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Background and study aims  Endoscopic ultrasound (EUS)-guided pancreaticogastrostomy (PG) has been used as an alternative to surgery to drain pancreatic ducts for treatment of disconnected pancreatic duct syndrome (DPDS). Previous techniques involved using needle-knife cautery, bougie dilation or a stent extraction screw to allow stent passage through the gastric wall and pancreatic parenchyma, with potential for severe complications including duct leak, especially if drainage fails. A novel technique employing EUS guided puncture of the main pancreatic duct (MPD) with a 19- or a 22-gauge needle, passage of an 0.018-guidewire, dilation of the tract with a small-diameter (4 F) angioplasty balloon and placement of 3F plastic stents with the pigtail curled inside the duct as an anchor. Methods  This is a retrospective case series at a single tertiary center. EUS-guided PG was considered when conventional endoscopic pancreatic duct drainage failed. Main outcomes included technical and clinic success and complications. Results  Eight patients underwent PG. Indications were DPDS (n = 4), stenotic pancreaticoenteral anastomosis after Whipple procedure (n = 3) and chronic pancreatitis with dilated MPD (n = 1). Median MPD diameter was 6.75 mm [IQR 2.8 - 7.6]. Technical success was achieved in seven of eight cases (88 %); angioplasty balloon passed into the pancreatic duct in all accessed ducts. There was one asymptomatic duct leak, and no major or delayed complications, with clinical improvement (complete or partial) in five of eight (71 %). Conclusions  EUS-guided PG using a small-caliber guidewire, 4F angioplasty balloon, and reverse 3F single pigtail stents offers a safe and atraumatic alternative without use of cautery., Competing Interests: Competing interests BSC Consulting Agreement (Author SKA) Cook Medical Consulting Agreement (Author SKA) Merit Medical Consulting Agreement (Author SKA) GIE Medical Consulting Agreement (Author SKA) US Endoscopy Consulting Agreement (Author SKA) Olypmus Consulting Agreement (Author SKA) Abbvie Consulting Agreement (Author MLF) Boston Scientific Consulting agreement (Authors MLF and SJM)

Mycobacterium abscessus is associated with antibiotic resistance and poor treatment outcomes. We described within-patient changes in M. abscessus resistance to clarithromycin and amikacin. Patients with amikacin exposure and a >50-month interval between M. abscessus isolates were identified. Antimicrobial susceptibility testing was performed on the first and last isolates by broth microdilution, and genetic markers of resistance were identified. 16 patients were identified with a median amikacin exposure of 2.3 years (range 0.6-8.6 years). 15 patients also received macrolides (median 7.2 years, range 1.3-10.7 years). All initial isolates were resistant to clarithromycin (minimum inhibitory concentration (MIC) ≥8 µg·mL -1 ). Two patients had later susceptible isolates, which were of a different subspecies ( M. abscessus subsp. massiliense ) than the initial isolates ( M. abscessus subsp. abscessus ). All initial isolates were susceptible or intermediately resistant to amikacin, and only one patient had a resistant final isolate (MIC >64 µg·mL -1 ), accompanied by an A→G mutation at position 1408 of the 16S ribosomal RNA. Forced expiratory volume in 1 s decreased significantly over the study period, while smear quantity and the proportions of patients with elevated C-reactive protein or cavitary lesions all increased significantly. Despite prolonged, mostly inhaled amikacin exposure, development of amikacin resistance was uncommon in this patient population; however, disease progression continued., Competing Interests: Conflict of interest: S. Daniel-Wayman has nothing to disclose. Conflict of interest: S. Shallom has nothing to disclose. Conflict of interest: N. Azeem has nothing to disclose. Conflict of interest: K.N. Olivier has nothing to disclose. Conflict of interest: A.M. Zelazney has nothing to disclose. Conflict of interest: D.R. Prevots has nothing to disclose.

Aflatoxin contamination in human food and animal feed is a threat to public safety. Aflatoxin B1 (AFB1) can be especially damaging to poultry production and consequently economic development of Pakistan. The present study assessed the in vitro binding of AFB1 by indigenously characterized probiotic lactobacilli. Six isolates ( Lactobacillus gallinarum PDP 10, Lactobacillus reuetri FYP 38, Lactobacillus fermentum PDP 24, Lactobacillus gallinarum PL 53, Lactobacillus paracasei PL 120, and Lactobacillus gallinarum PL 149) were tested for activity against toxigenic Aspergillus flavus W-7.1 (AFB1 producer) by well diffusion assay. Only three isolates (PL 53, PL 120, and PL 149) had activity against A. flavus W-7.1. The ameliorative effect of these probiotic isolates on AFB1 production was determined by co-culturing fungus with lactobacilli for 12 days, followed by aflatoxin quantification by high-performance liquid chromatography. In vitro AFB1 binding capacities of lactobacilli were determined by their incubation with a standard amount of AFB1 in phosphate buffer saline at 37 °C for 2 h. AFB1 binding capacities of isolates ranged from 28-65%. Four isolates (PDP 10, PDP 24, PL 120, and PL 149) also ceased aflatoxin production completely, whereas PL 53 showed 55% reduction in AFB1 production as compared to control. The present study demonstrated Lactobacillus gallinarum PL 149 to be an effective candidate AFB1 binding agent against Aspergillus flavus . These findings further support the binding ability of lactic acid bacteria for dietary contaminants.

