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BACKGROUND: The optimal endoscopic protocol for treating postorthotopic liver transplantation (OLT) anastomotic biliary strictures (ABSs) has not been established. OBJECTIVE: To review the technique and outcomes of endoscopic retrograde cholangiopancreatography (ERCP) with maximal stenting for post-OLT ABSs at our institution. DESIGN: Retrospective study. SETTING: Tertiary-care center. PATIENTS: Eighty-three patients with a diagnosis of ABS. INTERVENTIONS: ERCP with balloon dilation and maximal stenting. MAIN OUTCOME MEASUREMENTS: Stricture resolution, stricture recurrence, and complication rates. RESULTS: Of 83 patients, 69 completed treatment, of whom 65 (94%) achieved resolution and 4 (6%) required hepaticojejunostomy (HJ). The remaining 14 patients who did not achieve a study endpoint were excluded (9 deaths or redo OLT unrelated to biliary disease, and 5 without follow-up). Comparing the resolution group and the HJ group, there were, respectively, 8.0 and 3.5 total stents (P = .021), 2.5 and 1.3 stents per ERCP (P = .018) (maximum = 9), 4.2 and 2.8 ERCPs (P = .15), and 20 and 22 months from OLT to ABS diagnosis (P = .19). There were 2 cases of ERCP pancreatitis (0.7%) and 2 cases of periprocedural bacteremia of 286 total ERCPs and no episodes of cholangitis caused by stent occlusion. In a median follow-up of 11 months (range 0-39), 2 (3%) patients had ABS recurrence that was successfully re-treated with ERCP. A multivariate Cox model demonstrated that treatment success was directly related to the number of stents used in total and per ERCP. LIMITATIONS: Retrospective study, single endoscopist. CONCLUSIONS: Our maximal stenting protocol for ABSs is effective, safe, rarely associated with ABS recurrence, and conducive to less frequent stent exchange and therefore fewer ERCPs compared with conventional treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Over the past decade, ERCP has become the preferred method of treatment for biliary strictures in patients after orthotopic liver transplantation (OLT). Although data strongly support ERCP for treating anastomotic strictures, the little information available for the role of ERCP in the treatment of nonanastomotic strictures (NAS) has been unpromising. OBJECTIVE: We investigated the efficacy and safety of using balloon dilation and multiple biliary stents to treat NAS. DESIGN: A retrospective study. SETTING: A tertiary-care medical center. PATIENTS: Fifteen patients who were diagnosed with post-OLT NAS between January 2003 and June 2007. INTERVENTIONS: ERCP with balloon dilation and multiple stenting. MAIN OUTCOME MEASUREMENTS: Resolution, complication, and recurrence rates. RESULTS: Eleven of the 15 patients completed endoscopic treatment, of whom 9 had cholangiographic improvement, biochemical normalization, and cholestatic symptom relief (treatment success), and 1 required retransplantation (treatment failure). None of the 9 successfully treated patients experienced NAS recurrence in a mean follow-up of 17 months. Of the remaining 4 patients, 1 died of nonbiliary causes and 3 were still undergoing treatment with stents in place, of whom 2 have near-normalized total serum bilirubin and were cholestatic symptom free. LIMITATIONS: A retrospective study, small sample size, single endoscopist. CONCLUSIONS: Endoscopic treatment of NAS with balloon dilation and multiple stents appears to be safe and effective, and it may reduce the need for retransplantation because of NAS. Larger studies are still required to confirm its utility as a mainstay for treating NAS and to determine what factors are associated with endoscopic treatment success. [ABSTRACT FROM AUTHOR]

Machine learning and its specialized forms, such as Artificial Neural Networks and Convolutional Neural Networks, are increasingly being used for detecting and managing gastrointestinal conditions. Recent advancements involve using Artificial Neural Network models to enhance predictive accuracy for severe lower gastrointestinal (LGI) bleeding outcomes, including the need for surgery. To this end, artificial intelligence (AI)-guided predictive models have shown promise in improving management outcomes. While much literature focuses on AI in early neoplasia detection, this review highlights AI's role in managing LGI and small bowel disorders, including risk stratification for LGI bleeding, quality control, evaluation of inflammatory bowel disease, and video capsule endoscopy reading. Overall, the integration of AI into routine clinical practice is still developing, with ongoing research aimed at addressing current limitations and gaps in patient care., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Colonic endoluminal stent placement is a commonly utilized and effective endoscopic approach for the management of malignant large bowel obstruction and is an emerging approach for the management of some benign etiologies of large bowel obstruction. However, recent studies evaluating the evolution of clinical scenarios and patient populations for which stenting is performed in real-world practice are lacking., Methods: We assessed colonic stent utilization patterns in a tertiary care academic medical center over the past 10 years. We analyzed the demographics and patient and procedure characteristics of the initial (first half of study period) and latter (second half of the study period) procedures to assess trends over time using standard descriptive statistics., Results: Our analysis was notable due to its provision of some novel insights. The frequency of colonic stent placement procedures increased significantly over time by comparison of the procedure volume for the initial 5-year interval (22 colonic stent procedures) relative to the latter 5-year interval (49 colonic stent procedures) ( p = 0.03). The median age of patients who underwent colonic stent placement was significantly lower in the latter 5 years, compared with the initial 5 years of the study period (mean of 81.41 vs. 58.73 years, respectively, p < 0.001). The increased diversity of indications for colonic stent placement was also noted over time., Conclusions: Our data highlight the evolution of colonic stent placement in tertiary care practice over time and are notable for some interesting trends, including the increased utilization of colonic stent placement over time, the broadening of indications for colonic stent placement to include benign indications, and lower patient age at the time of colonic stent placement over time. These findings will help inform the clinical practice of colonic stent placement and provide a foundation to guide future research on the topic.

