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Background and aims: Self-expandable metal stent (SEMS) insertion is the standard palliative treatment for unresectable malignant extrahepatic biliary obstruction (MBO). Drawbacks of conventional fully covered SEMS (FCSEMS) and uncovered SEMS (USEMS) include stent migration and tumor ingrowth, respectively. This study aimed to compare stent patency in MBO with the newly design multi-hole SEMS (MHSEMS), which has multiple small side holes in the stent membrane, with conventional FCSEMS and UCSEMS. Patients and methods: This retrospective study using a propensity score matching design and stent patency times of 40 patients with MHSEMS was compared to 40 and 34 patients with FCSEMS and UCSEMS during the same period, respectively. Secondary outcomes were procedure-related adverse events, clinical success rate, time to recurrent biliary obstruction (RBO), and etiology of RBO. RBO was compared using Kaplan–Meier analysis. Results: Baseline characteristics after matching were comparable among the 3 groups. RBO rates were 21%, 37%, and 55% for MHSEMS, FCSEMS, and UCSEMS, respectively (p= 0.014), at a mean time of 479, 353, and 306 days, respectively (MHSEMS vs UCSEMS, p= 0.002). Rate of tumor ingrowth was highest in the UCSEMS group (42.4% vs 13.2% in MHSEMS; p= 0.005 and vs 0% in FCSEMS; p< 0.001). Stent migration rate was highest in the FCSEMS group at 15.8% vs 2.6% in MHSEMS (p= 0.047) and 0% in UCSEMS (p= 0.005). Conclusion: MHSEMS provided the longest stent patency time with lowest RBO rate compared to conventional SEMS by showing a lower stent migration rate than FCSEMS and a lower tumor ingrowth rate than UCSEMS.

Background: Endoscopists’ experience influences narrow-band imaging (NBI)-guided gastric intestinal metaplasia (GIM) diagnostic performance. We aimed to evaluate the general gastroenterologists (GE) performance in NBI-guided GIM diagnosis compared to NBI experts (XP) and assess GEs’ learning curve. Methods: A cross-sectional study was conducted between 10/2019 and 2/2022. Histology-proven GIM who underwent esophagogastroduodenoscopy (EGD) were randomly assessed by 2XPs or 3GEs. Endoscopists’ performance on NBI-guided diagnoses were compared to the pathological diagnosis (gold standard) in five areas of the stomach according to the Sydney protocol. The primary outcome were GIM diagnosis validity scores of GEs compared to XPs. The secondary outcome was the minimum number of lesions required for GEs to achieve an accuracy of GIM diagnosis ≥ 80%. Results: One thousand one hundred and fifty-five lesions from 189 patients (51.3% male, mean age 66 ± 10 years) were examined. GEs performed EGD in 128 patients with 690 lesions. the GIM diagnosis sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of GEs compared to the XPs, were 91% vs.93%, 73% vs.83%, 79% vs.83%, 89% vs.93%, and 83% vs.88%, respectively. GEs demonstrated lower specificity (mean difference − 9.4%; 95%CI − 16.3, 1.4; p= 0.008) and accuracy (mean difference − 5.1%; 95%CI − 3.3, 6.3; p= 0.006) compared to XPs. After 100 lesions (50% GIM), GEs achieved an accuracy of ≥ 80% and all diagnostic validity scores were comparable to the XPs (p< 0.05 all). Conclusions: Compared to XPs, GEs had lower specificity and accuracy for GIM diagnosis. The learning curve for a GE to achieve comparable performance to XPs would necessitate at least 50 GIM lesions. Graphical abstract: Created with BioRender.com

IntroductionOver-the-scope clip (OTSC) has been used recently for primary haemostasis of peptic ulcers. This study aimed to compare the efficacy of OTSC to standard endoscopic therapy in primary treatment of patients with peptic ulcer bleeding that are of size ≥1.5 cm. The target population accounts for only 2.5% of all upper GI bleeders.MethodsThis was a multicentre international randomised controlled trial from July 2017 to October 2020. All patients with Forest IIa or above peptic ulcers of ≥1.5 cm were included. Primary outcome was 30-day clinical rebleeding. Secondary endpoints include 3-day all-cause mortality, transfusion requirement, hospital stay, technical and clinical success, and further interventions. 100 patients are needed to yield a power of 80% to detect a difference of −0.15 at the 0.05 significance level (alpha) using a two-sided Z-test (pooled).Results100 patients were recruited. Success in achieving primary haemostasis was achieved in 46/50 (92%) and 48/50 (96%) in the OTSC and conventional arm, respectively. Among patients who had success in primary haemostasis, 2/46 (4.35%) patients in the OTSC arm and 9/48 (18.75%) patients in the conventional arm developed 30-day rebleeding (p=0.03). However, in an intention-to-treat analysis, there was no difference in rebleeding within 30 days (5/50 (10%) OTSC vs 9/50 (18%) standard, p=0.23) or all-cause mortality (2/50 (4%) OTSC vs 4/50 (8%) standard, p=0.68; OR=2.09, 95% CI 0.37 to 11.95). There was also no difference in transfusion requirement, hospital stay, intensive care unit admission and further interventions.ConclusionThe routine use of OTSC as primary haemostasis in large bleeding peptic ulcers was not associated with a significant decrease in 30-day rebleeding.Trial registration numberNCT03160911.

Background: Morphology of the major duodenal papilla (MDP) influences the outcome of standard biliary cannulation. However, those data on advanced cannulation techniques are scarce. We aimed to study the impact of MDP morphology on the outcome of both standard and advanced cannulation methods. Methods: Images of naïve papilla were retrospectively reviewed and independently classified into 4 types (1: classic appearance, 2: small, 3: bulging, and 4: ridged papillae). All cannulation was started with guidewire cannulation. After failure, advanced cannulation including double guidewire (DG) and/or precut sphincterotomy (PS) was performed. Outcomes including success rate and complications were analyzed. Results: A total 805 naïve papilla were included. The overall advanced cannulation rate was 23.2%. The MPD type 2 (OR 1.8, 95% CI 1.8–2.9) and type 4 (OR 2.1, 95% CI 1.1–3.8) required advanced cannulation technique at a higher rate than type 1. Type 3 significantly needed a higher proportion of PS when compared with type 1 (59.09% vs 27.03%, OR 3.90, 95% CI 1.51–10.06). Overall post-ERCP pancreatitis (PEP) was 8% and was not different among MDP types. PEP was significantly increased in difficult cannulation group (15.38% vs 5.71%, p-value < 0.001). Multivariate analysis demonstrated that DG independently increased risk of PEP (OR 3.6, 95% CI 2.0–6.6). Conclusions: MDP type 2 and type 4 were related to difficult cannulation. Although DG and PS can be used as advanced cannulation in all types, DG carries risk of PEP and PS may be preferred over DG in MDP type 3. Graphical abstract:

Mucosal‐associated invariant T (MAIT) cells are innate‐like, unconventional T cells that are present in peripheral blood and mucosal surfaces. A clear understanding of how MAIT cells in the mucosae function and their role in host immunity is still lacking. Therefore, our aim was to investigate MAIT cell distribution and their characteristics in the gastrointestinal (GI) mucosal tissue based on Vα7.2+CD161hiidentification. We showed that Vα7.2+CD161hiT cells are present in both intraepithelial layer and lamina propriae of the GI mucosa, but have different abundance at each GI site. Vα7.2+CD161hiT cells were most abundant in the duodenum, but had the lowest reactivity to MR1‐5‐OP‐RU tetramers when compared with Vα7.2+CD161hiT cells at other GI tissue sites. Striking discrepancies between MR1‐5‐OP‐RU tetramer reactive cells and Vα7.2+CD161hiT cells were observed along each GI tissue sites. Vα7.2+CD161hiTCR repertoire was most diverse in the ileum. Similar dominant profiles of TRBV usage were observed among peripheral blood, duodenum, ileum, and colon. Some TRBV chains were detected at certain intestinal sites and not elsewhere. The frequency of peripheral blood Vα7.2+CD161hiT cells correlated with mucosal Vα7.2+CD161hiT cells in lamina propriae ileum and lamina propriae colon. The frequency of peripheral blood Vα7.2+CD161hiT cells in Helicobacter pylori‐infected individuals was significantly lower than uninfected individuals, but this was not observed with gastric Vα7.2+CD161hiT cells. This study illustrates the biology of Vα7.2+CD161hiT cells in the GI mucosa and provides a basis for understanding MAIT cells in the mucosa and MAIT‐related GI diseases. Study of human Vα7.2+CD161hi T cell distribution in peripheral blood and different sites of gastrointestinal tract, its TCR characteristics and response to Helicobacterpyloriinfection

Background: The recommendation of second look endoscopy (SLOGD) in selected patients at high risk for rebleeding has been inconclusive. This study aimed to evaluate the benefit of SLOGD in selected patients predicted at high risk of recurrent bleeding. Methods: From a cohort of 939 patients with bleeding peptic ulcers who underwent endoscopic hemostasis, we derived a 9-point risk score (age > 60, Male, ulcer ≥ 2 cm in size, posterior bulbar or lesser curve gastric ulcer, Forrest I bleeding, haemoglobin < 8 g/dl) to predict recurrent bleeding. We then validated the score in another cohort of 1334 patients (AUROC 0.77). To test the hypothesis that SLOGD in high-risk patients would improve outcomes, we did a randomized controlled trial to compare scheduled SLOGD with observation alone in those predicted at high risk of rebleeding (a score of ≥ 5). The primary outcome was clinical bleeding within 30 days of the index bleed. Results: Of 314 required, we enrolled 157 (50%) patients (SLOGD n= 78, observation n= 79). Nine (11.8%) in SLOGD group and 14 (18.2%) in observation group reached primary outcome (absolute difference 6.4%, 95% CI − 5.0% to 17.8%). Twenty-one of 69 (30.4%) patients who underwent SLOGD needed further endoscopic treatment. No surgery for bleeding control was needed. There were 6 vs. 3 of 30-day deaths in either group (p= 0.285, log rank). No difference was observed regarding blood transfusion and hospitalization. Conclusions: In this aborted trial that enrolled patients with bleeding peptic ulcers at high-risk of recurrent bleeding, scheduled SLOGD did not significantly improve outcomes.

Background: Per-oral cholangioscopy (POC) has evolved over the past decade from fiberoptic to digital and video imaging systems. Nowadays, only direct per-oral cholangioscopy (DPOC) and digital single-operator cholangioscopy (DS) are performed in daily practice. With better image resolution, POC is increasingly used as diagnostic tools in patients with suspected malignant biliary stricture (MBS). We aimed to evaluate the diagnostic yield of digital/video cholangioscopes for the diagnosis of MBS. Methods: A systematic search was performed in MEDLINE, Embase, and ISI Web of Knowledge databases until April 2020, to identify randomized controlled trials and prospective studies using digital or video POC. The meta-analysis of diagnostic accuracy study was performed to calculate summary estimates of the primary outcomes, including pooled sensitivity, and specificity of POC to diagnose MBS using bivariate random-effects models. Tissue histopathology was used as the reference standard for MBS diagnosis. For benign stricture, negative tissue histopathology and at least 6 months clinical follow-up were required. Results: Thirteen original articles with 876 patients were identified. The overall pooled sensitivity and specificity were 88 (95% CI 83–91) and 95 (95% CI 89–98), respectively. The area under the curve (AUROC) was 0.94 (95% CI 0.92–0.96). Subgroup analysis showed that cholangioscopic image impression provided significantly higher sensitivity (93% (95% CI 88–96) vs 82% (95% CI 76–87); p= 0.007), but lower specificity 86% (95% CI 75–92) vs 98 (95% CI 95–99); p< 0.001) than the tissue diagnosis from cholangioscopic-guided biopsy. In addition, biopsy obtained from DPOC had significantly higher sensitivity than that of DS (92% (95% CI 81–97) vs 79% (95% CI 72–84); p= 0.004). Diagnostic performance under image-enhanced endoscopy was not significantly better from white light endoscopy. Conclusions: Digital/video POC has very high diagnostic performance to diagnose MBS. While image diagnosis provides higher sensitivity than biopsy, its specificity drops as a trade-off.

