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Idiopathic chronic pancreatitis (ICP) is the second most common subtype of CP. In 1994, researchers reported the bimodal age at onset of ICP symptoms: early onset ICP (EO-ICP; median age, 19.2 y) and late-onset ICP (LO-ICP; median age, 56.2 y). Ages of onset and clinical features of ICP differed from those of alcohol-related CP (ACP). However, variants in PRSS1 had not yet been associated with ICP. We reexamined ages of onset of ICP in a large, North American cohort of patients, and investigated the effects of genetic factors and alcohol use in patients with EO-ICP, LO-ICP, and ACP. We performed a cross-sectional analysis of patients with CP of European ancestry enrolled in the North American Pancreatitis Study 2, a prospective study of 1195 patients with CP from 26 centers in the United States from August 2000 through December 2014. We compared age at onset of symptoms for 130 patients with CP who were lifetime abstainers from alcohol (61 patients with early onset and 69 patients with late onset), 308 light to moderate alcohol drinkers with CP, and 225 patients with ACP and heavy to very heavy alcohol use. DNA from available patients was analyzed for variants associated with CP in SPINK1 , CFTR , and CTRC. The Kruskal–Wallis test was used to compare continuous variables across groups and based on genetic variants. Median ages at onset of symptoms were 20 years for patients with EO-ICP and no alcohol use, 58 years for patients with LO-ICP and no alcohol use, 47 years for light to moderate alcohol drinkers with CP, and 44 years for patients with ACP. A higher proportion of patients with EO-ICP had constant pain (65%) than patients with LO-ICP (31%) (P =.04). A higher proportion of patients with ACP had pseudocysts (43%) than patients with EO-ICP (11%) (P =.001). A higher proportion of patients with EO-ICP had pathogenic variants in SPINK1 , CFTR , or CTRC (49%) than patients with LO-ICP (23%), light to moderate alcohol drinking with CP (26%), or ACP (23%) (P =.001). Among patients with variants in SPINK1 , those with EO-ICP had onset of symptoms at a median age of 12 years, and light to moderate alcohol drinkers with CP had an age at onset of 24 years. Among patients with variants in CFTR , light to moderate alcohol drinkers had an age at onset of symptoms of 41 years, but this variant did not affect age at onset of EO-ICP or ACP. We confirmed previously reported ages at onset of symptoms for EO-ICP and LO-ICP in a North American cohort. We found differences in clinical features among patients with EO-ICP, LO-ICP, and ACP. Almost half of patients with EO-ICP have genetic variants associated with CP, compared with approximately one quarter of patients with LO-CP or ACP. Genetic variants affect ages at onset of symptoms in some groups. [ABSTRACT FROM AUTHOR]

Background & Aims Chronic pancreatitis is characterized by inflammation, atrophy, fibrosis with progressive ductal changes, and functional changes that include variable exocrine and endocrine insufficiency and multiple patterns of pain. We investigated whether abdominal imaging features accurately predict patterns of pain. Methods We collected data from participants in the North American Pancreatitis Study 2 Continuation and Validation, a prospective multicenter study of patients with chronic pancreatitis performed at 13 expert centers in the United States from July 2008 through March 2012. Chronic pancreatitis was defined based on the detection of characteristic changes by cross-sectional abdominal imaging, endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, or histology analyses. Patients were asked by a physician or trained clinical research coordinator if they had any abdominal pain during the year before enrollment, those who responded “yes” were asked to select from a list of 5 pain patterns. By using these patterns, we classified patients’ pain based on timing and severity. Abnormal pancreatitis-associated features on abdominal imaging were recorded using standardized case report forms. Results Data were collected from 518 patients (mean age, 52 ± 14.6 y; 55% male; and 87.6% white). The most common physician-identified etiologies were alcohol (45.8%) and idiopathic (24.3%); 15.6% of patients reported no abdominal pain in the year before enrollment. The most common individual pain pattern was described as constant mild pain with episodes of severe pain and was reported in 45% of patients. The most common imaging findings included pancreatic ductal dilatation (68%), atrophy (57%), and calcifications (55%). Imaging findings were categorized as obstructive for 20% and as inflammatory for 25% of cases. The distribution of individual imaging findings was similar among patients with different patterns of pain. The distribution of pain patterns did not differ among clinically relevant groups of imaging findings. Conclusions Mechanisms that determine patterns and severity of pain in patients with chronic pancreatitis are largely independent of structural variants observed by abdominal imaging techniques. Pancreas-relevant quantitative and qualitative pain measures should be included in the evaluation of patients with chronic pancreatitis to assess pain severity independently of imaging findings. [ABSTRACT FROM AUTHOR]

