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Despite the introduction of serological neoplastic biomarkers and typical radiological characteristics in clinical practice, liver biopsy (LB) is often still necessary to establish a histological diagnosis, especially in ambiguous cases. Nowadays, LB via the percutaneous approach (PC-LB), under computed tomography (CT) scan or ultrasonography (US) guidance, is the route of choice. However, certain focal liver lesions can be challenging to access percutaneously. In such cases, endoscopic ultrasound (EUS)-guided fine needle biopsy (FNB) may represent an attractive, minimally invasive alternative. This retrospective observational study aimed to evaluate the efficacy, diagnostic performance, and safety of EUS-FNB conducted on 58 focal liver lesions located in both liver lobes. The adequacy of FNB samples for focal liver lesions located in the left and right lobes was 100% and 81.2%, respectively, and the difference was statistically significant (p = 0.001). Technical success was 100% for both liver lobes. The overall sensitivity and specificity were 95% and 100%, respectively. EUS-FNB is effective in making an accurate diagnosis with an excellent safety profile for focal liver lesions located in both liver lobes. [ABSTRACT FROM AUTHOR]

The utilization of graphic novels in the realm of clinical medicine is an infrequent occurrence. However, there is a burgeoning interest in their application across a spectrum of pathological conditions with the ultimate aim of enhancing patient care. This study is a prospective pilot designed to assess the influence of graphic novels on the stress levels and behavioral responses of patients diagnosed with pancreatic lesions and who are to undergo endoscopic ultrasound-guided fine needle biopsy (EUS-FNB). Patients exhibiting radiological and clinical pancreatic lesions needing biopsy will be evaluated consecutively. The inclusion criteria encompass the presence of a solid pancreatic mass or a partially solid mass in the event of a cystic component. The exclusion criteria include patients with cognitive impairments, those currently on benzodiazepines or other psychotropic medications, and those with a prior diagnosis of cancer. The authors have developed a comic panel comprising a sequence of six vibrant vignettes, which delineate the standard procedure of EUS-FNB to the patient. Following hospital admission, patients whomeet the enrolment criteria and consent to participate in the studywill be randomly assigned to either the test or the control group. A graphic novel will be distributed to all patients in the test group, who will have the opportunity to peruse it while awaiting the procedure. Subsequent to the EUS-FNB, all enrolled patients will complete the Beck Anxiety Inventory (BAI) and amodified version of the Depression Anxiety Stress Scales-21 (termed mDASS-21 or mASS-14). The BAI, a 21-itemself-report inventory, is employed to gauge the severity of anxiety in adults. The other questionnaire is a modified rendition of the DASS-21, which originally comprised 21 items segregated into three subscales (anxiety, stress, and depression) with seven items each. The anxiety subscale measures physiological arousal, situational anxiety, and the subjective experience of the effects of anxiety, while the stress subscale assesses chronic non-specific arousal, difficulty relaxing, nervous tension, irritability, agitation, and impatience. [ABSTRACT FROM AUTHOR]

These images involved the case of a 51-year-old woman who had a history of chronic abdominal pain, iron deficiency, and diarrhoea but no blood or mucus in her stool. She had never undergone major abdominal surgery, and her past medical evaluation diagnosed her with celiac disease, leading to the adoption of a gluten-free diet alleviating most of her gastrointestinal symptoms. However, years later, her abdominal pain returned, so she underwent an abdominal ultrasound, revealing non-specific bowel loop dilation, and a weakly positive faecal occult blood test led to a colonoscopy. Despite many efforts to advance the scope beyond the transverse colon, colonoscopy was arduous and not complete, even after several changes in decubitus and abdominal compressions. Therefore, a virtual colonoscopy was conducted, revealing no intraluminal masses, but the entire colon was located on the left side of the abdomen. Indeed, the results showed sigma and that most of the colon was curled up in the small pelvis. This rare anatomical variant, known as "Mesenterium commune" (MC), is a type of gut malrotation that develops in childhood due to a lack of omphalomesenteric loop rotation during the embryonic period. This condition can lead to episodes of intestinal obstruction, potentially resulting in an acute abdomen and leading to surgical correction. Symptoms include chronic recurring abdominal pain, nausea, vomiting, and occasionally bloody stools. Few cases of this extremely rare condition have been reported in the literature so far. [ABSTRACT FROM AUTHOR]