Background: Primary sclerosing cholangitis (PSC) is an immune-mediated, chronic cholestatic liver disease. Currently, liver transplantation is the only established life-saving treatment. Several studies have evaluated the effect of different biologic therapies on PSC with inconclusive findings. We conducted a systematic review and meta-analysis to assess the effects of biologics in PSC and associated inflammatory bowel disease (IBD)., Methods: MEDLINE, Scopus, and Embase were searched up to July 31, 2023, for studies reporting the effects of biologics in patients with PSC-IBD. Effects of biologic therapy on alkaline phosphatase, total bilirubin, ulcerative colitis response score, and adverse events were calculated and expressed as standardized difference of means (SMD), proportions, and 95% CI using a random-effects model., Results: Six studies, including 411 PSC-IBD patients who received biologics, were included. Biologic treatment was associated with no change in alkaline phosphatase (SMD: 0.1, 95% CI: -0.07 -0.17, p=0.43), but a small and statistically significant increase in total bilirubin (SMD: 0.2, 95% CI: 0.05-0.35, p<0.01). 31.2% (95% CI: 23.8-39.7) of patients with IBD achieved endoscopic response, and there was a significant improvement in ulcerative colitis response score (SMD: -0.6,95% CI: -0.88 to 0.36, p<0.01). Furthermore, 17.6% (95% CI: 13.0-23.5) of patients experienced adverse events severe enough to discontinue therapy, and 29.9% (95% CI: 25.2-34.8) had a loss of response to biologics., Conclusions: Treatment of patients with PSC-IBD with biologics (vedolizumab, infliximab, and adalimumab) was not associated with improvement of biochemical markers of cholestasis. Biologics are effective in treating the colitis associated with PSC. Vedolizumab was associated with worsening liver enzymes in contrast to other biologics, a finding that warrants further study., (Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the American Association for the Study of Liver Diseases.)

Background and Objective: Over the years, telemedicine has played a prominent role in delivering healthcare to patients. Due to its flexibility and many benefits, telemedicine confers physicians the ability to guide and promote medical care remotely. The advent of the coronavirus disease 2019 (COVID-19) pandemic has changed the landscape of medicine and has accelerated the usage of digital and remote healthcare systems for clinical care. Herein, we provide an overview of telemedicine, its applications in managing inflammatory bowel disease (IBD), celiac disease (CD), and liver diseases, its advantages and limitations, and its use in educating the next generation of gastroenterologists., Methods: We conducted a review of scientific articles published in PubMed and Google Scholar. Articles were selected based on the search terms included in the search strategy summary. The language of the articles was restricted to English only., Key Content and Findings: We report that telemedicine has the potential to streamline and improve patient care in gastroenterology (GI) and hepatology while also limiting health care expenses. Additionally, we noted the importance of tele-education for training the next generation of physicians who intend on practicing in rural settings. Furthermore, we identified barriers to telemedicine care that exacerbate health inequities and potential solutions to achieving digital health equity. Lastly, we briefly discuss the role of artificial intelligence (AI) in remote patient monitoring., Conclusions: Although telemedicine has existed for many decades, over the past decade there have been many advancements in telemedicine applications in GI and hepatology. Despite its broad benefits, further research needs to be done to alleviate barriers to telemedicine care., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://mhealth.amegroups.com/article/view/10.21037/mhealth-23-27/coif). JHT serves as an unpaid editorial board member of mHealth from December 2022 to November 2024. The other authors have no conflicts of interest to declare., (2023 mHealth. All rights reserved.)

Background and Aims: No studies have evaluated trainees' outcomes when learning ERCP with patients in the supine and prone positions simultaneously. We aimed to assess whether patient position impacts procedural outcomes and learning curve., Methods: We prospectively evaluated patients undergoing ERCP by a supervised advanced endoscopy trainee (AET) at a tertiary care center. Adult patients with native papillae were included. The AET was universally given 5 attempts per cannulation. Outcomes were evaluated quarterly., Results: Successful cannulation was achieved in 44 supine (69%) and 17 prone (68%) patients (P = .95). Although mean time to reach the papilla was shorter in the supine patient position, time to biliary cannulation (7.8 vs 9.4 minutes, P = .53) and number of attempts were similar. A stepwise increase was seen in cannulation rates throughout the academic year (P < .01) and increased more in supine patients (P = .01). Procedure and total room times were shorter in supine patients., Conclusions: Shorter procedure and room turnover times and a comparable cannulation rate were found for supine versus prone ERCP., (Copyright © 2023 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

Indications for endoscopic placement of endoluminal and transluminal stents have greatly expanded over time. Endoscopic stent placement is now a well-established approach for the treatment of benign and malignant biliary and pancreatic diseases (ie, obstructive jaundice, intra-abdominal fluid collections, chronic pancreatitis etc.). Ongoing refinement of technical approaches and development of novel stents is increasing the applicability and success of pancreatico-biliary stenting. In this review, we discuss the important developments in the field of pancreatico-biliary stenting, with a specific focus on endoscopic retrograde cholangiopancreatography and endoscopic ultrasound-associated developments., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)

Background/purpose: The role and optimal timing of endoscopic retrograde cholangiopancreatography (ERCP) in acute biliary pancreatitis without cholangitis (ABPwoC) remains unclear. Using a large national database, we aimed to examine hospitalization outcomes of patients with ABPwoC as a function of the performance and timing of ERCP., Methods: This was a retrospective study of adult patients with ABPwoC utilizing the National Inpatient Sample from 2016-2017. Patients who underwent inpatient ERCP were stratified into performance: within 24, 24-48, 48-72, and >72 h of hospital admission. The primary outcome was all-cause inpatient mortality as a function of the performance and timing of ERCP; secondary outcomes, including healthcare utilization, were assessed. Multivariate modeling was used to adjust for potential confounders. Statistical analyses were conducted using STATA, version 16.0., Results: Of the 70 030 patients with ABPwoC, 31.37% underwent inpatient ERCP. Performance (aOR: 0.6, p < .05), but not timing (aOR: 0.98, p = .9), of inpatient ERCP was associated with significantly lower all-cause inpatient mortality. Urgent ERCP (within 24 h) was associated with shorter hospital length of stay, lower charges and cost, and less need for pancreatic drainage procedures, while ERCP within 72 h was associated with less frequent intensive care unit admission (all p < .05)., Discussion: Based on this large, nationwide analysis, inpatient ERCP for ABPwoC is associated with lower all-cause mortality. ERCP within 24 and 72 h, though not associated with lower mortality, are associated with multiple improved clinical outcomes, including lower healthcare charges and costs., (© 2022 Japanese Society of Hepato-Biliary-Pancreatic Surgery.)

