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There is cumulative evidence that pancreatic exocrine insufficiency (PEI) is under-recognised and can occur in patients with 'at-risk' conditions. Thus, we aimed to assess the current practice and yield of requesting faecal elastase FEL-1), an indicator of PEI, in patients with 'at-risk' conditions. We prospectively recruited patients attending secondary care clinics with diabetes mellitus (DM), people living with HIV (PLHIV) and inpatients admitted to hospital with high alcohol intake (HAI). All patients underwent testing with FEL-1. Those patients with PEI (FEL-1 <200 μg/g) were contacted and offered a follow-up review in gastroenterology clinic. In total, 188 patients were recruited (HAI, n=78; DM, n=64; and PLHIV, n=46). Previous FEL-1 testing had not been performed in any of the patients. The return rate of samples was 67.9% for patients with HAI, 76.6% for those with DM and 56.5% for those with PLHIV. The presence of PEI was shown in 20.4% of patients with DM, 15.4% of patients with PLHIV and 22.6% in those with HAI. Diarrhoea and bloating were the most reported symptoms in followed-up patients with low FEL-1 (31.8% and 22.7% of patients, respectively). Follow-up computed tomography (CT) scans in those patients with PEI identified chronic pancreatitis changes in 13.6% and pancreatic atrophy in 31.8% of patients. These results suggest that there is a lack of testing for PEI in 'at-risk' groups. Our findings also suggest that using FEL-1 to test for PEI in patients with DM, PLHIV and HAI has a significant impact, although further studies are required to validate these findings. [ABSTRACT FROM AUTHOR]

Simple Summary: Endoscopic ultrasound-guided gallbladder drainage is emerging as an important technique for patients with malignant biliary obstruction where ERCP has failed. This meta-analysis is conducted to evaluate the efficacy and safety of this procedure. A comprehensive search of key databases was conducted, and all relevant studies were interrogated. A total of 7 studies were included in the final analysis with a total of 136 patients. The pooled clinical success rate of the procedure was 85%. Adverse events occurred in 13% of cases. No severe adverse events were reported. This meta-analysis supports the use of endoscopic ultrasound-guided drainage in malignant biliary obstruction when standard treatment has failed. Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is a rescue technique for patients with malignant biliary obstruction who fail conventional treatment with ERCP or EUS-guided biliary drainage. The technique has been successfully employed in the management of acute cholecystitis in patients not fit for surgery. However, the evidence for its use in malignant obstruction is less robust. This review article aims to evaluate the data available at present to better understand the safety and efficacy of EUS-guided gallbladder drainage. Methods: A detailed literature review was conducted and several databases were searched for any studies relating to EUS-GBD in malignant biliary obstruction. Pooled rates with 95% confidence intervals were calculated for clinical success and adverse events. Results: Our search identified 298 studies related to EUS-GBD. The final analysis included 7 studies with 136 patients. The pooled rate of clinical success (95% CI) was 85% (78–90%, I2: 0%). The pooled rate of adverse events (95% CI) was 13% (7–19%, I2: 0%). Adverse events included: peritonitis, bleeding, bile leakage, stent migration, and stent occlusion. No deaths directly related to the procedure were reported; however, in some of the studies, deaths occurred due to disease progression. Conclusion: This review supports the use of EUS-guided gallbladder drainage as a rescue option for patients who have failed conventional measures. [ABSTRACT FROM AUTHOR]

