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Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4 weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation. Plain language summary: Endoscopic ultrasound drainage of pancreatic fluid collections This review summarizes the current knowledge on the indications, techniques, outcomes, complications, and treatment-associated EUS drainage of pancreatic fluid collections. Special attention is paid to the practical approach in necrosectomy and postprocedural antibiotherapy, discontinuation of proton pump therapy, and timing of stent removal. [ABSTRACT FROM AUTHOR]

Pancreatic fluid collection often occurs as a local complication of acute pancreatitis, and drainage is indicated in symptomatic patients. The drainage may be surgical, percutaneous, or endoscopic ultrasound (EUS) guided. In symptomatic collections older than 4weeks and localized in the upper abdomen, EUS-guided drainage is the first choice of treatment. Lumen-apposing metal stents are useful in cases of walled-off necrosis, facilitating access to the cavity; however, they do not reduce the number of necrosectomy sessions required. In most pancreatic pseudocysts requiring drainage, plastic stents remain the first choice of treatment. This review aimed to summarize the principles and techniques of step-up therapy of pancreatic fluid collections, including preprocedural and postprocedural assessment and practical approaches of drainage and necrosectomy, making available evidence more accessible to endoscopists aiming to train for this procedure. Successful and safe EUS drainage connotes early recognition and treatment of complications and the presence of a multidisciplinary team for optimal patient management. However, the best time for necrosectomy, modality of drainage method (lumen-apposing metal stents or plastic stents), and duration of antibiotherapy are still under evaluation. Plain language summary Endoscopic ultrasound drainage of pancreatic fluid collections This review summarizes the current knowledge on the indications, techniques, outcomes, complications, and treatment-associated EUS drainage of pancreatic fluid collections. Special attention is paid to the practical approach in necrosectomy and postprocedural antibiotherapy, discontinuation of proton pump therapy, and timing of stent removal. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) or fine-needle aspiration (EUS-FNA) from focal liver lesions are indicated in selected cases, but there has been no previous comparison of needle types of the same size. The aim of our study was to compare the histologic diagnostic accuracy and adequacy of cores obtained with EUS-FNB needles in contrast to those obtained with FNA needles in focal liver lesions. This prospective one-center study included patients with left lobe hepatic focal lesions with contraindications for percutaneous liver biopsy or need for EUS for concomitant lesions. Each patient had one pass of 22G EUS-FNB (Franseen) needle and one pass of 22G EUS-FNA in a crossover manner, without macroscopic on-site evaluation. Each sample was analyzed separately for histologic adequacy and diagnosis. The final diagnosis was based on histology results or on imaging follow-up in the case of negative biopsies. The EUS-FNB samples (n = 30) were found to be more adequate for histologic analysis, with more cellularity and longer tissue aggregates than the EUS-FNA samples (n = 30). The accuracy of EUS-FNB was 100%, whereas that of EUS-FNA was 86.7% (p = 0.039). No post-procedure complications were noted. The 22G EUS-FNB needle proved superior to 22G EUS-FNA in terms of tissue acquisition diagnostic accuracy and histologic adequacy in focal liver lesions. [ABSTRACT FROM AUTHOR]

Background & Aims: The fully-covered, lumen apposing metal stents are designed for one step placement, facilitating the direct endoscopic necrosectomy into the walled-off pancreatic necrosis. However, the prediction of the number of necrosectomy sessions in these patients is not known. This study evaluated the association between the proportion of solid necrotic material inside walled-off necrosis, as assessed during the endosonography placement of a lumen apposing metal stent, and the number of necrosectomies subsequently required. Methods: Patients from three tertiary medical centers with symptomatic walled off pancreatic necrosis (pain, infection, gastric/biliary obstruction) at more than 4 weeks after onset of acute pancreatitis were retrospectively analysed. Proportion of solid necrotic debris was estimated during endosonography procedure of lumen apposing metal stents placement. Necrosectomy was performed when obstruction or inflammation occurred subsequently. Lumen apposing metal stents were removed after clearance of necrotic content. Results: In 46 patients with successful lumen apposing metal stents placement, necrosectomy was performed in 39 patients (72.78%). Performance of 3 or more necrosectomies was significantly associated with more than 50% pancreatic necrosis (p=0.032), but not with walled-off pancreatic necrosis size or location. Necrotic infection during lumen apposing metal stents stenting was associated with hypoalbuminemia, but not with necrosectomy requirement. Clinical success after a median follow-up of 13.37 months was 87%. Conclusions: Walled-off pancreatic necrosis with more than 50% solid necrotic content were associated with more necrosectomy procedures, requiering longer endoscopy time, intravenous sedations, and higher costs. [ABSTRACT FROM AUTHOR]