BackgroundThe side effect of allopurinol was severe allopurinol hypersensitivity (SAH). There are two major causes including genetic risk factor, HLA-B*58:01 and non-genetic risk factors including female, old age, renal impairment, inadequate starting dosage of allopurinol and received diuretic. Although HLA-B*58:01 testing is recommended in Thai, the several problems including cost, limitation of the testing and the delay of the result. Therefore, we aimed to use these non-genetic risk factors for developing the model to predict SAH.MethodThe study was a retrospective observational incidence density sampling. SAH cases were collected from tertiary care medical center which some cases were referred from primary care medical center; where most non-SAH cases were collected from primary care hospitals and tertiary care medical centers. The data of non-genetic factors particularly sex, age, renal function, co-diuresis, starting dosage of allopurinol and serum uric acid (SUA) of non-SAH cases selected the first description of allopurinol. The binary prevalence-weighted logistic regression statistical method was used to develop the prediction models. Three models were developed following general practice.ResultTotally, there were 209 cases of SAH and 23,068 cases of non-SAH. Factors that were associated with the development of SAH within 90 days were female, old age (¿ 65 years old), renal impairment, inadequate starting dosage of allopurinol, co-medication(s) with diuretic and high SUA before prescription of allopurinol. Model 1a and model 1b were applied for patients who did not have and have SUA when starting allopurinol, respectively. Model 2 was applied for patients who had all non-genetic risk factors and started allopurinol within 60 days but have not SAH. The area under the receiver operating characteristic curve for model 1a, model 1b and model 2 were 0.72, 0.81 and 0.82, respectively (Figure 1). The performance for each predictions SAH were good.ConclusionModel 1a and model 1b predict SAH for the patients who had their first prescribed allopurinol, model 2 predicts SAH for the patients who had been taken allopurinol within 60 days but no SAH. The scoring system of each model helps clinician to prescribe allopurinol in real clinical practice before the patients develop SAH. The score of 0-1%, 1-2% and 2-100% indicates the low, moderate and high risk, respectively. The low-risk group can start allopurinol. The moderate-risk group considers to start allopurinol with closed monitoring of SAH. The high-risk group suggests to change to other urate lowering agents for preventing SAH (Table 1).

Background: Double-balloon endoscopy (DBE) provides both diagnosis and treatment in overt obscure gastrointestinal bleeding (OGIB). The aim of this study was to evaluate the rebleeding rate after DBE. Methods: This retrospective review was conducted between January 2006 and July 2018, 166 patients with overt OGIB who underwent DBE were enrolled. Therapeutic intervention was defined as endoscopic treatment, embolization, or surgery. Primary outcome was rebleeding rate after DBE. The patients were divided into 3 groups based on their DBE; (1) positive DBE requiring therapeutic intervention (G1), (2) positive DBE without therapeutic intervention required (G2) and (3) negative DBE (G3). Cumulative incidence of rebleeding was estimated using the Kaplan–Meier method. Cox regression was used to assess the association of DBE with rebleeding risk. This study was approved by our Institutional Review Board. Results: Sixty-eight patients (41%) were categorized in G1, 34 patients (20%) in G2 and 64 patients (39%) in G3. Overall rebleeding occurred in 24 patients (15%). The cumulative incidence of rebleeding for G1 was the lowest. The 1-year and 2-year cumulative probability of developing rebleeding after DBE in G1 were 3.5% and 3.5%, 8.2% and 14.0% in G2, and 18.2% and 20.6% in G3, respectively (p= 0.02). After adjusting for bleeding severity and comorbidities, patients with positive DBE requiring therapeutic intervention had a significantly lower rate of rebleeding when compared with patients who did not receive intervention (hazard ratio 0.17; 95% CI 0.03–0.90). Conclusion: DBE-guided therapeutic intervention was associated with a lower risk of rebleeding when compared with those with negative and positive DBE without therapeutic intervention. One-fifth of patients with overt OGIB had false negative after DBE.

Aromatic antiepileptic drugs (AEDs)-induced cutaneous adverse drug reactions (cADRs) add up to the limited use of the AEDs in the treatment and prevention of seizures. Human leukocyte antigen-B(HLA-B) alleles have been linked to AEDs-induced cADRs. We investigated the association between cADRs (including Stevens–Johnson syndrome; SJS/toxic epidermal necrolysis; TEN, drug reaction with eosinophilia and systemic symptoms; DRESS, and Maculopapular eruption; MPE) caused by AEDs (phenytoin, carbamazepine, lamotrigine, phenobarbital and oxcarbazepine) and HLA-Balleles in Thai population. Through the case-control study, 166 patients with AEDs-induced cADRs, 426 AEDs-tolerant patients (AEDs-tolerant controls), and 470 healthy subjects (Thai population) were collected. The HLAgenotypes were detected using the polymerase chain reaction-sequence specific oligonucleotide probe (PCR-SSOP) method. We also performed a meta-analysis with these data and other populations. The carrier rate of HLA-B*15:02was significantly different between AEDs-induced cADRs group and AEDs-tolerant group (Odds ratio; OR 4.28, 95% Confidence interval; CI 2.64–6.95, p< 0.001), AEDs-induced cADRs group and Thai population (OR 2.15, 95%CI 1.41–3.29, p< 0.001). In meta-analysis showed the strong association HLA-B*15:02with AEDs-induced cADRs (OR 4.77, 95%CI 1.79–12.73, p< 0.001). Furthermore, HLA-B*15:02was associated with SJS/TEN induced by AEDs (OR 10.28, 95%CI 6.50–16.28, p< 0.001) Phenytoin (OR 4.12, 95%CI 1.77–9.59, p= 0.001) and carbamazepine (OR 137.69, 95%CI 50.97–371.98, p< 0.001). This study demonstrated that genetic association for AEDs-induced cADRs was phenotype-specific. A strong association between HLA-B*15:02and AEDs-induced SJS/TEN was demonstrated with an OR of 10.79 (95%CI 5.50–21.16, p< 0.001) when compared with AEDs-tolerant group. On the other hand, the carrier rates of HLA-B*08:01, HLA-B*13:01, and HLA-B*56:02were significantly higher in the DRESS group compared with the AEDs-tolerant group (p= 0.029, 0.007, and 0.017, respectively). The HLA-B*15:02allele may represent a risk factor for AEDs-induced cADRs.

The RV144 phase 3 vaccine trial in Thailand demonstrated that ALVAC-HIV (vCP1521) and AIDSVAX B/E administration over 6 months resulted in a 31% efficacy in preventing HIV acquisition. In this trial, we assessed the immunological effect of an additional vaccine boost to the RV144 regimen at varying intervals between the priming vaccine series and the boost.