Background: Gastric intestinal metaplasia (GIM) is a precursor to gastric adenocarcinoma (GAC). In the United States, there is no consensus on the utility of surveillance for GIM, and minority populations most affected by GAC are understudied. Our aims were to define clinical and endoscopic features, surveillance practices, and outcomes in patients with GIM in a multicenter safety-net system., Methods: We identified patients with biopsy-proven GIM between 2016-2020 at the three medical centers comprising Los Angeles County Department of Health Services. Demographics, findings at index esophagogastroduodenoscopy (EGD) first showing GIM, recommended interval for repeat EGD, and findings at repeat EGD were abstracted. Descriptive statistics were performed to characterize our cohort. T-tests and chi-squared (χ 2 ) tests were used to compare patients with and without multifocal GIM., Results: There were 342 patients with newly-diagnosed biopsy-proven GIM, 18 (5.2%) of whom had GAC at index EGD. Hispanic patients comprised 71.8% of patients. For most patients (59%), repeat EGD was not recommended. If recommended, 2-3 years was the most common interval. During a median time to repeat EGD of 13 months and cumulative follow-up of 119 patient-years, 29.5% of patients underwent at least one repeat EGD, of whom 14% had multifocal GIM not previously detected. Progression to dysplasia or GAC was not detected in any patients., Conclusion: In a predominantly minority population with biopsy-proven GIM, there was a 5% incidence of GAC on index EGD. Though progression to neither dysplasia nor GAC was detected, there was significant variability in endoscopic sampling and surveillance practices., (© 2023. The Author(s).)

Background: The optimal timing of esophagogastroduodenoscopy (EGD) and the impact of clinico-demographic factors on hospitalization outcomes in non-variceal upper gastrointestinal bleeding (NVUGIB) remains an area of active research., Aim: To identify independent predictors of outcomes in patients with NVUGIB, with a particular focus on EGD timing, anticoagulation (AC) status, and demographic features., Methods: A retrospective analysis of adult patients with NVUGIB from 2009 to 2014 was performed using validated ICD-9 codes from the National Inpatient Sample database. Patients were stratified by EGD timing relative to hospital admission (≤ 24 h, 24-48 h, 48-72 h, and > 72 h) and then by AC status (yes/no). The primary outcome was all-cause inpatient mortality. Secondary outcomes included healthcare usage., Results: Of the 1082516 patients admitted for NVUGIB, 553186 (51.1%) underwent EGD. The mean time to EGD was 52.8 h. Early (< 24 h from admission) EGD was associated with significantly decreased mortality, less frequent intensive care unit admission, shorter length of hospital stays, lower hospital costs, and an increased likelihood of discharge to home (all with P < 0.001). AC status was not associated with mortality among patients who underwent early EGD (aOR 0.88, P = 0.193). Male sex (OR 1.30) and Hispanic (OR 1.10) or Asian (aOR 1.38) race were also independent predictors of adverse hospitalization outcomes in NVUGIB., Conclusion: Based on this large, nationwide study, early EGD in NVUGIB is associated with lower mortality and decreased healthcare usage, irrespective of AC status. These findings may help guide clinical management and would benefit from prospective validation., Competing Interests: Conflict-of-interest statement: All the authors have no potential conflict of interest to disclose., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Self-expanding metallic stents (SEMSs) are frequently used to decompress malignant large bowel obstruction (LBO) and avoid emergent surgery with often permanent colostomy creation. However, limited data are available on the use and outcomes of SEMS in patients with nonmalignant LBO. We present a case series of 4 patients who were found to have nonmalignant LBO for which they underwent emergent colonic stenting as a bridge to elective surgery following interdisciplinary discussion between gastroenterology, colorectal surgery, and radiology. Through each patient vignette, we illustrate the use of SEMSs as a potential alternative to emergent surgery. 2 of 4 patients avoided stoma creation at the time of surgery, and 1 patient avoided surgery altogether; overall, however, the outcomes of this approach were mixed in this series, indicating a need for further investigation to better identify the patient population that would benefit most from initial SEMS placement for decompression of nonmalignant LBO., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Although CA 19-9 is a commonly used tumor marker in the management of PBMs, the literature describing outcomes in patients with PBMs who have undetectable or low (hereinafter "low") CA 19-9 levels remains scarce. In this study, we sought to compare clinical features and outcomes in patients with PBMs and low CA 19-9 levels to those with normal and elevated CA 19-9 levels., Methods: We retrospectively collected data on patients with biopsy-confirmed PBMs and stratified patients into categories based on their CA 19-9 level at diagnosis. Survival curves were estimated for patients in each of the three aforementioned CA 19-9 groups using the Kaplan-Meier method and compared using a Cox proportional hazards regression model., Results: Of the 283 patients identified, 23 (8.1%) had low, 70 (24.7%) had normal, and 190 (67.1%) had elevated CA 19-9 levels. After controlling for sex, age, BMI, the presence of metastases at the time of diagnosis, and treatment with curative intent, the hazard ratio for death in the elevated CA 19-9 group compared to the low CA 19-9 group was 1.993 (95% CI 1.089-3.648; p = 0.025)., Conclusion: The elevated CA 19-9 level compared to the low CA 19-9 level and the presence of metastases were associated with an increased hazard of death, while treatment with curative intent was associated with a decreased hazard of death.

Introduction: Nonalcoholic steatohepatitis (NASH) is the most common cause of chronic liver disease, but no drug therapies have been approved to date. While glucagon-like peptide-1 (GLP-1) analogues may help in the management, the existing evidence remains conflicting., Aim: This meta-analysis aims to elucidate the efficacy of liraglutide in patients with NASH., Material and Methods: We searched 4 databases for randomized controlled trials assessing the efficacy of liraglutide in patients with NASH. We analysed continuous outcomes using the mean difference (MD) and relative 95% confidence interval (CI), while dichotomous outcomes were analysed using the risk ratio (RR) and relative 95% CI. Primary endpoints included alanine aminotransferase (ALT) (IU/l), aspartate aminotransferase (AST) (IU/l), alkaline phosphatase (ALP) (IU/l), and γ-glutamyl transferase (GGT) (IU/l). Secondary outcomes were body mass index (BMI) (kg/m 2 ), waist circumference (cm), total cholesterol (TC) (mmol/l), triglyceride (TG) (mmoll), high-density lipoprotein (HDL) (mmol/l), low-density lipoprotein (LDL) (mmol/l), and glycated hemoglobin (HbA 1c ) (%)., Results: A total of 5 clinical trials were included. The analysis showed that liraglutide is effective in increasing HDL (MD = +0.10 (-0.18, -0.02), p = 0.02) and reducing LDL levels in blood (MD = -0.29 (-0.56, -0.02), p = 0.04). No significant difference was noted in levels of ALT (MD = 2.66 (-1.56, 6.87), p = 0.22), AST (MD = -1.99 (-5.70, 1.72), p = 0.29), GGT (MD = 5.02 (-0.86, 10.90), p = 0.09), ALP (MD = -5.16 (-11.90, 1.59), p = 0.13), TC (MD = -0.31 (-0.65, 0.03), p = 0.07), or TG (MD = -0.14 (-0.53, 0.25), p = 0.48). The HbA 1c (%) level was found to be significantly reduced in the liraglutide arm (MD = -0.62 (-0.88, -0.36), p < 0.01)., Conclusions: Liraglutide effectively improves the lipid profile in patients with NASH., Competing Interests: The authors declare no conflict of interest., (Copyright © 2023 Termedia.)