This case reports a iatrogenic gastric fistula due to external draining successfully closed by using an overthe- scope clip. A 50-year old patient with a history of acute pancreatitis, segmental portal hypertension and splenectomy for splenic rupture, with long-term external drainage for a low volume pancreatic fistula, was referred to our hospital. The patient noticed the occurrence of a sudden increase of the drain flow and the immediate drainage of ingested liquid, with no fever or pain. An upper gastrointestinal endoscopy evidenced the gastric fistula with the presence of the drain inside the stomach near a gastric varix. The surgical approach was inappropriate due to bleeding risk. An over-the-scop clip was placed succeeding to stop the gastric flow. The external fistula closed one week later. [ABSTRACT FROM AUTHOR]

Background & Aim: Endoscopic ultrasonography (EUS) and EUS-guided fine-needle aspiration (EUS-FNA) are considered good tools for the diagnosis of pancreatic cancer and for obtaining material for cytology or histology. The accuracy of EUS-FNA can rise to 85-95%, but it is lower in cases with a chronic pancreatitis background or with previous biliary stenting. We aimed to establish the diagnostic yield of the visible length of the core biopsy samples in pancreatic cancer by using one single type of standard 22G needle and to evaluate the factors which can influence the results. Method: EUS-FNA was performed by using a 22G standard needle on patients prospectively recruited with the suspicion of pancreatic masses on transabdominal ultrasound or CT scan over a period of eight months. The number of passes was limited by the length of the core obtained. The final diagnosis was based on EUS-FNA or hepatic biopsy for their metastasis or by follow up every three month by imaging methods. Results: The study included 118 patients. Previous stents were present in 10 patients and chronic pancreatitis features were found in 3 patients. The procedure sensitivity was 89% and the global accuracy was 89%. The presence of biliary stents did not impede the accuracy of results. The number of passes did not influence the results. Conclusions: The diagnostic rate of core biopsy by using 22G needles had a high accuracy and it is safe when the length of core dictates the number of passes. The presence of biliary stents did not influence the results. [ABSTRACT FROM AUTHOR]

In assessing exocrine pancreatic insufficiency (EPI), its diverse etiologies and the heterogeneous population affected should be considered. Diagnosing this condition remains a challenge in clinical practice especially for mild-to-moderate EPI, with the support of the time-consuming breath test or the coefficient of fat absorption. The fecal elastase-1 test, less precise for the diagnosis, cannot be useful for assessing treatment efficacy. Pancreatic enzyme replacement therapy (PERT) is the mainstay of treatment, whereby entericcoated mini-microspheres are taken with every meal, in progressive doses based on an individual's weight and clinical symptoms. The main indication for PERT is chronic pancreatitis, in patients who have clinically relevant steatorrhea, abnormal pancreatic function test or abnormal function tests associated with symptoms of malabsorption such as weight loss or meteorism. While enzyme replacement therapy is not recommended in the initial stages of acute pancreatitis, pancreatic exocrine function should be monitored for at least 6-18 months. In the case of unresectable pancreatic cancer, replacement enzyme therapy helps to maintain weight and improve overall quality oflife. It is also indicated in patients with celiac disease, who have chronic diarrhea (in spite of gluten-free diet), and in patients with cystic fibrosis with proven EPI. [ABSTRACT FROM AUTHOR]

Undetermined pancreatic cystic lesion (PCL) differentiation benefits from endoscopic ultrasound (EUS) based on morphology and cyst fluid analysis, but room for new biomarkers exists. Our aim was to assess the intracystic and serum diagnostic value of neutrophil gelatinase-associated lipocalin (Ngal) and interleukin 1 beta (IL-1β) for differentiation of PCLs. This prospective study included patients from one tertiary hospital, evaluated between April 2018 and May 2020. EUS fine-needle aspiration or pancreatic pseudocysts drainage was the source of PCL intracystic liquid. The final diagnosis was based on surgery or EUS results (morphology, cytology, glucose, and CEA—carcinoembryogenic antigen). The intracystic samples were tested for Ngal, IL-1β, glucose, and CEA, and serum for Ngal and IL-1β. We evaluated 63 cysts, 33 pseudocysts, and 30 non-inflammatory cysts. The diagnostic sensitivity and specificity for mucinous PCL was 70.8% and 92.3% for intracystic Ngal (cut-off: 500–800 ng/dL), without correlation with serum Ngal, no matter the inclusion of infected pseudocysts. After exclusion of infected pseudocysts, the sensitivity and specificity for glucose were 87% and 75%, respectively, and for CEA, they were 87.1%, and 96.8%, respectively. Intracystic Ngal shows promise in differentiating mucinous PCLs, but researchers need to conduct further studies to confirm its effectiveness. Intracystic IL-1β and serum Ngal made no diagnostic contribution. [ABSTRACT FROM AUTHOR]