Background: Biliopancreatic-type postcholecystectomy pain, without significant abnormalities on imaging and laboratory test results, has been categorized as “suspected” sphincter of Oddi dysfunction (SOD) type III. Clinical predictors of “manometric” SOD are important to avoid unnecessary ERCP, but are unknown. Objective: To assess which clinical factors are associated with abnormal sphincter of Oddi manometry (SOM). Design: Prospective, cross-sectional. Setting: Tertiary. Patients: A total of 214 patients with suspected SOD type III underwent ERCP and pancreatic SOM (pSOM; 85% dual SOM), at 7 U.S. centers (from August 2008 to March 2012) as part of a randomized trial. Interventions: Pain and gallbladder descriptors, psychosocial/functional disorder questionnaires. Main Outcome Measurements: Abnormal SOM findings. Univariate and multivariate analyses assessed associations between clinical characteristics and outcome. Results: The cohort was 92% female with a mean age of 38 years. Baseline pancreatic enzymes were increased in 5%; 9% had minor liver enzyme abnormalities. Pain was in the right upper quadrant (RUQ) in 90% (48% also epigastric); 51% reported daily abdominal discomfort. Fifty-six took narcotics an average of 33 days (of the past 90 days). Less than 10% experienced depression or anxiety. Functional disorders were common. At ERCP, 64% had abnormal pSOM findings (34% both sphincters, 21% biliary normal), 36% had normal pSOM findings, and 75% had at least abnormal 1 sphincter. Demographic factors, gallbladder pathology, increased pancreatobiliary enzymes, functional disorders, and pain patterns did not predict abnormal SOM findings. Anxiety, depression, and poorer coping were more common in patients with normal SOM findings (not significant on multivariate analysis). Limitations: Generalizability. Conclusions: Patient and pain factors and psychological comorbidity do not predict SOM results at ERCP in suspected type III SOD. (Clinical Trial registration number: NCT00688662.) [Copyright &y& Elsevier]

Background: Few studies have evaluated the impact of biliary stents on EUS-guided FNA. Aim: To compare diagnostic yield of EUS-FNA in patients with or without biliary stents. Design: Retrospective study. Setting: Tertiary referral center. Patients: Patients with obstructive jaundice secondary to solid pancreatic mass lesions who underwent EUS-FNA over 5 years. Main Outcome Measures: The primary objective was to compare the diagnostic accuracy of EUS-FNA in patients with or without biliary stents and between patients with plastic stents or self-expandable metal stents (SEMSs). Secondary objectives were to assess the technical difficulty of EUS-FNA by comparing the number of passes required to establish diagnosis and to identify predictors of a false-negative diagnosis. Results: Of 214 patients who underwent EUS-FNA, 150 (70%) had biliary stents and 64 (30%) had no stents in place. Of 150 patients with biliary stents, 105 (70%) were plastic and 45 (30%) were SEMSs. At EUS-FNA, the diagnosis was pancreatic cancer in 155 (72%), chronic pancreatitis in 17 (8%), other cancer in 31 (14%), and indeterminate in 11 (5%). There was no difference in rates of diagnostic accuracy between patients with or without stents (93.7% vs 95.3%; P = .73) and between plastic or SEMSs (95.2% vs 95.5%, P = .99), respectively. Median number of passes to diagnosis was not significantly different between patients with or without stents (2 [interquartile ratio range (IQR) = 1-3] vs 2 [IQR = 1-4]; P = .066) and between plastic or SEMS (2.5 [IQR = 1-4] vs 2 [IQR = 1-4], P = .69), respectively. On univariate analysis, EUS-FNA results were false-negative in patients with large pancreatic masses (>3 cm vs <3 cm, 9.35% vs 0.93%, P = .005) that required more FNA passes (<2 vs >2 passes, 0% vs 11.8%, P < .0001). Limitations: Retrospective study. Conclusions: The presence or absence of a biliary stent, whether plastic or metal, does not have an impact on the diagnostic yield or technical difficulty of EUS-FNA. [Copyright &y& Elsevier]