Background & Aims: In the setting of increasing attention to representation in medicine, we aimed to assess current perspectives of racial and ethnic workforce diversity and health care disparities among gastroenterology (GI) and hepatology professionals in the United States., Methods: We developed and administered a 33-item electronic cross-sectional survey to members of 5 national GI and hepatology societies. Survey items were organized into thematic modules and solicited perspectives on racial and ethnic workforce diversity, health care disparities in GI and hepatology, and potential interventions to enhance workforce diversity and improve health equity., Results: Of the 1219 survey participants, 62.3% were male, 48.7% were non-Hispanic White, and 19.9% were from backgrounds underrepresented in medicine. The most frequently reported barriers to increasing racial and ethnic diversity in GI and hepatology were insufficient representation of underrepresented racial and ethnic minority groups in the education and training pipeline (n = 431 [35.4%]), in professional leadership (n = 340 [27.9%]), and among practicing GI and hepatology professionals (n = 324 [26.6%]). Suggested interventions were to increase career mentorship opportunities (n = 545 [44.7%]), medical student opportunities (n = 520 [42.7%]), and program and professional society leadership roles for underrepresented racial and ethnic minority groups (n = 473 [38.8%])., Conclusions: Our survey explored imperative and timely perspectives on racial and ethnic representation and health equity among professionals in GI and hepatology. The findings should inform future interventions to address workforce diversity and establish priorities toward improving health equity, ultimately serving as a springboard for professional societies, academic institutions, and other organizations that aim to increase diversity, equity, and inclusion in our field., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Endoscopic stenting is an area of endoscopy that has witnessed noteworthy advancements over the last decade, resulting in evolving clinical practices among gastroenterologists around the world. Indications for endoscopic stenting have progressively expanded, becoming a frequent part of the management algorithm for various benign and malignant conditions of the gastrointestinal tract, from esophagus to rectum. In addition to expanded indications, continuous technological enhancements and development of novel endoscopic stents have resulted in an increased success of these approaches and, in some cases, allowed new applications. This review aimed to summarize best practices in esophageal, gastroduodenal, and colonic stenting., Competing Interests: None of the authors acted as reviewer or editor of this article. None of the authors disclosed personal conflicts of interest or financial relationships relevant to this publication., (Copyright © 2022 by The Author(s). Published by S. Karger AG, Basel.)

Diversity in medicine and the gastroenterology (GI) subspecialty is a topic warranting attention, especially in light of a number of recent incidents highlighting the persistence of racial, ethnic, and gender injustice in our nation. Insight into this topic is important insofar as the multitude of racial, ethnic, and gender backgrounds comprising the national patient population should be reflected, to the degree possible, by the providers serving it. Inclusion becomes particularly imperative because the quality of health care and health research and bridging disparities may be closely linked to adequate representation among healthcare providers. Despite the urgency of this topic, there is a paucity of data examining trends in gender and racial/ethnic diversity among medical professionals within the field of GI. In this narrative review, we examine how ethnoracial and gender representation has changed over time at critical points along the educational, training, and career pathways in GI., (Copyright © 2022 by The American College of Gastroenterology.)

Background: Colonic stents are indicated for preoperative and palliative decompression of large bowel obstruction. We aim to investigate post Food and Drug Administration (FDA) approval outcomes associated with colonic stents., Materials and Methods: We analyzed postmarketing surveillance data from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from January 2011 to December 2020., Results: During the study period, 691 device issues and 742 patient complications were identified. The number of adverse events reported to the FDA mildly increased from 6.40% in 2011 to 7.4% in 2020. Most device complications were due to a positioning problem (n=201, 29%), followed by device break (n=60, 8.6%), delamination (n=41, 6.3%), and migration or expulsion device (n=38, 5.55%). A number of reports described an unclassified adverse event without specifying device or operator problem (n=141, 20.3%). The most reported patient adverse events were perforation (n=150, 20.1%), death (n=47, 6.3%), abdominal pain/discomfort (n=27, 3.6%), and peritonitis (n=24, 3.2%)., Conclusion: Findings from the MAUDE database highlight rare but important patient and device complications which endoscopists and referring providers should be aware of before consideration for colonic stent placement., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction: Little data is available surrounding societal recommendations regarding extra-colonic malignancy in patients with inflammatory bowel disease (IBD). As a result, we systematically analyzed these international guidelines to assess their overall quality as well as their adherence to standards for high-quality practice guidelines., Methods: A systematic search was performed in multiple databases to identify all guidelines pertaining to extra-colonic malignancy in IBD in April 2020. All guidelines were reviewed for conflicts of interest (COI)/funding, recommendation quality and strength, external document review, use of patient representation, and plans for update-as per Institute of Medicine standards. In addition, recommendations were compared between guidelines/societies. Statistical analysis was conducted using R., Results: A total of 11 recommendations on extra-colonic malignancy in IBD were put forth by 5 guidelines/societies. Zero percent of recommendations were found to be based on high-quality evidence, 36.4% of recommendations on moderate-quality evidence, and 63.6% of recommendations on low-quality evidence. 9.1% were strong recommendations, 0% were weak/conditional recommendations, and 90.9% of recommendations did not provide a strength. No guideline included patient representation or had plans for future update of their recommendations., Conclusion: There is a consistent lack of high-quality recommendations for extra-colonic malignancy in IBD across different societal guidelines. The need for high-quality studies to improve the strength of recommendations is eminent, as this will ultimately lead to high-quality patient care., (© 2021. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Primary sclerosing cholangitis (PSC) is linked to inflammatory bowel diseases (IBD). Evidence suggests an association between the gut microbiome and PSC. However, the putative relationship between exposure to antibiotics and onset of PSC has never been reported. We observed 3 cases in which patients without antecedent liver or bowel issues developed symptoms leading to diagnosis of IBD and subsequently PSC after being exposed to doxycycline. We aimed to identify, through the PSC Partners national patient registry, additional cases of PSC in which there is a temporal relationship between exposure to doxycycline and onset of PSC or PSC-IBD., Areas of Uncertainty: The etiopathogenesis of PSC remains an enigma., Data Sources: We collected data from patients with PSC and PSC-IBD in which there seemed to be a temporal relationship between exposure to doxycycline and PSC. Time from doxycycline exposure to: (1) onset of PSC or PSC-IBD symptoms and (2) diagnosis of PSC were documented for each patient. Descriptive statistical analyses were performed., Results: We identified 6 additional patients with PSC or PSC-IBD in whom there was a temporal relationship between exposure to doxycycline and onset of PSC or PSC-IBD. The median age of these 9 patients was 20 years, 6 were female, and 7 had ulcerative colitis. The median time from doxycycline exposure to onset of first symptoms was 3 months, and median time from doxycycline exposure to diagnosis of PSC was 15 months., Therapeutic Hypothesis: We describe 9 cases of PSC and PSC-IBD in which there seem to be a temporal relationship between exposure to doxycycline and onset of PSC., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.)

