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Introduction: Roux-en-Y gastric bypass (RYGB) surgery imposes anatomic barriers to endoscopic retrograde cholangiopancreatography (ERCP). Potential options for biliary access in these patients include laparoscopic-assisted ERCP or balloon enteroscopy. However, these approaches require specialized equipment and/or operating room personnel and are associated with high rates of failure and adverse events compared to conventional ERCP. A recently described technique, EDGE, is an endoscopic approach which involves accessing the excluded stomach to facilitate ERCP., Objective: The objective of this study is to describe the results of EDGE procedures performed in Canada., Methods: Data were collected from patient cases who had undergone an EDGE procedure across centers in Canada. All patients had a history of RYGB bariatric surgery. In each procedure, a 20-mm diameter lumen-apposing metal stent (LAMS) was deployed under EUS guidance to allow access from the gastric remnant/proximal jejunum to the excluded stomach. Subsequently, during a separate procedure, a duodenoscope was passed through the LAMS to perform ERCP. Following ERCP, the LAMS was replaced with a pigtail stent or APC was used to facilitate closure of the gastro-jejunal/gastro-gastric fistula., Results: The indication for EDGE in the seven included cases was for the treatment of choledocholithiasis (six) or gallstone pancreatitis (one). The technical success rate of the EDGE procedure in these cases was 100%. Clinical success, defined by normalization of bilirubin and symptomatic relief, was observed in all cases. There were no adverse events reported., Conclusion: The results of this series support EDGE as a safe and minimally invasive approach to biliary access and therapy in patients with previous RYGB surgery., (© The Author(s) 2021. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.)

Background: Underwater endoscopic mucosal resection without submucosal injection (UEMR) is an appealing therapy for large colorectal polyps. However, this technique is not practiced widely and there are limited data evaluating UEMR in community settings., Methods: The study comprised patients undergoing UEMR of large (≥20 mm) sessile colorectal lesions at a community-based center. Residual neoplasia was assessed via follow-up colonoscopy., Results: Among 264 lesions (diameter 38 ± 18 mm; range 20-110 mm) 99% were successfully resected with UEMR. Two lesions involving the cecum/IC valve required multiple sessions. There were no cases of perforation or post-polypectomy syndrome. Delayed bleeding occurred in 1.6%, all managed conservatively. Residual neoplasia was present in 5.7% and was amenable to UEMR., Conclusion: This large community-based series demonstrated high efficacy and safety of UEMR for large sessile colorectal lesions. The results support UEMR as first-line therapy for these lesions., Summary: Underwater endoscopic mucosal resection without submucosal injection (UEMR) is a recently developed method that has advantages over conventional EMR for treatment of large colorectal lesions. However, UEMR is not practiced widely and there are limited data evaluating this technique in everyday practice. This large community-based series demonstrated high efficacy and safety of UEMR for large sessile colorectal lesions., Competing Interests: Declaration of competing interest Manuscript title: Underwater endoscopic mucosal resection without submucosal injection (UEMR) for large polyps: A community-based series. The authors whose names are listed below certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this manuscript. There are no conflicts of interest to disclose. We confirm that this work has not been published elsewhere, nor is it currently under consideration for publication elsewhere., (Copyright © 2020. Published by Elsevier Inc.)

Background: Screening improves outcomes related to colorectal cancer (CRC); however, suboptimal participation for available screening tests limits the full benefits of screening. Non-invasive screening using a blood based assay may potentially help reach the unscreened population., Objective: To compare the performance of a new Septin9 DNA methylation based blood test with a fecal immunochemical test (FIT) for CRC screening., Design: In this trial, fecal and blood samples were obtained from enrolled patients. To compare test sensitivity for CRC, patients with screening identified colorectal cancer (n = 102) were enrolled and provided samples prior to surgery. To compare test specificity patients were enrolled prospectively (n = 199) and provided samples prior to bowel preparation for screening colonoscopy., Measurements: Plasma and fecal samples were analyzed using the Epi proColon and OC Fit-Check tests respectively., Results: For all samples, sensitivity for CRC detection was 73.3% (95% CI 63.9-80.9%) and 68.0% (95% CI 58.2-76.5%) for Septin9 and FIT, respectively. Specificity of the Epi proColon test was 81.5% (95% CI 75.5-86.3%) compared with 97.4% (95% CI 94.1-98.9%) for FIT. For paired samples, the sensitivity of the Epi proColon test (72.2% -95% CI 62.5-80.1%) was shown to be statistically non-inferior to FIT (68.0%-95% CI 58.2-76.5%). When test results for Epi proColon and FIT were combined, CRC detection was 88.7% at a specificity of 78.8%., Conclusions: At a sensitivity of 72%, the Epi proColon test is non- inferior to FIT for CRC detection, although at a lower specificity. With negative predictive values of 99.8%, both methods are identical in confirming the absence of CRC., Trial Registration: ClinicalTrials.gov NCT01580540.