Background & Aim: There is a paucity of data reflecting the symptomatic responses to dietary gluten (SRDG) in patients with Coeliac Disease (CD). We aimed to determine the type, timing and severity of SRDG with reference to a range of disease-related factors. Methods: Postal survey of 224 biopsy-proven patients including gluten-free diet (GFD) adherence, symptom checklist, ROME II criteria and The Hospital Anxiety & Depression Scale. Case-note review was also conducted. Results: 26% of respondents were male. Full GFD adherence: n=159 (70%). Irritable bowel syndrome (IBS): n=50 (22%). Anxiety: n=30 (13%); Depression: n=33 (14%); Anxiety & Depression: n=72 (32%). Pruritus, fatigue and bloating were a more common SRDG in the partial/none GFD adherent group (p=ns). Co-existing IBS was associated with a greater prevalence of nausea and fatigue in response to gluten (p=<0.05). Fully GFD adherent patients are more likely to have SRDG <1hr than partial/none adherent (OR 4.8; p=0.004), as are a third of patients with co-existing IBS (OR 1.5; p=0.027) and those patients at risk of both anxiety and depression (OR 1.9; p=0.04). Inadvertent exposure to dietary gluten in the fully GFD adherent group is more likely to result in a severe SRDG in comparison to symptoms arising prior to consistent GFD adherence (OR 2.3; p=0.01). IBS sufferers are also more likely to rate their SRDG as severe in nature (OR 1.4; p=0.038). Conclusion: Patients with consistent GFD adherence experience a SRDG faster and more severe in comparison to prior gluten exposure possibly demonstrating an adept immunological response. Anxiety and depression also enhance the speed of symptom onset and co-existing visceral hypersensitivity is a risk factor for severe reactions to dietary gluten. [ABSTRACT FROM AUTHOR]

OBJECTIVE--The implications of celiac disease (CD) in adult patients with type 1 diabetes are unknown, with respect to diabetes-related outcomes including glycemic control, lipids, microvascular complications, quality of life, and the effect of a gluten-free diet (GFD). We identified CD in adults with type 1 diabetes and investigated the effect of a GFD on diabetes-related complications. RESEARCH DESIGN AND METHODS--This was a case-control study conducted at a U.K. leaching hospital. Patients with type 1 diabetes aged >16 years (n = 1,000) were assessed for CD. HbA1c, lipid profile, quality of life, retinopathy stage, nephropathy stage, and degree of neuropathy before and after 1 year on a GFD were assessed. RESULTS--The prevalence of CD was 33 per 1,000 subjects (3.3% [95% CI 2.3-4.6]). At diagnosis of CD, adult type 1 diabetic patients had worse glycemic control (8.2 vs. 7.5%, P = 0.05), lower total cholesterol (4.1 vs. 4.9, P = 0.014), lower HDL cholesterol (1.1 vs. 1.6, P = 0.017), and a higher prevalence of retinopathy (58.3 vs. 25%, P = 0.02), nephropathy (41.6 vs. 4.2%, P = 0.009), and peripheral neuropathy (41.6 vs. 16.6%, P = 0.11). There was no difference in quality of life (P > 0.1). After 1 year on a GFD, only the lipid profile improved overall, but in adherent individuals HbA1c and markers for nephropathy improved. CONCLUSIONS--Adults with undetected CD and type 1 diabetes have worse glycemic control and a higher prevalence of retinopathy and nephropathy. Treatment with a GFD for 1 year is safe in adults with type 1 diabetes and does not have a negative impact on the quality of life. [ABSTRACT FROM AUTHOR]

Background: Coeliac Disease (CD) is an increasingly common autoimmune condition, the treatment of which is a gluten-free diet (GFD). Previous studies fail to reach consensus of the impact this restrictive diet has on an individual's quality of life (QoL). Furthermore, how patient characteristics, such as demographic and educational background, may predict GFD adherence is poorly understood. We aimed to assess which factors had an impact on Qol in patients with CD. Methods: Case-control postal survey (n=573). Biopsy-proven CD patients (n=225; mean disease duration 8yrs; range 0.5-S2yrs; male 26%) and age and sex matched controls (n=348; male 36%) completed The Short-Form 36-Item (SF-36) Q0L measure, The Hospital Anxiety & Depression Scale (HADS), GFD assessment, and demographic questionnaire. Results: We found a high proportion of GFD adherence: `Full Adherence' 65%, `Partial Adherence' 31%, `None Adherence' 4%, accompanied however, by 80% of patients reporting difficulty adhering to the GFD: 'Impossible' 5%, 'Mostly difficult' 14%, 'Sometimes difficult' 61%, 'No difficulty' 20%. Negligible differences in QoL scores were observed when comparing full versus partial/none GFD patients (P>0.05), however, stepwise reductions in Q0L and increasing likelihood of anxiety/depression were found in association with increasing degree of difficulty adhering to the GFD (P<0.000l). Demographic assessment suggests that an affluent background and a university education promote greater GFD adherence. Conclusions: Most coeliac patients adhere to a GFD but encounter difficulty doing so (potentially influenced by social and educational background). The degree of GFD difficulty is associated with reductions in patient wellbeing and psychological distress that the dietician is critically placed to address. [ABSTRACT FROM AUTHOR]

