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Conventional percutaneous endoscopic gastrostomy (PEG) in patients with upper aerodigestive malignancies inevitably carries a risk of stomal metastasis that could be avoided by the direct insertion of the gastrostomy tube through the abdomen. This study compared the efficacy and safety between surgical gastrostomy (SG) and Introducer PEG in patients with upper aerodigestive malignancies.We retrospectively reviewed patients with upper aerodigestive malignancies undergoing SG or Introducer PEG. Procedure data, postprocedural clinical outcomes and 30-day mortality were assessed.In total, 99 patients were feasible to analysis: 53 were in the SG group, and 46 were in the Introducer PEG group. The SG group had a higher incidence of (in-hospital) major complications [28.3% VS 4.3%, p = 0.002], a longer procedure duration [52.02 ± 21.30 VS 21.46 ± 8.22 min, p 0.001], higher pain scores at 24 h [median (interquartile range, IQR); 5(3-8) VS 1(0-5), p 0.001] and longer length of hospitalization (LOH) [median (IQR); 5(4-6) days VS 3(2-4) days, p 0.001)]. In-hospital (3.8% VS 0%, p = 0.493) and 30-day mortality (17.0% VS 13.0%, p = 0.586) were not different between the two groups. In univariate analysis, high BMI, anemia (hemoglobin 11 g/dL), normal nutritional status (serum albumin 3 g/dL) and procedural type were found to be predicting factors for complications. Procedural type (Introducer PEG) was an independent factor for major complications in multivariate analysis [OR = 0.12, 95% CI 0.02-0.61, p= 0.011].In patients with upper aerodigestive malignancies, Introducer PEG was associated with lower rate of (in-hospital) major complications, faster operative time, lower pain scores and shorter LOH.TCTR20181220004.

Background: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fineneedle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. Thus, we aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size (22 gauge), respectively, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). Methods: All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single center university hospital were retrospectively reviewed. The procedure was performed without an onsite cytologist. After macroscopic onsite evaluation (MOSE), the endoscopist finished the procedure. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. Results: A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, gender, mass location, tumour size and disease stage from imaging were not significantly different. The diagnostic performance was dramatically higher in EUS-FNB (100%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was less in FNB (34.7 minutes) than in FNA (41 minutes). The adverse event rate between FNB and FNA was not significantly different. Conclusions: The diagnostic performance for solid pancreatic mass without ROSE was significantly higher in FNB than in FNA. The number of needle passes and the total procedure time was also lesser in FNB.

Background Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine-needle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. We aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size 22-gauge needle, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). Methods All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single-centre university hospital were retrospectively reviewed. All procedures were performed without an onsite cytologist. Before the endoscopist finished the procedure, macroscopic onsite evaluation (MOSE) was confirmed. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. Results A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, sex, mass location, tumour size and disease stage from imaging were not significantly different between the two groups. The diagnostic performance was higher in EUS-FNB (94.6%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in FNB (34.7 min) than in FNA (41 min). The adverse event rate between FNB and FNA was not significantly different. Conclusions The diagnostic yield of solid pancreatic mass was higher in FNB using the Franseen needle than in FNA using the conventional FNA needle in a centre where ROSE is unavailable, without serious adverse event. In addition, FNB had fewer needle passes and shorter total procedure time.