Objectives: Endoscopy is a minimally invasive technique for the drainage of peripancreatic fluid collections. This study evaluated the clinical outcomes and predictors of treatment success in consecutive patients undergoing endoscopic transmural drainage of peripancreatic fluid collections.Methods: This is a retrospective study of patients who underwent endoscopic drainage of peripancreatic fluid collections over 7 years. Prior to drainage, an ERCP was attempted for stent placement in all patients with a pancreatic duct leak. Drainages were performed using conventional endoscopy or endoscopic ultrasound. Transmural stents and/or drainage catheters were deployed and endoscopic necrosectomy was undertaken when required. Data on clinical outcomes and complications were collected prospectively.Results: A total of 211 patients underwent drainage of peripancreatic fluid collections that was classified as pseudocyst in 45%, abscess in 28%, and necrosis in 27%. Mean diameter of the fluid collection was 100.6 mm, and 34.5% of patients had pancreatic duct stent placement. Median duration of follow-up was 356 days. Treatment success was 85.3% and was higher for pseudocyst and abscess compared to necrosis (93.5% vs. 63.2%, p < 0.0001). Complications were encountered in 17 patients (8.5%) and was higher for drainage of necrosis than pseudocyst or abscess (15.8% vs. 5.2%, p = 0.02). Treatment success was more likely for patients with pseudocyst or abscess than necrosis (adjusted OR = 7.6, 95% CI [2.9, 20.1], p < 0.0001) when adjusted for serum albumin and white cell count, type of endoscopic modality or accessory used, pancreatic duct stenting, luminal compression, size and location of fluid collection.Conclusions: Endoscopic therapy is a highly effective technique for the management of patients with non-necrotic peripancreatic fluid collections. [ABSTRACT FROM AUTHOR]

Background: Walled-off pancreatic necrosis often leads to severe clinical deterioration necessitating open debridement or endoscopic necrosectomy. A new EUS-based approach was devised to manage this condition by creating multiple transluminal gateways to facilitate effective drainage of the necrotic contents. Objective: To compare treatment outcomes between patients with walled-off pancreatic necrosis managed endoscopically by a multiple transluminal gateway technique (MTGT) or a conventional drainage technique (CDT). Design: Retrospective study. Setting: Tertiary-care referral center. Patients: This study involved patients with severe acute pancreatitis complicated by walled-off pancreatic necrosis managed endoscopically. Intervention: In MTGT, 2 or 3 transmural tracts were created by using EUS guidance between the necrotic cavity and the GI lumen. While one tract was used to flush normal saline solution via a nasocystic catheter, multiple stents were deployed in others to facilitate drainage of necrotic contents. In the CDT, two stents with a nasocystic catheter were deployed via 1 transmural tract. Main Outcome Measurements: Resolution of symptoms, radiological findings on follow-up CT, and the need for subsequent surgery or endoscopic necrosectomy. Results: Of 60 patients with symptomatic walled-off pancreatic necrosis, 12 (3 women, mean age 55.1 years) were managed by MTGT and 48 (12 women, mean age 55.2 years) by CDT. Treatment was successful in 11 of 12 (91.7%) patients managed by MTGT versus 25 of 48 (52.1%) managed by CDT (P = .01). Although 1 patient in the MTGT cohort required endoscopic necrosectomy, in the CDT cohort, 17 required surgery, 3 underwent endoscopic necrosectomy, and 3 died of multiple-organ failure. Treatment success was more likely for patients treated by MTGT than by CDT (adjusted odds ratio = 9.24; 95% confidence interval, 1.08-79.02; P = .04) when we adjusted for the size of the walled-off pancreatic necrosis and pancreatic duct stent placement. Limitations: Selective patient population. Conclusion: The EUS-guided MTGT is an effective treatment option for the management of symptomatic walled-off pancreatic necrosis because it obviates the need for surgery and endoscopic necrosectomy and its attendant procedure-related morbidity. Prospective studies are required to confirm these preliminary but promising data. [Copyright &y& Elsevier]

Abstract: Background: Recent series describing the clinical presentation, response to therapy, and long-term outcome of Zollinger–Ellison syndrome are limited. Aims: To assess the clinical characteristics and long-term outcome of patients with Zollinger–Ellison syndrome. Methods: Over a 20-year period, patients with Zollinger–Ellison syndrome were enrolled in a prospective trial evaluating the efficacy of lansoprazole. Following dose stabilization, patients were followed on a 6-monthly basis with interval history, physical examination, endoscopy with gastric biopsies, gastric acid analysis and laboratory studies. Results: 72 patients (mean age 54±12 years, % male 58%, % Caucasian 69%) were prospectively enrolled. The clinical presentation was stereotypical for Zollinger–Ellison syndrome. Symptoms had been reported for a median of 9 years prior to diagnosis. Cross-sectional abdominal imaging was often negative for demonstrable tumour. All patients had gastric acid hypersecretion controlled with variable doses of lansoprazole (median dose 60mg/day, range 15–480mg/day). The median survival from the time of diagnosis was 6.6 years; only two of 19 deaths were due to metastatic gastrinoma. Conclusions: The clinical presentation of Zollinger–Ellison syndrome was similar to prior reports. Acid hypersecretion was controlled in all patients with variable doses of lansoprazole. Long-term survival was principally related to underlying co-morbidity. [Copyright &y& Elsevier]