Background: Celiac disease is associated with exocrine pancreatic insufficiency. We previously reported that in 30% (20/66) of adult celiac patients with current or persistent diarrhea the underlying cause was exocrine pancreatic insufficiency. Of these 20 patients, 19 initially improved on pancreatic supplementation. To date, there are no published longitudinal studies.Methods: The 20 patients who had initially received therapy for exocrine pancreatic insufficiency were prospectively followed-up for 4 years. Gastrointestinal symptoms, dietary adherence, celiac antibody status, and dose of enzyme supplementation were recorded. Fecal elastase-1 (Fel-1) was repeated to reassess exocrine pancreatic function.Results: In the study, 19/20 patients were reviewed, as one had died (mean age 59.7 years, 7 males). The mean duration of celiac disease was 13.2 years. Eleven out of nineteen were still taking enzyme supplementation at a mean dose of 45,000 units of lipase per day. Only 1/11 reported no symptomatic benefit and 8/19 patients had discontinued supplementation because their diarrhea had improved. In the whole group there was a significant increase in Fel-1 levels over time, with median values of 90 μg/g at 0 months, 212 μg/g at 6 months, and 365 μg/g at follow-up (45-66 months)(p < 0.0001).Conclusions: Fecal elastase-1 is useful in identifying exocrine pancreatic insufficiency in adult celiac patients with diarrhea. Our longitudinal data suggests that pancreatic enzyme supplementation could be discontinued in a substantial proportion of patients as symptoms improve. [ABSTRACT FROM AUTHOR]

Percutaneous endoscopic gastrostomy (PEG) is an accepted technique for long-term enteral feeding. Its use has increased because of its relative technical simplicity and low complication rate. As a result, the demands for gastrostomy insertion have risen and now encompass indications where the long-term outcomes are uncertain. One example of this, are patients with end-stage dementia who may be unable or unwilling to eat. For this reason, dementia has become one of the most common indications for gastrostomy feeding. This article reviews the current evidence relating to PEG feeding in dementia as well as work from the authors' own group. The purpose of this review is to provide the reader with an overview of the published literature and suggest a practical approach for this difficult clinical situation. The changes which the authors have implemented and described (including audit data), may be something which any practicing healthcare professional in this field may choose to incorporate into their own clinical practice. [ABSTRACT FROM AUTHOR]

Objective. The relationship between coeliac disease and inflammatory bowel disease (IBD) is controversial. The aim of this study was to determine the prevalence of coeliac disease in IBD and the prevalence of IBD in coeliac disease. Material and methods. Patients were enrolled from specialist IBD and coeliac clinics. Antigliadins, endomysial, tissue transglutaminase antibody and total IgA levels were measured in IBD patients. Patients with positive antibodies were offered a duodenal biopsy. The notes on coeliac patients were reviewed for colonoscopic and biopsy findings. Controls were recruited from the local population. Results. The study included 305 patients with coeliac disease, 354 with IBD and 601 healthy controls. The IBD group comprised 154 ulcerative colitis (UC) cases, 173 Crohn's disease, 18 indeterminate colitis and 9 cases of microscopic colitis. Forty-seven patients had positive antibodies and 3 had villous atrophy on biopsy. All three patients had positive anti-tissue transglutaminase antibodies but only two were endomysial antibody (EMA) positive. Ten coeliac patients had IBD (5 UC and 5 lymphocytic colitis). Five controls had coeliac disease and 2 had IBD (1 Crohn's disease and 1 UC). Stepwise multiple logistic regression showed only antibody positivity as being significant (p<0.0001). Conclusions. The prevalence of IBD in coeliac disease was increased 10-fold compared with that in controls (odds ratio 9.98, 95% CI 2.8-45.9, p=0.0006), while the prevalence of coeliac disease in IBD was comparable with that in controls (odds ratio 1.02, 95% CI, 0.24-4.29, p=1.0). [ABSTRACT FROM AUTHOR]

A letter to the editor in response to the article "The relationship between inflammatory bowel disease and type 1 diabetes mellitus: a study of relative prevalence in comparison with population controls," that was published in a previous issue of the journal is presented.

