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Endoscopic ultrasound (EUS)-guided tissue acquisition of pancreatic solid tumor requires a strict recommendation for its proper use in clinical practice because of its technical difficulty and invasiveness. The Korean Society of Gastrointestinal Endoscopy (KSGE) appointed a task force to draft clinical practice guidelines for EUS-guided tissue acquisition of pancreatic solid tumor. The strength of recommendation and the level of evidence for each statement were graded according to the Minds Handbook for Clinical Practice Guideline Development 2014. The committee, comprising a development panel of 16 endosonographers and an expert on guideline development methodology, developed 12 evidence-based recommendations in eight categories intended to help physicians make evidence-based clinical judgments with regard to the diagnosis of pancreatic solid tumor. This clinical practice guideline discusses EUS-guided sampling in pancreatic solid tumor and makes recommendations on circumstances that warrant its use, technical issues related to maximizing the diagnostic yield (e.g., needle type, needle diameter, adequate number of needle passes, sample obtaining techniques, and methods of specimen processing), adverse events of EUS-guided tissue acquisition, and learning-related issues. This guideline was reviewed by external experts and suggests best practices recommended based on the evidence available at the time of preparation. This guideline may not be applicable for all clinical situations and should be interpreted in light of specific situations and the availability of resources. It will be revised as necessary to cover progress and changes in technology and evidence from clinical practice. (Gut Liver 2021;15:354-374)

Although evidence indicates that use of procalcitonin to guide antibiotic decisions for the treatment of acute respiratory infections (ARI) decreases antibiotic consumption and improves clinical outcomes, algorithms used within studies had differences in PCT cut-off points and frequency of testing. We therefore analyzed studies evaluating procalcitonin-guided antibiotic therapy and propose consensus algorithms for different respiratory infection types. Areas covered: We systematically searched randomized-controlled trials (search strategy updated on February 2018) on procalcitonin-guided antibiotic therapy of ARI in adults using a pre-specified Cochrane protocol and analyzed algorithms from 32 trials that included 10,285 patients treated in primary care settings, emergency departments (ED), and intensive care units (ICU). We derived consensus algorithms for use of procalcitonin by the type of ARI including community-acquired pneumonia, bronchitis, chronic obstructive pulmonary disease or asthma exacerbation, sepsis, and post-operative sepsis due to respiratory infection. Consensus algorithm recommendations differ with regard to timing of treatment (i.e. timing of initiation in low-risk patients or discontinuation in high-risk patients) and procalcitonin cut-off points for the recommendation/strong recommendation to discontinue antibiotics (≤ 0.25/≤ 0.1 µg/L in ED and inpatients, ≤ 0.5/≤ 0.25 µg/L in ICU patients, and reduction by ≥ 80% from peak levels in sepsis patients). Expert commentary: Our proposed algorithms may facilitate safe and efficient implementation of procalcitonin-guided antibiotic protocols in diverse healthcare settings. Still, the decision about initiation and cessation of antibiotic treatment remains a clinical decision based on the patient assessment and the severity of illness and use of procalcitonin should not delay empirical treatment in high risk situations. info:eu-repo/semantics/publishedVersion

Some recent studies have found regression of liver cirrhosis after antiviral therapy in patients with hepatitis C virus (HCV)-related liver cirrhosis, but there have been no reports of complete regression of esophageal varices after interferon/peg-interferon and ribavirin combination therapy. We describe two cases of complete regression of esophageal varices and splenomegaly after interferon-alpha and ribavirin combination therapy in patients with HCV-related liver cirrhosis. Esophageal varices and splenomegaly regressed after 3 and 8 years of sustained virologic responses in cases 1 and 2, respectively. To our knowledge, this is the first study demonstrating that complications of liver cirrhosis, such as esophageal varices and splenomegaly, can regress after antiviral therapy in patients with HCV-related liver cirrhosis.

OBJECTIVES The aims of this study were to evaluate whether serum pancreatic enzyme levels could be used to aid screening for chronic pancreatitis (CP). METHODS 170 healthy volunteers were screened and prospectively enrolled in the control group. 150 patients who were diagnosed with calcific CP were enrolled in the patient group by retrospective review. Serum amylase and lipase levels were compared between the 2 groups. RESULTS The mean values ± SD of the control group were compared with those of the patient group for serum amylase level (48.1 ± 13.2 vs 34.8 ± 17.2 U/L, P < 0.001) and serum lipase level (26.4 ± 11.3 vs 16.3 ± 11.2 U/L, P < 0.001). On the receiver operating characteristic curve analysis for amylase level, area under the curve was 0.740 (95% confidence interval), and sensitivity and specificity were 38.7% and 94.1%, respectively, with a cutoff value of 27.5 U/L. On the receiver operating characteristic curve analysis for lipase level, area under the curve was 0.748 (95% confidence interval), and sensitivity and specificity were 33.3% and 95.9%, respectively, with a cutoff value of 10.5 U/L. CONCLUSIONS Our results suggest that low serum pancreatic enzyme levels can be used to aid in detection of CP.