In gastrointestinal perforation or fistula, endoscopic closure techniques could be used as alternatives to surgery. Early endoscopic recognition and treatment of gastrointestinal perforation is the most important factor determining procedural success and clinical outcomes. The over-the-scope clip with full-thickness grasping capability provides greater technical and clinical success rates compared with the through-the-scope clips. Although the technical success rate of chronic fistula closure is comparable to perforation closure, it has a significantly lower clinical success owing to its less healthy tissue edge of the fistula. The over-the-scope clip system should be considered before surgery for the closure of perforation and fistula.

Early cholecystectomy (EC) is recommended in patients with acute biliary pancreatitis (ABP). In real-life practice, cholecystectomy is frequently deferred due to various reasons and delayed cholecystectomy (DC) is performed instead. Endoscopic sphincterotomy (ES) is an alternative to prevent recurrent pancreatitis, however other gallstone-related complications (GCs) may still develop. We aimed to determine the impact of ES on future GCs in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed. During 2006–2016, we included patients with non-severe ABP while those with severe pancreatitis and concurrent cholangitis were excluded. GC events were compared between those who had DC with ES and those who had DC without ES. A similar comparison was made in patients with and without ES who did not receive cholecystectomy. Of 266 patients with ABP, non-severe ABP was identified in 146. Only 16 (11%) had EC. Of patients with non-severe ABP who underwent DC (n= 88), recurrent ABP in the ES group was lower than those from the non-ES group (2% vs. 17%; p= 0.01). Acute cholecystitis was found in 0%, 6% and 10% of patients with EC, DC and those without cholecystectomy (p= 0.39). Of those who did not undergo cholecystectomy (n= 42), recurrent ABP in the ES group was still lower than the non-ES group (4% vs. 36%; p= 0.006). ES related complications were mild pancreatitis (4%) and post sphincterotomy bleeding (5%). In patient with non-severe ABP, ES is an alternative to reduce recurrent ABP, however without EC, future cholecystitis may still develop.

ObjectivesIn the management of patients with bleeding peptic ulcers, recurrent bleeding is associated with high mortality. We investigated if added angiographic embolisation after endoscopic haemostasis to high-risk ulcers could reduce recurrent bleeding.DesignAfter endoscopic haemostasis to their bleeding gastroduodenal ulcers, we randomised patients with at least one of these criteria (ulcers≥20 mm in size, spurting bleeding, hypotensive shock or haemoglobin<9 g/dL) to receive added angiographic embolisation or standard treatment. Our primary endpoint was recurrent bleeding within 30 days.ResultsBetween January 2010 and July 2014, 241 patients were randomised (added angiographic embolisation n=118, standard treatment n=123); 22 of 118 patients (18.6%) randomised to angiography did not receive embolisation. In an intention-to-treat analysis, 12 (10.2%) in the embolisation and 14 (11.4%) in the standard treatment group reached the primary endpoint (HR 1.14, 95% CI 0.53 to 2.46; p=0.745). The rate of reinterventions (13 vs 17; p=0.510) and deaths (3 vs 5, p=0.519) were similar. In a per-protocol analysis, 6 of 96 (6.2%) rebled after embolisation compared with 14 of 123 (11.4%) in the standard treatment group (HR 1.89, 95% CI 0.73 to 4.92; p=0.192). None of 96 patients died after embolisation compared with 5 (4.1%) deaths in the standard treatment group (p=0.108). In a posthoc analysis, embolisation reduced recurrent bleeding only in patients with ulcers≥15 mm in size (2 (4.5%) vs 12 (23.1%); p=0.027).ConclusionsAfter endoscopic haemostasis, added embolisation does not reduce recurrent bleeding.Trial registration numberNCT01142180.

The purpose of this review was to highlight the importance of the skin barrier in the development of atopic dermatitis (AD). Skin barrier function relies on the stratum corneum (SC) and tight junction. These components are deranged in the AD epidermis. Deficiency in filaggrin gives rise to abnormal epidermal integrity. The intercellular lipid composition, ratio, and organization are found to be disturbed. Keratinocyte shedding from the SC is also impaired. Tight junction proteins are reduced and result in sweat leakage into the skin surface. Strategies to enhance skin barrier strength will alleviate AD symptoms and may prevent the disease.

Although previous studies have reported the possibility of therapeutic ERCP without fluoroscopy, more robust documentation of fluoroscopy-free common bile duct stone (CBDS) clearance is needed. Technically, “digital cholangioscopy” (DCS) may be used to confirm CBDS clearance. We aimed to compare the feasibility, safety, and radiation exposure between patients with CBDS undergoing stone removal by DCS and conventional ERCP (cERCP). Fifty (50) consecutive patients with a CBDS size < 15 mm underwent DCS (SpyGlass DS Direct Visualization System, Boston Scientific, Marlboro, MA, USA) between December 2015 and October 2016. Of 202 consecutive patients undergoing cERCP during the same time frame, 50 matched pairs were created using propensity score matching analysis. In the DCS group, patients underwent biliary cannulation and CBDS removal without fluoroscopy followed by DCS to confirm complete CBDS clearance. A final occlusion cholangiogram was performed as the current standard of care to confirm CBDS clearance. Cannulation success rates were similar between the DCS and cERCP groups (98 vs. 98%). By intention-to-treat analysis, CBDS clearance in the DCS and cERCP groups was not different (90 vs. 98%; p= 0.20, respectively). DCS had successful CBDS removal in 45 cases, whereas 5 (10%) failed for clearance by DCS due to technical limitations. Adverse events were not different between both groups. In the management of uncomplicated CBDS, our data confirmed the feasibility of DCS for CBDS clearance as it showed efficacy and safety comparable to those of cERCP. Although certain conditions may limit its effectiveness, DCS offers the ability to perform CBDS clearance without the need for fluoroscopy unit and can avoid radiation exposure while ERCP under fluoroscopy remains the current standard of care in patients with CBDS.