Background & Aims: Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM). The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS). Methods: We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for at least 12 months after stent removal. These patients were compared with age- and sex-matched asymptomatic WON controls without interventional treatment and healthy controls to assess the one-year occurrence of DM. Diabetes was defined according to the American Diabetes Association criteria. Results: Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; median age, 60 years), 13 patients (26%) had pre-existing DM and were excluded. Ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in asymptomatic WON controls (18.9%, p=0.581) and healthy controls (2%, p = 0.002). In the symptomatic WON group, NOD patients compared to non-DM patients were older (63.5 vs. 56 years old, p=0.042), had more frequent necrosis > 50% of the pancreatic parenchyma (p=0.002) and had a body-tail location of WON (p<0.001). On multivariate analysis, the number of direct endoscopic necrosectomy (DEN) sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients had poor glycemic control and required more DEN sessions to achieve WON resolution than patients with prior DM (p=0.017). Conclusions: In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up. Patients with extensive pancreatic necrosis were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence. [ABSTRACT FROM AUTHOR]

Anastomotic leakage (AL) constitutes a prominent cause of significant morbidity following gastrectomy for gastric cancer. The manifestation of AL typically occurs within 7 to 10 days post-surgery, with reported incidence rates of 5.8-6.7% for open gastrectomy and 3.3-4.1% for laparoscopic gastrectomy. Various predisposing risk factors have been identified, including the individual nutritional status (excluding obesity) and preoperative corticotherapy. Interestingly, the administration of neoadjuvant therapies appears to reduce the AL occurrence. In the context of distal gastrectomies, the rates of AL are comparable between laparoscopic, robotic, and open approaches. The total gastrectomies have higher AL rate compared to distal gastrectomies, which are considered the preferred approach. Prophylactic drainage measures have not demonstrated efficacy in preventing AL. As for postoperative management, conservative treatment is indicated for patients presenting with mild clinical symptoms and increased inflammatory blood tests. This approach involves fasting, enteral or parenteral nutrition, administration of antibiotics, and percutaneous drainage. For small AL, endoscopic therapies such as stents, vacuum therapy, clips, suturing devices, and injections are appropriate treatment options. In cases of high-volume fistulas, severe sepsis or failure of previous therapies, surgical reoperation becomes the ultimate solution. [ABSTRACT FROM AUTHOR]

Background & Aims: Real-world assessments of efficacy and safety of advanced therapies used for inflammatory bowel disease (IBD) patients are limited. We aimed to report safety, efficacy and treatment persistence of new molecules (infliximab, adalimumab, vedolizumab, tofacitinib, ustekinumab) in a retrospective multicentric national Romanian analysis. Methods: We conducted a nationwide, retrospective observational multicentric study. Data were collected retrospectively from electronic and paper files. Patients who started on one of the five investigated molecules during December 2019-December 2021 were included. The main outcome measures were clinical remission, endoscopic healing, persistence on treatment and safety data. Results: A total of 678 adult patients from 24 Romanian IBD centers with a diagnosis of ulcerative colitis or Crohn's disease were included. Participants had previously failure to one (268, 39.5%), two (108, 15%) or more treatment lines and only 38% (259) were biologic naïve. In the 24 months study period, most patients were started on vedolizumab (192, 28%), followed by adalimumab, infliximab, ustekinumab and tofacitinib. In biologic-naïve patients, most physicians (72%) preferred anti-TNF treatment as first line biologic (93 patients started on infliximab, 92 on adalimumab), followed by vedolizumab, ustekinumab and tofacitinib. During follow-up, 71% (470, p=0.05) of patients achieved clinical remission and 36% (134, p=0.03) achieved mucosal healing. The 6 months milestone for persistence was reached in 78% (530) of cases. Almost half of patients (47%, 316 patients) persisted on their current treatment for over 12 months. Overall, an adverse reaction was reported for 67 (10.4%) patients, with no lethal events. Conclusions: Population of biologic-experienced IBD patients in Romania is increasing and is becoming more difficult to achieve long-term disease control. Discontinuation rates for advanced therapies are high. [ABSTRACT FROM AUTHOR]

Crohn's disease (CD) is characterized by a chronic, progressive inflammation of the gastrointestinal tract often leading to complications, such as strictures and fistulae. Currently, there are no validated tools anticipating short- and long-term outcomes at an early stage. This investigation aims to elucidate variations in protein abundance across distinct CD phenotypes with the objective of uncovering potential biomarkers implicated in disease advancement. Serum samples collected from 30 CD patients and 15 healthy age-matched controls (HC) were subjected to depletion of highly abundant proteins and to a label-free mass spectrometry analysis. Twenty-four proteins were shown to be significantly different when comparing CD with HC. Of these, WD repeat-containing protein 31 (WDR31), and proteins involved in the acute inflammatory response, leucine-rich alpha-2-glycoprotein (LRG1) and serum amyloid A1 (SAA1), were more abundant in the aggressive subgroup. Against standard biomarkers, a positive correlation between SAA1 and WDR31 and C-reactive protein (CRP) was found. In this study, a unique serum biomarker panel for aggressive CD was identified, which could aid in predicting the disease course. [ABSTRACT FROM AUTHOR]

