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Background The impact of direct endoscopic necrosectomy (DEN) on risk of recurrence of symptoms or pancreatic fluid collections (PFCs) in patients with disconnected pancreatic duct (DPD) has not been previously evaluated.

The role of video capsule endoscopy (VCE) in inflammatory bowel disease (IBD) has evolved from small bowel to a panenteric evaluation tool over the past two decades. We systematically reviewed the techniques, applications, outcomes, and complications of VCE in IBD. A systematic literature search was performed using PubMed, Embase, and Medline. All relevant original articles involving VCE in IBD were included from 2003 to July 2022. After screening 3,089 citations, finally 201 references were included. The diagnostic yield of VCE in suspected Crohn's disease (CD) was highly variable (6–80%) with excellent sensitivity (77–93%) and specificity (80–89%). The diagnostic yield in known CD was 52 to 88.3% leading to a change in management (26–75%) and disease reclassification with variable retention rates. VCE was superior to small bowel series, computed tomography (CT) and could be better than magnetic resonance enterography (MRE), especially for proximal and superficial lesions. Colon or panenteric VCE has strong correlation to ileo-colonoscopy (IC) and combined magnetic resonance imaging and IC, respectively. The VCE retention rate in CD is higher in known CD which significantly decreases after the negative patency capsule test or CT/MRE. VCE can identify lesions beyond the reach of IC in postoperative CD. Colon Capsule Endoscopy is a noninvasive monitoring tool in ulcerative colitis (UC) having a strong correlation with IC and may uncover small bowel involvement. VCE is specifically useful in IBD-unclassified (IBD-U) which can lead to the diagnosis of CD in 16.7 to 61.5%. Various scoring systems have been established and validated for small bowel CD (Lewis score and capsule endoscopy CD activity index—CECDAI), UC (capsule scoring of UC: Capsule Scoring of Ulcerative Colitis), panenteric evaluation (Capsule Endoscopy Crohn's Disease Activity Index, Elaikim score), and flare prediction (APEX score). Technological advances include double head, three-dimensional reconstruction, sampling system, panoramic view (344 and 360 degree lateral), and panenteric capsule. Artificial intelligence and software like TOP100 and Quickview can help reduce capsule reading time with excellent sensitivity and specificity. VCE in IBD has widespread application in suspected and known small bowel CD, monitoring of UC, postoperative CD, IBD-U, and for panenteric evaluation. Patency capsule testing helps to reduce retention rates significantly. Artificial intelligence and technical advances can help evolve this novel technology.

A better understanding of the disease pathophysiology, improved imaging modalities, and the development of minimally invasive interventions led to the revision of the Atlanta classification and new terminologies for the pancreatic fluid collections (PFCs) occurring in acute pancreatitis. Peripancreatic necrosis (PPN) or extra-pancreatic necrosis (EPN) has been reported as a distinct morphological entity with a better outcome than combined pancreatic and peripancreatic necrosis as well as pancreatic parenchymal necrosis alone and slightly worse than acute interstitial pancreatitis. In this news and views, we discuss a study that compared the morphological features and outcomes of endoscopic drainage of walled off necrotic collections developing after EPN alone with those developing after PN with or without EPN.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has a potential risk of clinically significant adverse events including fatal complications. Learning from complications improves the results from interventional procedures especially the high-risk procedure like EUS-BD. The various complications that have been reported following EUS-BD include bile leak, bleeding, cholangitis, peritonitis, stent migration both internal and external as well as in the peritoneal cavity and fatal perforations. In this technical review, we discuss technical strategies to prevent serious adverse events during EUS-BD using a case based approach.