Pancreatico-pleural fistula is an uncommon cause of recurrent pleural effusion. Delayed diagnosis may occur if fluid amylase level is not obtained early in the clinical course. As most cases of pancreatico-pleural effusion are due to chronic pancreatitis, endoscopic therapy may be effective if pancreatic fluid secretion can be diverted to a more physiologic pathway. However, when severe pancreatitis leads to disconnection of the pancreatic duct, it precludes conventional endoscopic treatment via transpapillary stenting of the pancreatic duct. We describe a patient with a chronic, refractory pancreatico-pleural fistula arising from chronic pancreatitis with a disconnected pancreatic duct syndrome, which resolved following endoscopic ultrasound-guided therapy.

Aim: To compare the quality and tolerance of esophagogastroduodenoscopy (EGD)-assisted and conventional split-dose polyethylene glycol electrolyte solution for inpatient colonoscopy., Methods: The study was a randomized controlled trial in hospitalized patients. Hospitalized patients undergoing colonoscopy the day following EGD for evaluation of gastrointestinal (GI) bleeding or other symptoms. Patients randomized to either EGD-assisted bowel prep [2 L polyethylene glycol (PEG) administered endoscopically into distal duodenum at time of EGD, plus 1 L PEG orally the following day] or conventional-PEG (2 L PEG orally the evening prior and 1 L PEG orally the following day). The main outcome measurements are bowel preparation quality and patient tolerance of bowel prep., Results: Forty-two patients randomized to EGD-assisted bowel prep and 40 patients to conventional-PEG. Overall mean ± SD preparation quality was superior for EGD-PEG (4.1 ± 2.8) vs conventional-PEG (6.5 ± 3.1; P = 0.0005). Seventy-four percent of patients rated EGD-PEG as easy or slightly difficult to tolerate compared to 46% for standard-PEG (P = 0.0133). Mean EGD-procedural time was greater for EGD-assisted subject (24 ± 10 min) compared to conventional-PEG prep subjects (15 ± 7 min; P < 0.0001). Conscious sedation requirements did not differ between groups. There were no significant prep-related adverse events in either group., Conclusion: In selected hospitalized patients, compared to a conventional split-dose regimen, use of EGD to administer the majority of PEG solution improves patient tolerance and quality of bowel preparation for colonoscopy.

Endoscopic retrograde cholangiopancreatography (ERCP) is the standard approach to gaining access to the biliary and pancreatic ductal systems. However, in a small subset of cases anatomic constraints imposed by disease states or abnormal anatomy preclude ductal access via conventional ERCP. With the advent of endoscopic ultrasonography (EUS), with its unique capabilities of accurate imaging and ductal access via transmural puncture, there is now an alternative to surgical and percutaneous radiologic approaches in situations inaccessible to ERCP: endosonographic cholangiopancreatography (ESCP). This article reviews the background, technical details, published experience, and role of ESCP in clinical practice., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Background & Aims: Screening colonoscopy can prevent cancer by removal of adenomatous polyps. Recent evidence suggests that insufficient time for inspection during overly rapid colonoscope withdrawal may compromise adenoma detection. We conducted a study of the effect of a minimum prespecified time for instrument withdrawal and careful inspection on adenoma detection rates during screening colonoscopy., Methods: Baseline data consisted of neoplasia detection rates during 2053 screening colonoscopies performed without a specified withdrawal protocol. During a subsequent 13-month period we performed 2325 screening colonoscopies using dedicated inspection techniques and a minimum 8-minute withdrawal time. With colonoscopists comprising the study population, we compared overall and individual rates of neoplasia detection in postintervention procedures with those in baseline examinations., Results: As compared with baseline subjects, postintervention subjects had higher rates of any neoplasia (34.7% vs 23.5%, P < .0001) and of advanced neoplastic lesions per patient screened (0.080 +/- 0.358 vs 0.055 +/- 0.241, P < .01). Twenty-five percent of advanced neoplastic lesions detected in postintervention examinations were 9 mm or less in diameter, versus 10% in baseline examinations (P < .001). Endoscopists with mean withdrawal times of 8 minutes or longer had higher rates of detection of any neoplasia (37.8% vs 23.3%, P < .0001) and of advanced neoplasia (6.6% vs 4.5%, P = .13) compared with those with mean withdrawal times of less than 8 minutes., Conclusions: After implementing a protocol of careful inspection during a minimum of 8 minutes to withdraw the colonoscope, we observed significantly greater rates of overall and advanced neoplasia detection during screening colonoscopy.