Background & Aims: Walled-off necrosis (WON) is a serious complication of severe pancreatitis, patients with necrotizing pancreatitis having an increased risk of developing diabetes mellitus (DM). The aim of this study was to assess the frequency of new-onset diabetes (NOD) in patients with symptomatic WON after endoscopic ultrasound (EUS)-guided drainage with lumen-apposing metal stents (LAMS). Methods: We retrospectively analyzed a prospectively collected database of patients with symptomatic WON treated by EUS-guided drainage with LAMS in a tertiary referral center. The patients were followed-up for at least 12 months after stent removal. These patients were compared with age- and sex-matched asymptomatic WON controls without interventional treatment and healthy controls to assess the one-year occurrence of DM. Diabetes was defined according to the American Diabetes Association criteria. Results: Of the 50 patients with symptomatic WON included in the study (male/female ratio, 33:17; median age, 60 years), 13 patients (26%) had pre-existing DM and were excluded. Ten of the remaining 37 patients (27%) without prior DM developed NOD within one year after stent removal, this frequency being higher than in asymptomatic WON controls (18.9%, p=0.581) and healthy controls (2%, p = 0.002). In the symptomatic WON group, NOD patients compared to non-DM patients were older (63.5 vs. 56 years old, p=0.042), had more frequent necrosis > 50% of the pancreatic parenchyma (p=0.002) and had a body-tail location of WON (p<0.001). On multivariate analysis, the number of direct endoscopic necrosectomy (DEN) sessions was the only significant factor for NOD occurrence (OR=7.05, p=0.010). NOD patients had poor glycemic control and required more DEN sessions to achieve WON resolution than patients with prior DM (p=0.017). Conclusions: In patients with symptomatic WON treated by EUS-guided drainage, DM occurred in 27% of previously non-diabetic patients within one year of follow-up. Patients with extensive pancreatic necrosis were more likely to develop NOD, a high number of DEN sessions being a significant risk factor for NOD occurrence. [ABSTRACT FROM AUTHOR]

Extrahepatic cholangiocarcinoma (CCA) is a rare and aggressive type of cancer, presenting as a mass or as a biliary stricture. This review summarizes the utility of endoscopic ultrasound (EUS) in the detection, staging, and determination of the differential diagnosis, especially when no cause of bile duct dilatation is revealed by cross-sectional imaging. The EUS detection rate for distal CCAs is higher than that for the proximal CCAs. The accuracy of T staging varies between 60 and 80%, and vascular involvement is correctly assessed by conventional EUS. EUS-tissue acquisition from the primary tumors is reserved for unresectable or metastatic CCA, especially in distal strictures or mass CCAs. For proximal lesions, EUS could be performed as an adjunctive to ERCP sampling when the latter is inconclusive. EUS is not appropriate for assessing the malignant features of lymph nodes in CCAs. Lymph node EUS-tissue acquisition should be performed only if it changes the surgical decision. Perhaps the development of EUS-fine needle biopsy and the detection of molecular genetic alteration will increase the diagnostic yield in CCAs. [ABSTRACT FROM AUTHOR]

Endoscopic ultrasound fine needle aspiration (EUS-FNA) cytology from an intracystic fluid is useful in the differentiation of pancreatic cysts, with low sensitivity, which increases when the solid component is targeted. The clinical utility of contrast-enhanced guided EUS-FNA (CH-EUS-FNA) in the solid component is not known. We aimed to assess the diagnostic value of CH-EUS-FNA in enhanced mural nodules and discrimination between different cysts using contrast-enhanced endoscopic ultrasound (CH-EUS). The prospective study recruited patients with pancreatic cysts with an unclear diagnosis. The CH-EUS was followed by CH-EUS-FNA. The final diagnosis was based on surgery or the correlation between clinical history, cross-sectional imaging, echoendoscopic morphology, cystic fluid analysis, and follow-up. Fifty-eight patients with pancreatic cysts were evaluated. The mucinous cysts had wall arterial enhancement more often than non- mucinous cysts (p < 0.0001), with 90.2% sensitivity and 70.6% specificity. The CH-EUS-FNA from cystic fluid and mural nodules identified mucinous cysts and malignancy with 82.4% and 84.2% sensitivity and 92% and 100% specificity. Twenty-one cysts had solid components, but only 13 were enhanced mural nodules on EUS assessment with conclusive cytology in all cases and malignancy in 76.9%. Contrast-enhanced endoscopic ultrasound should be completed in all PCN with solid components in order to avoid unnecessary EUS-FNA and to guide FNA for the identification of malignant cysts. [ABSTRACT FROM AUTHOR]