Objective Colorectal cancer (CRC) is an emerging public health problem in Asia and India. However, there is scarcity of data on CRC and adenoma. We aimed to study prevalence and characteristics of colonic polyps in a large retrospective cohort. Methods For this retrospective single center study, all patients with age > 18 years undergoing colonoscopy from January 2018 to December 2019 were included. Age, gender, and polyp characteristics were collected from endoscopy and histology database. Patients with incomplete histology reports and anal canal polyps were excluded. Based on histology, polyps were divided into adenocarcinoma, adenoma with advanced pathology (AAP; size > 10 mm, villous morphology or high-grade dysplasia), nonadvanced adenomas (nAAP), and nonadenomas. Results Overall colon polyp prevalence was 10.18% (3551/34893). The mean age (standard deviation [SD]) was 51.51 (14.84) with 75.4% males, of which 128 (3.6%) were adenocarcinoma. A total of 1514 (42.64%) were adenomas; 344 (9.7%) were AAP and 1170 (32.9%) were nAAP. The remaining 1909 (53.8%) were nonadenomas. Colonic adenoma prevalence after excluding adenocarcinoma was 4.35% (1514/34893). Adenocarcinoma (68.8% vs. 31.2%), AAP (70.6% vs. 29.4%), other adenomas (75.4% vs. 24.6%), and nonadenomas (76.7% vs. 23.3%) were significantly higher in male compared with female (p < 0.05). Adenomas and adenocarcinomas were more common in left colon and rectum than right colon (p < 0.05). The mean age (SD) were significantly lower in nonadenomas than adenocarcinomas, AAP, and other adenomas (p 0.0001; 49.25 [14.84] vs. 55.97 [12.47], 54.78 [16.40], 53.76 [13.71]). Conclusions The prevalence of colonic adenoma in India is 4.35%. Male gender and increased age were associated with increased risk of colonic adenoma and adenocarcinoma, which is more common in left colon and rectum. Prospective multicenter studies are required for evaluation of other risk factors of CRC and colonic adenomas.

Surgical necrosectomy has been the traditional management for pancreatic necrosis and is done using blunt dissection. However, lack of dedicated endoscopic accessories has been a major limitation in direct endoscopic necrosectomy (DEN). Standard endoscopic accessories cannot effectively remove large necrotic material. Also, diameter of instrument channel of the endoscope limits the ability to use large-diameter graspers that can remove large chunks of necrotic material. In this news, we discuss a recent study that has evaluated a new powered endoscopic debridement system for DEN.

Background Recently updated guidelines for choledocholithiasis stratify suspected patients into high, intermediate, and low likelihood, with the aim to reduce risk of diagnostic endoscopic retrograde cholangiopancreatography. This approach has increased proportion of patients in intermediate likelihood making it heterogenous. We aim to substratify intermediate group so that diagnostic tests (endoscopic ultrasound/magnetic resonance cholangiopancreatography) are judicially used. Methods This is a single-center retrospective analysis of prospectively maintained data. We used subset of patients who met intermediate likelihood of American Society of Gastrointestinal Endoscopy (ASGE) criteria from previously published data (PMID:32106321) as derivation cohort. Binominal logistic regression analysis was used to define independent predictors of choledocholithiasis. A composite score was derived by allotting 1 point for presence of each independent predictor. The diagnostic performance of a composite score of ≥ 1 was evaluated in validation cohort. Results A total of 678 (mean age [standard deviation]: 47.0 [15.9] years; 48.1% men) and 162 (mean age 47.8 [14.8] years; 47.4% men) patients in ASGE intermediate-likelihood group were included as derivation cohort and validation cohort, respectively. Binominal logistic regression analysis showed that male gender (p = 0.024; odds ratio [OR] = 1.92), raised bilirubin (p = 0.001; OR = 2.40), and acute calculus cholecystitis (p = 0.010; OR = 2.04) were independent predictors for choledocholithiasis. A composite score was derived by allotting 1 point for presence of independent predictors Using ≥ 1 as cutoff, sensitivity and specificity for detection of choledocholithiasis were 80% (95% confidence interval [CI]: 68.2–88.9) and 36.2% (95% CI: 32.2–40.0), respectively, in derivation cohort. Applying composite score in independent validation cohort showed sensitivity and specificity of 73.3% (95% CI: 44.9–92.2) and 40.1% (95% CI: 30.1–48.5), respectively. Conclusion Substratification of intermediate-likelihood group of ASGE criteria is feasible. It may be useful in deciding in whom confirmatory tests should be performed with priority and in whom watchful waiting may be sufficient.

Tuberculosis is one of the common causes of benign small bowel obstruction and endoscopic management mainly relies on serial balloon dilatation. In this report, we describe a 35 year male with refractory post-tubercular ileal stricture that was successfully treated with a lumen apposing metal stent

Permanent indwelling transmural stents is a safe and effective strategy for prevention of recurrence of pancreatic fluid collections following successful endoscopic transmural drainage of walled-off necrosis (WON) with coexistent disconnected pancreatic duct syndrome (DPDS). Long-term studies have shown this strategy to be safe and effective with rarely reported adverse effects. In this case series, we describe three patients of successfully treated WON and DPDS presenting later with a rare complication of permanent indwelling transmural plastic stents.