Simple Summary: Palliation of gastric outlet obstruction (GOO) and obstructive jaundice due to malignancy is a fundamental step in improving quality of life (QoL) and initiating or restarting systemic oncologic therapy in these patients. Endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is still the primary treatment for malignant biliary obstruction (MBO), but it fails more frequently when GOO is concomitant. Poor quality studies are present in the medical literature on the application of endoscopic ultrasound (EUS) guided procedures among patients suffering from double obstruction, and few studies explore outcomes when endoscopy is performed during the same session or within a few days. Our aim was to systematically search the evidence supporting the use of EUS-guided procedures in this scenario in order to evaluate the best strategy for concomitant treatment of MBO and MGOO. Background: The treatments for cancer palliation in patients with concomitant malignant biliary obstruction (MBO) and gastric outlet obstruction (MGOO) are still under investigation due to the lack of evidence available in the medical literature. We performed a systematic search and critical review to investigate efficacy and safety among patients with MBO and MGOO undergoing both endoscopic ultrasound-guided biliary drainage (EUS-BD) and MGOO endoscopic treatment. Methods: A systematic literature search was performed in PubMed, MEDLINE, EMBASE, and the Cochrane Library. EUS-BD included both transduodenal and transgastric techniques. Treatment of MGOO included duodenal stenting or EUS-GEA (gastroenteroanastomosis). Outcomes of interest were technical success, clinical success, and rate of adverse events (AEs) in patients undergoing double treatment in the same session or within one week. Results: 11 studies were included in the systematic review for a total number of 337 patients, 150 of whom had concurrent MBO and MGOO treatment, fulfilling the time criteria. MGOO was treated by duodenal stenting (self-expandable metal stents) in 10 studies, and in one study by EUS-GEA. EUS-BD had a mean technical success of 96.4% (CI 95%, 92.18–98.99) and a mean clinical success of 84.96% (CI 95%, 67.99–96.26). The average frequency of AEs for EUS-BD was 28.73% (CI 95%, 9.12–48.33). Clinical success for duodenal stenting was 90% vs. 100% for EUS-GEA. Conclusions: EUS-BD could become the preferred drainage in the case of double endoscopic treatment of concomitant MBO and MGOO in the near future, with the promising EUS-GEA becoming a valid option for MGOO treatment in these patients. [ABSTRACT FROM AUTHOR]

Background and Aim: Dedicated studies evaluating the impact of COVID‐19 on outcomes of pancreatobiliary IgG4 related disease (IgG4‐RD) patients are scarce. Whether COVID‐19 infection or vaccination would trigger IgG4‐RD exacerbation remains unknown. Methods: Pancreatobiliary IgG4‐RD patients ≥ 18 years old with active follow‐up since January 2020 from nine referral centers in Asia, Europe, and North America were included in this multicenter retrospective study. Outcome measures include incidence and severity of COVID‐19 infection, IgG4‐RD disease activity and treatment status, interruption of indicated IgG4‐RD treatment. Prospective data on COVID‐19 vaccination status and new COVID‐19 infection during the Omicron outbreak were also retrieved in the Hong Kong cohort. Results: Of the 124 pancreatobiliary IgG4‐RD patients, 25.0% had active IgG4‐RD, 71.0% were on immunosuppressive therapies and 80.6% had ≥ 1 risk factor for severe COVID. In 2020 (pre‐vaccination period), two patients (1.6%) had COVID‐19 infection (one requiring ICU admission), and 7.2% of patients had interruptions in indicated immunosuppressive treatment for IgG4‐RD. Despite a high vaccination rate (85.0%), COVID‐19 infection rate has increased to 20.0% during Omicron outbreak in the Hong Kong cohort. A trend towards higher COVID‐19 infection rate was noted in the non‐fully vaccinated/unvaccinated group (17.6% vs 33.3%, P = 0.376). No IgG4‐RD exacerbation following COVID‐19 vaccination or infection was observed. Conclusion: While a low COVID‐19 infection rate with no mortality was observed in pancreatobiliary IgG4‐RD patients in the pre‐vaccination period of COVID‐19, infection rate has increased during the Omicron outbreak despite a high vaccination rate. No IgG4‐RD exacerbation after COVID‐19 infection or vaccination was observed. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic changed the management of emergency medicine and those complications that needed interventional procedures, such as endoscopy or other radiological procedures. At the beginning of the outbreak, there were no exploitable recommendations regarding the proper policy to apply for limiting the virus spread during endoscopy. Between the first and the second wave, the approach regarding interventional procedures changed, due to higher awareness and newly defined protocols, even if different among the health centers. Patients with severe COVID-19 may develop major gastrointestinal complications or require nutritional support, so interventional procedures are required at bedside, even if patients are in isolated rooms. Our tertiary center admitted 95 patients with severe COVID-19 at our ICU-dedicated department until May 2021, and 56% of them died. Among them, 61 endoscopic procedures were performed, mainly gastroscopies (81.96%) followed by colonoscopies (11.47%) and other more advanced procedures (6.55%). Our approach aimed to adapt and create COVID-related protocols, dedicated itineraries, and rooms in a separate department with the prospect to easily organize complete and safe endoscopic theaters at the COVID-ICU department. [ABSTRACT FROM AUTHOR]