Introduction. EUS guided gastroenteroanasomosis (EUS-GE) established itself as an effective and safe procedure to alleviate malignant gastric outlet obstruction (mGOO), but enteral stenting (ES) is often preferred in patients with short life expectancy and disseminated malignant disease. Our aim was to compare survival rates, technical and clinical success and complications between the two groups as our center has begun performing this novel technique, EUS-GE. Methods. The patients with mGOO treated by EUS-GE between March-2022 and March 2023 were included and then retrospectively matched 1:1 (primary disease & stage and Charson Comorbidity Index) with patients that underwent ES. Results. 5 EUS-GE and 20 ES patients were included. After matching, 5 patients per arm were analyzed with no significant differences within the matched parameters. The indication of the procedure was mGOO related to inoperable pancreatic cancer invading duodenum (n=8) and gastric antrum carcinoma obstructing the pylorus (n=2), with no/minimum ascites and hepatic metastasis (n=8). Technical success rate was 100% in both arms. Median survival was 4mos in the EUS-GE group and 5mos in the ES group. All patients in the EUS-GE group and 3/5 in the ES group were able to eat solid food (GOOSS score=3). Symptom recurrence after an initial improvement occurred in 1/5 in the EUS-GE group and 3/5 in the ES group. Significant complications (defined as II or higher on AGREE classifications) appeared in 1/5 cases in both groups. Conclusions. Initial experience with EUS-GE seems to be more efficient and longer lasting than ES for alleviating symptoms associated with malignant gastric outlet obstruction without increase in complication rates. The low survival rate in both groups was related to the advanced disease stage of the patients. [ABSTRACT FROM AUTHOR]

Background. Primary sclerosing cholangitis (PSC) is a chronic, progressive cholestatic disease that is associated with inflammatory bowel disease (IBD) in approximately 70-75% of cases. Most cases of IBD are represented by ulcerative colitis (UC) (80%). Existing data are from the literature, but the profile of this rare disease in association with inflammatory bowel disease in Romania is less studied. Aims. The clinic-demographic profile in patients diagnosed with sclerosing cholangitis. Methods. We performed a retrospective analysis of patients diagnosed with PSC between Jan 2018 to Oct 2022 in a tertiary medical center. The diagnosis was based on both typical aspect on MRI (paucity of biliary ducts with dilatations and stenosis) and hepatic biopsy. All patients had colonoscopy with ileal intubation with biopsy for excluding the association of inflammatory bowel diseases. Results. From 14 patients diagnosed with PSC there were 11 patients included, mean age was 46, male: female ratio being 3:2. UC was identified in 89% of cases, as pancolitis in 4 (36%) patients. Only one patient was diagnosed with ileo-colonic Crohn's disease (CD). The clinical presentation included obstructive jaundice in 5 (45%) patients, liver cirrhosis in 3 (27%) patients (Child-Pugh B in all cases) and cholangiocarcinoma in one (9%) patient. The MRCP aspect showed a dominant stricture in 5 (45%) patients, located in the hilum in 2 (18%) cases. Perinuclear anti-neutrophil cytoplasmic antibodies (pANCA) were not suggestive for diagnosis, were identified in only 9% of cases. ERCP with stenting was performed in case of dominant strictures with cholangitis in 5 (45%) patients, with secondary lithiasis in 2 (18%) cases. Conclusions. The association of PSC-inflammatory bowel disease is a rare disease, with involvement of ulcerative colitis in most of the patients and mild symptoms. [ABSTRACT FROM AUTHOR]

Introduction. Sometimes we find cases of elevated transaminases with an unclear etiology. A detailed history is useful and can uncover hidden causes. We report here two cases of herbal-induced liver injury with severe hypertransaminasemia caused by ingestion of Chelidonium majus L (celandine), considered an alternative therapeutic. Case description. Case No. 1: A 64-year-old female patient presented to the emergency department for jaundice. The patient reported using celandine capsules for one month to treat her gallstones. The diagnosis was herb-induced liver injury (HILI), gallstones, and choledocolithiasis. Transaminases were over 1000 UI/l. After discontinuing the use of celandine and receiving intravenous treatment consisting of amino acids and phospholipids, the patient's condition improved. Following this, they were referred for endoscopic extraction of common bile duct stones and cholecystectomy. Case no. 2: A 66-year-old female patient presented to our medical department for investigation of increased liver function tests that were incidentally detected while evaluating musculoskeletal pain. After a directed questionnaire, she reported consuming celandine tea regularly for "health promotion." Transaminases normalized after intravenous therapy with amino acids and phospholipids. Discussion. As more and more people use herbal substances as alternative therapies, it is important to expect an increase in cases with unexplained elevated liver function tests. Celandine is one of the most aggressive herbs, and physicians should clearly ask about its use in cases of unexplained liver injury. Conclusion. Celandine is an herb used as an alternative therapy with high liver toxicity. Patients with unexplained liver injuries should be asked about the consumption of this herb. [ABSTRACT FROM AUTHOR]