Endoscopic ultrasound (EUS) is an excellent imaging modality for the evaluation of common bile duct (CBD) because of its close proximity to the transducer placed in duodenum. However, in the presence of portal cavernoma, identification and proper evaluation of CBD become difficult because of presence of numerous venous collaterals. In these circumstances, the evaluation of CBD is more difficult if it is nondilated. In these difficult situations, contrast-enhanced EUS can provide better and clear images of CBD and therefore seems to be an excellent modality to evaluate nondilated CBD in the presence of portal cavernoma.

Obstructive jaundice is a common manifestation of malignancies involving pancreaticobiliary area of the gastrointestinal tract. The palliation of obstructive jaundice involves bypassing the obstruction by an endoprosthesis using either endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage route. Endoscopic ultrasound‑guided choledochoduodenostomy (ECD) is a challenging alternative for obstructive jaundice due to distal bile duct obstruction in patients who have failed ERCP. In this report, we describe a challenging case of disseminated urinary bladder cancer that presented with extensive duodenal as well as periduodenal infiltration leading on to gastrointestinal bleed and severe pruritus along with obstructive jaundice and was successfully managed with initial argon plasma coagulation of bleeding duodenal lesions followed by ECD.

A 62‑year‑old female presented with abdominal pain and was diagnosed as acute on chronic pancreatitis based on elevated serum amylase and imaging findings. The pancreatic duct was dilated with abrupt cutoff at neck of pancreas, but no mass was visualized. Positron emission tomography‑computed tomography (PET‑CT) revealed a fluorodeoxyglucose (FDG) avid lesion in the neck of the pancreas but ultrasound (USG)‑guided fine‑needle aspiration (FNA) from the lesion revealed only inflammatory cells. Endoscopic ultrasound, done 2 days after USG‑guided FNA, revealed pseudoaneurysm (PA) in the neck of pancreas that was confirmed on CT angiography. The PA was occluded by USG‑guided percutaneous cyanoacrylate injection. As pain persisted, repeat PET CT was done which revealed FDG avidity around the cyanoacrylate cast as well in multiple small hypodense lesions in the right lobe of the liver. USG‑guided FNA from both the liver lesion as well as the periphery of the glue cast revealed features of adenocarcinoma. We herein report a case of pancreatic adenocarcinoma that presented as acute pancreatitis and got masked because of formation of PA consequent to USG‑guided FNA.

Hydatid cysts can be found in almost any organ of the body with the most common sites being liver, lung, spleen, and kidney. A pancreatic hydatid cyst is rare but an isolated pancreatic hydatid cyst is even rarer. Cysts in the head of pancreas usually present with jaundice, whereas cysts located in the body and tail are usually asymptomatic. We present a rare case of isolated pancreatic hydatid cyst that presented with acute pancreatitis and mimicked a pancreatic fluid collection.

Pancreatic fluid collections are usually peripancreatic in location but can be found at various atypical locations such as the mediastinum. Mediastinal pseudocysts are very rare and are very unusual cause of dysphagia. Here, we report a rare case of mediastinal pseudocyst occuring because of pancreatic duct disruption due to chronic pancreatitis and presenting as dysphagia and successfully treated with endoscopic transpapillary stent placement.

Etiology of ascites can be usually determined with ascitic fluid cytological and biochemical evaluation. Occasionally, the cause of ascites cannot be determined despite repeated ascitic fluid evaluations. These patients with undiagnosed ascites usually undergo diagnostic laparotomy/laparoscopy for etiological diagnosis. Endoscopic ultrasound (EUS) can help in resolving the diagnostic conundrum of undiagnosed ascites by visualizing as well as sampling peritoneal and omental deposits/thickening. However, rarely fine-needle aspiration from deposits may be falsely negative and patient may need repeat sampling. Newer EUS imaging techniques such as elastography and contrast-enhanced harmonic EUS by providing additive information on stiffness and enhancement pattern of the lesion can help in differential diagnosis.

