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Colorectal Cancer (CRC) has seen a dramatic increase in incidence globally. In 2019, colorectal cancer accounted for 1.15 million deaths and 24.28 million disability-adjusted life-years (DALYs) worldwide. In India, the annual incidence rates (AARs) for colon cancer was 4.4 per 100,000. There has been a steady rise in the prevalence of CRC in India which may be attributed to urbanization, mass migration of population, westernization of diet and lifestyle practices and a rise of obesity and metabolic risk factors that place the population at a higher risk of CRC. Moreoever, CRC in India differs from that described in the Western countries, with a higher proportion of young patients and more patients presenting with an advanced stage. This may be due to poor access to specialized healthcare and socio-economic factors. Early identification of adenomatous colonic polyps, which are well-recognized pre-cancerous lesions, at the time of screening colonoscopy has been shown to be the most effective measure used for CRC prevention. However, colonic polyps are frequently missed during colonoscopy and moreover, these screening programs necessitate man-power, time and resources for processing resected polyps, that may hamper penetration and efficacy in mid- to low-income countries. In the last decade, there has been significant progress made in the automatic detection of colonic polyps by multiple AI-based systems. With the advent of better AI methodology, the focus has shifted from mere detection to accurate discrimination and diagnosis of colonic polyps. These systems, once validated, could usher in a new era in Colorectal Cancer (CRC) prevention programs which would center around "Leave in-situ " and "Resect and discard" strategies. These new strategies hinge around the specificity and accuracy of AI based systems in correctly identifying the pathological diagnosis of the polyps, thereby providing the endoscopist with real-time information in order to make a clinical decision of either leaving the lesion in-situ (mucosal polyps) or resecting and discarding the polyp (hyperplastic polyps). The major advantage of employing these strategies would be in cost optimization of CRC prevention programs while ensuring good clinical outcomes. The adoption of these AI-based systems in the national cancer prevention program of India in accordance with the mandate to increase technology integration could prove to be cost-effective and enable implementation of CRC prevention programs at the population level. This level of penetration could potentially reduce the incidence of CRC and improve patient survival by enabling early diagnosis and treatment. In this review, we will highlight key advancements made in the field of AI in the identification of polyps during colonoscopy and explore the role of AI based systems in cost optimization during the universal implementation of CRC prevention programs in the context of mid-income countries like India., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Rao, Sastry, Venu and Pattanayak.)

Background/aims: In patients undergoing endoscopic retrograde cholangiopancreatography (ERCP), calcineurin activates zymogen, which results in pancreatitis. In this study, we aimed to determine the efficacy of tacrolimus, a calcineurin inhibitor, in preventing post-ERCP pancreatitis (PEP)., Methods: This was a prospective pilot study in which patients who underwent ERCP received tacrolimus (4 mg in two divided doses); this was the Tac group. A contemporaneous cohort of patients was included as a control group. All patients were followed-up for PEP. PEP was characterized by worsening abdominal pain with an acute onset, elevated pancreatic enzymes, and a duration of hospital stay of more than 48 hours. Serum tacrolimus levels were measured immediately before the procedure in the Tac group., Results: There were no differences in the baseline characteristics between the Tac group (n=48) and the control group (n=51). Only four out of 48 patients (8.3%) had PEP in the Tac group compared to eight out of 51 patients (15.7%) who had PEP in the control group. The mean trough tacrolimus level in patients who developed PEP was significantly lower (p<0.05)., Conclusion: Oral tacrolimus at a cumulative dose of 4 mg safely prevents PEP. Further randomized controlled studies are warranted to establish the role of tacrolimus in this context.

Introduction: Systemic inflammation triggered by bacterial products like lipopolysaccharides (LPS) in the circulation is an important factor leading to decompensation in patients with chronic liver disease (CLD). High-density lipoprotein cholesterol (HDL-C) has a significant role in innate immune response to LPS in the circulation and could therefore increase the risk for decompensation in patients with CLD. In this study, we have explored the role of HDL-C as a prognostic marker for decompensation., Methods: This was a prospective, observational, cohort study where consecutive patients with CLD were included. Patients with cholestatic liver disease and hepatocellular carcinoma were excluded. Fasting lipids were measured in all patients at the time of recruitment. Each patient was carefully followed up for development of decompensation events such as new-onset/worsening ascites, hepatic encephalopathy, or variceal bleed during follow-up., Results: A total of 170 patients were included (mean age 60 ± 11.5 years, M : F = 6 : 1). At the end of follow-up, 97/170 patients (57%) had decompensation events. Mean HDL-C levels were significantly lower among patients with decompensation (27.5 ± 15 mg/dL vs. 43.5 ± 13.9 mg/dL; p value 0.004). Using ROC analysis, cut-off for HDL-C of 36.4 mg/dL was identified. On multivariate analysis, HDL-C (OR = 6.072; 95% CI 2.39-15.39) was found to have an independent association with risk of decompensation., Conclusions: HDL-C level (<36.4 mg/dL) is a reliable marker for risk of decompensation and can be a useful addition to existing prognostic scoring systems in CLD. It can be a valuable tool to streamline treatment protocols and prioritise liver transplantation., Competing Interests: There are no conflicts of interest to report., (Copyright © 2021 Harshavardhan Rao B et al.)

