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Colorectal cancer remains a leading cause of morbidity and mortality in the United States. Advances in artificial intelligence (AI), specifically computer aided detection and computer-aided diagnosis offer promising methods of increasing adenoma detection rates with the goal of removing more pre-cancerous polyps. Conversely, these methods also may allow for smaller non-cancerous lesions to be diagnosed in vivo and left in place, decreasing the risks that come with unnecessary polypectomies. This review will provide an overview of current advances in the use of AI in colonoscopy to aid in polyp detection and characterization as well as areas of developing research.

Pancreatic fluid collections (PFCs) are a common sequela of pancreatitis. Most PFCs can be managed conservatively, but symptomatic PFCs require either surgical, percutaneous, or endoscopic intervention. Recent advances in the therapeutics of PFCs, including the step-up approach, endoscopic ultrasound-guided transmural drainage with lumen apposing metal stents, and direct endoscopic necrosectomy, have ushered endoscopy to the forefront of PFCs management and have allowed for improved patient outcomes and decreased morbidity. In this review, we explore the progress and future of endoscopic management of PFCs.

Background & Aims The prevalence and significance of digestive manifestations in coronavirus disease 2019 (COVID-19) remain uncertain. We aimed to assess the prevalence, spectrum, severity, and significance of digestive manifestations in patients hospitalized with COVID-19. Methods Consecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were abstracted manually from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19. Results A total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least 1 gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were increased to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio, 0.93; 95% CI, 0.76–1.15) or liver test abnormalities on admission (odds ratio, 1.31; 95% CI, 0.80–2.12) were not associated independently with mechanical ventilation or death. Conclusions Among patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common, but the majority were mild and their presence was not associated with a more severe clinical course.

Intraductal papillary neoplasm of the biliary tree (IPNB) is a rare non-invasive neoplasm that carries a high potential for progression to malignancy. Typically, these tumors are managed via surgery with total resection being the fundamental goal. Recently, radiofrequency ablation (RFA) has gained momentum as a treatment option for biliary cancers. Prior studies examining the effect of RFA on biliary tumors usually group all tumor types together, leaving few reports looking at sole outcomes in IPNB. We present an elderly woman with advanced dementia who was admitted with obstructive jaundice secondary to intrahepatic IPNB, and underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) with RFA and stenting resulting in objective improvement in both the size of the lesion and laboratory markers. In the right subset of patients, endobiliary RFA can be used as a safe and effective modality of treatment with minimal complications.

BackgroundThe prevalence and significance of digestive manifestations in COVID-19 remain uncertain.MethodsConsecutive patients hospitalized with COVID-19 were identified across a geographically diverse alliance of medical centers in North America. Data pertaining to baseline characteristics, symptomatology, laboratory assessment, imaging, and endoscopic findings from the time of symptom onset until discharge or death were manually abstracted from electronic health records to characterize the prevalence, spectrum, and severity of digestive manifestations. Regression analyses were performed to evaluate the association between digestive manifestations and severe outcomes related to COVID-19.ResultsA total of 1992 patients across 36 centers met eligibility criteria and were included. Overall, 53% of patients experienced at least one gastrointestinal symptom at any time during their illness, most commonly diarrhea (34%), nausea (27%), vomiting (16%), and abdominal pain (11%). In 74% of cases, gastrointestinal symptoms were judged to be mild. In total, 35% of patients developed an abnormal alanine aminotransferase or total bilirubin level; these were elevated to less than 5 times the upper limit of normal in 77% of cases. After adjusting for potential confounders, the presence of gastrointestinal symptoms at any time (odds ratio 0.93, 95% confidence interval 0.76-1.15) or liver test abnormalities on admission (odds ratio 1.31, 95% confidence interval 0.80-2.12) were not independently associated with mechanical ventilation or death.ConclusionsAmong patients hospitalized with COVID-19, gastrointestinal symptoms and liver test abnormalities were common but the majority were mild and their presence was not associated with a more severe clinical course