Background: The fecal immunochemical test (FIT) is the primary modality used by the Los Angeles County Department of Health Services (LADHS) for colorectal cancer (CRC) screening in average-risk patients. Some patients referred for FIT-positive diagnostic colonoscopy have neither adenomas nor more advanced pathology. We aimed to identify predictors of false-positive FIT (FP-FIT) results in our largely disenfranchised, low socioeconomic status population., Methods: We conducted a retrospective study of 596 patients who underwent diagnostic colonoscopy following a positive screening FIT. Colonoscopies showing adenomas (or more advanced pathology) were considered positive. We employed multiple logistic and linear regression as well as machine learning models (MLMs) to identify clinical predictors of FP-FIT (primary outcome) and the presence of advanced adenomas (secondary outcome)., Results: Overall, 268 patients (45.0%) had a FP-FIT. Female sex and hemorrhoids (odds ratios [ORs] 1.59 and 1.89, respectively) were associated with increased odds of FP-FIT and fewer advanced adenomas (β = - 0.658 and  - 0.516, respectively). Conversely, increasing age and BMI (ORs 0.94 and 0.96, respectively) were associated with decreased odds of FP-FIT and a greater number of advanced adenomas (β = 0.073 and 0.041, respectively). MLMs predicted FP-FIT with high specificity (93.8%) and presence of advanced adenoma with high sensitivity (94.4%)., Conclusion: Increasing age and BMI are associated with lower odds of FP-FIT and greater number of advanced adenomas, while female sex and hemorrhoids are associated with higher odds of FP-FIT and fewer advanced adenomas. The presence of the aforementioned predictors may inform the decision to proceed with diagnostic colonoscopy in FIT-positive patients., (© 2021. The Author(s).)

Telemedicine generally refers to the use of technology to communicate with patients and provide health care from a distance. Advances in technology, specifically computers, cellphones, and other mobile devices, have facilitated healthcare providers' growing ability to virtually monitor and mentor patients. There has been a progressive expansion in the use of telemedicine in the field of gastroenterology (GI), which has been accelerated by the COVID-19 pandemic. In this review, we discuss telemedicine-its history, various forms, and limitations-and its current applications in GI. Specifically, we focus on telemedicine in GI practice in general and specific applications, including the management of inflammatory bowel disease, celiac disease, and colorectal cancer surveillance and its use as an aid in endoscopic procedures., (Copyright © 2022 by The American College of Gastroenterology.)

Gastrointestinal endoscopy in patients with advanced liver disease poses various challenges, a major one being procedural sedation and its associated considerations. While sedation during endoscopy can improve patient comfort, decrease anxiety, and facilitate procedural completion, in patients with advanced liver disease, it is also associated with substantial and unique risks due to alterations in drug metabolism and other factors. As such, the choice of sedative agent(s) and related logistics may require careful inter-disciplinary planning and individualized considerations. Furthermore, a large proportion of agents require dose reductions and particular monitoring of the vital signs, level of consciousness, and other indices. In the present review, we provide a contemporary overview of procedural sedation considerations, commonly used intravenous sedatives, and second-line as well as novel sedatives for gastrointestinal endoscopy in patients with advanced liver disease., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Variceal upper gastrointestinal bleeding (VUGIB) is a common and potentially lethal complication of cirrhosis. Population-based data regarding hospital readmission and other outcomes in VUGIB are limited., Aim: In a large United States database of patients with VUGIB, we evaluated readmission rates, mortality rates, healthcare resource consumption, and identified predictors of readmission., Methods: The 2017 Nationwide Readmission Database using ICD-10 codes was used to identify all adult patients admitted for VUGIB. Primary outcomes were 30- and 90-day readmission rates. Secondary outcomes included mortality, healthcare resource consumption, and predictors of readmission. Multivariate regression analysis was used to adjust for potential confounders., Results: In 2017, there were 26,498 patients with VUGIB discharged from their index hospitalization, and 24.7% were readmitted (all-cause) within 30-days and 41.5% within 90-days. Recurrent VUGIB accounted for 26.7% and 28.9% of 30- and 90-day readmissions, respectively. Compared to index admissions, 30-day readmissions were associated with higher mortality (4.3% vs. 6.4%, p < 0.01), increased mean hospital length of stay (5.6 days vs. 4.5 days, p < 0.01), and charges ($65,984 vs. $53,784, p < 0.01), with similar findings in 90-day readmissions. Factors associated with 30-day readmission included end-stage renal disease (HR 1.2, p < 0.05), chronic kidney disease (HR 1.31, p < 0.01), and acute kidney injury (HR 1.14, p < 0.05)., Conclusion: Based on a nationwide cohort of hospitalized VUGIB patients, 25% were readmitted within 30-days and 42% within 90-days. Readmission was associated with increased mortality and healthcare consumption compared to the index admission. Additionally, acute and chronic renal injury were predictors of patients at high-risk for readmission., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Gastrostomy tube placement is a procedure that achieves enteral access for nutrition, decompression, and medication administration. Preprocedural evaluation and selection of patients is necessary to provide optimal benefit and reduce the risk of adverse events (AEs). Appropriate indications, contraindications, ethical considerations, and comorbidities of patients referred for gastrostomy placement should be weighed and balanced. Additionally, endoscopist should consider either a transoral or transabdominal approach is appropriate, and radiologic or surgical gastrostomy tube placement is needed. However, medical history, physical examination, and imaging prior to the procedure should be considered to tailor the appropriate approach and reduce the risk of AEs., Competing Interests: Conflict-of-interest statement: All the Authors have no conflict of interest related to the manuscript., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background and study aims  Data regarding endoscopic findings and symptom correlation in patients with gastroesophageal reflux disease (GERD) symptoms are largely limited to single-center experiences. We performed a nationwide study to examine the association between patient-reported GERD symptoms and clinically relevant endoscopic findings. Patients and methods  Using the National Endoscopic Database, we retrospectively identified all esophagogastroduodenoscopies (EGDs) performed for GERD symptoms from 2000 to 2014. Patients were categorized into three symptom groups: 1) typical reflux only (R); 2) airway only (A); and 3) both R and A (R + A). Outcomes were the point prevalence of endoscopic findings in relation to patient-reported GERD symptom groups. Statistical analyses were performed using R. Results  A total of 167,459 EGDs were included: 96.8 % for R symptoms, 1.4 % for A symptoms, and 1.8 % for R + A symptoms. Of the patients, 13.4 % had reflux esophagitis (RE), 9.0 % Barrett's esophagus (BE), and 45.4 % hiatal hernia (HH). The R + A group had a significantly higher point prevalence of RE (21.6 % vs. 13.3 % and 12 %; P  < 0.005) and HH (56.9 % vs. 45.3 % and 38.3 %; P  < 0.005) compared to the R or A groups, respectively. The R group had a significantly higher point prevalence of BE compared to the A or R + A groups, respectively (9.1 % vs. 6.1 % and 6.1 %, P  < 0.005). Conclusions  On a national level, patients experiencing R + A GERD symptoms appear more likely to have RE and HH, while those with only R symptoms appear more likely to have BE. These real-world data may help guide how providers and institutions approach acid-suppression therapy, set thresholds for recommending EGD, and develop management algorithms., Competing Interests: Competing interests The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