Near-focus versus Normal-focus Narrow Band Imaging Colonoscopy in Diagnosis of Colorectal Polyps based on Combined NICE and WASP Classification in routine colonoscopy: a Randomized Controlled TrialNisa Netinatsunton1, Natcha Cheewasereechon1Tanawat Pattarapuntakul1, Jaksin Sottisuporn1, Kanet Kanjanapradit2, Bancha Ovartlarnporn1Background: NICE (NBI International Colorectal Endoscopic) and WASP (Workgroup on Serrated Polyps and Polyposis) classification were developed for optical diagnosis of adenoma and sessile serrated polyps, respectively. Near focus NBI with NICE combined with WASP criteria for optical diagnosis of colonic polyps has not been assessed formerly. Aims: To compare the accuracy of near focus NBI (group A) with normal focus NBI (group B) in real time optical diagnosis of colorectal polyps using combined NICE and WASP criteria.Methods: 118 out of 362 patients with 227 polyps were recruited. 62 patients with 130 polyps (3 lost polyps) were assigned to group A and 56 patients with 106 polyps (6 lost polyps) were assigned to group B. Optical diagnoses were compared with pathological reports.Results: The performance of optical diagnosis of neoplastic polyps in group A compared with group B in terms of accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) was not significantly difference (76%, 72%, 81%, 86%, 64%, in group A, and 71%, 66%, 83%, 90%, 51%, in group B, respectively). Combined NICE and WASP criteria provided all false positive diagnosis of sessile polyps as serrated polyps in 31 (15.9%).Conclusions: Near-focus NBI was not superior to normal-focus NBI in in optical diagnostic of neoplastic polyps using NICE criteria. Combined NICE and WASP classification yielded all false positive in the diagnosis SSAPs in our study. Routine real life optical diagnosis of polyps is still not recommended.Trial registration: Clinical Trials.gov, NCT 04831814, was retrospectively registered on 04/01/2021.

Biliary fascioliasis is a rare infection of the hepatobiliary system. In human, it is known to present with two main phases; acute phase (hepatic phase) presenting with abdominal pain or abnormal liver biochemistry then chronic phase (biliary phase) presenting with biliary obstruction or cholangitis. Optimal treatment of biliary fascioliasis consists of endoscopic retrograde cholangiography with removal of the parasite and single oral dose of triclabendazole. We report a rare case of biliary fascioliasis in chronic calcified pancreatitis who presented with ascending cholangitis and biliary stricture. A 63-years-old Thai man was referred to our hospital for treatment of clinical symptoms severe cholangitis. Magnetic resonance cholangiopancreatography showed evidence of distal common bile duct stricture associated with chronic calcific pancreatitis. ERCP was performed, that found a few amorphous filling defects in the common bile duct and distal biliary stricture. After removal of the foreign body of what seems to be a fluke parasite followed with single oral dose triclabendazole thereafter, the clinical symptom was improved dramatically.

Background and Aims ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal. Methods A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed. Results After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups. Conclusions EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients. (Clinical trial registration number: NCT02870686.)

Endoscopic biliary drainage (EBD) is the mainstay treatment for inoperable malignant distal biliary obstruction (MDBO). Some authorities suggest that metallic stents are more cost-effective than plastic stents in patients with expected survival of at least 6 months. However, studies attempting to define the predictive factors for such survival times are limited. This study aims to develop a scoring system for predicting a survival time of

Background and Objectives: Endoscopic ultrasound (EUS) achieves results comparable to endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis of common bile duct (CBD) stone, but studies from the western have shown EUS to be less expensive in patients with intermediate risk for CBD stones. The aim of this study was to compare the costs of EUS and ERCP in the diagnosis of CBD stones in a developing country. Materials and Methods: A prospective study was done with 141 patients with suspected CBD stones, categorized as having high or intermediate risk for CBD stone. All underwent EUS, and the high-risk patients had ERCP after the EUS. For intermediate-risk patients, an ERCP was done at the discretion of the attending physician. The CBD stone was confirmed by ERCP in patients who underwent both EUS and ERCP. Patients who received EUS only were followed up every 3 months for 1 year. The false negative rate in patients with EUS and ERCP was estimated in the clinical follow-up. Result: One hundred and forty-one patients (141: 83 females, 58 males) with a mean age ± standard deviation (SD) of 55.71 ±18.68 years were recruited. Ninety-four (94) patients underwent both EUS and ERCP. ERCP confirmed the diagnosis in 83 of 85 patients (97.6%) with CBD stone detected by EUS. Forty-seven (47) patients with a negative EUS and no ERCP done were symptom-free during the follow-up. The overall sensitivity, specificity, positive predictive value, and negative predictive value of EUS were 97.6%, 80%, 97.6%, and 80% respectively. An EUS-based strategy for high-risk patients was 15% more expensive than an ERCP-based strategy, but the EUS-based strategy reduced the cost to 37.78% less than the ERCP-based strategy in intermediate-risk patients. The EUS-based strategy was cost-saving when the CBD stone prevalence was less than 52.5%. Conclusion: EUS is safer and less costly than ERCP for CBD stone diagnosis in patients with intermediate risk.

