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Hepatitis B is a global healthcare problem. An estimated one third of the global population have been infected with the hepatitis B virus (HBV). Various guidelines have been proposed for management of chronic hepatitis B. These guidelines have similarities and differences and are changed from time to time. Here, we have reviewed the management guidelines of chronic hepatitis B published after 2007 and highlighted the similarities and differences between their different recommendations. [ABSTRACT FROM AUTHOR]

Background and Aim Methods Results Conclusions Although rapid on‐site cytological evaluation (ROSE) for endoscopic ultrasound (EUS)‐guided tissue acquisition (EUS‐TA) may increase diagnostic yield, it is not widely available. Macroscopic on‐site evaluation (MOSE) is an alternative modality although it is not standardized for EUS‐guided fine‐needle biopsy (FNB). We evaluated diagnostic performance of MOSE compared with conventional technique of EUS‐TA using core biopsy needle.Consecutive patients undergoing EUS‐FNA for solid lesions were randomized to MOSE or conventional arms. The primary and secondary outcome measures were diagnostic accuracy, diagnostic yield, sensitivity, specificity, positive and negative predictive values, and the number of passes, respectively. The optimum parameters for macroscopic visible core (MVC, i.e., length, number) by MOSE to achieve accurate diagnosis were evaluated.Ninety‐six patients (48 conventional and 48 MOSE) were enrolled. Mean lesion size was larger in MOSE arm (32.67 ± 7.22 vs 29.31 ± 6.98 mm, P = 0.023). Diagnostic accuracy (95.8% vs 91.6%), diagnostic yield (97.9% vs 95.8%), procedure duration, and adverse events of the two methods were similar. Median number of passes with MOSE was less (2 vs 3 P = 0.000). Area under the receiver operating characteristic curve showed that with MOSE, obtaining a total MVC length of 11.5 mm had 93.3% sensitivity, and 2.5 MVC cores (each 4 mm) had 86.7% sensitivity for malignancy diagnosis.EUS‐FNB with MOSE, a simple reliable technique, can achieve a high and comparable diagnostic accuracy with lesser number of passes. Obtaining longer length and greater number of MVC increase the sensitivity to diagnose malignancy with MOSE. [ABSTRACT FROM AUTHOR]

A prospective study was performed to evaluate the prevalence of anorectal varices and their clinical significance as well as to study other proctosigmoidoscopic changes in 75 patients with portal hypertension of diverse etiology. Sixty-seven patients (89.3%) had lower gastrointestinal varices with no significant difference (p > 0.05) in prevalence between cirrhosis (92.1%), non-cirrhotic portal fibrosis (87%), and extrahepatic portal venous obstruction (85.7%). The rectum was the most common site of lower gastrointestinal varices. External anal and sigmoid colonic varices almost always occurred in the presence of rectal and/or internal anal varices. There was no correlation between the presence of rectosigmoid varices and the severity of esophagogastric mucosal changes or portal hypertension. There was no suggestion that esophageal variceal sclerotherapy influenced the presence of anorectal varices. Seven patients (9.3%) had recent hematochezia, including three patients in whom it occurred in the absence of any upper gastrointestinal hemorrhage. Varices were the cause of bleeding in at least five patients. An abnormal mucosal vascular pattern in the form of telangiectasias or spiders was seen, irrespective of etiology of portal hypertension, in nine patients (12%). Hemorrhoids were present in 31 patients (41.3%.) with an age-related difference (p > 0.05) between patients with cirrhosis (55.3%) and extrahepatic portal venous obstruction (21.4%). [ABSTRACT FROM AUTHOR]

Pregnancy in patients with portal hypertension is an uncommon occurrence. Hence, there are no clear guidelines for management of variceal bleed during pregnancy. Moreover, the outcome of variceal sclerotherapy, particularly its effect on conception, as well as its safety and efficacy when used during pregnancy, is not known. We have treated four patients of portal hypertension during pregnancy with sclerotherapy. Two of them presented to us before conception, were put on sclerotherapy for variceal bleed, and conceived while on sclerotherapy schedule. Two other patients were started on sclerotherapy during pregnancy when they presented with variceal bleed. Sclerotherapy with absolute alcohol was effective in control of variceal bleed as well as obliteration of varices in pregnant patients. There was no untoward effect on mother or fetus. The mean number of sessions and volume of alcohol required for variceal obliteration were 6.5 and 42.0 ml, respectively. Variceal sclerotherapy does not interfere with conception and successful pregnancy, and is safe as well as effective during pregnancy. [ABSTRACT FROM AUTHOR]