Background: A novel fork-tip fine-needle biopsy (FNB) needle has recently been introduced for endoscopic ultrasound (EUS)-guided sampling. The aim of this study was to compare the performance of fork-tip FNB histology and standard fine-needle aspiration (FNA) cytology in the diagnosis of solid pancreatic masses.Methods: A randomized crossover study was performed in patients referred for EUS-guided sampling. Three passes were taken with each needle in a randomized order. Only samples reported as diagnostic of malignancy were considered positive. The primary end point was the sensitivity of diagnosis of malignancy. Secondary end points included the amount of sample obtained, ease of diagnosis, duration of tissue sampling, pathologist viewing time, and cost.Results: 108 patients were recruited. Median age was 69 years (range 30 - 87) and 57 were male; 85.2 % had a final diagnosis of malignancy. There were statistically significant differences in sensitivity (82 % [95 % confidence interval (CI) 72 % to 89 %] vs. 71 % [95 %CI 60 % to 80 %]), accuracy (84 % [95 %CI 76 % to 91 %] vs. 75 % [95 %CI 66 % to 83 %]), proportion graded as a straightforward diagnosis (69 % [95 %CI 60 % to 78 %] vs. 51 % [95 %CI 41 % to 61 %]), and median pathology viewing time (188 vs. 332 seconds) (P < 0.001) between FNB and FNA needles, respectively. There was no significant difference in cost between an FNB or FNA strategy.Conclusion: The diagnostic performance of the fork-tip FNB needle was significantly better than that of FNA; it was associated with ease of diagnosis, shorter pathological viewing times, and was cost neutral. [ABSTRACT FROM AUTHOR]

Background: Stents are frequently placed in patients with biliary obstruction due to a mass in the head of the pancreas. The impact of plastic or self-expandable metal stents (SEMSs) on endoscopic ultrasound (EUS)-guided tissue sampling is unclear. This study aimed to assess, using strict pathological criteria, whether stents impair fine-needle aspiration (FNA) or fine-needle biopsy (FNB).Methods: All patients with a solid mass in the head of the pancreas who underwent EUS-guided tissue sampling between 2010 and 2016 at our unit were included. Factors with possible impact on diagnostic performance were analyzed using logistic regression. Analysis was performed using both strict (malignant only) and less strict (suspicious for malignancy) cutoffs.Results: Of 631 individuals undergoing 698 procedures, 535 (84.8 %) had a final diagnosis of malignancy, 141 had SEMS, 149 had plastic stents, and 341 had no stent. Using strict criteria, SEMS were associated with an increased occurrence of incorrect diagnosis of EUS tissue sampling, with an odds ratio (OR) of 1.96 (95 % confidence interval [CI] 1.24 - 3.10). Increasing tumor size (OR 0.72, 95 %CI 0.59 - 0.87), increasing number of passes (OR 0.84, 95 %CI 0.72 - 0.99), and fork-tip biopsy needle (OR 0.52, 95 %CI 0.31 - 0.86) were independently associated with a decrease in incorrect diagnosis. Repeat tissue sampling was more common with SEMSs (10.2 %) than with plastic stents (2.9 %) or no stents (4.5 %) (P < 0.02).Conclusion: SEMS use had a negative impact on tissue diagnosis in pancreatic head masses, whereas use of a fork-tip biopsy needle and increasing number of passes were independently associated with improved accuracy. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Efficacy of Fibre, Antispasmodics, and Peppermint Oil in Irritable Bowel Syndrome: Systematic Review and Meta-analysis," by A.C. Ford, N.J. Talley, B.M.R. Spiegel, A.E. Foxx-Orenstein, L. Schiller, E.M.M. Quigley, et al, published in the November 13, 2008 issue.