Background: Anxiety is common in patients undergoing endoscopy. Pre-endoscopy education may decrease the level of anxiety. Limited data on the use of educational video media in decreasing anxiety among upper endoscopy (EGD) patients are available. Aims: To compare the efficacy of a paper handout with that of video media in reducing patient anxiety in EGD Methods: A prospective randomized study from February 2010 to February 2012 was conducted. The patients were randomized into either the paper handout group (Group A) or the paper handout with video media one (Group B), and completed a validated Thai version of the State-Trait Anxiety Inventory (STAI) questionnaire assessing their state anxiety (SA) and trait anxiety at baseline and after education. Results. Ninety-one patients were recruited – 50 were in group A and 41 in group B. In Group A, SA was high in 3 participants and moderate in the other 47 at baseline, and high among 28 and moderate in the remaining 22 post education (p = 0.00). In Group B, high-level SA was observed in 4 patients and medium-level in the other 37 at baseline, and high in 13 and medium in 28 post education(p = 0.012). The baseline SAs between the two groups were not statistically different (p = 0.69). The post-education SA was lower in Group B than Group A (p = 0.02). The mean SA score + SD at baseline was 21.04 + 5.89 in Group A and 20.49 + 5.31 in Group B (p = 0.64). The mean SA score + SD after education in Group A was 22.38 + 5.82 and in Group B was 19.71 + 5.03 (p = 0.021). Conclusion: Education increased SA, and the video media reduced SA more than the paper handout.

To date, there have been no studies to evaluate the influence of posture on anorectal manometric measurements in patients with functional constipation. The present study aimed to compare differences in anorectal manometric measurements in constipated patients when performing the test in the lying and sitting positions.Anorectal manometry with a conventional solid state manometric catheter was performed in 30 constipated patients in both the lying and sitting positions. Anorectal manometric variables at rest and during attempted defecation with empty rectum were assessed in both positions. A colonic transit study using Sitzmarks radiopaque markers and a 50-mL water-filled balloon expulsion test was also performed in all patients. Patients exhibiting an abnormal manometric pattern of defecation in either the sitting or lying position proceeded to a simulated defecation test. The anorectal pressure parameters of resting and during attempted defecation of the both positions were compared.The resting rectal pressure, maximum rectal straining pressure, and defecation index during attempted defecation were significantly higher in the sitting position than the lying position. A dyssynergic manometric pattern during attempted defecation with empty rectum was seen in 46% of the patients in the lying position, not significantly different from the 56% in the seated position (p = 0.58). Most patients (71%) who exhibited manometric dyssynergia with an empty rectum could relax their anal sphincter during the simulated defecation test. Only six (20%) constipated patients had abnormal dyssynergic anal sphincter contraction confirmed by a simulated defecation test.Body position affects the results of manometric measurements related to the defecation mechanism.

Background/Aims To report gastric emptying scintigraphy, normal values should be established for a specific protocol. The aim of this study was to provide normal gastric emptying values and determine factors affecting gastric emptying using Asian rice-based meal in healthy volunteers. Methods One hundred and ninety-two healthy volunteers were included at 7 tertiary care centers across Thailand. Gastric emptying scintigraphy was acquired in 45 degree left anterior oblique view immediately after ingestion of a 267 kcal steamed-rice with technetium-99m labeled-microwaved egg meal with 100 mL water for up to 4 hours. Results One hundred and eighty-nine volunteers (99 females, age 43 ± 14 years) completed the study. The medians (5–95th percentiles) of lag time, gastric emptying half time (GE T1/2) and percent gastric retentions at 2 and 4 hours for all volunteers were 18.6 (0.5–39.1) minutes, 68.7 (45.1–107.8) minutes, 16.3% (2.7–49.8%) and 1.1% (0.2–8.8%), respectively. Female volunteers had significantly slower gastric emptying compared to male (GE T1/2, 74 [48–115] minutes vs. 63 (41–96) minutes; P < 0.05). Female volunteers who were in luteal phase of menstrual cycle had significantly slower gastric emptying compared to those in follicular phase or menopausal status (GE T1/2, 85 [66–102] mintes vs. 69 [50–120] minutes or 72 [47–109] minutes, P < 0.05). All of smoking volunteers were male. Smoker male volunteers had significantly faster gastric emptying compared to non-smoker males (GE T1/2, 56 [44–80] minutes vs. 67 [44–100] minutes, P < 0.05). Age, body mass index and alcohol consumption habits did not affect gastric emptying values. Conclusions A steamed-rice with microwaved egg meal was well tolerated by healthy volunteers. Gender, menstrual status and smoking status were found to affect solid gastric emptying.