Objectives:We tested the hypothesis that the risk of colorectal cancer (CRC), advanced colorectal neoplasia (ACN), and colorectal adenoma among screening participants with different first-degree relatives (FDRs) affected by CRC was similar.Methods:A multi-center, prospective colonoscopy study involving 16 Asia-Pacific regions was performed from 2008 to 2015. Consecutive self-referred CRC screening participants aged 40–70 years were recruited, and each subject received one direct optical colonoscopy. The prevalence of CRC, ACN, and colorectal adenoma was compared among subjects with different FDRs affected using Pearson’s χ2tests. Binary logistic regression analyses were performed to evaluate the risk of these lesions, controlling for recognized risk factors including age, gender, smoking habits, alcohol drinking, body mass index, and the presence of diabetes mellitus.Results:Among 11,797 asymptomatic subjects, the prevalence of CRC was 0.6% (none: 0.6%; siblings: 1.1%; mother: 0.5%; father: 1.2%; ≥2 members: 3.1%, P<0.001), that of ACN was 6.5% (none: 6.1%; siblings: 8.3%; mother: 7.7%; father: 8.7%; ≥2 members: 9.3%, P<0.001), and that of colorectal adenoma was 29.3% (none: 28.6%; siblings: 33.5%; mother: 31.8%; father: 31.1%; ≥2 members: 38.1%, P<0.001). In multivariate regression analyses, subjects with at least one FDR affected were significantly more likely to have CRC (adjusted odds ratio (AOR)=2.02–7.89), ACN (AOR=1.55–2.06), and colorectal adenoma (AOR=1.31–1.92) than those without a family history. The risk of CRC (AOR=0.90, 95% confidence interval (CI) 0.34–2.35, P=0.830), ACN (AOR=1.07, 95% CI 0.75–1.52, P=0.714), and colorectal adenoma (AOR=0.96, 95% CI 0.78–1.19, P=0.718) in subjects with either parent affected was similar to that of subjects with their siblings affected.Conclusions:The risk of colorectal neoplasia was similar among subjects with different FDRs affected. These findings do not support the need to discriminate proband identity in screening participants with affected FDRs when their risks of colorectal neoplasia were estimated.

Drug reaction with eosinophilia and systemic symptoms (DRESS) is a rare but life-threatening adverse drug reaction. Several criteria have been established to aid the diagnosis. However, patients with DRESS remained underdiagnosis and undertreatment.

Objectives:Adenoma detection rate (ADR) cannot distinguish between endoscopists who detect one adenoma and those who detect ≥2 adenomas. Hypothetically, adenoma miss rate (AMR) may be significant for endoscopists with high ADRs who examine the rest of colon with less care after detecting first polyp. Our objective was to evaluate other quality indicators plus ADR vs. ADR alone in prediction of AMR.Methods:We conducted a cross-sectional study of asymptomatic participants aged 50–75 years who underwent back-to-back screening colonoscopies by four faculty endoscopists. Each round of colonoscopy was performed by two of the endoscopists in a randomized order. During each round of colonoscopy, all detected polyps were removed. The second endoscopist was blinded to the results of the first. The total number of adenomas per positive participant (APP), the total number of adenomas per colonoscopy (APC), the additional adenomas found after the first adenoma per colonoscopy (ADR-Plus), and ADR were calculated for prediction of AMR.Results:In all, 200 participants underwent back-to-back colonoscopies. There were no significant differences in ADRs of four endoscopists (44, 50, 54, and 46%). APPs were 1.91, 2.12, 2.19, and 2.43. APCs were 0.84, 1.06, 1.18, and 1.12. ADR-Plus were 0.40, 0.56, 0.64, and 0.66, respectively. AMRs differed significantly between the endoscopists (36, 27, 21, and 13%; P=0.01). There was no correlation between ADR and AMR (r=−0.25; P=0.75). Whereas APP exhibited a strong inverse correlation with AMRs (r=−0.99; P<0.01). APC and ADR-Plus appeared to be inversely correlated with AMR, however this was not statistically significant (r=−0.82; P=0.18 and r=−0.93; P=0.07, respectively).Conclusions:Among high-ADR endoscopists, AMRs still varied. APP may be a promising secondary indicator for distinguishing between the one-and-done polyp endoscopist and the meticulous endoscopist. The evaluation of influence of new metrics on colorectal cancer (CRC) prevention requires a larger population-based study.

Mechanical complications in peritoneal dialysis (PD), including intraluminal clogging of the PD catheter by fibrin, omentum, or blood clot, are major causes of outflow problems and, in rare cases, lead to technical failure. To visualize an intraluminal image of patients undergoing PD with ineffective ultrafiltration (UF), a SpyGlass fiber optic probe was inserted into the catheter, together with SpyBite biopsy forceps, should the removal of clogging materials be needed. Applying these transcatheter devices in 2 PD patients with unexplained UF failure led to the demonstration of omental plugging at the catheter tip in the first patient and demonstration of intraluminal blood clots in the second patient from whom clots were removal successfully. Both patients achieved better UF volume thereafter without procedure-related complications.

Hepatocellular carcinoma (HCC) surveillance rates are suboptimal. We aimed to identify HCC surveillance barriers from both physician’s and patient’s perspectives and assess the effectiveness of physician education using social networks. A nationwide survey with 513 physicians and another single-center survey with 315 HCC-risk patients were conducted. Barriers to suboptimal surveillance were identified using univariate and multivariate logistic regression analysis. We educated 143 physicians by sending brief notes on HCC surveillance guidelines via social networks and re-evaluated their knowledge after 60 days using ttest. Surveys showed 458 (86.3%), 254 (47.8%), and 225 (42.4%) physicians recommended surveillance in patients with cirrhosis, at-risk hepatitis B virus, and hepatitis C virus infection, respectively. Only 228 (42.9%) and 241 (38.0%) respondents adhered to recommended surveillance tools and interval, respectively. The main surveillance barriers among physicians were the lack of knowledge and resource limitations. The lack of a doctor’s prescription was identified as a major barrier by patient’ perspectives (odds ratio 1.4, 95% CI: 1.1–1.8, P = .024). Education via social networks enhanced physicians’ knowledge, with pre- and post-education scores for guideline awareness of 63.0% versus 84.3% (P < .001) and for surveillance indication and tools of 40.0% versus 63.0% (P = .001), and 42.0% versus 59.3% (P = .015), respectively. Physicians’ knowledge gap is a primary barrier for adherence to HCC surveillance protocols. Brief education via social networks shows effectiveness at increasing physicians’ knowledge of HCC surveillance.