Background: Intra-abdominal lymphadenopathy due to tuberculosis (TB) poses a diagnostic challenge due to difficulty in tissue acquisition. Although endoscopic ultrasound guided fine needle aspiration/biopsy (EUS-FNA/B) has shown promise in the evaluation of mediastinal lymph nodes, its role in the evaluation of intra-abdominal lymphadenopathy is not clear., Aim: To assess the role of EUS-FNA/B in the evaluation of intra-abdominal lymphadenopathy due to TB., Methods: This was a retrospective study where patients with intra-abdominal lymphadenopathy who underwent evaluation with EUS-FNA/B were included. TB was diagnosed if the patient had any one of the following: (1) Positive acid fast bacilli (AFB) stain/TB GeneXpert/TB-polymerase chain reaction/AFB culture of tissue sample; and (2) Positive Mantoux test and response to anti-tubercular therapy. EUS-FNA reports, clinical reports and imaging characteristics of patients were recorded for a detailed analysis of patients with TB., Results: A total of 149 patients underwent an EUS-FNA/B from lymph nodes (mean age 51 ± 17 years, M:F = 1.2). Benign inflammatory reactive changes were seen in 45 patients (30.2%), while 54 patients (36.2%) showed granulomatous inflammation with/without caseation. Among these, 51 patients (94.4%) were confirmed to have TB as per pre-defined criteria. Patients with TB were more likely to have hypoechoic and matted nodes [40 patients (67.7%)]. EUS-FNA/B was found to have a sensitivity and specificity of 86% and 93% respectively, with a diagnostic accuracy of 88% in the evaluation of intra-abdominal lymphadenopathy due to TB., Conclusion: EUS-FNA/B has a high diagnostic yield with a good sensitivity and specificity in the evaluation of intra-abdominal lymphadenopathy due to TB. However, the validity of these findings in populations with low prevalence of TB needs further evaluation., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report., (©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Biliary strictures following living donor liver transplantation (LDLT) are usually managed by endoscopic retrograde cholangiography (ERC) with stricture dilation and stent placement. While current endoscopic techniques are successful in most cases, high-grade biliary strictures (HGBS) pose a challenge using currently employed techniques which have a low rate of technical success., Aims: In this study, we have explored the safety and efficacy of Soehendra stent retrievers (SSR) for the dilation of HGBS complicating LDLT., Methods: This was a prospective cohort study where all patients with anastomotic biliary strictures following LDLT from January 2016 till February 2018 were included. Patients with HGBS defined as the exclusive passage of 0.018-inch guidewire, were included in Group 1. In these patients, 5 Fr Soehendra stent retrievers were used to dilate HGBS over guidewire, using torsional movements. Technical success, safety and clinical response was compared with patients who required Per-cutaneous transhepatic cholangiography (PTC) with rendezvous procedure due to a failed ERC, before the commencement of the study (Group 2)., Results: Ten patients with HGBS were included into Group 1. Technical success defined as successful placement of a biliary stent across the stricture was achieved in all the patients in group 1. Favorable response to endotherapy was higher in group 1(8/10 patients (80%)) as compared to group 2(6/14 patients (42.8%)). There were no post procedure complications in patients of group 1, while 3 patients developed cholangitis in group 2., Conclusions: HGBS can be successfully treated with SSR for stricture dilation. It is safe with no significant complications and requires fewer procedures.