Infectious complications of endoscopic injection sclerothcrapy (EIS) are rare. We report here a case in which pyogenic meningitis and multiple cerebral abscesses developed after a session of EIS. The patient was successfully treated with a combination of parenteral antibiotics and repeated bedside pus aspirations. Prophylactic antibiotics may be considered in such situations for subsequent sessions of EIS. [ABSTRACT FROM AUTHOR]

Cholangioscopy-guided lithotripsy for difficult bile duct stone clearance in a single session of ERCP: results from a large multinational registry demonstrate high success rates. b Endoscopy, DOI 10.1055/a-0942-9336 In the above-mentioned article, the sentence on page 5 has been corrected to: The rate of stone clearance in the first procedure using laser lithotripsy was 82 % (96/117) vs. using EHL 74 % (29/39) ( I P i = 0.35). This was corrected in the online version on August 21, 2019. [Extracted from the article]

Small intestine, hitherto an obscure area for endoscopists before 2000, is now easily evaluated non-invasively using capsule endoscopy and invasively by device-assisted enteroscopies. Major advances in understanding the causes and management of small bowel diseases have been in obscure gastrointestinal (GI) bleed, currently re-named as small bowel bleed, after the discovery of capsule endoscopy. The current article is a narrative review of the technology of capsule endoscopy, its advantages and limitations, future perspective and Indian studies on its utility in patients with small bowel bleed. Till date, eight large series reporting 2319 patients with obscure GI bleed (1554 overt and 765 occult) undergoing capsule endoscopy have been reported from India. Overall yield of capsule endoscopy to detect lesions in these studies varied from 43.5% to 90%. The major causes detected in various studies for small bowel bleed include vascular malformation, portal hypertensive enteropathy, ulcer, stricture, tumor, polyps, etc. Hookworm can cause both occult as well as overt small bowel bleed as shown mainly from India. Capsule endoscopy has also been quite safe in patients with small bowel bleed as despite 0.6% to 15% retention of imaging capsule in Indian studies, development of clinically evident small bowel obstruction has rarely been reported. The major limitations of capsule endoscopy include lack of maneuvrability and therapeutic capability. Research is in progress to overcome some of the limitations of the current capsule endoscopy system. It is concluded that discovery of capsule endoscopy has brought a new paradigm in GI endoscopy and explored a hitherto unexplored area of GI tract, i.e. small bowel that continued to be a black box for the endoscopists., (© 2024. Indian Society of Gastroenterology.)

Background and Aims: A robust model of post-ERCP pancreatitis (PEP) risk is not currently available. We aimed to develop a machine learning-based tool for PEP risk prediction to aid in clinical decision making related to periprocedural prophylaxis selection and postprocedural monitoring., Methods: Feature selection, model training, and validation were performed using patient-level data from 12 randomized controlled trials. A gradient-boosted machine (GBM) model was trained to estimate PEP risk, and the performance of the resulting model was evaluated using the area under the receiver operating curve (AUC) with 5-fold cross-validation. A web-based clinical decision-making tool was created, and a prospective pilot study was performed using data from ERCPs performed at the Johns Hopkins Hospital over a 1-month period., Results: A total of 7389 patients were included in the GBM with an 8.6% rate of PEP. The model was trained on 20 PEP risk factors and 5 prophylactic interventions (rectal nonsteroidal anti-inflammatory drugs [NSAIDs], aggressive hydration, combined rectal NSAIDs and aggressive hydration, pancreatic duct stenting, and combined rectal NSAIDs and pancreatic duct stenting). The resulting GBM model had an AUC of 0.70 (65% specificity, 65% sensitivity, 95% negative predictive value, and 15% positive predictive value). A total of 135 patients were included in the prospective pilot study, resulting in an AUC of 0.74., Conclusions: This study demonstrates the feasibility and utility of a novel machine learning-based PEP risk estimation tool with high negative predictive value to aid in prophylaxis selection and identify patients at low risk who may not require extended postprocedure monitoring., Competing Interests: Disclosure The following authors disclosed financial relationships: A. Kuo: Equity holder in Apollo Endosurgery and patent applications for intellectual property related to cancer early detection. S. S. Mok: Consultant for Sovereign Laboratories, ConMed, and Medtronic-Covidien Corporation. M. A. Khashab: Advisory board member and consultant for Boston Scientific. E. J. M. van Geenen: Grants from Mylan and Olympus and personal fees outside the submitted work from MTW-Endoskopie. V. K. Singh: Grant support and personal fees outside the submitted work from AbbVie; advisory board participant for Ariel Precision Medicine, and Envara; grants from Orgenesis and Theraly; and advisory board participant for and stock options from Kyttaro. C. Tomasetti: Scientific advisory board member for PrognomiQ, Inc; royalty distributions from Exact Sciences (under a license agreement between Exact Sciences Corp and the Johns Hopkins University, C. Tomasetti and the university are entitled to royalty distributions); paid consultant for Bayer A; and patent applications for intellectual property related to cancer early detection (these arrangements have been reviewed and approved by the Johns Hopkins University in accordance with its conflict-of-interest policies). V. S. Akshintala: Cofounder and chief medical officer for Origin Endoscopy and Solv Endotherapy and consultant for Dragonfly Endoscopy and Olympus. All other authors disclosed no financial relationships. C. Tomasetti received funding from the John Templeton Foundation., (Copyright © 2024 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.)

