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Introduction: Endoscopic retrograde cholangiopancreatography (ERCP) plays an indispensable role in treating pancreato-biliary diseases but carries a risk of post-ERCP pancreatitis (PEP). Despite advances in the prevention strategies, prevention of PEP remains imperfect, necessitating more refined hydration methods. This study investigates the effectiveness of lactated Ringer's solution versus plasma solution in preventing PEP., Method and Analysis: This multicentre, double-blind, randomised controlled trial, will be initiated by the investigator-sponsor, and conducted in three tertiary centres in South Korea. The aim of this study is to assess the effectiveness of hydration in preventing PEP in patients with naïve papillae. It will target patients with naïve papillae, focusing on those at medium to high risk of PEP. Patients aged ≤18 years and those with serious comorbidities, acute/chronic pancreatitis and various other medical conditions will be excluded. Eligible participants will be randomly assigned into two arms in equal numbers: (1) PEP prevention using lactated Ringer's solution and (2) PEP prevention using plasma solution. The primary outcome of this study will be the occurrence of PEP, and secondary outcomes will be additional risk factors and potential adverse events related to ERCP. With a total enrolment of 844 patients, the study will be able to detect significant differences between the intervention arms., Ethics and Dissemination: Ethical approval is obtained from each institution (Asan Medical Centre, 2023-0382; Seoul National University Hospital, H-2302-05-1404; Samsung Medical Centre, SMC 2023-02-001-009). All participants provided informed consent following clear explanation of the study procedures. The results of the study will be disseminated in peer-reviewed journals and research conferences., Trial Registration Number: NCT05832047., Protocol Version: Ver 4.1 (2023)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Solobacterium moorei is an anaerobic gram-positive bacillus that rarely causes bacteremia. Herein, we report a case of S. moorei bacteremia associated with acute cholangitis in a patient without malignancy. The patient had a history of chronic pancreatitis with pancreaticogastrostomy and presented with fever and abdominal pain. Computed tomography scans showed acute cholangitis and S. moorei identified in blood cultures were confirmed by matrix-assisted laser desorption/ionization-time of flight mass spectrometry and 16S rRNA sequencing. The patient was successfully treated with endoscopic retrograde biliary drainage and antibiotics including meropenem and piperacillin-tazobactam., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background/aims: Type 2 autoimmune pancreatitis (AIP) has been considered extremely rare in East Asia. This study aimed to clarify the prevalence, clinical characteristics and radiological findings of type 2 AIP highlighting patients presenting as acute pancreatitis in a single center., Methods: Type 2 AIP patients were classified according to International Consensus Diagnostic Criteria. Radiological findings were compared between type 2 AIP presenting as acute pancreatitis and gallstone pancreatitis., Results: Among 244 patients with AIP, 27 (11.1%) had type 2 AIP (definite, 15 [55.5%] and probable 12 [44.5%]). The median age of patients with type 2 AIP was 29 years (interquartile range, 20 to 39 years). Acute pancreatitis was the most common initial presentation (n=17, 63%) while obstructive jaundice was present in only one patient. Ulcerative colitis (UC) was associated with type 2 AIP in 44.4% (12/27) of patients. Radiological pancreatic imaging such as delayed enhancement of diffusely enlarged pancreas, homogeneous enhancement of focal enlargement/mass, absent/minimal peripancreatic fat infiltration or fluid collection, and multifocal main pancreatic duct narrowings were helpful for differentiating type 2 AIP from gallstone pancreatitis. During follow-up (median, 32.3 months), two patients (2/25, 8%) experienced relapse., Conclusions: In South Korea, type 2 AIP is not as rare as previously thought. Overall, the clinical profile of type 2 AIP was similar to that of Western countries. Type 2 AIP should be considered in young UC patients with acute pancreatitis of uncertain etiology.