Background: Sphincter of Oddi dysfunction (SOD) is a controversial topic, especially in patients with no objective findings on laboratory or imaging studies (SOD type III). The value of ERCP manometry with sphincterotomy is unproven and carries significant risks. Objective: To describe the process of planning and initiating a randomized sham-controlled study to establish whether patients with SOD respond to sphincter ablation, and whether the outcomes are predicted by the pain patterns, presence or absence of other functional GI or psychosocial problems, or the results of manometry. Design: Planning a trial to establish which patients with “suspected SOD” (if any) respond to endoscopic sphincter ablation. Setting: Meetings and correspondence by a planning group of gastroenterologists and clinical research specialists hosted at the Medical University of South Carolina. Patients: Clarifying subject characteristics and inclusion and exclusion criteria. Interventions: Defining the questionnaires, therapies, randomizations, and numbers of subjects required by outcome measures. Defining the metrics of success and failure. Results: The planning resulted in funding for the proposed study as a cooperative agreement with the National Institute of Diabetes and Digestive and Kidney Diseases. Limitations: Lack of data required several consensus decisions in designing the protocol. Conclusion: The planning process was challenging, and some changes were needed after initiation. ⁎ (Clinical trial registration number: NCT00688662.) [Copyright &y& Elsevier]

A variety of factors have been linked to post-ERCP pancreatitis. However, the role of biliary stenting has not been well studied. Objective: To evaluate the relationship between biliary stenting and post-ERCP pancreatitis. Design: Prospective study of all patients undergoing ERCP with biliary stenting over a 7.5-year period. All patients had follow-up at 24 to 48 hours after the procedure and at 1 month. Setting: A single-center tertiary referral academic medical center. Patients: Consecutive patients undergoing ERCP over a 7.5-year period. Interventions: Endoscopic therapy based on the indication for and findings of ERCP. Main Outcome Measurements: The rate of post-ERCP pancreatitis. Results: A total of 3499 patients underwent ERCP with bile duct stent placement of a native papilla performed in 660: 544 (83%) 10F and 116 (17%) 7F. The most common indication for stent placement was pancreaticobiliary malignancy in 250 patients (37%). The overall rate of pancreatitis for the entire cohort was 3.17%. Multivariate analysis identified 6 factors that were associated with pancreatitis: previous ERCP pancreatitis (odds ratio [OR], 2.44; 95% CI, 1.31-4.55), age (OR, 2.30; 95% CI, 1.44-3.67), history of acute pancreatitis (OR, 1.78; 95% CI, 1.12-2.88), pancreatic sphincterotomy (OR, 2.30, 95% CI, 1.43-3.70), suspected sphincter of Oddi dysfunction (OR, 3.91; 95% CI, 2.36-6.46), and bile duct stenting (OR, 1.72; 95% CI, 1.03-2.88). The rates of pancreatitis were not significantly different based on performing sphincterotomy before stent placement, stent type, stent length, stent size, or indication. Limitations: Single-center study. Conclusions: Bile duct stent placement is an independent predictor for pancreatitis, and pancreatitis is not related to performing sphincterotomy before stenting or to stent characteristics. [Copyright &y& Elsevier]