Background: Relative adrenal insufficiency (RAI) is common in compensated and decompensated chronic liver disease in the presence of sepsis. This study was performed to find out the prevalence of RAI in decompensated cirrhotic patients presenting with hepatic encephalopathy and variceal bleeding without any evidence of infection., Methods: The study prospectively included 75 cirrhotic patients with signs of decompensation. The short Synacthen test (SST) was performed on all patients after ruling out infection. Patients with positive blood, urine, sputum, ascitic and pleural fluid cultures or evidence of infection on chest X-ray and those with elevated procalcitonin levels (>0.05 ng/ml) were excluded. RAI in critical illness was defined by a delta cortisol level (difference between basal and post-stimulation cortisol) of ≤9 μg/dl after SST., Results: The mean age of the study population was 54 ± 11 years. Upper gastrointestinal bleed and hepatic encephalopathy were seen in 56.6% and 41.5%, respectively, and both were seen in 1.9%. Of the 75 patients, 55 (73%) were in Child-Turcotte-Pugh (CTP) class C and the mean model for end-stage liver disease (MELD) score was 21 ± 7. Forty-five patients (60%) met our criteria for RAI. Those with RAI had lower serum albumin (2.4 ± 0.5 g/dl vs 2.7 ± 0.5 g/dl, p = 0.03) and higher MELD scores (22 ± 7 vs 19 ± 6, p = 0.03). Prevalence of RAI in CTP class C was 65% (36 out of 55 patients) compared to 45% (9 out of 20 patients) in Child-Pugh stage A and B. Similarly, 82% (23 out of 28 patients) with MELD scores >25 had RAI compared to 54% with MELD scores <20. None of biochemical parameters were predictive of RAI on logistic regression analysis. Three-month mortality rate was not significantly different in patients with or without adrenal insufficiency (44% vs 28%, p = 0.11)., Conclusion: The present study showed RAI to be common in noninfected decompensated cirrhotic patients, but did not predict 3-month mortality. There were no other predictive factors in those with RAI. Hence, in patients with cirrhosis without infection, the clinical utility of routine adrenal function testing needs further elucidation., Competing Interests: No conflict of interests declared

Aim: Validation of new metrics to identify functionally significant obstruction (FSO), to better define biliary strictures complicating living donor liver transplantation (LDLT)., Methods: All LDLT recipients who presented with cholestasis were studied. Novel metrics for FSO are as follows: (1) magnetic resonance cholangiopancreatography (MRCP) ductal ratio (MDR): The ratio between hepatic duct and recipient duct diameter on the MRCP taken at presentation; (2) endoscopic retrograde cholangiography (ERC) ductal ratio (EDR): The ratio between hepatic duct and recipient duct diameter on the first ERC done for suspected biliary strictures; (3) delayed contrast drainage (DCD): > 50% contrast retained above the anastomotic site, in more than three consecutive fluoroscopic images taken at least 15 min after contrast instillation. Association between these metrics and endotherapy response was analyzed along with patient demographics, intraoperative variables (cold ischemia time, blood transfusions, biliary anastomosis) and perioperative complications (hepatic artery thrombosis [HAT], bile leak). Favorable response to endotherapy was defined as symptomatic relief with ≥ 80% reduction in total bilirubin/alkaline phosphatase., Results: A total of 83 LDLT recipients presented with altered liver function tests. Favorable response was seen in 18/39 patients (46.2%). On univariate analysis, HAT, multiple biliary anastomoses, graft-to-recipient weight ratio (GRWR), MDR, EDR and DCD were significant (p value ≤ 0.05). On multivariate analysis, only MDR ≥ 1.15 was an independent predictor of favorable response to endotherapy (OR 48 [95% CI 7.096-324.71])., Conclusion: A paradigm shift in the approach to management of biliary strictures complicating LDLT is proposed whereby a multidimensional definition of FSO can help in reliable patient selection for endotherapy and improve patient outcome as a whole.

Introduction: Chronic calcific pancreatitis (CCP) is a major risk factor for pancreatic ductal adenocarcinoma (PDAC) and is common in southern India. Endoscopic ultrasound fine-needle aspiration (EUS-FNA) is useful for tissue acquisition in patients with solid pancreatic lesions. Multiple factors may affect the diagnostic yield of FNA samples. The present study was performed to assess the impact of pancreatic calcifications on the diagnostic yield of EUS-FNA in PDAC., Methods: All patients with confirmed PDAC from January 2013 to December 2017 were included. CCP was diagnosed based on typical imaging characteristics with or without evidence of pancreatic insufficiency along with surgical histopathology reports showing features of chronic pancreatitis. The diagnostic yield and adequacy of cellularity were  assessed by a pathologist who was blinded and were compared between the two groups: group 1: PDAC patients with no evidence of CCP and, group 2: PDAC patients with CCP., Results: A total of 122 patients were included in the study. The diagnostic yield was lower in patients in group 2 (n = 42, 25 [59.52%]) as compared to those in group 1 (n = 80, 63 [78.75%]) (p-value = 0.01). On multivariate analysis, only the presence of calcifications was found to have an independent association with diagnostic yield (odds ratio 3.83 [95% confidence interval 1.22-11.9])., Conclusions: CCP had a significant impact on the diagnostic yield of EUS-FNA for pancreatic adenocarcinoma. Novel techniques and newer technology that may mitigate the negative effect of calcification on diagnostic yield of EUS-FNA in patients with CCP.