Background The association of minimal change esophagitis (MCE) with GERD is controversial. i-Scan endoscopy (SE) provides high resolution and modulation of images that may improve minimal change lesion (MCL) detection. We aimed to assess the efficacy of SE in detecting MCL in dyspeptic patients with GERD compared with patients without GERD by GerdQ or by endoscopy with 24-h pH monitoring (PHM) and in normal volunteers. Methods This is a cohort study conducted at a tertiary center. All dyspeptic patients were prospectively recruited. All patients completed a validated Thai version of GerdQ and then underwent endoscopy. Forty normal volunteers as a control group were recruited for endoscopy. The distal esophagus was examined by high definition endoscopy and SE sequentially. All had PHM done. GERD was diagnosed by Los Angeles classification A-D and/or by a positive PHM. MCE was diagnosed when MCL or combination of MCL was present. Results Of 174 patients, 144 completed the study protocol. After the exclusion of 6 patients, 138 remained for analysis. Overlapping GERD symptoms were found in 44.2 % and 26.8 % had confirmed GERD. Group A was comprised of 61 patients with a positive GerdQ and 77 patients in group B had a negative GerdQ. Twenty-four in group A, 28 in group B and 7 in the control group had MCE that was not significantly different. MCE in GERD was significantly higher (51.45 %) than in non-GERD (32.7 %) (p = 0.047) and in the control group (20.58 %) (p = 0.007). The sensitivity, specificity, positive predictive value, and negative predictive value of SE were 51.35 %, 67.33 %, 36.54 % and 79.06 %, respectively. Conclusion In dyspeptic patients, SE detected more MCE in GERD than in non-GERD patients and in the control group. Trial registration ClinicalTrials.gov number NCT01742377

Background and Aim. EUS-guided intervention (EGI) for biliary therapy has been increasingly used in recent years. This report aims to describe the spectrum and experience of EUS-guided interventions in biliary diseases in a single-tertiary center. Methods. All patients with EGI were analyzed retrospectively by retrieving data from a prospectively stored endoscopic database between January 2006 and September 2010. Results. There were 31 cases with EGIs (17 female, 14 male) with a mean age ± SD of 58.03 ± 16.89 years. The majority of cases (17/31; 55%) were ampullary or pancreatic cancers with obstructive jaundice. The major indications for EGI were obstructive jaundice ( 𝑛 = 1 6 ) and cholangitis ( 𝑛 = 9 ). The EGIs were technically successful in 24 of the 31 cases (77%). The success rate for the first 3 years was 8 of 13 procedures (61.5%) as compared to that of the last 2 years (16/18 procedures (89%); 𝑃 = 0 . 0 7 2 ). Twenty-three of the 24 cases (96%) with technical success for stent placement also had clinical success in terms of symptom improvement. The complications were major in 4 (13%) and minor in 7 (23%) patients. Conclusion. The EUS-guided drainage for biliary obstruction, acute cholecystitis, bile leak, and biloma was an attractive alternative and should be handled in expert centers.