Background: Laparoscopy-assisted ERCP (LAERCP) allows the diagnosis and treatment of biliopancreatic conditions in patients with Roux-en-Y anatomy (RY). However, experience with this technique is limited. Objectives: To report on the experience with LAERCP in consecutive patients from a high-volume bariatric surgery center and to evaluate success rates of ERCP with the laparoscopy-assisted approach. Design: Retrospective case series. Setting: High-volume bariatric surgery center. Patients: Consecutive patients undergoing LAERCP between 2003 and 2009. Intervention: LAERCP. Outcomes: Immediate/delayed complications, biliary/pancreatic duct cannulation, endoscopic/laparoscopic interventions, postprocedure hospital stay, procedure duration. Results: Ten patients underwent LAERCP: 9 after Roux-en-Y gastric bypass (RYGB) and 1 after antrectomy with RY (9 female, 1 male; 9 white, 1 black). Indications for the procedure were choledocholithiasis (n=4), biliary stricture (n=3), and sphincter of Oddi dysfunction (n=3). Endoscopic access was obtained to the gastric remnant (n=9) or biliopancreatic limb (n=1). Biliary cannulation was successfully achieved in 9 of 10 patients, biliary sphincterotomy was performed in all, pancreatography in 3 of 3, and sphincter of Oddi manometry in 2. In 1 patient, a 3F pancreatic duct stent was placed prophylactically. Mild post-ERCP pancreatitis developed in 2 patients, and 1 patient had a pneumothorax intraoperatively that was treated successfully. The mean duration of the procedure was 89 minutes (range 41-245), and the median postprocedure hospital stay was 2 days (mean 2.59, standard deviation 2.46). Limitations: Single-center, retrospective design. Conclusion: LAERCP is safe and successful for the diagnosis and therapy of biliopancreatic conditions in patients with RY. It additionally allows the diagnosis and treatment of internal hernias, a known complication of RYGB. [Copyright &y& Elsevier]

Background: Although prior studies evaluated the role of EUS and EGD for drainage of pancreatic pseudocysts, there are no randomized trials that compared the technical outcomes between both modalities. Objective: To compare the rate of technical success between EUS and EGD for transmural drainage of pancreatic pseudocysts. Study design: A prospective randomized trial. Setting: A tertiary-referral center. Patients: Those with a history of pancreatitis and symptomatic pancreatic pseudocysts that measured greater than 4 cm in size who were referred for endoscopic transmural drainage. Patients with pancreatic abscess or necrosis were excluded. Main Outcome Measurements: Technical success was defined as the ability to access and drain a pseudocyst by placement of transmural stents. Complications were assessed at 24 hours and at day 30. Treatment success was defined as the complete resolution or decrease in size of the pseudocyst to ≤2 cm on CT in association with clinical resolution of symptoms at 6 weeks of follow-up. Results: Thirty patients were randomized to undergo pseudocyst drainage by EUS (n = 15) or EGD (n = 15) over a 6-month period. Of the 15 patients randomized to EUS, drainage was not undertaken in one, because an alternative diagnosis of biliary cystadenoma was established at EUS and was excluded (after randomization) from analysis. The mean age of the patients was 47 years; 62% were men (18/29). Except for their sex, there was no difference in patient or clinical characteristics between the 2 cohorts. Although all the patients (n = 14) randomized to an EUS underwent successful drainage (100%), the procedure was technically successful in only 5 of 15 patients (33%) randomized to an EGD (P < .001). All 10 patients who failed drainage by EGD underwent successful drainage of the pseudocyst on a crossover to EUS. There was no significant difference in the rates of treatment success between EUS and EGD after stenting, either by intention-to-treat (ITT) analysis (100% vs 87%; P = .48) or as-treated analysis (95.8% vs 80%; P = .32). Major procedure-related bleeding was encountered in 2 patients in whom drainage by EGD was attempted; one resulted in death and the other necessitated a blood transfusion. No significant difference was observed between EUS and EGD with regard to complications either by ITT (0% vs 13%; P = .48) or as-treated analyses (4% vs 20%; P = .32). Technical success was significantly greater for EUS than EGD, even after adjusting for luminal compression and sex (adjusted exact odds ratio 39.4; P = .001). Limitation: Short duration of follow-up. Conclusions: When available, EUS should be considered as the first-line treatment modality for endoscopic drainage of pancreatic pseudocysts given its high technical success rate. [Copyright &y& Elsevier]