Background: Pancreatic pseudocysts (PP) at atypical locations are a therapeutic challenge and are usually managed surgically. Objective: We evaluated safety and efficacy of nonfluoroscopic endoscopic ultrasound (NF-EUS)-guided transmural drainage in the management of PP at atypical locations. Patients and Methods: Retrospective analysis of 11 patients (all males; age range: 28–46 years) with PP at atypical locations who were treated with NF-EUS-guided transmural drainage during the last 18 months was done. Results: Four patients had intra/peri-splenic, three patients had mediastinal, three patients had intrahepatic, and one patient had renal PP. Nine patients had chronic pancreatitis whereas two patients had acute pancreatitis. Alcohol was the etiology of pancreatitis in ten patients. The size of PP ranged from 4 to 10 cm. All patients had abdominal pain, and two patients had fever whereas one patient with mediastinal PP also had dysphagia. NF-EUS-guided transmural drainage could be done successfully in all patients. 7 Fr transmural stent(s) was/were placed in six patients whereas single-time complete aspiration of PP was done in five patients. On endoscopic retrograde pancreatography, six patients had partial duct disruption whereas five patients had complete disruption. Bridging transpapillary stent (5 Fr) was placed in all patients with partial disruption. All PP healed in 10/11 (91%) patients within 2–4 weeks, and there has been no recurrence in 9 of these patients during a follow-up period of 4–18 months. One patient with splenic PP needed surgery for gastrointestinal bleed. Conclusion: PP at atypical locations can be effectively and safely treated with NF-EUS-guided transmural drainage.

Background: Carbon dioxide (CO2) insufflation has been shown to be superior to air insufflation in colonoscopy, and double balloon enteroscopy. However, the value of CO2 insufflation in endoscopic retrograde cholangiopancreatography (ERCP) is not established. This study aims to assess the efficacy and safety of CO2 insufflation during ERCP. Materials and Methods: Consecutive patients referred for ERCP at a single center were randomized to either air or CO2 insufflation during ERCP. The primary objectives were a post-ERCP abdominal pain (measured by 10 cm visual analog scale [VAS] 30 and 90 min, and 3 h and 24 h after ERCP). Secondary objectives included end-tidal CO2 (ETCO2) values and procedural complications. Results: We randomized 298 patients; 149 into air group and 149 into CO2 group. The VAS score for pain was higher in the air group compared to the CO2 group at 30 min, with a median of 1 (interquartile range 1–0) versus median of 1 (interquartile range 1–0); P = 0.031 and 90 min after the procedure with a median of 0 (interquartile range 1–0) versus median of 0 (interquartile range 0–0); P = 0.006. There were no serious adverse events, and the ETCO2 was within normal limits in both groups. Conclusions: CO2 insufflation is superior to air insufflation during ERCP with regard to patient pain and discomfort and warrants wide adoption. Clinical Trials.gov registration number NCT 01321203.

Esophagobronchial fistula is an uncommon complication of esophageal or mediastinal tuberculosis. A 35‑year‑old man, a known case of esophageal tuberculosis, who had received 9 months of antitubercular therapy (ATT) presented with persistent cough. He had previously been detected to have an esophagobronchial fistula for which multiple hemoclips had been applied elsewhere, but the fistula persisted. A fistulous communication between the esophagus and the left main bronchus was successfully closed with the help of over‑the‑scope‑clip (OTSC) system. The present case is unique as patient developed fistulous communication during the treatment with ATT and it persisted despite successful treatment of esophageal tuberculosis. Moreover, this refractory fistula could be successfully closed with OTSC.

Walled-off necrosis (WON) is a delayed local complication of acute pancreatitis. It is usually associated with acute necrotizing pancreatitis. It requires drainage if it is infected, associated with gastric or biliary obstruction or is painful. Asymptomatic WON are usually managed conservatively. Occasionally, WON may spontaneously fistulize into gastrointestinal lumen or may rupture into the peritoneum. We describe the endoscopic demonstration of a case of spontaneous rupture of WON into the stomach and its subsequent uncomplicated resolution. Spontaneous rupture of WON into gastrointestinal tract with uncomplicated resolution is a rare event.