Background/Aims Symptom-based diagnosis for gastroesophageal reflux disease (GERD) has been accepted in the population with high prevalence. Carlsson-Dent questionnaire (CDQ) is a standardized symptom-based diagnosis tool for GERD. The value of this tool in the population with low prevalence is unknown. The aim of this study was to determine CDQ performance for diagnosis of GERD in Thai population with low prevalence versus endoscopy or 24 hour pH monitoring. Methods Patients with dyspepsia by Rome II criteria were recruited. All patients completed a Thai version of CDQ and underwent endoscopic examination. Those without esophagitis or peptic ulcer and positive CDQ score took pH monitoring. Results One hundred patients (68 female) with mean age ± SD of 45.6 ± 12.4 years were recruited. Six with Los Angeles grade A esophagitis had negative CDQ score. In 44 with positive CDQ score, 3 had Los Angeles grade B esophagitis and 41 had pH monitoring done with 8 having positive test. The GERD diagnosis by CDQ was confirmed in 11 of 44 patients (25%). CDQ detected 11 out of 17 GERD detected by endoscopy and pH monitoring and the sensitivity of CDQ was 64%. Conclusions CDQ diagnosed more GERD in Thai population with low prevalence compared with endoscopy and pH monitoring. This may be due to some patients with functional heartburn were picked up by CDQ and some patients with GERD were not detected by endoscopy and pH monitoring.

Unlike endoscopic retrograde cholangiopancreatography (ERCP) service, endoscopic ultrasonography (EUS) service in Thailand is at its elementary state. Currently, there are only 11 hospitals in Thailand carrying out EUS whereas there are more than 50 hospitals carrying out ERCP. This is a multicenter questionnaire survey that obtained information on EUS practice for pancreatic cysts. Of those 11 hospitals, only three hospitals provided enough number of patients with pancreatic cysts undergoing EUS. There were many differences in endosonographers opinions regarding specific information in the pancreatic cyst. In addition, the threshold to carry out and not to carry out fine needle aspiration are varies.

Objective Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery. Methods The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed. Results No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group ( p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication. Conclusion Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.

Aims: The aim of this work is to evaluate the role of liver biopsy and to determine the histological findings in patients infected with the human immunodeficiency virus (HIV) who have abnormal liver function tests (LFT). Methods: We performed a percutaneous liver biopsy in 46 HIV-seropositive patients with abnormal LFT. Parts of biopsied tissue were used for bacterial and fungal culture and the rest was processed for histological examination including special staining. Results: Of these 46 patients, 41 patients were males and five were females. The median age was 31 ± 6 years. Mycobacterium tuberculosis was the most common histological finding (15 cases). Of 15 tuberculosis patients, 11 (73.3%) had lymphadenopathy and positive acid-fast bacilli (AFB) in node aspiration or biopsy. The other findings included AFB-negative granuloma (eight cases), histoplasmosis (six cases), cryptococcosis (six cases), penicillosis (four cases), viral hepatitis: hepatitis C virus (HCV; one case), hepatitis B virus and HCV infection (one case), fatty liver (two cases), drug-induced hepatitis (one case) and non-specific changes (five cases). There were double infections in three patients. We were able to demonstrate opportunistic infections in 41 cases (89.3%). Conclusions: Mycobacterium tuberculosis was the most common histological finding in HIV patients with abnormal LFT in Thailand. Liver biopsy was a useful procedure in evaluating abnormal LFT in HIV patients.

Summary Liver involvement was retrospectively evaluated in 137 patients with murine typhus. Fifteen (10.9%) were jaundiced. One patient had been subjected to cholecystectomy after misdiagnosis of acute cholecystitis. Serum aminotransferase levels were abnormal in 48/52 measurements, and there were elevations of > 5-fold in 14 patients. Liver biopsies and/or necropsies from four jaundiced patients showed portal tract and sinusoidal infiltrates, cloudy swelling/and necrosis of the hepatocytes and occasional pseudogranuloma formation. There were striking mitoses even in the early stage, suggesting rapid hepatocellular regeneration. Haemolytic diseases (G6PD deficiency or haemoglobinopathies), alcoholism, and a second infection probably also contributed to the pathogenesis of jaundice in murine typhus. This rickettsiosis should be included among differential diagnoses of acute hepatitis in patients exposed to areas endemic for Rickettsia typhi.