Background. In patients with cirrhosis, the gold standard for assessment of portal hypertension is the measurement of the hepatic venous pressure gradient (HVPG), a minimally invasive radiological technique that determines indirectly the porto systemic pressure gradient (PPG). However, the technique is available only in referral centres and requires special expertise. Recently, EUS-guided techniques for the measurement of the PPG (EUSPPGm) by directly puncturing the portal vein and the hepatic vein, have shown promising results in terms of feasibility and safety. Nevertheless, the equipment for this procedure uses special devises that require a high purchase cost, and the pressure results are difficult to interpret. The aim of our study was to evaluate the feasibility and safety of EUS-PPGm using a 22 G FNA in a cohort of patients with cirrhosis undergoing TIPS placement for the indication of recurrent variceal bleeding or refractory ascites. Methodology. The patients were included prospectively. Patients with complete portal vein thrombosis were excluded. The EUS-PPGm was performed under general anesthesia, prior to TIPS procedure, by experienced endosonographers, using a linear echoendoscope and a 22-G FNA transgastrically, close to the cardia. After checking the intravascular position of FNA by injecting saline, the pressures were recorded using the same hemodynamic unit as the HVPG, XperFlex Cardio (Philips). The systemic pressure was measured at the level of the median SHV and the portal pressure was measured at the level of the portal trunk. Feasibility was defined as successful PPGm in each patient. Safety was based on adverse events captured during the perioperative period and in a the postprocedural interview. Results. The study included 7 patients (5 male and 2 female), mean age 57 years, mean platelets count 104/mm3, range [52-172]. The indication for TIPS was refractory ascites in 5 patients and variceal bleeding in the other 2 patients. In two patients, the direct puncture of the SHV was not feasible due to poor visualization of portal vein in an obese patient and narrow SHV in a patient with advanced cirrhosis. The mean PPG-EUS was 12.2 mmHg SD 2.68 and mean PPG-TIPS was 15 mmHg, SD 3.317. There were no intraprocedural or post procedural complications recorded. Conclusion. EUS-PPGm using a 22-G FNA is feasible and appears safe. Given the availability of EUS, EUS-PPGm may represent a promising breakthrough for procuring indispensable information in the management of patients with liver disease. [ABSTRACT FROM AUTHOR]

Background & Aims: Pancreatic cancer is associated with poor survival and quality of life. In Romania the prognostic influence of known risk factors for pancreatic adenocarcinoma, such as age, smoking, chronic pancreatitis, diabetes mellitus, and obesity is little known. Their importance in developing cancer in families with a history of adenocarcinoma is less studied. This study aims to assess the risk factors in pancreatic ductal adenocarcinoma, in familial pancreatic adenocarcinoma, in neuroendocrine tumors and to evaluate their predictive role on survival. Methods: We performed a prospective bicentric study of patients with pancreatic tumors detected in transabdominal imaging; we assessed the risk factors and their possible association with survival. Results: 312 pancreatic cancer patients (279 with pancreatic ductal adenocarcinoma and 24 patients with neuroendocrine tumors, and nine patients with other malignant types) and 312 controls were included. The median body mass index was significantly higher in patients with neuroendocrine tumors. Positive family history for pancreatic cancer was found in 4% of patients with pancreatic cancer. The risk for familial pancreatic carcinoma was associated with the presence of new-onset diabetes (OR: 4.64, p=0.018). The multivariate logistic analysis suggested that advanced age (OR: 1.67), smoking (OR: 1.67), low body mass index (OR: 12.07), and diabetes (OR: 3.91) were risk factors for pancreatic cancer. The overall survival analysis after adjustment for age and tumor stage showed only advanced tumoral stage (HR=1.6, p=0.003) and metastasis as independent predicting factors (HR=1.67, p<0.001). Conclusion: Our study suggests that diabetes, smoking, underweight, and age over 60 years are risk factors for pancreatic cancer. Patients with a family history of pancreatic cancer, especially those with new-onset diabetes, should be followed carefully and considered for screening. Only an advanced tumor stage was associated with poor overall survival for patients with pancreatic ductal adenocarcinoma. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy with jejunal extension (PEG/J) was first described in 1998 and has become the standard technique for fixing the tube in place for levodopa carbidopa intestinal gel (LCIG) infusion. The Romanian Society of Digestive Endoscopy (RSDE) decided to create a consensus paper to meet the needs in medical training and practice. After reviewing the available published data and existing recommendations, a consensus process was carried out involving the leaders of opinion in this field. The resulting text and recommendations were approved, after reaching expert consensus, and reflects the views of the RSDE for the best practice of PEG/J tube placement. The pull through method ("pull technique") is the prevailing PEG-tube placement procedure in Romania. The procedure can be performed with intravenous sedation combined with local anesthesia. Although minor complications are common, serious complications are infrequent, and the tube insertion procedures have a good safety record. Redo procedures are sometimes necessary and clinicians should be aware of these situations. [ABSTRACT FROM AUTHOR]

