endoscopic session. The overall success rate of the endoscopic treatment was 97.3%.

CONCLUSION

Using a "hand-made bezoaratome" is effective and reliable for the endoscopic treatment of large gastric bezoars.

The Importance of Eosinopenia for Predicting Treatment Response in Patients with Cholangitis

OBJECTIVE

To compare recovery of eosinopenia, C-reactive protein (CRP) and procalcitonin levels in predicting the response to treatment in patients with cholangitis.

STUDY DESIGN

Descriptive, analytical study.

PLACE AND DURATION OF STUDY

Department of Gastroenterology, Sakarya Training and Research Hospital, Turkey between September 2018 and February 2019.

METHODOLOGY

 Patients with cholangitis, who underwent endoscopic retrograde cholangiopancreatography (ERCP), were inducted. Those with choledocholic thiasis alone were considered controls. Eosinophil count above 100.5 cells/µL was the limit value accepted as improvement. ERCP repeat was decided according to eosinophil count below 100.5 and not clinically improving. Relationship between inflammatory markers such as CRP, procalcitonin and eosinopenia values in patients with stone-associated cholangitis was investigated.

RESULTS

The cholangitis group was comprised of 62 patients [mean age 67±14.57 years; 26 (41.9%) female], while control group was comprised  of 57 patients [mean age 57.4±18.10 years; 39 (68.4%) females, p=0.004]. At time of admission, median eosinophils was significantly lower in cholangitis group at 17.50 [9.82-84] ×103/µL compared to control group at 168 [100.11-270] ×103/µL (p=0.001). ERCP were repeated on two patients as their clinical conditions and unremitting eosinophil counts worsened. Eosinophil and CRP markers and clinical improvement were observed after  second ERCP procedure.

CONCLUSION

Eosinopenia may be used as inflammatory marker in  evaluation of response to treatment and for predicting the need to repeat ERCP during clinical follow-up of patients who undergo cholangitis treatment. Key Words: Cholangitis, C-reactive protein, Endoscopic retrograde cholangiopancreatography, Eosinopenia, Procalcitonin.

HBV flare associated with immunosuppressive treatments: it is still dangerous in the third-generation antivirals era

BACKGROUND

There are limited data about the mortality and morbidity of patients with HBV flare related to immunosuppressive treatments (IST) in the third-generation antivirals era. Herein, we performed a multi-centric study in patients treated with entecavir (ETV) or tenofovir disoproxil fumarate (TDF) and evaluated their clinical course.

METHODS

The study group included patients who were referred to gastroenterology or infectious disease specialists at eight different hospitals in Turkey. HBV flare was defined as at least a threefold elevation in alanine aminotransferase (ALT) levels above the upper limit of normal range. The demographic data, IST protocol, virological markers, liver tests, international normalized ratio (INR), HBV DNA, reactivation risk profile according to AGA guideline, MELD and MELD-Na scores were retrospectively evaluated. The primary aim of the study was to determine the liver-related mortality, including transplantation, at 12 weeks and factors predicting it. Secondary aims were to compare ETV and TDF with respect to mortality and time to ALT, bilirubin normalization and HBV DNA undetectability.

RESULTS

The study group included 40 patients (29 males, mean age: 57 ±12 years). Twenty-five patients (62.5%) had a high risk of reactivation. Twenty-six patients received TDF and 14 patients received ETV treatment. Eight (20%) patients developed acute liver failure and one patient (2.5%) underwent living donor liver transplantation. Seven patients died due to liver-related complications, revealing a mortality rate of 17.5%. In multivariate analysis, total bilirubin levels at the onset, ALT levels and delta-MELD score at the first week were the independent risk factors for liver related mortality (HR: 1.222, 1.003, 1.253 and 95% CI: 1.096, 1.362; 1.001, 1.004 and 1.065, 1.470, respectively). There was no significant difference between the TDF and ETV groups with respect to time to normalize ALT and bilirubin levels, HBV DNA undetectability and mortality rates (16% and 21.4%, respectively).

CONCLUSIONS

HBV flare associated with IST has a high mortality in the third-generation antivirals era. High total bilirubin at the onset and high ALT and delta-MELD score at the first week predict poor prognosis.