Unlike endoscopic retrograde cholangiopancreatography (ERCP) service, endoscopic ultrasonography (EUS) service in Thailand is at its elementary state. Currently, there are only 11 hospitals in Thailand carrying out EUS whereas there are more than 50 hospitals carrying out ERCP. This is a multicenter questionnaire survey that obtained information on EUS practice for pancreatic cysts. Of those 11 hospitals, only three hospitals provided enough number of patients with pancreatic cysts undergoing EUS. There were many differences in endosonographers opinions regarding specific information in the pancreatic cyst. In addition, the threshold to carry out and not to carry out fine needle aspiration are varies.

AIM: To evaluate the efficacy of endoscopic ultrasound guided biliary drainage (EUS-BD) in patients with surgically altered anatomies. METHODS: We performed a search of the MEDLINE database for studies published between 2001 to July 2014 reporting on EUS-BD in patients with surgically altered anatomy using the terms “EUS drainage” and “altered anatomy”. All relevant articles were accessed in full text. A manual search of the reference lists of relevant retrieved articles was also performed. Only full-text English papers were included. Data regarding age, gender, diagnosis, method of EUS-BD and intervention, type of altered anatomy, technical success, clinical success, and complications were extracted and collected. Anatomic alterations were categorized as: group 1, Billroth I; group 2, Billroth II; group 4, Roux-en-Y with gastric bypass; and group 3, all other types. RESULTS: Twenty three articles identified in the literature search, three reports were from the same group with different numbers of cases. In total, 101 cases of EUS-BD in patients with altered anatomy were identified. Twenty-seven cases had no information and were excluded. Seventy four cases were included for analysis. Data of EUS-BD in patients categorized as group 1, 2 and 4 were limited with 2, 3 and 6 cases with EUS-BD done respectively. Thirty four cases with EUS-BD were reported in group 3. The pooled technical success, clinical success, and complication rates of all reports with available data were 89.18%, 91.07% and 17.5%, respectively. The results are similar to the reported outcomes of EUS-BD in general, however, with limited data of EUS-BD in patients with altered anatomy rendered it difficult to draw a firm conclusion. CONCLUSION: EUS-BD may be an option for patients with altered anatomy after a failed endoscopic-retrograde-cholangiography in centers with expertise in EUS-BD procedures in a research setting.

Dyspepsia is common in clinical practice with frequent relapses and often requires multiple investigations to assess intraluminal and extraluminal etiologies. Endoscopic ultrasound (EUS) has the potential of serving both purposes in a single setting.Patients with dyspepsia who underwent EUS in four-year period were retrospectively reviewed. Diagnostic findings of US, final diagnoses were noted and compared with the reference standards.131 patients with a mean age +/- SD of 50 +/- 12.7 years were included. The common diagnoses were non-ulcer dyspepsia in 56%, symptomatic gallstone (GS) in 22.9%. EUS detected two GS missed by transabdominal ultrasound (TUS). EUS missed one GS documented by surgery. EUS detected seven cases of ERCP-proven CBD stones undetected by TUS and had a sensitivity, specificity, positive predictive value and negative predictive value for CBD stones of 87.5%, 91.7%, 87.5%, and 91.7% respectively.EUS is a potential investigation for the management of dyspepsia.

The goal of this study was to evaluate the effect of preoperative education on patient satisfaction and cooperation during an endoscopic retrograde cholangiopancreatography (ERCP) procedure. Risk reduction was also studied in terms of decreased meperidine administration. Subjects were preoperatively educated by the endoscopy nurse regarding the ERCP procedure and how to communicate with the nurse during the procedure. Forty-five patients with a mean age of 58 years participated in the study. Effective patient cooperation was achieved. All subjects were satisfied with the educational process and the ERCP team. These findings suggest preoperative education is a cost-effective intervention in enhance patient cooperation and patient satisfaction for patients undergoing ERCP.