In 2019, the American Society for Gastrointestinal Endoscopy (ASGE) guideline on the endoscopic management of choledocholithiasis modified the individual predictors of choledocholithiasis proposed in the widely referenced 2010 guideline to improve predictive performance. Nevertheless, the primary literature, especially for the 2019 iteration, is limited. We performed a systematic review with meta-analysis to examine the diagnostic performance of the 2010, and where possible the 2019, predictors. PROSPERO protocol CRD42020194226. A comprehensive literature search from 2001 to 2020 was performed to identify studies on the diagnostic performance of any of the 2010 and 2019 ASGE choledocholithiasis predictors. Identified studies underwent keyword screening, abstract review, and full-text review. The primary outcomes included multivariate odds ratios (ORs) and 95% confidence intervals for each criterion. Secondary outcomes were reported sensitivities, specificities, and positive and negative predictive value. A total of 20 studies met inclusion criteria. Based on reported ORs, of the 2010 guideline "very strong" predictors, ultrasound with stone had the strongest performance. Of the "strong" predictors, CBD > 6 mm demonstrated the strongest performance. "Moderate" predictors had inconsistent and/or weak performance; moreover, all studies reported gallstone pancreatitis as non-predictive of choledocholithiasis. Only one study examined the new predictor (bilirubin > 4 mg/dL and CBD > 6 mm) proposed in the 2019 guideline. Based on this review, aside from CBD stone on ultrasound, there is discordance between the proposed strength of 2010 choledocholithiasis predictors and their published diagnostic performance. The 2019 guideline appears to do away with the weakest 2010 predictors., (© 2022. The Author(s).)

Endoscopic mucosal resection (EMR) is an endoscopic technique used to remove sessile or flat lesions from the gastrointestinal tract. This article reviews EMR and focuses on large colorectal polyps, which constitute the most common indication for EMR. Various methods of polyp evaluation can help gastroenterologists determine whether EMR is feasible and whether referral to an advanced endoscopist may be necessary. Techniques for performing EMR include conventional hot-snare EMR with submucosal injection and electro-cautery snare removal of colorectal lesions, as well as alternative EMR techniques such as cold-snare EMR and underwater EMR. Key adverse events associated with EMR include bleeding, perforation, and post-polypectomy coagulation syndrome. Finally, as residual or recurrent polyp formation is possible regardless of EMR technique, this article addresses the importance of surveillance post-EMR and the patients who are at highest risk for polyp recurrence., (Copyright © 2022, Gastro-Hep Communications, Inc.)

Telemedicine refers to the use of information and communication technologies for providing health care at a distance. Through the use of telecommunication technologies such as cell phones, computers, and other electronic devices, health care providers are able to conduct patient visits, mentor/train other providers, and monitor patients' chronic diseases remotely, potentially hundreds or thousands of miles away. Over the past 2 decades, the use of telemedicine has grown in the field of hepatology. In this review, we provide a focused primer on telemedicine and its current applications in hepatology. In particular, we discuss the use of telemedicine in the management of chronic hepatitis C, the complications of liver disease, as well as preliver transplantation evaluation and posttransplantation care. In addition, we provide a synopsis of the effect of the coronavirus disease 2019 (COVID-19) pandemic on the use of telemedicine in hepatology., (Copyright © 2021 by the American Association for the Study of Liver Diseases.)

Percutaneous endoscopic gastrostomy (PEG) tubes can facilitate enteric feeding in patients with severe malnutrition but may be technically challenging to place. We present a man with disseminated tuberculosis and severe cachexia refractory to oral intake and nasogastric tube placement. PEG placement was initially deemed high-risk, through endoscopic, interventional radiologic, or surgical approach, because of severe cachexia and dilated bowel loops interposed between the abdominal wall and stomach. We describe a novel, minimally invasive technique to enhance safety and feasibility of PEG placement, which led to significant improvement in nutritional status and facilitated successful response to tuberculosis therapy., (© 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Endoscopic stenting is a well-established option for the treatment of malignant obstruction, temporary management of benign strictures, and sealing transmural defects, as well as drainage of pancreatic fluid collections and biliary obstruction. In recent years, in addition to expansion in indications for endoscopic stenting, considerable strides have been made in stent technology, and several types of devices with advanced designs and materials are continuously being developed. In this review, we discuss the important developments in stent designs and novel indications for endoluminal and transluminal stenting. Our discussion specifically focuses on (i) biodegradable as well as (ii) irradiating and drug-eluting stents for esophageal, gastroduodenal, biliary, and colonic indications, (iii) endoscopic stenting in inflammatory bowel disease, and (iv) lumen-apposing metal stent., Competing Interests: None of the authors disclosed personal conflicts of interest or financial relationships relevant to this publication., (Copyright © 2022 Joel Ferreira-Silva et al.)