Biliary stricture complicating living donor liver transplantation (LDLT) is a relatively common complication, occurring in most transplant centres across the world. Cases of biliary strictures are more common in LDLT than in deceased donor liver transplantation. Endoscopic management is the mainstay for biliary strictures complicating LDLT and includes endoscopic retrograde cholangiography, sphincterotomy and stent placement (with or without balloon dilatation). The efficacy and safety profiles as well as outcomes of endoscopic management of biliary strictures complicating LDLT is an area that needs to be viewed in isolation, owing to its unique set of problems and attending complications; as such, it merits a tailored approach, which is yet to be well established. The diagnostic criteria applied to these strictures are not uniform and are over-reliant on imaging studies showing an anastomotic narrowing. It has to be kept in mind that in the setting of LDLT, a subjective anastomotic narrowing is present in most cases due to a mismatch in ductal diameters. However, whether this narrowing results in a functionally significant narrowing is a question that needs further study. In addition, wide variation in the endotherapy protocols practised in most centres makes it difficult to interpret the results and hampers our understanding of this topic. The outcome definition for endotherapy is also heterogenous and needs to be standardised to allow for comparison of data in this regard and establish a clinical practice guideline. There have been multiple studies in this area in the last 2 years, with novel findings that have provided solutions to some of these issues. This review endeavours to incorporate these new findings into the wider understanding of endotherapy for biliary strictures complicating LDLT, with specific emphasis on diagnosis of strictures in the LDLT setting, endotherapy protocols and outcome definitions. An attempt is made to present the best management options currently available as well as directions for future research in the area., Competing Interests: Conflict-of-interest statement: All authors declare no potential conflicts of interest in regards to this manuscript.

Background: Percutaneous endoscopic gastrostomy (PEG) placement is the modality of choice for long-term enteral nutrition in view of technical ease and cost-effectiveness. Peristomal infection (PI) remains the most common complication following PEG tube placement. The aim of this study was to assess the incidence and risk factors for PI and outline a microbiological profile that can aid in prophylactic and therapeutic strategies., Methods: A retrospective study of 781 patients who underwent PEG placement (Cook PEG-Pull-S-20Fr/24Fr) from 2010 to 2015 at our tertiary care center were included. Relevant data were collected from the hospital electronic medical records. The incidence of PI was computed and potential risk factors were assessed using univariate analysis. The microbiological profile was created along with sensitivity patterns after reviewing the culture reports. Statistical analysis was performed using SPSS version 20.0., Results: PEG tube placement was performed in 781 patients (mean age 55.9 ± 36.1; M:F = 2:75). The major indication was oropharyngeal malignancies. PI was seen in 171 patients (21.9%). Diabetes mellitus, duration of hospital stay more than 7 days, and hypoalbuminemia were found to be significant risk factors for the development of PI (p < 0.05). Patients who had chemotherapy or radiotherapy before PEG placement had a higher incidence of peristomal infections (p 0.00). Pseudomonas and Klebsiella were the most common organisms causing infection., Conclusions: PI remains a significant complication of PEG placement. Pseudomonas and Klebsiella are the most common organisms and prophylactic antibiotic protocols should be tailored accordingly. Elective PEG before the institution of chemotherapy/radiotherapy in patients with oropharyngeal malignancies is recommended.

Aim: To identify factors predicting outcome of endoscopic therapy in bile duct strictures (BDS) post living donor liver transplantation (LDLT)., Methods: Patients referred with BDS post LDLT, were retrospectively studied. Patient demographics, symptoms (Pruritus, Jaundice, cholangitis), intra-op variables (cold ischemia time, blood transfusions, number of ducts used, etc .), peri-op complications [hepatic artery thrombosis (HAT), bile leak, infections], stricture morphology (length, donor and recipient duct diameters) and relevant laboratory data both pre- and post-endotherapy were studied. Favourable response to endotherapy was defined as symptomatic relief with > 80% reduction in total bilirubin/serum gamma glutamyl transferase. Statistical analysis was performed using SPSS 20.0., Results: Forty-one patients were included (age: 8-63 years). All had right lobe LDLT with duct-to-duct anastomosis. Twenty patients (48.7%) had favourable response to endotherapy. Patients with single duct anastomosis, aggressive stent therapy (multiple endoscopic retrograde cholagiography, upsizing of stents, dilatation and longer duration of stents) and an initial favourable response to endotherapy were independent predictors of good outcome ( P < 0.05). Older donor age, HAT, multiple ductal anastomosis and persistent bile leak (> 4 wk post LT) were found to be significant predictors of poor response on multivariate analysis ( P < 0.05)., Conclusion: Endoscopic therapy with aggressive stent therapy especially in patients with single duct-to-duct anastomosis was associated with a better outcome. Multiple ductal anastomosis, older donor age, shorter duration of stent therapy, early bile leak and HAT were predictors of poor outcome with endotherapy in these patients., Competing Interests: Conflict-of-interest statement: There are no conflicts of interest to report.