Background and aims. Despite their usefulness, CT-guided procedures have a low profile in Romania. The current study has the purpose of describing a first experience in performing these procedures. Methods. Tumors and fluid collections that were inaccessible for biopsy or drainage by ultrasound or endoscopic guidance were included. The procedures were performed using a 64-slice GE Optima CT660 CT scanner. The biopsies were carried out using the coaxial technique with an 18 G semiautomatic needle. The drainages were performed using 10 F pig-tail drains that were inserted using the Seldinger technique. Data regarding the size and location of the target lesion, puncture technique, success and complication rates were recorded. Results. Between May 2017 and April 2018, 30 procedures were performed, of which 26 biopsies and 4 drainage insertions. Of the biopsies 3 were mediastinal, 8 pulmonary, 6 retroperitoneal, 4 pelvic, and 5 of the bone. The drainages were performed for pelvic lymphoceles. The average lesion size was 3.2 cm (0.7-9 cm), with a depth from the skin of 9.1 cm (0.6-15.2 cm). The average procedure duration was 58 minutes (31-93 minutes). A conclusive histopathological diagnosis was set after 92.3% of biopsies. Three procedures resulted in complications, two being minor (hemothorax, soft tissue hematoma) and one severe (tension pneumothorax requiring drainage). Conclusions. CT guidance offers safe access to lesions that cannot be biopsied or drained under ultrasound or endoscopic guidance. [ABSTRACT FROM AUTHOR]

Introduction. Endoscopic retrograde cholangiopancreatography (ERCP) is the main procedure for managing obstructive biliary disease. In the context of unsuccessful ERCP, endoscopic ultrasound-guided biliary drainage (EUS-BD) has become a promising alternative to surgical bypass and percutaneous biliary drainage (PTBD). We report one case of successful biliary decompression through direct transluminal stenting using EUS guidance. Case presentation. We report the case of a 60-year-old female patient with stage IV colorectal adenocarcinoma previously submitted to palliative gastrojejunostomy L-L for duodenal malignant obstruction. The patient presented with obstructive jaundice, cholestasis, and inflammatory syndrome due to local relapse of her malignancy and peritoneal carcinomatosis. The papillary region was not reached by conventional enteroscopy/duodenoscopy. EUS was performed with a linear therapeutic echoendoscope, and intrahepatic biliary duct dilation was confirmed. With the echoendoscope positioned in the upper part of the lesser curvature, a segment III intrahepatic bile duct was punctured with a 19-G needle. A guidewire was then advanced through the needle to the intrahepatic ducts, followed by dilation with a cystotome. A proximally covered metal stent was then delivered into the left hepatic bile duct through the stomach wall, but the length of the remaining part of stent into the stomach was insufficient, so a second partially covered metal biliary stent was placed inside the metal stent. The patient was discharged 6 days after the procedure with regression of biliary retention. The stent was still patent 60 days after the procedure and the patient restarted chemotherapy. Discussion and conclusion. EUS-BD has emerged as an alternative to percutaneous and surgical drainage in cases where ERCP techniques are difficult or not feasible. Conventionally, percutaneous drainage is considered the rescue therapy in the setting of ERCP failure. Although the technical success rate of percutaneous drainage is over 95%, drainage complications continue to be a major problem along with the significantly reduced quality of life. A recent review compared the efficacy and safety of EUS-BD and PTBD, proving equivalent technical success. However, EUS-biliary drainage was associated with better clinical success, fewer post-procedure adverse events, and lower reintervention, with a stent patency of 329 days. No significant differences were observed for the duration of hospital stay between the two procedures, but EUS-biliary procedure was more cost-effective. In conclusion, EUS-BD is a useful tool in case of failure of ERCP or altered anatomy, with a high rate of technical success and clinical efficacy. [ABSTRACT FROM AUTHOR]