Background: Although EUS-guided cyst-gastrostomy is increasingly being performed, there are no studies that compare the clinical outcomes and cost-effectiveness with surgical cyst-gastrostomy. Objectives: To compare the clinical outcomes of EUS-guided cyst-gastrostomy with surgical cyst-gastrostomy for the management of patients with uncomplicated pancreatic pseudocysts and to perform a cost analysis of each treatment modality. Design: A retrospective case-controlled study. Setting: A tertiary-referral center. Patients: Consecutive patients with uncomplicated pancreatic pseudocysts managed by surgical and EUS-guided cyst-gastrostomy. Methods: An independent observer blinded to all clinic outcomes matched each patient who underwent a surgical cyst-gastrostomy with 2 patients who underwent an EUS-guided cyst-gastrostomy for age, etiology of pancreatitis, and the size of the pseudocyst. Main Outcome Measurements: Rates of treatment success, complications, and reinterventions; length of postprocedure hospital stay; and cost associated with each treatment modality. Results: Ten patients (6 men; mean age 42.3 years, range 22-65 years) who underwent surgical cyst-gastrostomy were matched with 20 patients who underwent an EUS-guided cyst-gastrostomy. There were no significant differences in demographics, major comorbidities, and clinical characteristics between both cohorts. Although there were no significant differences in rates of treatment success (100% vs 95%, P = .36), procedural complications (none in either cohort), or reinterventions (10% vs 0%, P = .13) between surgery versus an EUS-guided cyst-gastrostomy, the mean length of a postprocedure hospital stay for an EUS-guided cyst-gastrostomy was significantly shorter than for surgical cyst-gastrostomy (2.65 vs 6.5 days, P = .008). The average direct cost per case for EUS-guided cyst-gastrostomy was significantly less when compared with surgical cyst-gastrostomy ($9077 vs $14,815, P = .01), which corresponded to a cost savings of $5738 per patient. Limitations: Retrospective, nonrandomized design; patients with pancreatic abscess or necrosis were not evaluated; a limited sample size and a short duration of follow-up. Conclusions: EUS-guided cyst-gastrostomy should be considered as a first-line treatment approach for patients with uncomplicated pancreatic pseudocysts, because the procedure is cost saving and is associated with a shorter length of a postprocedure hospital stay when compared with surgical cyst-gastrostomy. There was no significant difference in clinical outcomes between both treatment modalities. [Copyright &y& Elsevier]

Background: Although there are several large series on endoscopic resection of the major duodenal papilla, only commentary on individual cases has been presented on endoscopic minor papilla resection. Objective: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Design: Observational study. Setting: Academic tertiary-referral center. Patients: Consecutive patients referred for endoscopic resection of minor papilla adenomas over a 12-month period. Interventions: All patients underwent an EUS before an ERCP to exclude ductal involvement by the tumor and for evaluation of pancreatic-ductal anatomy. The minor papilla was removed by snare electrocautery in all patients. A pancreatic stent was placed in the dorsal duct in patients with pancreas divisum as a prophylaxis for post-ERCP pancreatitis. Complications were assessed per consensus criteria. Main Outcome Measurements: To evaluate the technical success and safety of endoscopy for resection of minor papilla adenomas. Observations: Three patients underwent endoscopic resection of minor papilla adenomas over a 12-month period. The first patient had minor papilla adenoma, the second had coexisting pancreas divisum anatomy, and the third had adenomatous involvement of both the major and minor papillas. Minor papilla resection was technically successful in all 3 patients, with dual major and minor papilla resection in 1 patient who had adenomatous changes at both sites. Although 2 patients experienced no complications, the patient with pancreas divisum developed mild post-ERCP pancreatitis. At a 12-month follow-up, there was no evidence of tumor recurrence in any of the 3 patients. Limitation: Small number of patients. Conclusions: In experienced hands, endoscopic resection of the minor papilla is technically feasible, safe, and is associated with favorable clinical outcomes. [Copyright &y& Elsevier]

Background: Although the role of bedside endoscopy for the provision of emergent diagnosis and therapy is well known, the concept of bedside EUS requires further validation. Objective: To evaluate the concept of bedside EUS and assess its impact on patient management. Design: A prospective study. Setting: A tertiary-referral center. Patients: Patients included those with pancreaticobiliary and thoracic disorders who required EUS but who were clinically unstable to be evaluated in the endoscopy suite. Interventions: All procedures were performed by one endosonographer at the patient''s bedside by using an EUS cart that was equipped with a therapeutic curvilinear echoendoscope. Main Outcome Measurements: To evaluate the technical feasibility, safety, and impact of bedside EUS in the clinical management of patients. EUS was considered to have a significant impact if a new diagnosis was established and/or if the findings altered subsequent management. Results: Within a 3-month period, 6 patients (4 men; median age 56 years; American Society of Anesthesiologists class III/IV) were evaluated in the intensive care unit by using the mobile EUS cart. Procedural indications were the following: drainage of symptomatic pseudocyst (n = 2), evaluate the cause of cholangitis (n = 2), diagnose and treat a suspected postoperative (distal esophagectomy) fluid collection (n = 1), and provide tissue diagnosis in one patient with a pancreatic-head mass, who presented with intrahepatic bleeding. The procedure was technically successful in all 6 patients (100%), and no complications were encountered. Bedside EUS established a diagnosis of choledocholithiasis (n = 1), mediastinal abscess (n = 1), and pancreatic abscess (n = 1) in 3 patients, and ruled out the presence of choledocholithiasis (n = 1) and pancreatic pseudocyst (n = 1) in 2 other patients. Also, by using bedside EUS, transmural drainage of a pancreatic pseudocyst and mediastinal abscess was successfully undertaken in 2 patients. Bedside EUS had an impact on management in all 6 patients (100%): established a new diagnosis (n = 3), precluded the need for an ERCP and/or other interventions (n = 2), and enabled focused endotherapy (n = 3). Limitations: Small number of patients; a single endosonographer. Conclusions: Bedside EUS is technically feasible, safe, facilitates both diagnosis and therapy, and enables the clinical management of patients who are critically ill. [Copyright &y& Elsevier]