BACKGROUND AND OBJECTIVES: Persistent gastrointestinal (GI) symptoms and functional gastrointestinal disorders (FGIDs) are increasingly being recognized after Coronavirus disease-19 (COVID-19). Though quite a few studies addressed irritable bowel syndrome (IBS) following COVID-19, the disorders' prevalence varies greatly. We evaluated, (i) overall frequency of post-COVID-19 IBS, (ii) relative risk of development of IBS among COVID-19 patients compared to healthy controls using systematic review and meta-analysis techniques., Methods: Literature search was performed for studies on GI symptoms and FGIDs after COVID-19 using electronic databases (Medline, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar and Web of Science) till April 28, 2023. We included studies reporting IBS after COVID-19 with any duration of follow-up and any number of subjects. Studies on pediatric population and those not providing relevant information were excluded. Relative risk of development of IBS using Rome criteria among COVID-19 patients compared to healthy controls was calculated. Analysis was done using MedCalc (Applied Math, Mariakerke, Belgium, version 7.2) and Comprehensive Meta-Analysis version 3.3.070 (Biostat Inc. Englewood, NJ 07631, USA)., Results: Of the available studies, 13 (four case-control) reporting on IBS after COVID-19 met inclusion criteria. Among 3950 COVID-19 patients and 991 controls, 7.2% of COVID-19 patients and 4.9% of healthy controls developed IBS. Of the four case-control studies reporting post-COVID-19 IBS, patients with COVID-19 were 2.65 (95% confidence interval [CI] 0.538 to 13.039) times more likely to have post-COVID-19 IBS as compared to healthy controls., Conclusions: Patients with COVID-19 are more likely to develop post-COVID-19 IBS than healthy controls. The heterogeneity of studies, different criteria used by various studies to diagnose post-COVID-19 IBS and some studies not meeting the six-month follow-up duration of the Rome criteria for diagnosing IBS are limitations of this systematic review., (© 2024. Indian Society of Gastroenterology.)

Background and Objectives: Hepatitis A virus (HAV)-related hepatitis is witnessing an epidemiological transition with increasing trends in adults. While uncomplicated hepatitis remains common, evidence suggests it to be a growing cause for acute liver failure (ALF). In between the two extremes exists severe acute liver injury (s-ALI) which has a propensity to transition to ALF. We aimed at describing the clinical profile of patients with HAV-related s-ALI and identifying potential predictors of progression to ALF., Methods: This was a single-center retrospective analysis of adult patients admitted with HAV-related s-ALI between April 2022 and December 2023. Demographic and laboratory parameters were compared between patients with only s-ALI and those with ALF. Predictors of progression from s-ALI to ALF were identified using logistic regression., Results: Forty-three patients satisfied criteria of s-ALI, of which 33 (76.7%) had only s-ALI, while 10 (23.3%) had ALF. Patients with s-ALI had lesser leukocytosis (6.3 ± 3 vs. 13.2 ± 4.8), less incidence of acute kidney injury (9.1% vs. 40%) and lower model for end-stage liver disease (MELD) (20 [18-24.5] vs. 31.5 [26-42]), arterial lactate (2.1 [1.3-3.1] vs. 6.3 [5.2-8.0]), arterial ammonia (94 [72-118] vs. 299 [188-573]), procalcitonin (0.5 [0.28-1.25] vs. 3.2 [1.2-6.1]) and ferritin (482 [213-1633] vs. 5186 [1341-11,053]) compared to HAV-ALF (p < 0.05 for all). Three patients (9.09%) with s-ALI progressed to ALF of whom one (3%) died. Baseline ammonia levels (unadjusted odds ratio [OR] 1.03 [1.01-1.06]) and leukocyte count (OR 1.00 [1.00-1.01]) tended to be associated with ALF progression, although none was significant after multi-variable adjustment. Ammonia levels had an area under receiver operating curve of 0.816 (0.64-0.93) (p = 0.009) (cut-off of 144 μmol/L). Additional comorbidities did not impact overall outcomes., Conclusion: HAV presents as s-ALI in young adults, with almost one in 10 progressing to ALF. Baseline ammonia may be an important predictor of progression even in s-ALI, but mandates larger well-designed studies., (© 2024. Indian Society of Gastroenterology.)