BACKGROUND : Data are limited regarding pancreatic cancer diagnosed following a pancreaticobiliary endoscopic ultrasound (EUS) that does not diagnose pancreatic cancer. We have studied the frequency of, and factors associated with, post-EUS pancreatic cancer (PEPC) and 1-year mortality. METHODS : Between 2010 and 2017, patients with pancreatic cancer and a preceding pancreaticobiliary EUS were identified in a national cohort using Hospital Episode Statistics. Patients with a pancreaticobiliary EUS 6-18 months before a later pancreatic cancer diagnosis were the PEPC cases; controls were those with pancreatic cancer diagnosed within 6 months of pancreaticobiliary EUS. Multivariable logistic regression models examined the factors associated with PEPC and a Cox regression model examined factors associated with 1-year cumulative mortality. RESULTS : 9363 pancreatic cancer patients were studied; 93.5 % identified as controls (men 53.2 %; median age 68 [interquartile range (IQR) 61-75]); 6.5 % as PEPC cases (men 58.2 %; median age 69 [IQR 61-77]). PEPC was associated with older age (≥ 75 years compared with < 65 years, odds ratio [OR] 1.42, 95 %CI 1.15-1.76), increasing co-morbidity (Charlson co-morbidity score > 5, OR 1.90, 95 %CI 1.49-2.43), chronic pancreatitis (OR 3.13, 95 %CI 2.50-3.92), and diabetes mellitus (OR 1.58, 95 %CI 1.31-1.90). Metal biliary stents (OR 0.57, 95 %CI 0.38-0.86) and EUS-FNA (OR 0.49, 95 %CI 0.41-0.58) were inversely associated with PEPC. PEPC was associated with a higher cumulative mortality at 1 year (hazard ratio 1.12, 95 %CI 1.02-1.24), with only 14 % of PEPC patients (95 %CI 12 %-17 %) having a surgical resection, compared with 21 % (95 %CI 20 %-22 %) of controls. CONCLUSIONS : PEPC occurred in 6.5 % of patients and was associated with chronic pancreatitis, older age, more co-morbidities, and specifically diabetes mellitus. PEPC was associated with a worse prognosis and lower surgical resection rates. [ABSTRACT FROM AUTHOR]

A response by John S. Leeds and colleagues to a letter to the editor about their article "High Prevalence of Microvascular Complications in Adults With Type 1 Diabetes and Newly Diagnosed Celiac Disease" is presented.

A letter to the editor is presented in response to the article by Higaki and colleagues on the lack of evidence that would support a poor prognosis after percutaneous endoscopic gastrostomy in elderly people with dementia compared with the cognitively preserved elderly.

Background & Aims: Our study aimed to assess the sensitivity of EUS and EUS-FNA for pancreatic neuroendocrine tumors (pNETs) and compare performance over two consecutive 4 year 2 month periods, to investigate the comparative performance between solid and cystic pNETs and determine the incremental yield of EUS±FNA in individuals with a mass not diagnosed as a pNET after cross-sectional imaging. Methods: A retrospective review of a prospectively maintained database was carried out to identify all pNET patients who underwent EUS-FNA between April 2003 and September 2011. Results: A final diagnosis of solid and cystic pNETs was made in 43 and 10 patients, respectively. Overall, the yield of combined EUS imaging and cytology was significantly higher than that of CT and/or MRI (p< 0.05) across all groups [solid (83.7% vs. 41.8%), cystic (70% vs. 10%) and combined solid-cystic (81.1% vs. 35.8%)]. The yield of combined EUS imaging and cytology was significantly better than EUS imaging alone (p<0.05) in the solid (83.7% vs. 58%) and combined pNET cohort (81.1% vs. 52.8%) of patients. After a non-diagnostic CT and or MRI, EUS/EUS-FNA confirmed pNET in 19 out of 25 patients (76.0%) with solid pNETs and 6 out of 9 patients (66.7%) with cystic pNETs. Conclusion: EUS and EUS-FNA had a significant clinical impact in the 25/34 of cases where pNET was not suspected after initial cross-sectional imaging. [ABSTRACT FROM AUTHOR]