Background: Increasingly, peripancreatic fluid collections (PFCs) are managed endoscopically with conventional transmural drainage (CTD). The role of interventional EUS in drainage of PFCs requires further clarification, because the procedure is technically challenging, with limited availability. Objective: Identify characteristics that determine the need for drainage of PFC by CTD versus EUS. Patients: Consecutive patients with symptomatic PFCs (types: pseudocyst, abscess, and necrosis) referred for endoscopic drainage. Study Design: Prospective study. Setting: Tertiary-referral center. Methods: After ERCP, transmural drainage was attempted by CTD. If unsuccessful, drainage by EUS was then attempted. Findings on contrast-enhanced CT and endoscopy were collected to identify characteristics that predict the need for CTD versus EUS drainage. Main Outcome Measurements: Identify characteristics to determine whether CTD or EUS is best suited for drainage of a particular PFC. Technical outcomes and safety of both techniques were also compared. Results: Of 53 patients with PFCs, CTD was technically successful in 30 (57%) and failed in 23 (43%). PFC regional location was the pancreatic head in 16, the body in 20, and the tail in 17; in these locations, CTD was successful in 13 (81%), 17 (85%), and 0, respectively. The causes of failed CTD were absence of luminal compression (LC) in 20, difficulty with scope positioning in 2, and bleeding with attempted drainage (portal hypertension) in 1. One PFC drained by CTD was later diagnosed as necrotic sarcoma. Of the 23 patients who failed CTD and underwent EUS, an alternate diagnosis of mucinous neoplasm was made in 2 patients, and EUS-guided drainage was successful in the other 21 patients (100%). Although CTD failed in all PFCs in the tail, all were successfully drained by EUS. In the pancreatic-head region, only those PFCs superior to pancreas and extending into porta hepatis (n = 3) required drainage by EUS. In the pancreatic body, only PFCs that developed bleeding from a transmural puncture or without definitive LC because of gastric mural edema (albumin <1.5 mg/dL, n = 2) required EUS drainage. When compared with PFCs at other locations, those in the tail were best accessed by EUS (P < .001). Patients with luminal compression at CT were significantly more likely to undergo successful drainage by CTD (adjusted odds ratio [OR] 13.6; P = .02). When compared with CTD, EUS drainages were longer in duration (40 versus 75 minutes; P < .001), with similar rates of PFCs resolution (90% versus 95%). Although bleeding occurred in 1 patient in the CTD group, no complications were encountered in patients who underwent EUS-guided drainage. PFCs located at the tail of the pancreas were more likely to require drainage by EUS than CTD (adjusted OR 22.9, P = .003) when adjusted for the presence of luminal compression at CT, size of the PFC, serum albumin, and etiology of pancreatitis. Limitations: Nonrandomized study. Conclusions: Because a majority of PFCs can be drained by CTD in a shorter duration, with comparable outcomes, EUS-guided drainage should be reserved mainly for PFCs located at the pancreatic tail, because these are unlikely to cause luminal compression or are technically difficult to access. Also, all pseudocyst-type PFCs must be evaluated by EUS before any attempts at endoscopic drainage, because EUS identifies an alternate diagnosis in 5% of such patients. [Copyright &y& Elsevier]

Background: Traumatic bile leaks often result in prolonged morbidity and an increased length of hospital stay that requires multimodality management. Data on endoscopic management of traumatic bile leaks are scarce. Objective: To evaluate the efficacy of endotherapy in the management of traumatic bile leaks. Design: Retrospective evaluation of prospectively collected data. Setting: Tertiary academic referral center. Patients: Consecutive patients referred for ERCP after traumatic abdominal injury for the management of bile leaks. Interventions: Biliary stent placement at ERCP. Main Outcome Measures: Resolution of a bile leak on follow-up ERCP. Results: Ten patients underwent ERCP for the management of a traumatic bile leak over a 3-year period. The etiology included a penetrating injury from a gunshot wound in 5 patients, blunt injuries from a motor vehicle accident in 4 patients, and injury secondary to a fall in 1 patient. Liver injuries were grade II in 1 patient, grade IV in 7 patients, and grade V in 2 patients. A bile leak was treated by biliary stent placement in all patients, and the outcome was successful in 9 of 10 cases (90%). The mean duration of follow-up was 337 days (range, 101-821 days). Nine of 10 patients underwent surgery to control bleeding or other associated injuries. There were no ERCP-related complications. Limitations: Small number of patients. Conclusions: Consideration should be given to incorporate ERCP as first-line therapy in management of traumatic bile leaks, because endobiliary stent placement provides a successful outcome in a majority of cases, irrespective of the severity of injury. [Copyright &y& Elsevier]