Background/Aims Anisakiasis is frequent in Jeju Island because of the people's habit of ingesting raw fish. This study evaluated the clinical characteristics of patients with small bowel anisakiasis and compared them with those of patients with gastric anisakiasis. Methods We retrospectively reviewed the medical records of 109 patients diagnosed with anisakiasis between May 2003 and November 2011. Results Of the 109 patients diagnosed with anisakiasis, those with suspicious anisakiasis (n=38) or possible anisakiasis (n=12) were excluded. The age and gender distributions did not differ between patients with small bowel anisakiasis (n=30; age, 45±13 years) and those with gastric anisakiasis (n=29; age, 46±10 years). The mean duration of hospitalization was 5.4±4.3 days for patients with small bowel anisakiasis and 0.5±1.7 days for patients with gastric anisakiasis. Small bowel anisakiasis was accompanied by leukocytosis (76.7% vs 25.5%, p=0.003) and elevated C-reactive protein levels (3.4±3.2 mg/dL vs 0.5±0.3 mg/dL, p=0.009). Contrast-enhanced abdominopelvic computed tomography showed small bowel wall thickening with dilatation in 93.3% (28/30) of patients and a small amount of ascites in 80.0% (24/30) of patients with small bowel anisakiasis. Conclusions Compared with gastric anisakiasis patients, small bowel anisakiasis patients had a longer hospitalization time, higher inflammatory marker levels, and small bowel wall thickening with ascites.

Background/Aims Pancreatic duct calcifications are common in chronic pancreatitis. Secretin (SEC) stimulates pancreas duct cells to secrete bicarbonate-rich fluid. SEC may aid fragmentation and facilitate excretion of pulverized pancreatic stones during extracorporeal shock wave lithotripsy (ESWL). The aim was to evaluate the effect of SEC administered during ESWL on clearance of main pancreatic stone (MPDS) at endoscopic retrograde cholangiopancreatography (ERCP). Methods Between Jan. 2003 and Sept. 2010, patients with MPDS who were treated with ESWL and ERCP were identified retrospectively. The number and diameter of calcifications were assessed at pre-ESWL images. Before 2006, ESWL was performed without SEC stimulation. From 2007, 16 μg of SEC was administered IV near the beginning of ESWL at the discretion of the managing physician. Clearance of the pancreatic duct was assessed with ERCP after ESWL. Results A total of 233 consecutive cases (SEC group: 71, no SEC group: 162) were tallied. Overall there were 310 ESWLs and 332 ERCPs in the 233 cases. On univariate analysis, the use of SEC showed significantly higher rate of complete MPDS clearance (63% vs. 46%, p = 0.021) after first ESWL/ERCP. The number of repeat sessions of ESWL/ERCP was similar between the two groups (SEC vs. No SEC, ESWL/ERCP: 1.27 vs. 1.36/1.34 vs. 1.46). Independent predictors of complete/nearly complete stone clearance included the use of SEC ( p = 0.005), pre-ESWL pancreatic stent ( p = 0.001). Conclusions Secretin during ESWL appears to aid clearance of MPDS in chronic calcific pancreatitis. Further prospective randomized studies would be of interest.

Objectives Tumor growth factor beta (TGF-beta) is an immunosuppressive cytokine and has been implicated in a variety of disease processes, including those in autoimmune disease. Tumor growth factor beta is also involved in fibrosis by regulating matrix metalloproteinases (MMPs) and the tissue inhibitor of MP (TIMP). The purpose of this study was to compare the expression patterns of TGF-beta1, MMP-2, and TIMP-2 between autoimmune chronic pancreatitis (AIP) and alcoholic chronic pancreatitis (ACP) by immunohistochemical staining of pancreatic tissue specimens. Methods Pancreatic tissue specimens were obtained from 16 of 57 patients who had a diagnosis of AIP at the Asan Medical Center. Pancreatic tissue specimens of ACP were obtained from 10 patients who were surgically treated. Immunohistochemical staining was performed with antibodies specific for TGF-beta1, MMP-2, and TIMP-2. Results The degree of immunohistochemical staining for TGF-beta1 was significantly weaker in AIP than in ACP in the pancreatic ductal epithelial and mononuclear cells (P = 0.029 and P = 0.018, respectively). Conclusions This finding suggests that there may be a defect in the function of regulatory T (Treg) cells, which normally prevents autoimmune disease progression via a suppressor mechanism. Further studies are needed to identify the type of regulatory T cell involved in this process.