Background and Aims: Colonoscopy is recommended post-acute diverticulitis (AD) to exclude underlying adenocarcinoma (CRC). However, post-AD colonoscopy utility remains controversial. We aimed to examine yield of post-AD colonoscopy in our majority-Hispanic patient population., Methods: Patients undergoing post-AD colonoscopy between 11/1/2015-7/31/2021 were identified from a prospectively maintained endoscopic database. AD cases without computed tomography confirmation were excluded. Pertinent data, including complicated vs uncomplicated AD, fecal immunochemical test (FIT) result post-AD/pre-colonoscopy, and number/type/location of non-advanced adenomas, advanced adenomas, and CRC, were abstracted. Analyses were conducted using two-sample Wilcoxon rank-sum and Fisher's exact tests., Results: 208 patients were included, of whom 62.0% had uncomplicated AD. Median age was 53, 54.3% were female, and 77.4% were Hispanic. Ninety non-advanced adenomas were detected in 45 patients (21.6%), in addition to advanced adenoma in eight patients (3.8%). Two patients (1.0%) had CRC, both of whom had complicated AD in the same location seen on imaging, and one of whom was FIT+ (the other had not undergone FIT). Patients with uncomplicated versus complicated AD had similarly low rates of advanced adenomas (4.7% vs. 2.5%, p=0.713). FIT data were available in 51 patients and positive in three (5.9%); non-advanced adenomas were found in all three FIT+ patients. No FIT- patient had an advanced adenoma or CRC., Conclusion: Colonoscopy post-AD is generally low yield, with CRC being rare and found only in those with complicated AD. Colonoscopy post-complicated AD appears advisable, whereas less invasive testing (e.g. FIT) may be considered post-uncomplicated AD to inform the need for colonoscopy., Competing Interests: Conflict-of-interest statement: No potential conflicts of interest, no financial support.

Background and Aims: Gastrointestinal (GI) symptoms occur among patients diagnosed with coronavirus disease 2019 (COVID-19), and there is clear evidence that SARS-CoV-2, the causative pathogen, infects the GI tract. In this large, multicenter cohort study, we evaluated variations in gastrointestinal and hepatic manifestations of COVID-19 throughout the United States (US)., Methods: Patients hospitalized with a positive COVID-19 test prior to October 2020 were identified at 7 US academic centers. Demographics, presenting symptoms, laboratory data, and hospitalization outcomes were abstracted. Descriptive and regression analyses were used to evaluate GI manifestations and their potential predictors., Results: Among 2031 hospitalized patients with COVID-19, GI symptoms were present in 18.9%; diarrhea was the most common (15.2%), followed by nausea and/or vomiting (12.6%) and abdominal pain (6.0%). GI symptoms were less common in the Western cohort (16.0%) than the Northeastern (25.6%) and Midwestern (26.7%) cohorts. Compared to nonintensive care unit (ICU) patients, ICU patients had a higher prevalence of abnormal aspartate aminotransferase (58.1% vs 37.3%; P < .01), alanine aminotransferase (37.5% vs 29.3%; P  = .01), and total bilirubin (12.7% vs 9.0%; P < .01). ICU patients also had a higher mortality rate (22.7% vs 4.7%; P < .01). Chronic liver disease was associated with the development of GI symptoms. Abnormal aspartate aminotransferase or alanine aminotransferase was associated with an increased risk of ICU admission., Conclusion: We present the largest multicenter cohort of patients with COVID-19 across the United States. GI manifestations were common among patients hospitalized with COVID-19, although there was significant variability in prevalence and predictors across the United States., (© 2022 The Authors.)

Polyps are precursors to colorectal cancer, the third most common cancer in the United States. Large polyps, i.e.,, those with a size ≥ 20 mm, are more likely to harbor cancer. Colonic polyps can be removed through various techniques, with the goal to completely resect and prevent colorectal cancer; however, the management of large polyps can be relatively complex and challenging. Such polyps are generally more difficult to remove en bloc with conventional methods, and depending on level of expertise, may consequently be resected piecemeal, leading to an increased rate of incomplete removal and thus polyp recurrence. To effectively manage large polyps, endoscopists should be able to: (1) Evaluate the polyp for characteristics which predict high difficulty of resection or incomplete removal; (2) Determine the optimal resection technique ( e.g., snare polypectomy, endoscopic mucosal resection, endoscopic submucosal dissection, etc. ); and (3) Recognize when to refer to colleagues with greater expertise. This review covers important considerations in this regard for referring and receiving endoscopists and methods to best manage large colonic polyps., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to disclose., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background and Aims: Noninvasive predictors of choledocholithiasis have generally exhibited marginal performance characteristics. We aimed to identify noninvasive independent predictors of endoscopic retrograde cholangiopancreatography (ERCP)-confirmed choledocholithiasis and accordingly developed predictive machine learning models (MLMs)., Methods: Clinical data of consecutive patients undergoing first-ever ERCP for suspected choledocholithiasis from 2015-2019 were abstracted from a prospectively-maintained database. Multiple logistic regression was used to identify predictors of ERCP-confirmed choledocholithiasis. MLMs were then trained to predict ERCP-confirmed choledocholithiasis using pre-ERCP ultrasound (US) imaging only and separately using all available noninvasive imaging (US/CT/magnetic resonance cholangiopancreatography). The diagnostic performance of American Society for Gastrointestinal Endoscopy (ASGE) "high-likelihood" criteria was compared to MLMs., Results: We identified 270 patients (mean age 46 years, 62.2% female, 73.7% Hispanic/Latino, 59% with noninvasive imaging positive for choledocholithiasis) with native papilla who underwent ERCP for suspected choledocholithiasis, of whom 230 (85.2%) were found to have ERCP-confirmed choledocholithiasis. Logistic regression identified choledocholithiasis on noninvasive imaging (odds ratio (OR) = 3.045, P = 0.004) and common bile duct (CBD) diameter on noninvasive imaging (OR=1.157, P = 0.011) as predictors of ERCP-confirmed choledocholithiasis. Among the various MLMs trained, the random forest-based MLM performed best; sensitivity was 61.4% and 77.3% and specificity was 100% and 75.0%, using US-only and using all available imaging, respectively. ASGE high-likelihood criteria demonstrated sensitivity of 90.9% and specificity of 25.0%; using cut-points achieving this specificity, MLMs achieved sensitivity up to 97.7%., Conclusions: MLMs using age, sex, race, presence of diabetes, fever, body mass index (BMI), total bilirubin, maximum CBD diameter, and choledocholithiasis on pre-ERCP noninvasive imaging predict ERCP-confirmed choledocholithiasis with good sensitivity and specificity and outperform the ASGE criteria for patients with suspected choledocholithiasis., Competing Interests: Declaration of competing interest The authors declare that they have no conflict of interest.