Background and Aims: Fluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial., Methods: Twelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard., Results: Fully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient., Conclusions: In patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340)., Competing Interests: The authors disclose the following:Wiriyaporn Ridtitid: Research support from Boston Scientific CorporationRungsun Rerknimitr: Research support from Boston Scientific CorporationMohan Ramchandani: No disclosuresSundeep Lakhtakia: No disclosuresRaj J Shah: Consultant for Boston Scientific Corporation and OlympusJanak N Shah: Research support from Boston Scientific CorporationNirav Thosani: Consultant for Boston Scientific Corp, Pentax America, Ambu Inc; Speaker for Abbvie; Royalty from UpToDate; Creatorship Rights for ROSEAid IncMahesh K Goenka: no disclosuresGuido Costamagna: Research grants from Cook Medical and Boston Scientific, Advisory Board Grant from OlympusMihir S Wagh: Consultant for Boston Scientific, Olympus, Medtronic, Fujifilm, ConMed and Incyte; Research support from SterisVincenzo Perri: No financial relationships with a commercial entity producing health‐care‐related products and/or services relevant to this article.Joyce Peetermans: Full‐time employee of Boston Scientific CorporationPooja G Goswamy: Full‐time employee of Boston Scientific CorporationZoe Liu: Full‐time employee of Boston Scientific Corporation at the time of this studySrey Yin: Full‐time employee of Boston Scientific Corporation at the time of this studySubhas Banerjee: Boston Scientific: Consultant and research support; Ambys Medicines: consultant, (© 2023 The Authors. DEN Open published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

The presence of anaemia has been linked to increased complications and a worse prognosis in cirrhosis. Spur cell anaemia (SCA) is a specific form of haemolytic anaemia reported in patients with advanced cirrhosis. The literature on the entity has not been systematically reviewed, despite the classical association and frequent association with worse outcomes. We undertook a narrative review of available literature on SCA which yielded only 4 were original studies, one case series and the rest of the literature as case reports and clinical images. SCA is usually defined by the presence of spur cell rate of ≥5%, although there remains a lack of consensus in the definition. SCA has been classically associated with alcohol-related cirrhosis but can be seen across the spectrum of cirrhosis and acute to chronic liver failure. Patients with SCA tend to have evidence of higher grades of liver dysfunction, abnormal lipid profiles, worse prognostic scores and a high mortality. Experimental therapies including corticosteroids, pentoxifylline, flunarizine and plasmapheresis has been tried with variable effect, but liver transplantation remains the management of choice. We propose a stepwise approach to diagnosis and re-enforce the need for further prospective research, especially in subgroups of advanced cirrhosis like acute to chronic liver failure., (© 2022 Indian National Association for Study of the Liver. Published by Elsevier B.V.)

Objectives: Psoas muscle parameters have been proposed as a simple and quick method for sarcopenia assessment. The aim of this study was to assess sarcopenia in cirrhotics by psoas muscle on computed tomography and its impact on mortality., Methods: One hundred and fifty patients (75 cirrhotics, 75 subjects) were assessed for psoas muscle on CT scan. Psoas muscle index (PMI) was calculated as 'total psoas muscle area/(height of subject) 2 '. Cut off values for sarcopenia diagnosis were derived from local subjects (n = 75) who did not have cirrhosis/other causes of sarcopenia., Results: Sarcopenia assessed by PMI was seen in 36% (n = 27) of the cirrhotics. Sarcopenia was significantly higher in patients having Child-Pugh C. Ascites, hepatic encephalopathy (HE) and gastro-intestinal bleed were seen in 48%, 18.7% and 24%, respectively. Sarcopenia was significantly associated with ascites and HE ( P  < 0.05). Out of the 75 cases, 53 cases completed the follow-up period of 1 year. Among the 20 cases who had sarcopenia, 35% (n = 7) succumbed to liver-related illness during 1 year follow-up, and out of the 33 cases without sarcopenia, only 6% (n = 2) died. The association of sarcopenia and 1 year mortality was statistically significant ( P  = 0.01)., Conclusions: The PMI, a simple method for sarcopenia assessment detected sarcopenia in 36% of cirrhotics. Patients with sarcopenia had a significantly higher 1 year mortality rate and appropriate prognostication of such patients is needed., (© 2022 Indian National Association for Study of the Liver. Published by Elsevier B.V.)