Serum immunoglobulin G (IgG) and/or IgG4 elevation is one of the notable characteristics of autoimmune chronic pancreatitis (AIP). The purpose of this study was to compare the sensitivity and specificity of IgG with those of IgG4 in the diagnosis of AIP.From December 2005 to March 2006, patients who were diagnosed as having ordinary chronic pancreatitis of a certain cause (n = 67) and pancreatic cancer (n = 76) in Asan Medical Center were enrolled. The IgG and IgG4 levels of these patients were compared with those of 35 AIP patients diagnosed in Asan Medical Center.The percentage of patients with serum IgG level more than 1800 mg/dL was 10.4% (7/67), 2.6% (2/76), and 54.3% (19/35) in patients with ordinary chronic pancreatitis, pancreatic cancer, and AIP, respectively. As for serum IgG4 levels more than 135 mg/dL, it was 11.9% (8/67), 1.3% (1/76), and 73.3% (22/30), respectively. The specificity of IgG at 1800 mg/dL and IgG4 at 135 mg/dL was both 93.7%. The serum IgG4 showed high specificity (98.7%) in differentiating AIP from pancreatic cancer. The IgG4 level at 141 mg/dL was determined as the most optimal cutoff value with resulting sensitivity and specificity of 73.3% and 95.1%, respectively (area under the curve, 0.816), whereas for IgG, it was determined as 1770 mg/dL, with sensitivity and specificity of 57.1% and 93.7% (area under the curve, 0.788).The sensitivity of serum IgG4 tended to be higher than that of IgG in the diagnosis of AIP. The IgG4 showed high specificity in the differential diagnosis of AIP from pancreatic cancer. Serum IgG4 should be included in the diagnostic workup for AIP.

Recent studies suggest that liver cirrhosis is reversible after administering oral nucleos(t)ide analogue therapy to patients with hepatitis B virus (HBV) infection. However, few studies have addressed whether esophageal varices can regress after such therapy. We report a case of complete regression of esophageal varices during entecavir therapy in patients with HBV-related liver cirrhosis, suggesting that complications of liver cirrhosis such as esophageal varices can regress after the long-term suppression of HBV replication.

Background/Aims Spontaneous HBeAg seroconversion occurs frequently in the immune reactive phase in HBeAg-positive chronic hepatitis B (CHB). Therefore, observation for 3-6 months before commencing antiviral therapy is recommended in patients with alanine aminotransferase (ALT) levels that exceed twice the upper limit of normal (ULN). However, HBeAg seroconversion occurs infrequently in patients infected with hepatitis B virus (HBV) genotype C. The aim of the present study was to determine whether the waiting policy is necessary in endemic areas of HBV genotype C infection. Methods Ninety patients with HBeAg-positive CHB were followed prospectively without administering antiviral therapy for 6 months. Antiviral therapy was initiated promptly at any time if there was any evidence of biochemical (i.e., acute exacerbation of HBV infection or aggravation of jaundice) or symptomatic deterioration. After 6 months of observation, antiviral therapy was initiated according to the patient's ALT and HBV DNA levels. Results Only one patient (1.1%) achieved spontaneous HBeAg seroconversion. Biochemical and symptomatic deterioration occurred before 6 months in 17 patients (18.9%) and 5 patients, respectively. High ALT and HBV DNA levels were both independent risk factors for biochemical deterioration. Of 15 patients with HBV DNA ≥5.1×107 IU/mL and ALT ≥5×ULN, biochemical deterioration occurred in 7 (46.7%), including 1 patient receiving liver transplantation due to liver failure. Conclusions Spontaneous HBeAg seroconversion in patients with HBeAg-positive CHB is rare within 6 months. Biochemical deterioration was common and may lead to liver failure. Immediate antiviral therapy should be considered, especially in patients with high ALT and HBV DNA levels in endemic areas of genotype C infection.

Objectives: Autoimmune chronic pancreatitis (AIP) is a very attractive disease to clinicians in terms of its dramatic response to the oral steroid therapy in contrast to ordinary chronic pancreatitis. In the year 2002, the Japan Pancreas Society published the diagnostic criteria of AIP, and many clinicians around the world use these criteria for its diagnosis. The purpose of this study was to evaluate whether the Japanese criteria for the diagnosis of AIP are adequate or not. Methods: We retrospectively analyzed the clinical, radiologic, laboratory, and histologic features of 31 patients with AIP who have been successfully treated with oral corticosteroid. All the enrolled patients showed normalization or marked improvement in symptoms, laboratory, and imaging findings after steroid treatment. Results: The mean patients' age was 56 years (range, 32-78 years) and comprised 25 males and 6 females. Seven patients who responded to the steroid did not satisfy the Japanese imaging criterion because the extent of irregular narrowing was less than one third of the entire length of main pancreatic duct. Among these 7 patients, 1 patient did not meet the laboratory and histopathologic criteria as well. Another 2 patients fulfilled the Japanese imaging criterion only and showed normal IgG level, negative results of autoantibody measurements, and nondiagnostic pancreatic histopathology. Taken together, 9 (29%) of the 31 patients did not meet the Japanese diagnostic criteria for AIP, yet responded to the steroid. Conclusions: Clinicians may miss a substantial portion of AIP patients who may benefit from steroid therapy when the diagnosis is confined to those who satisfy the criteria proposed by the Japan Pancreas Society. It is necessary to convene a worldwide consensus to develop an improved diagnostic criteria for AIP.