Objective: Despite being the most common healthcare-related infection in the US, nationwide data on readmission, healthcare consumption, and mortality in Clostridioides difficile infection (CDI) remain limited. We examined these outcomes in a US-based cohort of patients with CDI., Methods: We queried the 2017 Nationwide Readmission Database using ICD-10-CM codes to identify all adult patients admitted with a principal diagnosis of CDI. Primary outcomes were 30- and 90-day readmission rates. Secondary outcomes included mortality rates and healthcare consumption., Results: Of the 83,865 patients discharged from an index hospitalization for CDI, 22.37% were readmitted within 30 days, and an additional 15.01% were readmitted within 90 days. Recurrent CDI was responsible for more than 30% of readmissions at both 30 and 90 days. Compared to the index hospitalization, readmissions were characterized by higher mortality (1.41% index vs. 4.86% 30-day vs. 4.40% 90-day) and increased hospital length of stay and charges. Medicaid insurance (HR 1.16), cirrhosis (HR 1.31), Type 1 diabetes mellitus (HR 1.38), and end-stage renal disease (HR 1.36) were independently associated with 30-day readmission (all p < 0.01), with similar findings in 90-day readmissions., Conclusions: In a large cohort of patients hospitalized for CDI, we found that approximately 1 in 5 were readmitted within 30-days, and more than 1 in 3 within 90-days. Readmission was characterized by increased mortality and greater healthcare consumption. Additionally, we found independent associations for readmission that may help identify patients at high-risk. Prospective investigation is needed to identify means to reduce the healthcare consumption and mortality in CDI., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background and Aim: Inflammatory bowel diseases (IBD) have been associated with increased risk of cardiovascular events. We aimed to investigate the outcomes of myocardial infarction (MI) in patients with IBD., Methods: We performed a cross-sectional study utilizing data from the Nationwide Inpatient Sample from the years 1998 to 2010. ICD-9-CM codes were used to identify patients with Crohn's disease (CD) (555.X), ulcerative colitis (UC) (556.X), and acute MI (410.X). Outcomes in patients with MI with and without IBD were compared. Univariate analysis was performed. Multivariate logistic regression was used to determine the effect of UC and CD on in-hospital MI mortality after adjusting for confounders., Results: A total of 2,629,161 MI, 3,607 UC and 3784 CD patients were analyzed. UC (odds ratio [OR], 1.12; 95% CI 0.98-1.29) and CD (OR 0.99; 95% CI 0.86-1.15) did not affect in-hospital mortality in patients with MI. There was no difference between in-hospital mortality in patients with MI with or without UC (7.75% vs. 7.05%; p = 0.25) or in patients with MI with or without CD (6.50% vs. 6.59%; p = 0.87). The length of stay (LOS) was higher in IBD patients and total charges were statistically higher in patients with UC as compared to non-IBD patients ($65,182 vs. $53,542; p < 0.001)., Conclusions: This study shows that IBD does not impact in-hospital mortality from MI. However, patients with MI with IBD have longer LOS. Patients with UC have higher total hospitalization charges than patients with MI without IBD. Further prospective studies are needed to assess the outcomes of MI in IBD patients., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Background & Aims: Primary sclerosing cholangitis (PSC) is an idiopathic, cholestatic liver disease with a diverse range of clinical manifestations. Inter-regional data on PSC are variable, but its global geoepidemiology has not been well-studied. We aimed to examine the worldwide incidence, prevalence and features of PSC and PSC-inflammatory bowel disease (PSC-IBD)., Methods: A systematic search of multiple databases was conducted to identify all original, full-text studies until December 2020 with data regarding the incidence rate (IR) and/or prevalence of PSC. Outcomes were PSC IR, prevalence, features and IBD concurrence. Additionally, a meta-analysis of PSC IR was performed. The study was registered in PROSPERO (CRD42021224550)., Results: Of the 1003 studies identified, 17 studies spanning three continents were included. PSC IR was 0.60 per 100 000 person-years (PY) (95% confidence interval: 0.37-0.88 per 100 000 PY). In pooled subgroup analysis for studies conducted in Europe and North America, PSC IR was 0.62 and 0.53 per 100 000 PY, respectively. PSC prevalence ranged 0-31.7 per 100 000 persons, with notable inter-regional differences. Mean age at PSC diagnosis was bimodally distributed, with relative peaks at 15 and 35 years. Mean concurrence of IBD with PSC was 50%, with 76% having ulcerative colitis, 17% Crohn's disease and 8% indeterminate/unspecified IBD., Conclusion: While considerable heterogeneity exists in the geoepidemiology of PSC, overall, the classical dogmata of male predilection, bimodal distribution of mean age and high PSC-IBD concurrence appear to hold true. Despite a seemingly stable IR over time, further studies are needed to better understand the geoepidemiology of PSC., (© 2021 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: Medical professional liability (MPL) is a notable concern for many clinicians, especially in procedure-intensive specialties such as gastroenterology (GI). Comprehensive understanding of the basis for MPL claims can improve gastroenterologists' practice, lower MPL risk, and improve the overall patient care experience. This is particularly relevant in the setting of the increasing average compensation per paid GI-related MPL claim, and evolving healthcare delivery patterns and regulations. Areas Covered: MPL claims are generally grounded in the concept of negligence, a broad term that may apply to situations involving medical errors, ameliorable adverse events, inadequate informed consent and/or refusal, and numerous others. Though often not directly discussed in GI training or thereafter, there are various mechanisms and behaviors that can alter (decrease or increase) MPL risk. Additional dimensions of MPL include telemedicine, social media, and vicarious liability. We discuss these topics as well as takeaways to mitigate risk, thus reducing unnecessary clinician anxiety, promoting professional development, and optimizing healthcare outcomes. Expert Opinion: MPL risk is modifiable. Strong provider-patient relationships, through effective communication, patient reassurance, and enhanced informed consent, decrease risk, as does thorough documentation. Conversely, provider 'defensive' mechanisms intended to decrease MPL risk, including assurance and avoidance behaviors, may paradoxically increase it.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a significant role in the treatment of a vast array of pancreatobiliary diseases. However, despite significant progress in the optimisation of ERCP methods and accessories, the technical and clinical success of ERCP can vary significantly due to a variety of patient and operator factors. Over the past several decades, a number of advanced techniques have been developed to improve cannulation success rates, including the use of double-guidewire, pancreatic duct accessory-assisted, precut, and rendezvous techniques. Here, the authors provide an update and overview of the existing advanced techniques used in cases of difficult biliary cannulation, as well as the approach to their selection., Competing Interests: Disclosure: The authors have declared no conflicts of interest.