3 Arteriography with splenic artery embolization. a Arteriography, showing a slight and thin irregular sign of extravascular diffusion in the middle side of the splenic artery, next to the pancreatic body. b Embolization of the splenic artery. During his previous hospital stay at another institution, the patient underwent computed tomography scan, gastroscopy, colonoscopy, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound (EUS), and red blood cell scintigraphy. Because of his cardiovascular comorbidities (cardiopathy, atrial fibrillation, and type II diabetes), the patient was on anticoagulation therapy, which was paused after GI bleeding started. [Extracted from the article]

Computed tomography (CT) revealed bilateral lung involvement and a left pulmonary abscess drained by a percutaneous catheter (Fig. 1 Computed tomography scan of the thorax showing SARS-CoV-2-related pneumonia and left pulmonary drainage (red arrow). Percutaneous endoscopic gastrostomy (PEG) was performed, but the patient developed an early buried bumper syndrome [1][2][3][4] after one month, so the tube was removed and gastroscopy showed an unexpected gastric perforation of the fundus (Fig. [Extracted from the article]

Abstract Introduction Gastric outlet obstruction is a clinical syndrome caused by a variety of mechanical obstructions. Peptic ulcer disease used to be responsible for most gastric outlet obstruction, but in the last 40 years the prevalence of malignant tumors has risen significantly. Adhesive disease is an infrequent and insidious cause of mechanical gastric outlet obstruction. Case presentation We report the case of a 78-year-old Caucasian man who had a clinical history of a right nephrectomy for malignancy three years earlier and who was admitted for a severe gastric outlet obstruction (score of 1) confirmed both by an upper endoscopy and by a fluoroscopic view after contrast injection. A computed tomography scan and a laparotomy, with omental biopsies, showed a peritoneal carcinomatosis with the development of abdominal adhesions that prompted an abnormal gastric rotation around the perpendicular axis of his antrum with a dislocation in the empty space of his right kidney. Symptoms disappeared after surgical bypass through a gastrojejunostomy. Conclusions Our patient experienced a very rare complication characterized by the development of adhesions due to peritoneal carcinomatosis caused by a renal carcinoma treated with nephrectomy. These adhesions prompted an abnormal dislocation of his antrum, as an internal hernia, in the empty space of his right kidney.

Abstract Background Liver involvement, including elevated direct-reacting bilirubin levels, is common in patients with sickle cell disease. Fifty to seventy percent of sickle cell patients have pigmented gallstones due to precipitation of unconjugated bilirubin, and cholelithiasis or choledocholithiasis are common complications. The highest prevalence of these complications occurs in patients with Gilbert's syndrome because of the combined effect of increased bilirubin production and reduced bilirubin-diphosphate-glucuronosyltransferase enzyme activity. Cholelithiasis is also a common complication in patients with thalassemia. Endoscopic removal of choledochal stones does not always resolve the clinical picture, as in cases of dysfunction of the Vater's papilla, increased bile density due to persistently impaired bile flow or distortion of the choledocus due to dilatation, or inflammation secondary to gallstone. Case presentation We report here a case of severe and persistent obstructive jaundice in a child affected with thalassodrepanocytosis and Gilbert's syndrome, previously, and unsuccessfully, treated with endoscopic removal of choledochal stones. Deep and thorough biliary washing, and stenting with a new removable polytetrafluoroethylene (PTFE)-covered flared-type stent led to complete resolution of the obstructive jaundice. Conclusions This report shows that an aggressive endoscopic approach in this select category of patients can help resolve the severe complication of hemolytic anemia, thus avoiding surgery.