Competing Interests: Martin Freeman has acted as a consultant for Boston Scientific, Cook Medical, and Xlumena. Stuart Amateau has acted as a consultant for Merit Endoscopy, Boston Scientific, US Endoscopy, and Neurotronic, and has received research support from Cook Medical. Nabeel Azeem has no conflicts to report.

Immunoglobulin G4 (IgG4)-related disease is a fibroinflammatory systemic disorder with multiorgan involvement. Proximal bile duct involvement results in IgG4-related sclerosing cholangitis, which is characterized by a lymphoplasmacytic infiltrate with abundant IgG4-positive plasma cells and fibrosis. Differentiating between cholangiocarcinoma and IgG4-sclerosing cholangitis can present a diagnostic dilemma. We describe an unusual presentation of a hepatic mass meeting multiple criteria for IgG4-sclerosing cholangitis but was ultimately found to be cholangiocarcinoma. Several published case reports describe patients with suspected cholangiocarcinoma who are later found to have IgG4-sclerosing cholangitis, but few reports have demonstrated the reverse. Distinguishing between cholangiocarcinoma and IgG4-sclerosing cholangitis is challenging, and a high clinical suspicion for cholangiocarcinoma must always be maintained. ( Hepatology Communications 2018;2:349-353).

Aim: The aim of this article is to assess HFE C282Y gene mutations as a predictor of sustained virological response (SVR) to anti-hepatitis C virus (HCV) treatment in Egyptian patients., Materials and Methods: One hundred and forty chronic hepatitis C (CHC) patients were divided into two groups: 70 patients achieved SVR and 70 patients were nonresponders (NRs). All patients were subjected to quantitative polymerase chain reaction (PCR) at baseline, 12 and 24 weeks after therapy commencement. Deoxyribonucleic acid (DNA) sequencing for HFE (C282Y) was done by restriction fragment length polymorphism PCR., Results: Sixty five patients did not have mutation and 5 patients had C282Y mutation (GA) with SVR. While 45 NRs had heterozygous C282Y mutation (GA), 4 patients (5.7%) had homozygous mutation (AA) and 21 patients (30%) had no mutation (GG). The parameters of elevated iron [transferrin saturation (TS; p < 0.001), S iron (p < 0.02), total iron binding capacity (TIBC; p < 0.001), transferrin (p < 0.016), and soluble transferrin receptor (sTfR; p-value, 0.001)] were significantly associated with C282Y mutation. However, there was no significant difference regarding ferritin values and C282Y mutation in NR patients., Conclusion: Iron overload was frequently detected in CHC patients and associated with C282Y mutation, while biochemical markers of iron overload and C282Y HFE mutation were negative prognostic factor. How to cite this article: Mehrez MI, Fattah DSA, Azeem NAA, Saleh MA, Mostafa KM. Hemochromatosis Gene Polymorphism as a Predictor of Sustained Virological Response to Antiviral Treatment in Egyptian Chronic Hepatitis C Patients. Euroasian J Hepato-Gastroenterol 2017;7(2):154-157., Competing Interests: Source of support: Nil Conflict of interest: None

Background: Point-of-care ultrasound is a rapidly evolving component of internal medicine (IM) residency training. The optimal approach for teaching this skill remains unclear., Objective: We sought to determine whether the addition of a longitudinal ultrasound curriculum to a stand-alone workshop for ultrasound training improved knowledge retention in IM residents., Methods: We conducted an observational cohort study from July to December 2013. All postgraduate year (PGY)-1 IM residents attended an ultrasound workshop during orientation. Ability to identify static images of ascites, kidney, thyroid, pleural fluid, inferior vena cava, and internal jugular vein was assessed immediately after the workshop. An ultrasound curriculum, including morning report and ultrasound rounds, was initiated during the inpatient medicine rotation. PGY-1 residents were randomly assigned to participate in the longitudinal curriculum. Six months later, we conducted a follow-up survey with all PGY-1 residents., Results: Forty-eight PGY-1 residents (67%) completed the postworkshop test and the 6-month follow-up test. Of these, 50% (24 of 48) had participated in the ultrasound curriculum. Residents not exposed to the curriculum showed a decline in the identification of ascites, pleural effusion, and internal jugular vein at 6 months (P < .05), whereas those who participated in the curriculum maintained their performance (P < .05)., Conclusions: Six months after exposure to a longitudinal ultrasound curriculum, residents were more likely to correctly identify ultrasound images of ascites, kidney, and pleural effusion. The addition of a longitudinal ultrasound curriculum may result in improved knowledge retention in IM residents.