Objective: To assess antibiotic usage in gastrointestinal disorders with respect to appropriateness, pattern of resistance, and incidence of adverse drug reactions (ADRs)., Methodology: Antibiotic prescribing in the gastroenterology department of a tertiary care hospital was evaluated using the Gyssens criteria and also by assessing drug related problems (DRPs) using the Pharmaceutical Care Network Europe V.6.2. A total of 173 patients were studied prospectively by a team of clinical pharmacists. Antibiotic susceptibility was prospectively studied; in addition, retrospective data on culture and sensitivity reports of commonly isolated organisms from 1 October 2012 to 30 September 2014 were collected to determine the resistance pattern in previous years. ADRs were evaluated using the Naranjo scale., Results: Antibiotic therapy was appropriate in 60% of patients and inappropriate in the remaining patients due to incorrect decision, choice, and use. A total of 184 DRPs and 30 ADRs of antibiotics were identified. In the study patients, the most commonly isolated organism was Escherichia coli (27.3%) followed by Klebsiella pneumoniae (16.7%). Both E coli and K pneumoniae exhibited 100% resistance towards cefotaxime. There was an increase in the resistance of E coli and K pneumoniae against various antibiotics tested in 2013-2014 as compared to the previous year. An empirical antibiotic policy was developed which was endorsed by the gastroenterology department., Conclusions: Although antibiotic therapy was appropriate in the majority of patients, irrational use occurred due to incorrect choice, improper dosage, and improper duration of therapy. E coli and K pneumoniae isolates showed an increase in resistance towards various antibiotics tested., Competing Interests: Competing interests: None declared.

Background: Biliary complications associated with living donor liver transplantation (LDLT) remain a major problem. Information regarding biochemical abnormalities helpful for the diagnosis and the nonoperative management of such complications are limited., Methods: Adult patients who underwent LDLT were retrospectively studied for biliary complications. Clinical findings and laboratory studies, that is, serum bilirubin, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase were evaluated. Diagnostic percutaneous transhepatic cholangiogram or endoscopic retrograde cholangiogram followed by therapeutic interventions such as endoscopic sphincterotomy, stone extraction, balloon dilation, or stent placement were done as indicated. Follow-up data on clinical and biochemical outcomes were assessed., Results: Among the first 29 patients who underwent LDLT, 7 patients (24%) developed biliary complications. Nonoperative treatment was undertaken through endoscopic retrograde cholangiogram in 4 cases, percutaneous transhepatic cholangiogram in 3 cases with a successful clinical outcome in 6 cases (84%). All patients with biliary stricture had a bilirubin level >1.5 mg/dL with 100% sensitivity., Conclusions: A number of patients developed biliary complications after LDLT. Nonoperative treatments were successful in most patients. Elevated serum bilirubin level may be helpful in the diagnosis of biliary stricture complicating LDLT.

Background: Selective intrahepatic ductal cannulation during ERCP remains difficult, particularly when strictures involve the bifurcation and/or secondary intrahepatic branches., Methods: A retrospective review was conducted of a cohort of 16 patients (stones 5, cholangiocarcinoma 5, primary sclerosing cholangitis 4, hepatoma 1, bile leak 1) in whom selective cannulation of the intrahepatic ducts with conventional techniques was unsuccessful and who underwent ERCP with a sphincterotome and a hydrophilic coated guidewire to achieve intrahepatic ductal access., Results: The procedure was technically successful in 15 patients and clinically successful in 12. In the 5 patients with bile duct stones, clearance was obtained in 3 and stents were placed in the other 2 patients; one died of cholangitis within 30 days and the other underwent surgery. The procedure was technically successful in 3 of the 5 patients with cholangiocarcinoma. One patient died and the procedure was technically unsuccessful in another. For all patients with primary sclerosing cholangitis, the endoscopic therapy was technically successful and clinical outcomes satisfactory. The patient with a hepatoma was treated successfully and subsequently died of hepatic failure., Conclusion: Use of a sphincterotome and hydrophilic-coated guidewire can significantly enhance the success rate for selective intrahepatic ductal access.