Abstract: Background: A number of factors may result in lower than expected success rates for endoscopic retrograde cholangiopancreatography (ERCP) performed by overseas experts during live demonstrations (LDs). Stratifying the degree of ERCP difficulty may help in the assessment of procedure outcomes, but no prior reports have done so. This study aimed to compare the success rate and complications of ERCP between procedures performed in live demonstrations and for matched control subjects. Methods: From 2004 to 2011, a total of 82 patients who underwent ERCP during live demonstrations at the Endoscopy Unit of King Chulalongkorn Memorial Hospital were reviewed. The control for each patient was a patient admitted to the same ERCP unit with matched indications at the time closest to the demonstration course who had matching gender and techniques in therapeutic interventions during ERCP. The success rates and complications between the two groups were compared based on the grading scale for the degree of difficulty according to Cotton and colleagues. Results: For standard ERCP cases (levels 1–2), the success rate, complication rate, and duration of the procedure (DOP) did not differ significantly. In contrast, the success rate for complex ERCPs (levels 3–4) performed during LD was significantly lower (73% vs. 90%; P = 0.006). The complication rates and DOP were not significantly different (P = 0.31 and 0.23, respectively). The overall success rate was significantly lower for LD procedures than for control procedures (81% vs. 91%; P = 0.02). Conclusions: In this series, the standard ERCP performed during LD was associated with success and complication rates similar to those for the control subjects. Complex ERCP cases were, however, associated with lower success rates than those for the control subjects. A high proportion of complex ERCP cases during live demonstration can influence the overall success rate of ERCPs performed by overseas experts.

Abstract: Background: Although self-expandable metallic stent (SEMS) has a longer patency than plastic stent (PS) for malignant biliary obstruction, stent occlusion can occur and drainage has to be reestablished in a patient with expected long survival. However, the choices are still controversial among restenting with SEMS, PS, and percutaneous transhepatic biliary drainage (PTBD). This study was designed to determine the efficacy and outcome of PS, SEMS, and PTBD for patients with occluded SEMS. Methods: A total of 154 ERCPs with SEMS insertion were performed at the Endoscopy Unit of Chulalongkorn University. The causes of obstructive jaundice were cholangiocarcinoma (n = 110), pancreatic cancer (n = 41), and metastatic carcinoma (n = 3). Thirty-two patients (20.9%) with occluded SEMS (uncovered SEMS = 22 and covered SEMS = 10) were identified. PS, SEMS, and PTBD were used to reestablish drainage in 11, 14, and 7 patients, respectively. The second stent was inserted as stent-in-stent. Patients with less advanced disease were preferably opted to have a second SEMS. Results: The median stent patency of second SEMS (100 days) was significantly longer than PS (60 days) and PTBD (75 days; p < 0.05). The median survival time for patients with second SEMS (230 days) was significantly longer than patients with PS (130 days) and PTBD (150 days; p < 0.05). Subgroup analysis in hilar obstructions showed no statistical difference in second stent patency and survival between PS and SEMS. Pain that required oral narcotic developed in 71% (5/7) of PTBD patients. Conclusions: In general, a second SEMS insertion in occluded SEMS provides a significant longer patency time than PS and PTBD. However, the benefit of SEMS as a second intervention in hilar obstructed patients is still doubtful.

Patients with hilar obstruction usually require bilateral biliary drainage. The prognosis of patients who fail bilateral biliary drainage after contrast injection into both intrahepatic ducts is poor due to a high infection rate in the undrained segments. The incidence of post–endoscopic retrograde cholangiopancreatography cholangitis in those with successful bilateral biliary drainage was less, but still significant. Incomplete subsegmental intrahepatic duct drainage is suggested to be responsible for post–biliary drainage cholangitis in cases of advanced hilar tumors. This study was undertaken to determine the incidence of post–endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and stent clogging in different types of malignant biliary obstruction after biliary drainage. From our endoscopic retrograde cholangiopancreatography database, there were 63 patients who underwent endoscopic biliary drainage between September 2000 and November 2001, for malignant biliary obstruction. Sixty-one endoscopic retrograde cholangiopancreatographies had biliary drainage performed (2 patients who failed biliary drainage were excluded). We divided our patients into 3 groups: Group 1 = Bismuth I, Group 2 = Bismuth II, and Group 3 = Bismuth III and IV. All but 2 Group 1 patients had successful biliary endoprosthesis (plastic [n = 13], metallic [n = 12], failed [n = 2]) placement into an extrahepatic duct. All patients from Group 2 (n = 10) and 20 patients from Group 3 (n = 26) had successful bilateral biliary drainage. Unilateral biliary drainage was performed in 6 patients from Group 3, each with a plastic endoprosthesis. The incidence of post–biliary drainage cholangitis (new onset of fever >38.5°C with leukocytosis), jaundice resolution (normal bilirubin level), and the duration of endoprosthesis patency were compared among the 3 groups. The incidences of post–endoscopic retrograde cholangiopancreatography cholangitis, jaundice resolution, and the duration of endoprosthesis patency were: Group 1 (4%, 96%, and 87.2 days, respectively), Group 2 (10%, 100%, and 69.1 days, respectively) and Group 3 (57.7%, 73.1%, and 41.3 days, respectively). Of those patients who did not undergo surgery, patients from Group 3 required endoprosthesis exchange sooner than others. The outcome of biliary drainage in patients with advanced hilar tumors (Bismuth III or IV) was poorer than hilar tumor at earlier stages (Bismuth I or II).

Background:Cholangitis is a frequent complication of biliary stents. Empiric antibiotic selection is primarily based on bile cultures obtained from patients undergoing surgery and few data are available with respect to ERCP and biliary stents. This study analyzed the microbiology of bile and the antibiotic sensitivities of the organisms identified in patients presenting with clinical cholangitis or cholestasis. Methods:All bile cultures collected during ERCP from January 1994 to January 2000 were identified by using an ERCP database. Results:One hundred eighty cultures from 160 patients (mean age 55 years, range 6-94 years) were identified. Sixty-nine specimens were collected at ERCPs performed in patients with no biliary stent in place (group 1). One hundred eleven specimens were obtained from patients with a biliary stent in situ (group 2). The primary diagnoses for patients in groups 1 and 2 were as follows, respectively: malignant bile duct obstruction (25 and 85), choledocholithiasis (16 and 2), benign biliary strictures (6 and 18), acquired immunodeficiency syndrome (8 and 0), and miscellaneous (14 and 6). There were 38 positive bile cultures in group 1 (55%) and 109 positive cultures in group 2 (98%; p< 0.05). A higher frequency of polymicrobial infections (90%) was found in group 2 patients (vs. group 1, 45%; p< 0.001). Escherichia coliwas the most common organism found in group 1 (17%); Enterococcusthe most common in group 2 (31%). Among patients with positive bile cultures, bacteremia was more frequent in group 2 patients (46% vs. 21%; p< 0.05). Ciprofloxacin and cefiriaxone were the most effective antibiotics against identified gram-negative bacilli, and vancomycin against Enterococci. Conclusion:In patients with cholangitis associated with biliary obstruction, the antibiotic selected initially should be active against gram-negative bacilli. Use of quinolones is recommended because these agents effectively penetrate an obstructed biliary tree and can be administered orally. Enterococciand polymicrobial infections are found more commonly in patients with a biliary stent than those without a stent. Pending definitive biliary decompression, patients with sepsis and those who do not quickly respond to treatment with a quinolone may benefit from the addition of antibiotic coverage against gram-positive organisms, targeted against Enterococci. (Gastrointest Endosc 2002;56:885-9.)