Background: Accepted techniques for pancreatic sphincterotomy include use of a needle knife or a pull sphincterotome to ablate the sphincter. There are no prospective studies comparing outcomes between both techniques. Aim: Compare post–ERCP pancreatitis rates among high-risk patients undergoing pancreatic sphincterotomy with the pull-sphincterotome versus needle-knife technique. Study Design: Prospective, randomized trial. Methods: Patients diagnosed with pancreatic sphincter hypertension at sphincter of Oddi manometry were randomized to undergo pancreatic sphincterotomy with a pull sphincterotome (followed by pancreatic stenting) or a needle knife over a pancreatic stent. Main Outcome Measurements: To compare post-ERCP pancreatitis rates between the pull-sphincterotome and needle-knife groups. Results: Forty-eight patients were randomized. Patient demographics and the incidence of patient and procedure risk factors for pancreatitis were similar in both treatment groups. The trial was stopped early after an interim analysis showed that post-ERCP pancreatitis was significantly higher among patients undergoing sphincterotomy with a pull sphincterotome than a needle knife (7/24 = 29% [95% CI 13-51] vs 0/24 = 0% [95% CI 0-12]; P = .01). No other complications were encountered. At a mean follow-up of 12 months (range 6-18 months), 60% of patients had complete symptom relief, 15% partial symptom relief, and 25% recurrent symptoms. Reintervention rates and clinical outcomes were not significantly different between the 2 groups. Limitations: Short duration of follow-up. Conclusions: Pancreatic sphincterotomy is safer in high-risk patients when performed with a needle knife over a pancreatic stent. [Copyright &y& Elsevier]

In approximately 20% of patients with acute pancreatitis, a cause is not established by history, physical examination, routine laboratory testing, and abdominal imaging. For those with a single unexplained attack, the role of invasive evaluation with endoscopic retrograde cholangiopancreatography is unsettled but has been generally limited to those patients with suspected bile duct stones or malignancy. Recent studies suggest that microlithiasis is causative in up to 75% of patients with an unexplained attack and gallbladder in situ, whereas sphincter of Oddi dysfunction is most prevalent in those with recurrent attacks who have previously undergone cholecystectomy. EUS has been shown to be highly accurate for the identification of gallbladder sludge, common bile duct stones, and pancreatic diseases. Given this apparent diagnostic utility, an EUS-based strategy may be a reasonable approach to evaluate patients with a single idiopathic attack. ERCP and sphincter of Oddi manometry should generally be reserved for patients with multiple unexplained attacks and negative EUS results, especially for those patients who have previously undergone cholecystectomy. [Copyright &y& Elsevier]

Nonsteroidal anti-inflammatory drugs (NSAIDs) are among the most widely used classes of medications worldwide, available both through prescription and over the counter (OTC). Although these drugs are highly effective for pain, gastrointestinal (GI) complications may occur. Risk factors for GI complications from NSAIDs have been well studied, and the highest risk exists among the elderly and patients with a history of GI bleeding or complications. The increasingly widespread use of aspirin for both primary and secondary cardiovascular prophylaxis has also drawn attention to the potential increase in GI complications. Several strategies may minimize NSAID-mediated GI complications, including the use of drugs that do not injure the gut, such as acetaminophen or a low-dose opiate. The cyclooxygenase-2 (COX-2) inhibitors, which cause approximately 50% fewer GI complications than traditional NSAIDs, may also be used, although their cardiovascular safety has recently come into question. Antacid therapy with proton pump inhibitors (PPIs) may also be used to reduce NSAID-related dyspepsia and upper GI complications. Misoprostol is also effective in preventing NSAID-related complications, but is not as well tolerated. In any patient, the risk-benefit ratio must be assessed to determine the appropriate therapies to minimize GI complications resulting from daily aspirin therapy. [Copyright &y& Elsevier]