Background: Intraductal papillary mucinous tumor of the pancreas is a rare neoplasm managed by operative resection of the affected segment of the pancreas., Goals: To evaluate the role of peroral pancreatoscopy in the diagnosis and preoperative localization of the affected region of the pancreatic duct and to undertake the appropriate operation for each patient., Study: Five patients with suspected intraductal papillary mucinous tumor of the pancreas were studied using endoscopic retrograde cholangiopancreatography, computed tomography of the abdomen, endoscopic ultrasonography, and peroral pancreatoscopy. The findings from these studies were compared, and operative resection was performed in each patient based on pancreatoscopic findings., Results: Of the five patients with suspected intraductal papillary mucinous tumor, only four had histologically confirmed tumor, and the remaining one patient had a retention cyst of the pancreas. Pancreatoscopy correctly identified all four patients with the tumor while excluding the diagnosis of papillary tumor in one., Conclusion: Peroral pancreatoscopy is valuable in the preoperative evaluation of intraductal papillary mucinous tumor of the pancreas, especially in the localization of such tumor.

Endoscopic retrograde cholangiopancreatography (ERCP) plays a pivotal role in the management of patients with acute and chronic pancreatitis. Whereas endoscopic observation during ERCP permits recognition of abnormalities involving the major and minor duodenal papillae such as papillary tumors or choledochocele, radiographic evaluation enables the detection of structural abnormalities of pancreaticobiliary ducts like strictures or calculi. Sphincter of Oddi manometry, a technical advance of ERCP, is essential for the diagnosis of sphincter of Oddi dysfunction, which may present clinically as recurrent pancreatitis. Because structural alterations of the pancreatic duct forms the hallmark of chronic pancreatitis, ERCP is highly sensitive and specific in diagnosing chronic pancreatitis. Apart from its diagnostic role, ERCP offers a variety of possibilities for therapeutic interventions in selected problems associated with pancreatitis. Endoscopic papillectomy and mucosal resection for tumors of the papilla, unroofing of a choledochocele, and sphincterotomy for sphincter ablation in sphincter of Oddi dysfunction are some of the therapeutic interventions possible during ERCP. Pancreatic ductal hypertension, which is considered to be the major pathophysiologic mechanism for disabling abdominal pain in chronic pancreatitis, also can be managed by ERCP-directed treatments. Pancreatic sphincterotomy, dilation of strictures, lithotripsy, extraction of calculi, and deployment of endoprosthesis constitute the commonly used therapeutic techniques in this situation. Besides offering a noninvasive alternative, these treatments are associated with a favorable clinical outcome comparable with that of operative treatments. Nevertheless, complications such as acute pancreatitis, bleeding, perforation, or sepsis may occur in 5% to 10% of patients undergoing these procedures. Therefore, careful selection of patients, appropriate preoperative care, and a team approach, including surgeon, interventional radiologist, and endoscopist, are important.

Background: Pancreatic abscess is one of the serious complications of acute pancreatitis. Traditionally, pancreatic abscess has been treated by operative drainage. Based on experience with endoscopic transpapillary drainage of pseudocysts, a similar technique was used in patients with pancreatic abscess., Method: Patients were evaluated by endoscopic retrograde cholangiopancreatography. In those with pancreatic abscess communicating with the main pancreatic duct, pancreatic sphincterotomy, saline irrigation of the abscess cavity, and catheter dilation followed by 10F pancreatic stent placement were done. Instillation of gentamicin and nasopancreatic catheter drainage were used in difficult cases., Results: Of 22 patients with pancreatic abscess, 11 underwent endoscopic transpapillary drainage with technical success in 10 patients (90%); 8 patients (74%) had resolution of pancreatic abscess, clinically and radiographically. Intracavitary instillation of gentamicin and nasopancreatic catheter drainage were used in 2 patients. Two patients in whom endoscopic transpapillary drainage failed underwent operative drainage with a favorable outcome, and the one patient in whom endoscopic treatment was technically unsuccessful underwent successful percutaneous drainage. One patient had mild pancreatitis., Conclusion: Endoscopic transpapillary drainage is an effective nonoperative therapy for selected cases of pancreatic abscess and is associated with minimal morbidity and no mortality.

Autoimmune pancreatitis (AIMP) is a recently described clinical entity causing chronic pancreatitis. It often presents with diffuse enlargement of the pancreas and/or a focal mass at the head of the pancreas causing common bile duct obstruction and jaundice. In most instances, AIMP is mistaken for pancreatic cancer. A number of laboratory abnormalities such as positive antinuclear antibody, hypergammaglobulinemia, and antibody to carbonic anhydrase are often present in these patients. Currently, pancreatic biopsy demonstrating characteristic histopathologic changes is essential to establish the diagnosis. We report the first case of AIMP presenting as a pancreatic tail mass and lower gastrointestinal bleed.