Background: Biliary tract complications are a continuing source of morbidity after orthotopic liver transplantation. This is a retrospective examination of experience with ERCP in patients with biliary tract complications after orthotopic liver transplantation to determine type and frequency of complications and outcome after endoscopic therapy. Methods: From May 1988 to August 1999, orthotopic liver transplantation was performed 408 times; 4 additional patients who underwent orthotopic liver transplantation at another hospital were also followed. The records of 367 patients who underwent choledochocholedochostomy were reviewed. Of these, 121 underwent 325 ERCPs; 226 ERCPs were performed because of acute problems (typically cholestasis with or without cholangitis), and 99 were for reevaluation of the bile duct, stent change, or stent removal. Three patients underwent ERCP because of pancreatic problems. Results: A biliary complication was identified in 24.5% of patients (90 of 367) and more than 1 complication in 32%. At ERCP, 37 patients (30.5%) had biliary stones; 9 further patients (7.4%) had only sludge. Stones were completely cleared at the initial or a subsequent ERCP. Strictures were found in 55 patients (45.5%), either at the anastomosis (n = 43) or at another site(s) in the donor duct (n = 12). Balloon or bougie dilation followed by stent insertion was performed in 54 patients. Endoscopic therapy was successful in 91% of patients with biliary strictures. A biliary leak/fistulae was found in 22 patients (18.1%) and endoscopic therapy, when attempted, was successful in all. Eight patients had possible sphincter of Oddi dysfunction based on dilated recipient and donor ducts together with elevated liver enzymes. After sphincterotomy, the liver enzymes returned to normal in only one of these patients. Three patients had blood clots in the biliary tree. Conclusion: When biliary tract complications are suspected after orthotopic liver transplantation, ERCP identifies biliary abnormalities if present and offers multiple therapeutic options. Endoscopic therapy is usually successful but multiple procedures are often necessary, especially when treating strictures. (Gastrointest Endosc 2002;55:224-31.)

Background & Aims:Treatment of human exocrine pancreatic insufficiency is suboptimal. This study assessed the effects of bacterial lipase, porcine lipase, and diets on carbohydrate, fat, and protein absorption in pancreatic-insufficient dogs. Methods:Dogs were given bacterial or porcine lipase and 3 diets: a 48% carbohydrate, 27% fat, and 25% protein standard diet; a high-carbohydrate, low-fat, and low-protein diet; or a low-carbohydrate, high-fat, and high-protein diet (66%/18%/16% and 21%/43%/36% calories). Results:With the standard diet, coefficient of fat absorption increased dose-dependently with both lipases (P< 0.05), but more fat was absorbed with porcine lipase (P< 0.05); 600,000 IU of bacterial lipase (240 mg) and 300,000 IU of porcine lipase (18 g) nearly abolished steatorrhea. With 300,000 IU of bacterial lipase or 135,000 IU of porcine lipase, fat absorption was greater with the high-fat and -protein diet (P< 0.05 vs. low-fat and -protein diet). There were no interactions among carbohydrate, fat, and protein absorption. Conclusions:Correcting steatorrhea requires 75 times more porcine than bacterial lipase (18 vs. 240 mg). High-fat and high-protein diets optimize fat absorption with both enzymes. High-fat diets with bacterial or porcine lipase should be evaluated in humans with pancreatic steatorrhea.

Although a large pool of cells is infected during acute HIV infection, most of these early targets are rapidly cleared upon ART initiation.

The prevention and confirmation of drug-induced severe cutaneous adverse reactions (SCARs) are difficult.

Bile leak is one of the most common biliary complications after OLT. Because of the relatively high morbidity and mortality rates associated with surgical intervention, nonsurgical methods of treatment are being investigated. Endoscopic drainage has become a popular approach in OLT pts with a duct-to-duct anastomosis (DDA).We report our results of endoscopic therapy (ERx) in these pts. Patients and Methods: From 5/88-8/99, 408 OLTs were performed at our institution and 4 pts who had OLT at another hospital were followed by us. Twenty-two were referred for evaluation of a suspected bile leak. ERx included endoscopic sphincterotomy (ES), stent or nasobiliary tube (NBT) placement. Resolution of the bile leak was confirmed either by repeat ERCP or NBT cholangiogram. Results: A bile leak was diagnosed in 22 pts (15 men, 7 women; mean age 37.8 years, range 9-51 years). The mean interval between the OLT and endoscopic intervention was 9.8 weeks (range, 1-20 weeks). This complication occurred in 6.0% of the total number of pts who received transplants and had a DDA during this period. ERCP demonstrated a leak in all 22 pts arising from the T-tube tract (n=13), anastomosis (n=7), intrahepatic radicle (n=1), donor cystic duct (n=1). Six pts had fever at presentation and another six showed evidence of leak per T-tube cholangiogram. Management of the bile leak is shown on the table. Pts undergoing stent therapy had repeat ERCP with stent removal (if the leak sealed) at a mean time of 32 days (range, 22-60 days). Two pts who underwent NBT had fistula closure on day 6 and 8. Two pts also had stones removed at the time of stenting. All leaks treated by endoscopy sealed clinically and confirmed by follow-up ERCP or cholangiogram via NBT. Endoscopic evaluation and Rx was associated with a 4.5% major complication rate and 0% mortality rate. Summary: ERCP demonstrated a biliary fistula in 22 of 22 pts (100%). Endosocpic management resolved biliary fistulae in all pts in whom it was attempted. Conclusion: Endoscopic management of bile leak in OLT pts with DDA is very effective and can obviate the need for surgical intervention. Choice of biliary decompression does not effect the outcome of this approach.