The differential diagnosis for biliary strictures is broad. However, the likelihood of malignancy is high. Determining the etiology of a biliary stricture requires a comprehensive physical exam, laboratory evaluation, imaging, and ultimately tissue acquisition. Even then, definitive diagnosis is elusive, and many strictures remain indeterminant in origin. This literary review examines the diagnostic dilemma of biliary strictures and presents innovations in both histochemical and endoscopic techniques that have increased the diagnostic power of differentiating benign and malignant strictures. The field of tissue biopsy is revolutionizing with the advent of free DNA mutation profiling, fluorescence in situ hybridization (FISH), and methionyl t-RNA synthetase 1 (MARS 1), which allow for greater testing sensitivity. Endoscopic ultrasound, endoscopic retrograde cholangiopancreatography (ERCP), cholangioscopy, confocal laser endomicroscopy, and intraductal ultrasound build upon existing endoscopic technology to better characterize strictures that would otherwise be indeterminate in etiology. This review uses recent literature to insert innovative technology into the traditional framework of diagnostic methods for malignant biliary strictures.

Background Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs). Methods We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery. Results Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %; P = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %; P = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively; P = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %; P = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively; P = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %; P = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7]; P = 0.31). Conclusion When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.

Objectives An increasing number of providers have begun to use a minimally invasive step-up approach as opposed to traditional surgical necrosectomy in the management of acute necrotizing pancreatitis. Studies have shown mixed results, thus we hypothesized that the step-up approach is safer and associated with decreased mortality and length of stay (LOS). Methods This is a retrospective cohort study of patients admitted from January 2010 to March 2015 who underwent interventions for walled-off pancreatic necrosis (WOPN). Primary outcomes included LOS after intervention and mortality, in-hospital and 90-day, with secondary outcomes of procedural complications. Results Sixty-nine patients developed WOPN requiring intervention during the study period. In-hospital mortality was 5.6% (n = 2) in the step-up cohort compared with 18.2% (n = 6) in the surgical cohort (relative risk, 3.27; 95% confidence interval, 0.71-15.09). Ninety-day mortality was 9.1% (n = 3) in the step-up cohort and 21.9% (n = 7) in the surgical cohort (relative risk, 2.41; 95% confidence interval, 0.68-8.50). Postintervention LOS was 8 days in the step-up cohort and 17 days in the surgical cohort (P = 0.62). Conclusions A step-up approach, as compared with primary surgical necrosectomy in the management of WOPN, results in clinically significant decreases in mortality and LOS.

Endoscopic ultrasound-guided hepaticogastrostomy (EUS-HG) is a technique used to access the biliary tree in patients with surgically altered anatomy. Additionally, development of EUS-HG fistula permits intraductal therapy, thereby preventing patients from requiring surgery or percutaneous transhepatic biliary drainage (PTBD), thus decreasing morbidity. This clinical vignette describes an 83-year-old man with a history of gangrenous cholecystitis requiring cholecystectomy, partial gastrectomy, and Roux-en-Y gastrojejunostomy who presented to an outside hospital with abdominal pain and fever and found to have cholangitis and choledocholithiasis. He underwent two endoscopic retrograde cholangiopancreatography (ERCP) procedures at an outside hospital which were unsuccessful due to an inaccessible major papilla in the setting of the patient’s surgically altered anatomy. On arrival to Wake Forest, the patient underwent EUS-HG with successful biliary drainage and resolution of cholangitis. He returned for ERCP three months later with balloon sphincteroplasty, cholangioscopy, and electrohydraulic lithotripsy (EHL) performed through the existing metal stent (hepaticogastrostomy), resulting in stone fragmentation and antegrade removal with balloon sweeps. Repeat cholangioscopy post-EHL and balloon sweeps showed complete duct clearance with no residual stones. The hepaticogastrostomy stent was subsequently removed, and the patient recovered without any complications.