Background and Study Aims: Endoscopic palliative treatment may be effective in the management of malignant gastric outlet obstruction. However, experience in this area is limited, and the techniques vary widely. In this retrospective study, a uniform technique using nearly identical self-expandable metal stents was employed to assess technical feasibility, safety, and outcome., Patients and Methods: Eight patients presenting with clinical findings of gastric outlet obstruction confirmed by upper gastrointestinal radiography underwent endoscopic placement of expandable metal stents. All patients had primary or metastatic malignancy involving the pylorus or duodenum. Endoscopic and Gastrografin-enhanced upper gastrointestinal radiographic evaluations were carried out immediately after stent placement. Complications and clinical outcomes were assessed in each patient., Results: Five patients had extrinsic compression of the descending duodenum due to pancreatic cancer, two had pyloric stenosis from metastatic cancer, and one patient had primary duodenal cancer. Stent placement was successful in all patients, and was followed by clinical improvement. There was one death within 30 days, related to pneumonia., Conclusion: Endoscopic self-expandable stent placement appears to be a reasonable therapeutic alternative in patients with malignant gastric outlet obstruction.

Background: Conscious sedation is usually used during endoscopic retrograde cholangiopancreatography (ERCP). Little is known about the indications and outcomes for ERCP in patients who cannot undergo conscious sedation and therefore require general anesthesia. We retrospectively evaluated the indications and outcome for patients undergoing ERCP who required general anesthesia at four teaching hospitals over a 2-year period., Methods: Of 1200 ERCPs performed over a 2-year period, 65 patients required general anesthesia. Retrospective chart analysis was undertaken to determine indications and outcomes of ERCP performed under general anesthesia. Eleven patients underwent sphincter of Oddi manometry., Results: The major indication for general anesthesia was substance abuse. Therapeutic intervention was successful in 45 of 48 patients; 6 of the 63 patients had complications, all mild and not related to the anesthesia. Sphincter of Oddi manometry was normal in 7 patients; 4 patients had elevated basal pressures., Conclusions: ERCP under general anesthesia may be considered when conscious sedation fails to achieve a satisfactory level of sedation for a successful and safe ERCP. Procedure-related complication rates appear to be comparable if not lower with general anesthesia.

Background: Despite recent advances in cytology brush design, yield of endoscopic brush cytology in suspected pancreatic carcinoma remains low., Methods: We prospectively evaluated 32 such patients by ERCP to analyze differences in yield based on anatomic location of the pancreatic stricture, and the role of concurrent biliary stricture brush cytology, in improving the overall yield. Endoscopic brush cytology was performed on all strictures following ERCP. A final diagnosis of pancreatic carcinoma was confirmed in all patients., Results: Twenty-three of the 32 patients had positive cytology for pancreatic malignancy (71.9%). Eight patients had positive brushings from biliary strictures alone (25%) and 15 had positive brushings obtained from pancreatic strictures (46.9%). The yield varied widely depending on the anatomic location of the stricture; ampullary, genu, and tail regions had low rates of positive cytology, in part due to technical factors and brush design (1 of 8, 2 of 6, and 1 of 4, respectively). Strictures of the head and body yielded high rates of positive cytology (7 of 8 and 4 of 6, respectively)., Conclusions: The yield of endopancreatic brush cytology is related to the location of malignancy, with overall yield enhanced by concurrent brushing of bile duct strictures.

Background and Study Aims: Needle-knife sphincterotomy is an established technique in the management of some patients with biliary tract obstruction. However, the technique can be technically difficult in patients with very small papillae, specially when associated with distorted ampullary and duodenal anatomy. We present here a technique that may enhance successful needle-knife sphincterotomy in this situation., Patients and Methods: Eight patients with biliary tract obstruction who had small papillae and distorted ampullary or duodenal anatomy were evaluated. All patients had undergone one or more unsuccessful cannulations prior to referral. All eight patients underwent saline injection of their papillae, creating a bulging papilla, prior to needle-knife sphincterotomy., Results: Seven of the eight patients had successful needle-knife sphincterotomy following saline injection, and endoscopic therapy during the first attempt. In one patient, the procedure was successful at a second attempt 48 hours later. There were no instances of significant complications., Conclusion: Saline injection into the papilla prior to needle-knife sphincterotomy may improve success rates in patients with unusually small papillae and distorted ampullary or duodenal anatomy. However, at present this technique should only be attempted by experienced endoscopists. Further studies with larger numbers of patients are required before the safety of this technique can be fully evaluated.