Background: Acute pancreatitis remains the most common and morbid complication of endoscopic retrograde cholangiopancreatography (ERCP). The use of rectal indomethacin and pancreatic duct stenting has been shown to reduce the incidence and severity of post-ERCP pancreatitis (PEP), but these interventions have limitations. Recent clinical and translational evidence suggests a role for calcineurin inhibitors in the prevention of pancreatitis, with multiple retrospective case series showing a reduction in PEP rates in tacrolimus users., Methods: The INTRO trial is a multicenter, international, randomized, double-blinded, controlled trial. A total of 4,874 patients undergoing ERCP will be randomized to receive either oral tacrolimus (5 mg) or oral placebo 1-2 h before ERCP, and followed for 30 days post-procedure. Blood and pancreatic aspirate samples will also be collected in a subset of patients to quantify tacrolimus levels. The primary outcome of the study is the incidence of PEP. Secondary endpoints include the severity of PEP, ERCP-related complications, adverse drug events, length of hospital stay, cost-effectiveness, and the pharmacokinetics, pharmacodynamics, and pharmacogenomics of tacrolimus immune modulation in the pancreas., Conclusions: The INTRO trial will assess the role of calcineurin inhibitors in PEP prophylaxis and develop a foundation for the clinical optimization of this therapeutic strategy from a pharmacologic and economic standpoint. With this clinical trial, we hope to demonstrate a novel approach to PEP prophylaxis using a widely available and well-characterized class of drugs., Trial Registration: NCT05252754, registered on February 14, 2022., Competing Interests: Declaration of competing interest Mouen Khashab reports advisory board member and consultant for Boston Scientific. Erwin J.M. van Geenen reports grants from Mylan and Olympus, personal fees from MTW-Endoskopie, outside the submitted work. Vikesh Singh reports personal fees from Abbvie, advisory board participant for Cook Medical, and grants from Orgenesis and Theraly. Venkata Akshintala is co-founder and chief medical officer of Origin Endoscopy Inc. All other authors declare no competing interests., (Copyright © 2022 IAP and EPC. Published by Elsevier B.V. All rights reserved.)

Background & Aims: The aims of this study were to: (1) assess the performance of the Pancreatitis Activity Scoring System (PASS) in a large intercontinental cohort of patients with acute pancreatitis (AP); and (2) investigate whether a modified PASS (mPASS) yields a similar predictive accuracy and produces distinct early trajectories between severity subgroups., Methods: Data was prospectively collected through the Acute Pancreatitis Patient Registry to Examine Novel Therapies In Clinical Experience (APPRENTICE) consortium (2015-2018) involving 22 centers from 4 continents. AP severity was categorized per the revised Atlanta classification. PASS trajectories were compared between the three severity groups using the generalized estimating equations model. Four mPASS models were generated by modifying the morphine equivalent dose (MED), and their trajectories were compared., Results: A total of 1393 subjects were enrolled (median age, 49 years; 51% males). The study cohort included 950 mild (68.2%), 315 (22.6%) moderately severe, and 128 (9.2%) severe AP. Mild cases had the lowest PASS at each study time point (all P < .001). A subset of patients with outlier admission PASS values was identified. In the outlier group, 70% of the PASS variation was attributed to the MED, and 66% of these patients were from the United States centers. Among the 4 modified models, the mPASS-1 (excluding MED from PASS) demonstrated high performance in predicting severe AP with an area under the receiver operating characteristic curve of 0.88 (vs area under the receiver operating characteristic of 0.83 in conventional PASS) and produced distinct trajectories with distinct slopes between severity subgroups (all P < .001)., Conclusion: We propose a modified model by removing the MED component, which is easier to calculate, predicts accurately severe AP, and maintains significantly distinct early trajectories., (Copyright © 2022 AGA Institute. Published by Elsevier Inc. All rights reserved.)

Context: Spontaneous rupture of the bile duct, although rare, has been described as a known surgical cause of jaundice in infancy after biliary atresia., Case Report: This article describes a four-year-old girl who presented with severe abdominal pain and features suggestive of acute pancreatitis, who developed gradual distension of the abdomen, and was found to have a ruptured bile duct, producing biliary peritonitis. She was managed with laparoscopic drainage of the peritoneal cavity. However, in view of the persistent biliary drainage, an ERCP was performed followed by stent placement for a bile duct leak. She was subsequently diagnosed as having a choledochal cyst., Conclusion: A high index of suspicion, appropriate investigation, such as MRCP, combined with early drainage can help in reaching an early diagnosis, and reduced morbidity and mortality in this rare disorder.