BS is a common biliary complication after OLT. We report our results of endoscopic biliary treatment(ERx)in these pts. Patients and Methods: From 5/88 to 8/99, 121 OLT pts with a choledocho- choledochostomy anastomosis (CDC) were referred for ERCP for cholestasis evaluation. Fifty-five pts (28 men, 27 women; mean age 36.5 yrs, range 9-68) were found to have BS. BS were classified by their location into anastomotic (AS) and nonanastomotic (NAS). NAS were thought to be ischemic in origin. Pts with BS underwent dilation with balloon (4-10 mm) or Soehendra dilators (6-11.5 F) followed by stenting (5-11.5 F). One or more stents were placed with or without endoscopic sphincterotomy. Stent(s) were removed, replaced or upsized at 1-3 month intervals until the stricture diameter achieved approximately 65% of the narrower adjacent duct. The cholangiograms from 25 pts were available to review (pre and post Rx) for the change in parameters. (Table, *p<0.05) Results: There were 43 pts with AS and 12 pts with NAS (4 extrahepatic, 5 intrahepatic, 3 both sites). ERx was judged clinically successful in all AS pts and 58% NAS pts(7 of 12 pts). The mean number of ERCPs required to treat BS was 3.8 (range 1-8). Biliary stent(s) (mean 2.8, range 1-4) were placed for an average duration of 15.8 months (range 1.5-40.5). All pts demonstrated improvement of LFTs within 1 month of ERx and 83.6% (46 of 55 pts) normalized their LFTs at the end of ERx. All ERx failures were in NAS pts (n=5). Summary: In this OLT series, all AS resolved or nearly fully resolved with ERx. Only 58% of NAS adequately resolved with ERx. Conclusion: ERCP is an excellent diagnostic and therapeutic tool for suspected BS in OLT pts with CDC. Longerterm follow-up will be necessary to determine the frequency of symptomatic BS recurrence.

In OLT patients, stone formation appears to occur at an accelerated rate compared to the general population because of associated recurrent biliary tract infection, epithelial shedding, cyclosporine use and biliary strictures. We report the endoscopic findings and treatment results in OLT patients with a duct-to-duct anastomosis (DDA). Patients and Methods: From 5/88- 8/99, 412 OLTs were performed and 121 OLT patients with DDA underwent 325 ERCPs for evaluation of cholestasis. All duct stone patients underwent attempted endoscopic stone extraction following endoscopic sphincterotomy (ES), biliary stricture dilation or stone lithotripsy if needed. Results: Forty-six patients were found to have stones (n=37)or sludge (n=9). Stones were identified in 18 patients on T-tube cholangiogram prior to ERCP. Twenty-eight patients presented with cholangitis. Bile duct stones/sludge were detected at a mean of 19.2 months (range 1.8-53.5 months) after transplant. Twenty-nine patients also had biliary strictures and 28 had stone(s) upstream to the stricture. Eleven patients had castlike stones. Stones were located in both the donor and recipient ducts in 14 patients, in the donor duct alone in 18, and in the recipient duct alone in 14. Stones were present in intrahepatic ducts in 7 patients. ES was performed in all cases for stone and sludge removal. Stone removal was successful in all 46 patients and required one ERCP session in 27 patients (58.7%), two sessions in 11 patients (23.9%), and three or more sessions in 8 patients (17.4%). All patients with stones and stricture required at least 2 sessions of endoscopic treatment which included stent placement for stricture management. Recurrent stones were found in 8 patients (17.4%) during follow-up ERCP at a mean of 5.6 months (range 1.9-18.7 months). Conclusion: Endoscopic stone removal in OLT patients with duct-to-duct anastomosis can be performed in the same manner as the general population with choledocholithiasis. However, multiple sessions may be required, especially in patients with an associated stricture. Medical therapy to prevent stone formation/recurrence is needed.

INTRODUCTION: A spectrum of pancreatic neoplasms can exhibit a cystic component or excess mucus production. The Midwest Pancreaticobiliary Group has collected a series of mucinous/cystic pancreatic tumors (MCPT) to better define their ERCP characteristics. METHODS: In this multicenter series, data are recorded on standardized questionairres and added to a central database. Patients with the following MCPT s were included: intraductal papillary mucinous tumor/mucinous duct ectasia (IPMT), serous cystadenoma (serous cyst), mucinous cystadenocarcinoma (M cyst CA) and mucinous cystadenoma (M. cystaden). RESULTS: 206 cases have been collected with ERCP findings on 171. Presenting features were clinical pancreatitis 32%, steatorrhea or weight loss 43%, cholestasis or obstructive jaundice 22%, and new onset diabetes mellitus 6%. Histolgical confirmation was available in 79% of cases. See table. SUMMARY: ERCP features are similar in benign and malignant IPMT. Serous cyst adenomas mainly cause duct displacement. Mucinous cystadenocarcinomas are characterized by ductal filling defects and mucus at the papilla in addition to cyst filling and/or duct cutoff. Biliary obstruction was present mainly in malignant lesions. CONCLUSIONS: The ERCP features of mucinous and cystic pancreatic tumors are being better characterized. However, benign and malignant lesions cannot reliably be differentiated on ERCP findings alone and aggressive tissue sampling is indicated. **And Members of the Midwest Pancreatobiliary Group

Background: Temporary pancreatic duct stents are being increasingly used in a variety of conditions. However, stent-induced ductal and parenchymal injury is common, and may be irreversible. Small diameter (3-4F), long length (8-10cm), unflanged stents frequently dislodge spontaneously, potentially limiting ductal injury. This study examined the frequency of morphologic changes noted with these stents. Methods: From 9/1/97- 10/20/99, 86 pts who had undergone pancreatic stenting with a 3/4-single pigtail, 3-4F diameter, 8-10cm long stent modified with no intraductal flange (Wilson-Cook, Winston-Salem, NC) had follow-up pancreatograms available for review. Repeat exams were performed for stent removal (failure to spontaneously dislodge within 30 days) or symptomatic recurrence (long after stent migration or removal, mean 11 months, range 2-22). Stent-induced changes were graded as mild (<20% luminal narrowing), moderate (20-50%) or severe (>50%). Results: see Table. Summary: When using 3-4F stents, stent-induced ductal changes were frequently seen at 30 days, but rarely found on long-term follow-up. 2. There was no significant difference between 3F and 4F stents. Conclusion: This preliminary study suggests that concern over ductal changes with use of small diameter, long length unflanged stents remains, but their use may result in a lower incidence of irreversible stent-induced changes (i.e. fibrosis). Further study is indicated to identify the ideal stent characteristics required to reduce post-ERCP pancreatitis rates yet avoid ductal and parenchymal injury.