Background: Patients with primary sclerosing cholangitis (PSC) have an increased lifetime risk of cholangiocarcinoma (CCA). Detection of localized CCA in patients with PSC may result in curative liver transplantation. Recently, high-resolution per-oral video cholangioscopy (PVCS) has become available and may be useful for evaluating for biliary dysplasia. Narrow-band imaging (NBI) has shown promising results in detecting dysplasia in the esophagus and colon, but its utility in the bile duct is unproven., Objective: Evaluate NBI video PVCS in screening for dysplasia in patients with PSC., Design: Prospective case series., Setting: Tertiary-care referral center., Patients: Patients with PSC undergoing ERCP between December 2008 and July 2010., Intervention: ERCP with white-light and NBI PVCS and biopsy of suspicious lesions., Main Outcome Measurements: Dysplasia detection., Results: A total of 30 patients were enrolled. Median follow-up was 319.5 days. Four patients had a final diagnosis of CCA (2 extrahepatic, 2 intrahepatic). NBI visualized the 2 extrahepatic CCAs and allowed determination of tumor margins. The bile duct mucosa by NBI visual appearance in patients with PSC was variable. No correlation with CCA development could be determined. There was a 48% increase in suspicious lesions biopsied with NBI compared with white-light imaging, although NBI-directed biopsies did not improve the dysplasia detection rate., Limitations: Small sample size, single center, referral bias., Conclusion: NBI allowed visualization of tumor margins in CCA as compared with traditional fluoroscopy-based ERCP. An improvement in dysplasia detection in patients with PSC could not be demonstrated despite an increase in the biopsy rate. Additional experience is needed to assess the utility of NBI in screening for CCA in patients with PSC. (, Clinical Trial Registration Number: NCT00951327.)., (Copyright © 2014 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Background: Endoscopic retrograde cholangiography (ERC) is technically challenging in liver transplant patients with Roux-en-Y biliary anastomosis. The optimal endoscope for such cases remains unknown., Objective: Compare efficacy and safety of performing ERC in liver transplant patients with Roux-en-Y biliary anastomosis by using an adult colonoscope (AC), a pediatric colonoscope (PC), and a single-balloon enteroscope (SBE)., Design: Retrospective chart review., Setting: Tertiary-care referral center., Patients: Liver transplant patients with Roux-en-Y biliary anastomoses., Intervention: ERC with AC, PC, and SBE., Main Outcome Measurements: Rates of reaching the afferent limb and biliary anastomosis; rates of cannulation; rates of diagnostic, therapeutic, and procedural success; and number of adverse events., Results: Ninety patients underwent 199 ERCs from 2002 to 2012; 86 with an AC, 55 with a PC, and 58 with an SBE. Biliary cannulation and diagnostic, therapeutic, and procedural success rates were all significantly higher with an SBE than with a PC. Among patients undergoing the initial ERC, no statistical difference was found among SBE, the PC, and an AC. However, the rate of procedural success with SBE during initial ERC over the last 4 years has increased. Of 25 total failures with ACs, exchange for SBEs resulted in procedural success in 4 of 4 attempts. Of 22 failures with a PC, exchange for an SBE resulted in success in 3 of 4 cases. Of 4 failures with SBE exchange in 6 cases (4 to AC, 2 to PC), SBE resulted in success in only 1. No adverse events occurred directly related to type of endoscope., Limitations: Retrospective study, single center, lack of standardized approach to selection of endoscopes, uncontrolled variables (general anesthesia, learning curve)., Conclusion: In liver transplant patients with Roux-en-Y anatomy, rates of biliary cannulation, therapeutic success, and procedural success are higher with use of an SBE than with a PC and tend to be higher compared with use of an AC among the overall cohort. Use of an SBE and procedural success rates with SBEs have increased over the last 4 years. Failed cases with either an AC or PC can be completed if exchanged for an SBE., (Copyright © 2013 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

5-Androstene-3β,7β,17β-triol (AET) is a naturally occurring anti-inflammatory adrenal steroid that limits acute and chronic inflammation. HE3286 (17α-ethynyl-5-androstene-3β,7β,17β-triol) is a synthetic derivative of AET with improved pharmaceutical properties and efficacy in some animal models of autoimmunity. Here, daily oral doses of HE3286 led to a suppression of spontaneous autoimmune diabetes in the non-obese diabetic mouse model of type 1 diabetes mellitus when administered either shortly before or after the first incidence of disease onset. Efficacy was associated with reduced insulitis and a suppression of the pathogenic T helper cell type 1 and type 17 phenotypes in peripheral lymphoid organs. These results demonstrate that daily oral treatment with HE3286 administrated relatively late in the destructive autoimmune process led to a suppression of type 1 diabetes mellitus onset and of the pathological inflammatory status, supporting its clinical evaluation in type 1 diabetes mellitus subjects., (Copyright © 2011. Published by Elsevier B.V.)