Objectives: The goal of the study was to determine whether endoscopic ultrasound (EUS)-guided biliary drainage (EUS-BD) is comparable to conventional transpapillary stenting with endoscopic retrograde cholangiopancreatography (ERCP) in palliation of malignant distal biliary obstruction. Although ERCP for the palliation of malignant biliary obstruction is the standard of care, post-procedure pancreatitis and stent dysfunctions are not uncommon. While EUS-BD has garnered interest as a viable alternative when ERCP is impossible, its role as a primary palliation of malignant distal biliary obstruction is yet to be proven., Methods: We performed random allocation to EUS-BD or ERCP in 125 patients with unresectable malignant distal biliary obstruction at four tertiary academic referral centers in South Korea., Results: Technical success rates were 93.8% (60/64) for EUS-BD and 90.2% (55/61) for ERCP (difference 3.6%, 95% 1-sided confidence interval lower limit -4.4%, P = 0.003 for noninferiority margin of 10%). Clinical success rates were 90.0% (54/60) in EUS-BD and 94.5% (52/55) in ERCP (P = 0.49). Lower rates of overall adverse events (6.3% vs 19.7%, P = 0.03) including post-procedure pancreatitis (0 vs 14.8%), reintervention (15.6% vs 42.6%), and higher rate of stent patency (85.1% vs 48.9%) were observed with EUS-BD. EUS-BD was also associated with more preserved quality of life (QOL) than transpapillary stenting after 12 weeks of the procedure., Conclusions: This study demonstrated comparable technical and clinical success rates between EUS-BD and ERCP in relief malignant distal biliary obstruction. Substantially longer duration of patency coupled with lower rates of adverse events and reintervention, and more preserved QOL were observed with EUS-BD (cris.nih.go.kr, Identifier: KCT0001396, https://cris.nih.go.kr/cris/search/search_result_st01_en.jsp?seq=9716&ltype=&rtype= ).

Background: Some biliary complications after liver transplantation (LT) are difficult to manage by endoscopic or radiologic intervention alone. In these cases, percutaneous transhepatic cholangioscopy (PTCS) can be used as an adjuvant option., Methods: Patients who underwent PTCS for post-LT biliary complications between August 1992 and January 2016 were retrospectively reviewed., Results: Fifteen patients underwent PTCS for post-LT biliary complications. The median age at LT was 47 years and 11 patients were male. Indications for LT were as follows: decompensated liver cirrhosis (n = 9), hepatocellular carcinoma (n = 5), and acute fulminant liver failure (n = 1). Single living donor was common (n = 11) and duct-to-duct anastomosis was performed in 11 patients. The median age at PTCS was 52 years and indications for PTCS were as follows: intrahepatic duct stone (n = 10), common bile duct stone (n = 1), biliary cast (n = 1), and biliary stricture (n = 3). There were no significant PTCS-related morbidity and mortality. However, four patients (26.7%) needed additional radiologic intervention (n = 2) or surgery (n = 2) after PTCS., Conclusions: Percutaneous transhepatic cholangioscopy in conjunction with endoscopic and radiologic interventions can aid in managing post-LT biliary complications and avoiding reoperation., (© 2016 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background and Study Aim: Fully covered, self-expandable metal stents (FCSEMSs) are acceptable tools for treating benign biliary stricture (BBS). However, little is known about the long-term outcomes of this technique. The aim of the present study was to evaluate the procedural and long-term outcomes of FCSEMSs for treating BBSs., Patients and Methods: A total of 134 consecutive patients (median age 56 years; range 21 - 83) with BBS were retrospectively reviewed. The main outcomes were technical and clinical success, stricture resolution, recurrence, and adverse events. Outcomes were analyzed by reviewing patient medical records., Results: The success rates of FCSEMS placement and removal were 99.3 % and 98.2 %, respectively. Stricture resolution occurred in 103/132 (78.0 %) of the patients (median stent duration, 93 days; range 1 - 489). The associated factors for stricture resolution were longer stent indwelling period (≥ 120 days) and absence of stent migration. Stricture recurrence was seen in 26/103 patients (25.2 %; 95 % confidence interval [CI] 0.17 - 0.34) within a median of 390 days (range 4 - 903 days). Chronic pancreatitis was associated with stricture recurrence (hazard ratio [HR] 2.59, 95 %CI 1.20 - 5.61; P = 0.02). Stent migration occurred in 41/132 patients (31.1 %; 95 %CI 0.23 - 0.39). The FCSEMS with anchoring flaps appeared to protect against stent migration (HR 0.22, 95 %CI 0.08 - 0.63; P < 0.01)., Conclusion: FCSEMSs had a high success rate for BBS resolution. Longer indwelling periods and the absence of stent migration might be important factors for stricture resolution., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) is a well-established diagnostic technique for examining various organs of the gastrointestinal tract and pancreas, but little is known about its use in the diagnostic work-up of GB lesions. The objective of this retrospective study was to evaluate the efficacy of EUS-FNA of GB lesions., Methodology: Twenty-eight patients who underwent EUS-FNA for evaluation of GB lesions were enrolled. The pathological results and complications were assessed., Results: EUS-FNA of GB was performed in 13 patients and that of enlarged lymph nodes was done in 18. Of the 13 GB lesions sampled by EUS-FNA, 10 were diagnosed as malignant and 3 were negative for malignant cells. Of the latter 3, two were false negatives for malignancy. All 14 metastatic lymphadenopathy cases were diagnosed with EUS-FNA of lymph nodes. EUS-FNA could differentiate adenocarcinomas and other malignant diseases. Cholecystitis occurred in one patient after EUS-FNA of the GB., Conclusions: EUS-FNA is a feasible, safe and reliable method for obtaining samples from GB lesions. EUS-FNA of lymph nodes is complementary to EUS-FNA of the GB and provides nodal stage as well as histological diagnosis.