On each line: pCLE image representative of a query video (framed image on the left), followed by 3 pCLE images representative of the 3 atlas videos which have been automatically recognized by the Smart Atlas software as the most visually similar to the query video. Each pCLE video is annotated with final diagnosis. Su1663 An Open-Labeled, Randomized Controlled Trial Comparing Between Short Duration and Standard 14 Days Antibiotic Treatments for Acute Cholangitis in Patients With Common Bile Duct Stone After Successful Endoscopic Biliary Drainage. a Preliminary Report Duangswang Limmathurotsakul*, Nisa Netinatsunton, Siriboon Attasaranya, Bancha Ovartlarnporn Medicine, Faculty of Medicine, Prince of Songkla university, Division of gastroenterology, Hatyai, Thailand; NKC institute of Gastroenterology and Hepatology, Hatyai, Thailand Background: Acute cholangitis is generally treated with endoscopic biliary drainage (EBD) and systemic antibiotics. The traditional duration of antibiotic treatment varied from 7-14 days after endoscopic biliary drainage. Data regarding short duration of antibiotic treatment after EBD are limited. Aims. To compare the efficacy and safety of short duration with standard fourteen days antibiotic treatment in patients with acute cholangitis due to common bile duct stone (CBDS) after successful endoscopic biliary drainage. Methods: A prospective randomized study of patients with mild to moderate acute cholangitis due to CBDS with symptoms duration! 48 hours were randomized at the time of ERCP to a short duration (group A) or standard fourteen days antibiotic treatment (group B) from February 2013 to November 2013. Ceftriaxone was used for antibiotic therapy. The endoscopic drainage by ERCP was done within 72 hours after admission. Endoscopic drainage was defined as complete when all the CBDSs were removed and as incomplete when some residual stones were present with stent insertion done. In the short duration treatment group, antibiotic was stopped when the patient was afebrile for 72 hours. The study protocol was approved by local Ethics Committee. Results: 14 patients with 6 female and 8 male and the mean age 70.2+16.2 years were recruited. 7 were in group A and 7 in group B. The demographic data, the abdominal pain intensity, LFT and number of CBDS were not significantly different between the 2 groups. The clinical response including duration of fever, abdominal pain, improvement of LFT, and the number of patient with incomplete drainage after treatment were similar between group A and B. The mean duration + SD of antibiotic treatment in group A was 5 +1.8 days with a range of 4-9 days. There were 3 patients with bacteremia in each group but none of patients in both groups developed recurrent cholangitis after 2 months of follow-up. Conclusions: Our preliminary data suggested that short duration antibiotic therapy for acute CBDS cholangitis after successful endoscopic biliary drainage was safe and effective as the standard fourteen days antibiotic treatment. Baseline characteristic data AB358 GASTROINTESTINAL E Group A (Treatment) NDOSCOPY Vo Group B (Control) lume 79, No. P Value Total patient 7 7 Sex (male/female), n 4/3 5/2 Age (y), mean (SD) 72.9(17.2) 67.6(16.2) 0.564 Abdominal pain score before ERCP (0-10), mean (SD) 9.29(1.89) 8.71(1.60) 0.554 5S : 2014 Group A (Treatment) Group B (Control)