Aims. Contrast enhanced endoscopic ultrasound (CH-EUS) is superior to standard endoscopic ultrasound (EUS) for T staging of biliary duct tumors (BDT) but its role in guiding EUS-fine needle aspiration (EUS-FNA) is unknown. We compared the diagnostic performance of CH-EUS-fine needle aspiration (CH-EUS-FNA) and standard EUS-FNA in BTD and aimed to determine the factors influencing the Results. Methods. This randomized controlled study was conducted in a tertiary medical center and included jaundiced patients with BDT on CT scan. Patients were randomly assigned to EUS-FNA or to CH-EUSFNA group. Final diagnosis was based either on EUSFNA or surgical specimen results or endoscopic retrograde cholangiopancreatography (ERCP) or 12-month follow-up. Results. 61 patients were included in the study, 31 in EUS-FNA and 30 in CH-EUS-FNA group (mean age 74±11.04 years, mean tumor dimension 20.39±9.17mm). Most BDT were located in the distal bile duct (n= 40). Final diagnosis (based on: surgery in 9 cases, ERCP in 7, EUS-FNA in 41, follow-up in 4) were: cholangiocarcinoma (n=37), pancreatic ductal carcinoma (n=12), other malignancy (n=3), benign lesion (n=9). Diagnostic sensitivity, specificity and accuracy were 84%, 100% and 87% respectively in EUS-FNA and 82%, 100%, and 83% respectively in CH-EUS-FNA group (p=0.22). Plastic biliary stent placement or tumor location did not influence the results CH-EUS hyperenhancement with rapid washout was seen in 81.8% of cholangiocarcinoma cases. Conclusions. Most but not all of cholangiocarcinoma are hyperenhanced, but CHEUS-FNA had similar value with standard EUS-FNA in diagnosing bile duct tumors. [ABSTRACT FROM AUTHOR]

Background & Aim: Novel biological therapies in Crohn's disease (CD) or Ulcerative colitis (UC) require a proper follow-up for the assessment of bowel inflammation. While endoscopy is the standard method, the imaging techniques using contrast, particularly contrast enhanced ultrasonography (CUES), are better tolerated by the patients and can be used more frequently. Our aim was to find the usefulness of dynamic CEUS quantification as compared to endoscopy in the assessment of disease activity and in the follow-up under therapy of the patients suffering from either CD or UC. Method: We have prospectively evaluated 67 patients with UC and 46 with CD, diagnosed by ileo-colonoscopy and biopsy, comparing the endoscopic scores with clinical scores, C reactive protein (CRP), intestinal wall thickness, layer scores after CEUS and TIC parameters (using SonoLiver* software - Imax, RT, TTP, mTT and AUC). For 25 patients with UC and 13 with CD we performed comparisons of the parameters before and after 3 months of treatment and correlated them with the changes in the endoscopic scores. Results: For UC, time-intensity curves (TIC) volume parameters (AUC) correlated better with endoscopy (p=0.64) than the clinical score (p =0.62). Other parameters such as CRP and thickness showed significant but less strong correlation, while TIC flow parameters (RT, TTP and mTT) did not show a significant correlation. Results were similar for CD (p=0.64 for Imax vs p=0.58 for CDAI). The best predictor for endoscopic improvement in both UC and CD was ln(AUC), with a Wilcoxon Z score of 3.76 and 2.61, respectively. There was also a good correlation between the difference of its values and the difference in endoscopic scores before and after the treatment (rho is 0.68 in UC and 0.73 in CD). Conclusion: CEUS is a useful technique to monitor activity in IBD patiens during therapy. [ABSTRACT FROM AUTHOR]

Interleukin (IL)-17 and IL-23 are crucial for mediating gut mucosal inflammation in inflammatory bowel disease (IBD), which has led to new therapeutic strategies. We assessed the relevancy of IL-17 and IL-23 serum levels as potential biomarkers towards severe IBD discrimination and disease-related complications. Sixty-two patients diagnosed with Crohn's disease (CD) and ulcerative colitis (UC) were included. Serum IL-17 and IL-23 were measured by sandwich enzyme-linked immunosorbent assays (ELISA). IL-23 and fecal calprotectin (FCal) were significantly higher in severe CD (p < 0.001) and UC (p < 0.001 and p = 0.001, respectively), compared to mild or moderate. Elevated C-reactive protein (CRP) was correlated with severe disease only in CD (p = 0.008), whereas for UC, disease severity was associated with increased IL-17 values (p < 0.001). Diagnostic role of IL-23 was superior to FCal in discriminating between severe and mild to moderate CD (p < 0.001). IL-23 levels were also significantly higher in CD patients with intestinal complications (p = 0.04). Both IL-17 and IL-23 correlate with IBD severity, and IL-23 might be a promising novel biomarker for severe CD. Identifying the dominant IL pathway involved in IBD severity could serve as guidance for clinical decision-making on biologic therapy. [ABSTRACT FROM AUTHOR]