Isolated pancreatic tuberculosis is very rare, and it presents as a mass lesion and closely mimics pancreatic adenocarcinoma both clinically as well as on imaging. Further, pancreatic tuberculosis can also rarely mimic cystic tumor of the pancreas. We present an unusual case of pancreatic tuberculosis in a 42-year-old lady who presented with pain abdomen and had a cystic lesion with an enhancing mural nodule on computed tomography resembling a cystic tumor of the pancreas.

Introduction: The clinical course of ulcerative colitis (UC) ranges from a mild course with prolonged periods of remission to severe disease requiring long-term immunosuppression for disease control. There is limited data on the predictors of need for immunosuppression at presentation. Objective: The aim was to evaluate clinical, endoscopic and histopathological parameters at presentation in patients with UC that predict the need for long-term immunosuppressive therapy. Materials and Methods: We studied 81 patients (males; 40; mean age 38.69 ± 12.90 years) with UC (41 prospectively and 40 retrospectively). The clinical presentation, duration, extra-intestinal features, extent of disease, haematological and biochemical features, histology and outcome (drugs, surgery, and mortality) were recorded and analyzed. Subgroup analysis was done after dividing the patients into two groups depending upon whether they needed long term immunosuppressants or not. Results: The presenting symptoms were bloody stools (100%), mucus in stools (98.8%), abdominal pain (35.8%), anorectal pain (14.8%) and extra-intestinal symptoms (4.9%). Of these 81 patients, 7 (8.6%) patients required surgery and 2 (2.4%) patients died. Long term immunosuppressants were used in 19 patients (Azathioprine 16, Mycophenolate mofetil 2 and Tacrolimus 1). The patients who received immunosuppressants had a higher prevalence of pancolitis (47.4% vs. 16.1%, P = 0.005). Other clinical, hematological and histological parameters such as inflammatory grade, chronicity grade, cellular infiltrates, submucosal fibrosis, Paneth cell metaplasia, and the presence of neuronal cells were similar in the two groups. Conclusion: Of the clinical, biochemical, endoscopic and histological features at presentation only the presence of pancolitis predicts the need for long term immunosuppressants in ulcerative colitis.

Gastrointestinal duplication cysts are rare congenital abnormalities that are usually seen in childhood. Colonic duplication cyst is very rare in adults and is usually asymptomatic. We report a 42‑year‑old female with a duplication cyst in the proximal ascending colon who presented with recurrent episodes of colicky abdominal pain. The cyst could be well visualized on colonoscopy and the patient underwent successful right hemicolectomy with ileotransverse anastomosis.

Endoscopic therapy is the standard of care for management of most benign biliary strictures. However, endoscopic therapy can fail in very tight strictures. We report a case of a 52-year-old lady who had complete bile duct transection with stricture after laparoscopic cholecystectomy. In initial attempt, at endoscopic retrograde cholangiopancreatography (ERCP), guidewire could not be negotiated endoscopically across the narrowing as there was complete cut off of the bile duct and so a percutaneous transhepatic biliary drainage (PTBD) was done and subsequently internalized into the duodenum. We cannulated the internalized end of PTBD catheter with the standard ERCP cannula with guidewire and advanced it across the biliary stricture. PTBD catheter was withdrawn externally, and the guidewire was left in the left ductal system. We report this innovation as this may be helpful in managing patients with ERCP after an initial PTBD has been successfully internalized into the duodenum.

Colorectal polyps may be detected incidentally on a screening colonoscopy or when they present with symptoms like anemia or gastrointestinal bleeding. Early recognition and prompt management of polyps can cure the primary disease and prevent future risk of malignancies in the patient and provide an opportunity to screen the families in cases of inherited polyposis syndromes. We report a case of rectal bleeding due to colorectal polyps of varying histology. Histology showed hyperplastic polyp, juvenile polyps (JP) with focal dysplasia, adenomatous polyp and villous adenoma with dysplasia. He underwent total proctocolectomy with ileal pouch anal anastomosis (J-pouch) (TP-IPAA). Mixed polyposis syndrome is a rare entity. (J Dig Endosc 2013;4(2):39-41)

Hemostatic powder is a new hemostatic modality that is easy to use and covers a large surface area. It causes hemostasis by mechanical tamponade over the bleeding vessel and increases the concentration of the clotting factor. In this image, we report a case of gastric neuroendocrine bleeding presenting with refractory bleeding and hemostasis achieved with the endoscopic application of hemostatic powder.