Background and Aim: Type 2 autoimmune pancreatitis (AIP) has been reported mainly in Western countries and is thought to be very rare in Asia. The aim of this study was to compare the prevalence, clinical profiles, detailed radiological findings, and steroid responsiveness between type 1 and type 2 AIP in Korea., Methods: From 120 patients diagnosed with AIP between January 2003 and August 2010, 52 patients with histologically confirmed type 1 (n = 37) or type 2 (n = 15) AIP were included., Results: The median age of patients with type 2 AIP was significantly lower than that of patients with type 1 AIP (61 vs 34 years, P < 0.05). At initial presentation, severe abdominal pain and presentation with acute pancreatitis were more frequent in patients with type 2 AIP (P < 0.05). On computed tomography scan, the extent of pancreatic enlargement and the frequency of low-density mass did not differ significantly between the two groups. Detailed pancreatographic findings on endoscopic retrograde cholangiopancreatography/magnetic resonance cholangiopancreatography were not significantly different between the two groups. All patients with steroids therapy improved clinically and radiologically in response (25/25 in type 1 AIP and 14/14 in type 2 AIP). During the follow-up period, none of the patients with type 2 AIP experienced relapse., Conclusions: Type 2 AIP in all histologically confirmed AIP cases in Korea may not be as rare as originally thought, with an estimated prevalence rate of 28.8% (15/52). The detailed radiological findings of type 1 and type 2 AIP were not significantly different, and both subtypes responded well to steroids., (© 2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)

Background and Aim: This study aimed to determine the clinical characteristics of immunoglobulin G4 (IgG4)-associated sclerosing cholangitis (ISC) and provide clinical clues differentiating ISC from primary sclerosing cholangitis (PSC) or hilar cholangiocarcinoma (CCC)., Methods: Sixteen patients with ISC manifesting as hilar/intrahepatic strictures were analyzed for clinical characteristics and compared with patients with PSC and hilar CCC as disease controls for histology and serum IgG4 levels., Results: Distinguished biliary imaging findings of ISC included multifocal biliary tree involvement (n = 14), concentric bile duct thickening with preserved luminal patency (n = 13), and relatively mild proximal dilatation, despite prominent bile duct thickening (n = 11). Serum IgG4 levels were elevated in 12 patients (75%), but not in any of the 25 patients with hilar CCC. Ten patients (63%) had a past or concurrent history of autoimmune pancreatitis (AIP). The significant infiltration of IgG4-positive cells was observed with endobiliary or liver biopsy in 11 of 16 patients (69%) with ISC, but not in any patients with PSC or hilar CCC. Extrabiliary organ involvement, including sialadenitis, inflammatory pseudotumor of the liver and kidney, and retroperitoneal fibrosis, was present in seven patients. Marked improvement of biliary strictures and/or extrabiliary involvement was observed in all ISC patients after steroid therapy., Conclusions: ISC should be considered in the differential diagnosis of hilar/intrahepatic biliary strictures. Past or concurrent AIP or extrabiliary organ involvement strongly suggests the possibility of ISC. Significant infiltration of IgG4-positive cells on endobiliary or liver biopsy specimens, and/or elevated serum IgG4 levels, highly support the diagnosis of ISC and provide the rationale for steroid therapy., (© 2010 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd.)