Comparison of monopolar hemostatic forceps with soft coagulation versus hemoclip for peptic ulcer bleeding: a randomized trial (with video)

BACKGROUND AND AIMS

Although various methods are used in the treatment of peptic ulcer bleeding, there is not a standard recommended approach. The choice depends on multiple factors such as location of the ulcer, clinical experience of the endoscopist, and local facilities of the clinic. We aimed to compare the efficacy of monopolar hemostatic forceps soft coagulation (MHFSC) and hemoclips (HCs) in the treatment of peptic ulcer-related upper GI bleeding.

METHODS

The study group included patients who had GI bleeding due to Forrest 1a, 1b, and 2a gastric or duodenal ulcers within 1 year. Patients with bleeding diathesis, history of gastrectomy, pregnancy, or younger than age 18 years were excluded. The remaining were randomized to MHFSC and HC treatment groups and compared in terms of clinical and endoscopic features, initial hemostasis success rates, recurrent bleeding rates within the first 7 days, time to achieve hemostasis, length of hospitalization stay, and adverse events.

RESULTS

One hundred twelve patients were randomized to MHFSC (n = 56) and HC (n = 56) groups. There was no statistically significant difference between the groups with respect to demographic features, medications, underlying chronic diseases, location, and Forrest classification of the ulcers. The initial hemostasis success rate was 98.2% (55/56) in the MHFSC group and 80.4% (45/56) in the HC group (P = .004). Recurrent bleeding was detected in 2 patients in the MHFSC group (3.6%) and 8 patients in the HC group (17.7%; P = .04). The duration of endoscopic procedures (302 ± 87.8 vs 568 ± 140.4 seconds) and the length of hospital stay (3.50 ± 1.03 vs 4.37 ± 1.86 days) were significantly shorter in the MHFSC group. There were no adverse events in either group.

CONCLUSIONS

MHFSC is more effective in achieving initial hemostasis compared with HCs in the treatment of peptic ulcer bleeding and provides a shorter procedure time and a lower recurrent bleeding rate.

Pulmonary Manifestations among Patients with Primary Biliary Cirrhosis

Primary biliary cirrhosis (PBC) is a chronic progressive cholestatic liver disease caused by diffuse inflammation, destruction and fibrosis of the intrahepatic bile ducts, ultimately leading to cirrhosis, portal hypertension and liver failure. The pathogenesis of PBC is incompletely understood, but current data suggest roles for genetic susceptibility and environmental factors. PBC is often thought of as an organ-specific autoimmune disease, which mainly targets the liver; however, lung tissue is also a site for autoimmune involvement of PBC. The pulmonary manifestations of PBC include abnormalities in gas transfer and pulmonary function, subclinical alveolitis, interstitial lung disease, granulomatous lung disease, airway disease, pulmonary hypertension, pulmonary hemorrhage and pleural effusion.

The Prevalence of Barrett Esophagus Diagnosed in the Second Endoscopy: A Retrospective, Observational Study at a Tertiary Center

At present, we do not know the exact prevalence of Barrett esophagus (BE) developing later in patients without BE in their first endoscopic screening. The purpose of this study was to determine the prevalence of BE on the second endoscopic examination of patients who had no BE in their first endoscopic examination.The data of the patients older than 18 years who had undergone upper gastrointestinal system endoscopy more than once at the endoscopy unit of our clinic during the last 6 years were retrospectively analyzed.During the last 6 years, 44,936 patients had undergone at least one endoscopic examination. Among these patients, 2701 patients who had more than one endoscopic screening were included in the study. Of the patients, 1276 (47.3%) were females and 1425 (52.7%) were males, with an average age of 54.9 (18-94) years. BE was diagnosed in 18 (0.66%) of the patients who had no BE in the initial endoscopic examination. The patients with BE had reflux symptoms in their medical history and in both endoscopies, they revealed a higher prevalence of lower esophageal sphincter laxity, hiatal hernia, and reflux esophagitis when compared to patients without BE (P < 0.001).Our study showed that in patients receiving no diagnosis of BE on their first endoscopic examination performed for any reason, the prevalence of BE on their second endoscopy within 6 years was very low (0.66%).

Can Serum ST2 Levels Be Used as a Marker of Fibrosis in Chronic Hepatitis B Infection?