GOALS The aim of this study was to characterize current trends in the use of endoscopic retrograde cholangiopancreatography (ERCP) in the United States for patients hospitalized with chronic pancreatitis. BACKGROUND Historically, ERCP was the primary tool for diagnostic and therapeutic management of chronic pancreatitis. With increased availability of magnetic resonance imaging and endoscopic ultrasound, indications for ERCP are being redefined. STUDY We performed a retrospective cohort study using the Nationwide Inpatient Sample from 1998 to 2010. We identified patients with a primary discharge diagnosis of chronic pancreatitis who underwent ERCP. We excluded patients diagnosed with biliary, gallbladder, or pancreatic neoplasm and patients who underwent gallbladder or pancreatic operation during the same admission. We analyzed patient and hospital characteristics, length of stay, and in-hospital mortality, and adjusted for weighted sample schema. RESULTS During the study period, 29,318 patients with chronic pancreatitis (mean age 52 y, 57.2% female) underwent ERCP during their hospitalization. The majority of patients were white (56.1%). The majority of procedures were performed at large (72.4%), urban (95.2%), and academic (69.0%) hospitals. Mean hospital charges were $32,929 (SE= $1605). Mean length of stay was 6 days (SE=0.3), with in-hospital mortality of 0.76%. Over the study period, the number of procedures has decreased significantly (P

In addition to the poor prognosis associated with pancreatic adenocarcinoma, it can also lead to several other conditions including obstructive jaundice that can affect a patient's quality of life. This is a major concern in non-operative patients where palliation is considered the main therapeutic goal. Traditionally, there are several ways to pursue palliative biliary drainage including endoscopic methods, a variety of surgical procedures, and percutaneous techniques. Generally, endoscopic methods such as endoscopic retrograde cholangiopancreatography (ERCP) with transpapillary stent placement are considered first-line therapies. Unfortunately, ERCP is not always possible due to several potential reasons. Although endoscopic ultrasound-guided biliary puncture has been well described for several years, there are limitations to its usefulness in biliary drainage, in part due to complication concerns. However, more recently a lumen-apposing, self-expandable fully covered metal stent has been employed for such situations. We describe two cases in which this type of stent was used in patients for palliative biliary drainage in pancreatic adenocarcinoma where standard ERCP was not feasible. In both cases, stent deployment was successful without immediate complications related to the procedure or the stent. Furthermore, the main goal of these therapies was palliation and in both cases the patient chose this procedure for quality of life reasons. In the future, randomized trials are needed to better define the long-term effectiveness and safety of these stents compared to more standard therapies.

Endoscopic drainage is increasingly used in lieu of percutaneous or surgical drainage of pancreatitis-related fluid collections. The lumen-apposing, covered, self-expanding, metallic stent (LACSEMS) is a newly produced stent for the transmural drainage of such fluid collections. The use of LACSEMS devices requires close coordination between knowledgeable radiologic and gastrointestinal providers. We review pancreatitis-related fluid collections and show examples from our experience with LACSEMS and the appropriate case selection, planning, deployment, and follow-up for this novel device.

A 16-year-old adolescent boy presented with obstructive jaundice and was incidentally found to have a well-differentiated pancreatic endocrine neoplasm upon endoscopic ultrasound. The discovery of this tumor led to further investigation and the eventual diagnosis of MEN1 syndrome. The diagnosis of MEN1 can prove difficult, and lack of treatment has been shown to lead to early mortality. One must maintain clinical suspicion for this disease in the evaluation of patients presenting with suspicious lesions of unknown etiology, especially those involving the pancreas, anterior pituitary, and parathyroid glands.