Objective. Bile acid malabsorption (BAM) has been reported as a possible cause of diarrhea predominant irritable bowel syndrome (D-IBS) type symptoms. We aimed to determine how commonly patients with D-IBS type symptoms had a diagnosis of BAM as demonstrated by a positive SeHCAT (75 Selenium-homocholic acid taurine) test (retention <10% at seven days). Materials and methods. A retrospective analysis was undertaken of patient's records for all patients who underwent a SeHCAT test between 2001 and 2009 in a tertiary hospital (Group A). Concurrently, a cohort of patients with Rome II D-IBS type symptoms was examined to determine the potential utility of SeHCAT test (Group B). Results. In Group A 39.2% ( n == 107/273) of patients had a positive SeHCAT result. The median time from first hospital visit to SeHCAT result was 30 weeks. Predictive factors for BAM: terminal ileal Crohn's disease ( p < 0.01), terminal ileal resection ( p < 0.01), and previous cholecystectomy ( p < 0.01). 33.6% of patients who had a positive SeHCAT also had Rome II D-IBS. In Group B the D-IBS control cohort only 1.9% of patients had undergone a SeHCAT scan ( p < 0.001 compared to Group A). Conclusion. BAM is common and should be considered earlier when investigating unselected patients with D-IBS type symptoms. [ABSTRACT FROM AUTHOR]

Endoscopy 2022, DOI: 10.1055/a-1784-1661 In the above-mentioned article, the senior authorship for Oppong KW, Trudgill NJ has been included. B Rate of pancreatic cancer following a negative endoscopic ultrasound and associated factors b King D, Kamran U, Dosanjh A et al. [Extracted from the article]

Background: In patients with obscure gastrointestinal bleeding (OGB), capsule endoscopy (CE) is the investigation of choice after negative conventional endoscopy. However, there is paucity of data on which clinical factors predict the ability of CE to detect pathology and alter management. Aim: To investigate clinical factors which predict a higher diagnostic yield and a change in management in patients presenting with OGB. Methods: Data was collected in patients with OGB for type of OGB [overt (OB) or iron deficiency anaemia (IDA)], co-morbidity, use of anticoagulants, transfusion dependence, subsequent CE diagnosis and follow up data. Factors that predicted a higher yield and a change in management were identified using logistic regression. Results: There were 427 patients (IDA 74%) with a mean age of 58 years (range 17-92).The diagnostic yield was 50% with a change in management in 30% of patients. The commonest finding was angiodysplasia in 52% of patients. There was no significant difference in the diagnostic yield between the two groups (OB: 56%, IDA 48%, p=0.15). On logistic regression, age (p=0.001), the use of warfarin (p=0.02) and liver co-morbidity (p=0.001) were significant factors which predicted a higher yield with CE. Factors which predicted a change in management included the presence of co-morbidity (p=0.02) and having a diagnosis of angiodysplasia on CE (p=0.001). Conclusion: This is a large series of CE in OGB. Increasing age, anti-coagulation and liver co-morbidity are significant predictors of a positive diagnostic yield whilst the presence of co-morbidity or a diagnosis of angiodysplasia may predict a change in management. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented in response to the article "Population Screening for Coeliac Disease in Primary Care by District Nurses Using a Rapid Antibody Test: Diagnostic Accuracy and Feasibility Study" by I. R. Korponay-Szabó, K. Szabados, J. Pusztai, K. Uhrin, and E. Ludmány, in the December 15, 2007 issue.

The article presents a case study of a 32 year old Caucasian man who had two month history of fatigue, vague dyspepsia and four kilogram weight loss. He was previously healthy as he did not smoke and consumed only 10 units of alcohol per week and his systemic examination was also normal. His upper gastrointestinal endoscopy revealed a raised lesion in second part of duodenum. The article focuses on the diagnosis of lesion found in second part of duodenum of a normal Caucasian man.