Unlike fibrotic stricture dilation which requires liquid insufflation into the balloon, the dilation of biliary sphincter may be adequate by only air insufflation and air-insufflated 18 mm. BS may open the biliary orifice larger than that of a smaller balloon but retains the safety because of more controllable pressure by air. Objective: To evaluate the efficacy, the important parameters for requirement of adjunctive mechanical lithotripsy, and the safety of large balloon sphincteroplasty (18mm.) for difficult bile duct stone(s) clearance. Results: From 1 March 2006 to 31 October 2012, 72 patients (M 29, F 43), mean age 70.5 22.2 years, with large choledocholithiasis (17.6 0.8mm, range11-30mm.) underwent standard sphincterotomy, followed by an 18 mm-air-insufflated balloon sphincteroplasty for bile duct stone(s) extraction. All stones were removed within 1.14 0.4 ERCP sessions (one session in 63 patients, two sessions in 8 patients, and three sessions in one patient). Ductal clearance with only balloon extraction achieved in 51/72 patients (70.8%) whereas 21 patients required an adjunctive mechanical lithotripsy because of the significant larger size of stone(s) (15.9 5.2 vs.21.9 10.4 mm; p-value 0.01); OR 3.0 by multivariate analysis). Majority of stones smaller than 22 mm. did not require an adjunctive mechanical lithotripsy (78% vs. 22%, p 0.01, OR 5.6) Periampullary diverticulum, impact stone, distal bile duct stricture, and multiple stones were not demonstrated as factors for the requirement of an adjunctive mechanical lithotripsy, (Table 1). Immediate post sphincteroplasty bleeding occurred in 2 patients (2.8%) and only required a single dose of diluted adrenaline injection at the sphincterotomy site. There were 3 (4.2%) post ERCP pancreatitis and 3 post ERCP cholangitis (4.2%). All were managed conservatively without any requirement of intervention. No perforation occurred in any patient. Conclusion: Standard sphincterotomy followed by air-insufflated-18 mm balloon sphincteroplasty is an effective and safe method for large bile duct stone(s) clearance. By using this technique a stone larger than 22 mm. may require an adjunctive mechanical lithotripsy.

Interobserver and Intraobserver Variation in the Diagnosis of Minimal Change Esophagitis by High Definition and I-SCAN Upper Endoscopy Jaksin Sottisuporn*, Nisa Netinatsunton, Naichaya Chamroonkul, Teepawit Witeerungrot, Theeratus Jongboonyanuparp, Siriboon Attasaranya, Bancha Ovartlarnporn NKC institute of Gastroenterology and Hepatology, Hatyai, Thailand Background: Minimal changes esophagitis lesions (MCL) has been regarded as one of the spectrum of erosive esophagitis in some studies. The MCLs are subtle changes and are difficult to identify by conventional endoscopy. I-Scan endoscopy (SE) is a new imaging technology that enhances the mucosal details. Limited studies showed the SE to be better than white light endoscopy in detecting MCL. The intraobserver and interobserver variations of SE in detecting MCL have never been reported before. Aim: To assess the intraand interobserver variations in detecting MCL by high-definition endoscopy (HD) and SE in tone enhancement mode for esophagus (TE-e) in dyspeptic patients. Method: The endoscopic images in HD and TE-e modes of distal esophagus of all patients with upper abdominal symptoms scheduled for upper gastrointestinal endoscopy at the NKC institute from February 2010 till August 2011 were used to assess the consistency of images interpretation by 6 endoscopists. A set of images representing MCL that included punctate erythema (PE), blurred vessels (BV), minute erosion (ME) and triangular lesion with elongated pit (TLE) were used to educate all the endoscopists. 6 endoscopists randomly evaluated the endoscopic images of 89 patients in HD and TE-e mode twice with at least 24 hours interval in between. The intra and inter-observer consistency of images interpretation was analyzed. Result: Intraobserver kappa values (95% CI) for HD group were 0.44(0.24-0.65), 0.44(0.24-0.65), 0.410.2-0.62), 0.59(0.39-0.8), 0.45(0.24-0.65), 0.13(0.00-0.34) and for TE-e SE were 0.35(0.15-0.56), 0.56(0.360.77), 0.97(076-1.00), 0.51(0.31-0.71), 0.44 (0.61-0.27), 0.32(0.11-0.53) respectively. These represent fair to excellent agreement for intraobserver image interpretation in both HD and TE-e. One of the endoscopist had significant improvement in detecting MCL on the second image interpretation (kappa 0.13 versus 0.32 p 0.05). In the interobserver consistency of image interpretation, the pairwise kappa values for HD and TE-e of all 6 endoscopists were rather low (range 0.16-0.3 and 0.05-0.37 respectively). When the evaluations in both groups were analyzed by pairing individual endoscopist into 15 pairs, the kappa values improved with agreement in 7 of 15 pairs without statistical significance. (p 1) Conclusions: The intraobsever agreement for MCL by HD and i-Scan is fair to excellent. The poor interobserver agreement by HD and TE-e for MCL limits the value of the MCL in clinical practice. The SE imaging technology did not improve the interobserver image interpretation consistency.