Background and Aims The obesity epidemic has led to increased use of Roux-en-Y gastric bypass (RYGB). These patients have an increased incidence of pancreaticobiliary diseases, yet standard ERCP is not possible because of surgically altered gastroduodenal anatomy. Laparoscopy-assisted ERCP (LA-ERCP) has been proposed as an option, but supporting data are derived from single-center small case series. Therefore, we conducted a large multicenter study to evaluate the feasibility, safety, and outcomes of LA-ERCP. Methods This is a retrospective cohort study of adult patients with RYGB who underwent LA-ERCP in 34 centers. Data on demographics, indications, procedure success, and adverse events were collected. Procedure success was defined when all the following were achieved: reaching the papilla, cannulating the desired duct, and providing endoscopic therapy as clinically indicated. Results A total of 579 patients (median age, 51; 84% women) were included. Indication for LA-ERCP was biliary in 89%, pancreatic in 8%, and both in 3%. Procedure success was achieved in 98%. Median total procedure time was 152 minutes (interquartile range [IQR], 109-210), with a median ERCP time of 40 minutes (IQR, 28-56). Median hospital stay was 2 days (IQR, 1-3). Adverse events were 18% (laparoscopy related, 10%; ERCP related, 7%; both, 1%) with the clear majority (92%) classified as mild/moderate, whereas 8% were severe and 1 death occurred. Conclusions Our large multicenter study indicates that LA-ERCP in patients with RYGB is feasible with a high procedure success rate comparable with that of standard ERCP in patients with normal anatomy. The ERCP-related adverse events rate is comparable with conventional ERCP, but the overall adverse event rate was higher because of the added laparoscopy-related events.

Somatostatinoma of the gastrointestinal tract is a rare finding, especially arising from the ampulla of Vater. We present a man recently diagnosed with rectal adenocarcinoma who was found on imaging to have an ampullary mass. Histology and immunohistochemical staining of the biopsied tissue were consistent with a nonfunctioning somatostatinoma. The patient had neurofibromatosis, which have been reported in patients with ampullary somatostatinomas. Our case highlights the importance of gastrointestinal findings in those with underlying genetic conditions.

Image-guided radiation therapy allows precise tumor targeting using real-time tracking of radiopaque fiducial markers. To enable appropriate tracking, it is recommended to place fiducials with "ideal fiducial geometry" (IFG). Our objectives were to determine the proportion of patients in whom IFG can be achieved when fiducials are placed by endoscopic ultrasound (EUS) and surgery and to determine if attaining IFG is necessary for delivering radiation.This single-center retrospective cohort study included 77 patients with biopsy-proven advanced pancreatic cancer who underwent either EUS-guided or laparotomy/laparoscopy-assisted fiducial placement between September 2005 and July 2009.Gold fiducials were implanted by EUS in 39 patients (51%) and by surgery in 38 patients (49%). The proportion of patients with IFG was significantly higher for surgical placement [18/38, 47%; 95% confidence interval (CI), 32%-63%] compared with EUS-guided placement (7/39, 18%; 95% CI, 8%-32%), P = 0.0011. However, fiducial tracking was successfully used for Cyberknife therapy in 35 (90%) of 39 (95% CI, 77%-97%) patients in the EUS group compared with 31 (82%) of 38 (95% CI, 67%-92%) patients in the surgery group. There were 5 procedure-related complications in the EUS group.Achieving IFG appears unnecessary for successful tracking and delivery of radiation.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal tumors of the gastrointestinal tract; however, the occurrence of a GIST in the duodenum is rare. Our case demonstrates the importance of considering GIST in the evaluation of refractory duodenal ulcers, as well as the utilization of endoscopic ultrasound in the evaluation of these lesions.

Background and Objectives: The management of ampullary lesions has evolved to include endoscopic ampullectomy (EA) as a curative approach to cancers of the ampulla of Vater. With this change comes a need to risk-stratify patients at initial diagnosis. Materials and Methods: Patients with verified ampullary lesions (N = 50) were analyzed in a case-control design. We evaluated endoscopic ultrasound (EUS) data to define characteristics that yield a high sensitivity in selecting candidates for EA. Results: Using data from previously published studies yielded a sensitivity of 0.765 in appropriately identifying the 34 surgical cases. Expanding these characteristics increased the sensitivity of EUS to 0.971 in identifying surgical candidates. Additionally, of advanced disease cases, the expanded characteristics correctly identified these cases with a sensitivity of 1.0-improved over 0.708 using prior published data. Conclusion: EA should be strongly considered if ampullary lesions are found to fit the following characteristics after EUS evaluation: lesion size