The ampulla of Vater is strategically located at the confluence of the terminal end of the bile duct and the pancreatic duct. It is entwined by smooth muscle fibers often referred to as the sphincter of Oddi. As a result, the ampulla demonstrates dynamic motor activity. A variety of structural and functional abnormalities can involve the ampulla and the periampullary region. Disorders involving the ampulla often produce remarkably similar clinical features, such as acute pancreatitis, biliary colic, or jaundice. Therefore, it is important that patients with periampullary disorders are systematically studied using endoscopic retrograde cholangiopancreatography, sphincter of Oddi manometry, and endoscopic ultrasonography. Common disorders involving the periampullary region and state-of-the-art techniques for diagnosis and treatment of these disorders are discussed.

Sphincter of Oddi (SO) is a dynamic structure located strategically at the confluence of the bile duct, the pancreatic duct and the duodenum. The advent of lateral viewing endoscope along with a minimally compliant pneumocapillary manometry system has greatly enhanced our ability to evaluate the SO in health and disease. These studies have shown that the SO motor function is a complex phenomenon controlled by a variety of neurohumoral agents. The sphincter also actively participates in the Migratory Motor Complex (MMC). The major function of the SO seems to be in regulating the flow of bile and pancreatic juice into the duodenum. By maintaining a basal tone, the sphincter diverts bile into the gallbladder under fasting conditions. On the other hand it functions as "a pump" as well to milk bile into the duodenum. Recent manometric studies also have unravelled a number of abnormalities involving the SO motor function often referred to as SO dysfunction. Most such patients respond favorably to sphincter ablation. Studies are underway to better define patients with SO dysfunction as well as to identify them using noninvasive investigations.

A symptomatic lower esophageal ring generally responds to standard bougienage therapy. However, a subset of patients with a lower esophageal ring defy dilation therapy. We have evaluated the efficacy of electrocautery incision of "defiant" lower esophageal rings, the data of which forms the basis of this report. Seven of 75 patients with a lower esophageal ring failed to respond to conventional esophageal dilation. All seven patients underwent electrocautery incision of a "defiant" lower esophageal ring with alleviation of dysphagia. One patient had recurrence of dysphagia that occurred 6 months after initial electrocautery incision. No major complication occurred, although one patient had transient chest pain. Subsequently, all patients have remained without symptoms at a mean follow-up of 36 months. Electrocautery incision of "defiant" lower esophageal ring is efficacious, safe, and results in long-term relief of dysphagia.

Protein plug obstruction of the pancreatic duct is one of the early events in chronic pancreatitis yet little is known about its pathogenesis. GP2, a protein in the exocrine pancreas, is a glycosyl phosphatidylinositol-anchored protein that is cleaved from the zymogen granule membrane and secreted into pancreatic juice. Since its homologue, uromodulin, is involved in renal cast formation, we asked the question whether GP2 might play a similar role in plug formation in chronic pancreatitis. The protein composition of intraductal plugs from patients with noncalcific chronic pancreatitis was examined. Plugs purified from pancreatic juice obtained by endoscopic cannulation were analyzed by SDS-PAGE. A 97-kD protein was found not only to be a reproducible constituent but also enriched within intraductal plugs. This protein was confirmed as GP2 by its localization to zymogen granule membranes, its isoelectric point, and by Western blotting. Although the pancreatic stone protein was identified in plugs, it was not a major reproducible component. These results demonstrate that GP2 is an integral component of plugs in pancreatic juice and suggest that GP2 may play a role in pancreatic plug formation that is analogous to the role played by uromodulin in the pathogenesis of renal casts.

Patients with group II sphincter of Oddi dysfunction documented by elevated sphincter of Oddi pressure improve after endoscopic sphincterotomy. A large group II population was studied to determine the incidence of post-endoscopic sphincterotomy stenosis. Eighty-five patients (82 women and 3 men), ages 21 to 88 years (mean, 50 years), fulfilled the clinical criteria for group II sphincter of Oddi dysfunction; each had an elevated basal sphincter of Oddi pressure (> or = 40 mm Hg), and received endoscopic sphincterotomy. These patients were observed for a mean of 7 +/- 3 years. Four patients re-presented with clinical findings suggestive of recurrent sphincter of Oddi dysfunction; all were found to have a basal sphincter of Oddi pressure greater than or equal to 40 mm Hg. Symptoms re-developed within 4 months after endoscopic sphincterotomy (mean, 3.3 months). Endoscopic sphincterotomy was repeated in all four patients with one endoscopically treated complication. On 25-month mean follow-up, none of the patients had further signs or symptoms of papillary stenosis. Endoscopic sphincterotomy in patients with group II sphincter of Oddi dysfunction is associated with a low incidence of restenosis (4.7%). Repeat endoscopic sphincterotomy was found to be effective management in patients with papillary restenosis.