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Background and Aims: Serial stent placement may be necessary during endoscopic interventions, but the passage of a guidewire alongside an initial stent can be challenging, time-consuming, and sometimes unsuccessful. We describe a modification of a cytology brush catheter to allow simultaneous placement of 2 guidewires to facilitate serial stent placement and demonstrate its application in different scenarios. Methods: This is a retrospective series of 3 patients with different conditions (acute cholecystitis, pancreas pseudocyst, and severe biliary stricture) in whom placement of a second guidewire facilitated serial stent placement. A step-by-step demonstration of the technique is provided. Results: Serial stent placement was successful in all patients without adverse events. Conclusions: A modified cytology brush catheter can be used to deliver 2 guidewires simultaneously during ERCP and EUS procedures. This technique may improve procedural efficiency, maintain a safety track, and augment therapy in certain situations.

Background and Aims: Endoscopic stent placement in luminal GI strictures is not always feasible with traditional stents. For example, standard luminal stent delivery catheters may not successfully traverse severe strictures, and enteral stents may not be suitable for sites in the GI tract that pose significant adverse events if downstream migration were to occur. We demonstrate extrabiliary applications of specialized, fully covered antimigration biliary metal stents. Methods: This is a retrospective series of 4 patients with different benign and malignant luminal GI strictures who underwent placement of fully covered antimigration biliary metal stents in different configurations as a bridge or destination therapy. Results: Luminal obstruction resolved without adverse events in all cases. Conclusions: Although off label, extrabiliary use of these stents can successfully address scenarios of complex luminal pathology. To compensate for the small stent caliber, two stents may be placed side by side in a double-barrel configuration. Strict diet modifications are necessary when applying this therapeutic paradigm.

Sitosterolemia is an autosomal recessive metabolic disease caused by mutations in ABCG5 or ABCG8 genes which encode for the (ATP)-binding cassette (ABC) transporters that are responsible for the trafficking of xenosterols. Liver involvement is not a recognized manifestation of this disease, and cirrhosis has been reported only once in the medical literature. We describe a fatal case of a 21-year old South Asian male who presented with decompensated cirrhosis, and biochemical abnormalities consistent with sitostero-lemia. Genetic testing showed a homozygous pathogenic mutation in ABCG5, confirming the diagnosis. Sitosterolemia is a rare, but likely under-recognized condition, and a high degree of suspicion is imperative to make the diagnosis. We propose that sitosterolemia should be included in the differential diagnosis for patients with cryptogenic cirrhosis, especially as there are effective oral therapies to treat this condition. Newly diagnosed sitosterolemia patients should undergo a thorough hepatology evaluation and follow-up to evaluate for the presence, development, and progression of any hepatic involvement.