Interleukin 33 (IL-33) is a cytokine belonging to the IL-1 superfamily. Soluble ST2 (sST2) binds to IL-33 and by functioning as trap receptor inhibits signal sending to Th2 via transmembrane ST2. Because Th2-type cytokines play an important role in fibrosis, the aim of this study is to determine whether sST2 can be used as a marker of fibrosis in chronic hepatitis B (CHB) patients or not.The study included 19 healthy controls, 54 patients with CHB, and 14 patients with cirrhosis because of CHB. The aspartate aminotransferase-to-platelet ratio index (APRI) and fibrosis index based on the 4 factors (FIB-4) scores also calculated, and correlations between liver biopsies, sST2 levels, and these scores were analyzed in CHB and cirrhosis patients.The sST2 levels in patients with CHB were significantly higher than those in the control group subjects (median: 1133 pg/mL vs 762.5 pg/mL, respectively [P = 0.035]). In CHB patients, the METAVIR fibrosis score (stages from 0 to 4) showed a moderate correlation with serum sST2 level (r = 0.396, P = 0.004) and a weak correlation with FIB-4 score (r = 0.359, P = 0.008), but no correlation with APRI score (r = 0.253, P = 0.06). The under the curve value of serum sST2 was 0.68, and its prediction of significant fibrosis (METAVIR score ≥2) in values >674 pg/mL had a sensitivity of 91.7% and specificity of 40% (P = 0.009). According to multiple logistic regression analysis, only METAVIR fibrosis stage was found to be an independent predictor of serum sST2 elevation in CHB patients (P = 0.04).The sST2 level can be used for differentiating significant fibrosis from mild fibrosis in CHB patients. However, the efficacy of this marker should be verified by larger studies in the future.

Endoscopic retrograde cholangiopancreatography in patients with Billroth II gastroenterostomy

BACKGROUND AND AIM

Endoscopic retrograde cholangiopancreatography (ERCP) is more complicated in patients with Billroth II gastroenterostomy (B II GE) especially in those associated with Braun anastomosis (BA). The aim of the present study was to review experience of ERCP in patients with B II GE.

METHODS

The records of patients with B II GE who had undergone an ERCP within the last 2.5 years were retrospectively evaluated.

RESULTS

Fifty-two patients with simple B II GE and seven with additional BA underwent ERCP within this period. The probability of common bile duct cannulation and success of endoscopic treatment was 43/52 (83%) and 2/7 (29%) in the respective groups. The reasons for failure were long afferent loop in patients with BA; for the nine patients with B II GE the reasons for failure were tumoral infiltration at the orifice of afferent loop in one patient, peripapillary tumoral invasion in two patients, failure of entrance to the afferent loop due to angulation in two patients, and long afferent loop in the remaining four patients. Overall, perforation developed in 10.2% (6/59 of the patients. Two of these patients died (2/59, 3.4%) and one (1/59, 1.7%) had concomitant pancreatitis.

CONCLUSIONS

Although ERCP is successful in a large proportion of patients with B II GE, it carries significant risks such as perforation. ERCP must be performed by experienced endoscopists at institutions that have suitable facilities to manage endoscopy-related complications.

Endoscopic treatment of pancreatic fistulas

BACKGROUND

Pancreatic fistulas are managed primarily by conservative treatment. Surgery is performed in cases of conservative treatment failure. Endoscopic treatment is reported to be both effective and safe as an alternative treatment method.

METHODS

A total of 26 patients underwent endoscopic treatment after failure of conservative treatment between January 2002 and November 2004. The mean time between the onset of fistula and the endoscopic retrograde cholangiopancreatography (ERCP) procedure was 95 days. The mean fistula output volume was 400 ml per day. Four patients had pancreatic ascites. The aim of the endoscopic treatment was to bypass the ductal disruption by placing stents or drains where the origin of fistulous tract could be identified, and to lower the pancreatic duct pressure by performing pancreatic sphincterotomy or by placing stents where the site of the leak could not be identified.

RESULTS

Pancreatography could be performed in all the patients except one. Partial duct disruption occurred in 16 patients. All of the fistulas closed after the ductal disruption was bypassed. Pancreatic sphincterotomy or endoprothesis placement was effective for eight of the remaining nine patients in whom the ductal disruption originated from the tail of the pancreas and hence could not be bypassed. The overall success rate was 94% for the patients with partial duct disruption. Four patients had side branch leaks. All of them closed after placement of an endoprothesis. Fistulas closed in only one (20%) of the five patients with complete duct disruption. Pancreatic ascites resolved in two of the four patients after endoscopic treatment. No serious complications resulted from endoscopic treatment other than proximally migrated stents in two patients.

CONCLUSIONS

Endoscopic treatment is an effective and safe method for patients with pancreatic fistulas unresponsive to conservative treatment. The success rate is very high, especially for patients with partial and side branch duct disruption.