Background: Sodium phosphate, administered orally, is an effective, well-tolerated colonic cleansing agent. However, colonoscopic visualization is suboptimal in many patients after a conventional 2-dose regimen. This study assessed the safety, the efficacy, and patient tolerance of a 3-dose regimen of sodium phosphate., Methods: Patients without cardiac, renal, or hepatic insufficiency were randomized to precolonoscopy purgation with 3 (45 mL) doses vs. two doses of aqueous sodium phosphate administered orally. Hemodynamic measurements and serum and urine biochemical tests were obtained at baseline and after purgation. Tolerance of the bowel preparation and colonoscopic visualization were assessed via questionnaires., Results: Quality of colonic cleansing was significantly better with the 3-dose regimen compared with the 2-dose regimen (p < 0.0001). No clinically significant adverse event was detected in either group. Subclinical orthostasis was observed in 5% of patients given the 2-dose regimen vs. 3% of those who took the 3-dose regimen. Post-purgation hyperphosphatemia was greater in the 3-dose group vs. the 2-dose group (p = 0.0003). No other significant differences in biochemistry were noted between the groups. Patient tolerance of the 2-dose regimen was better than the 3-dose regimen (p = 0.0379)., Conclusions: A 3-dose regimen of orally administered sodium phosphate provides superior colonic cleansing without compromising volume status or serum biochemistry but is associated with poorer overall patient tolerance compared with a conventional 2-dose regimen.

Background: Colonic cleansing with sodium phosphate causes intravascular volume contraction in some patients. This study tested the hypothesis that carbohydrate-electrolyte oral rehydration would attenuate the hypovolemic changes associated with administration of sodium phosphate., Methods: Adult outpatients were randomized to ingest either regular clear fluids or a carbohydrate-electrolyte rehydration solution during precolonoscopy purgation by ingestion of aqueous sodium phosphate. Investigators were blinded to the treatment assignment of patients. Clinical hemodynamic measurements and biochemical tests were obtained at baseline and after bowel preparation. Tolerability and colonoscopic visualization were assessed with questionnaires., Results: One hundred sixty-eight patients completed the study (81 clear fluids, 87 rehydration). By comparison with clear fluids, rehydration resulted in significantly less intravascular volume contraction. Changes in estimated central venous pressure and orthostatic pulse were significantly greater in the clear fluid group versus the rehydration group (p < 0.03). Changes in biochemical parameters after purgation also suggested a greater degree of volume contraction in the clear fluid versus rehydration group. Colonoscopic visualization was superior in the rehydration versus clear fluid group (p < 0.01); tolerability of the preparations was similar between groups (p = 0.2)., Conclusions: Carbohydrate-electrolyte rehydration protects against intravascular volume contraction during preparation for colonoscopy by ingestion of sodium phosphate. This approach is well tolerated by patients and improves colonic cleansing.

Appendiceal involvement in ulcerative colitis may occur in the setting of either diffuse or distal disease, and is usually diagnosed incidentally at the time of proctocolectomy. The present patient had a rare case of 'ulcerative appendicitis' occurring on a background of clinically quiescent ulcerative colitis, and presented with the signs and symptoms of acute appendicitis.

Pre-epithelial defences include the coordinated actions of the lower esophageal sphincter and the esophageal muscles, which minimize reflux of gastric contents and promote clearance of refluxed material. The esophageal epithelium also possesses innate resistance to luminal damaging agents and may be protected luminally by a mucus or 'mucus bicarbonate' barrier and possibly a layer of hydrophobic surfactants. These components are derived from submucosal glands located in the submucosal connective tissue and from salivary secretions that may bind to the esophageal surface. Epithelial defences include the glycocalyx, permeability properties of the epithelial cell plasma membrane, junctional barriers to proton permeation through the paracellular pathway and ion transport processes for regulation of intracellular pH. Subepithelial defences involve mainly regulation of blood supply via responses of nerves, mast cells and blood vessels to influxing protons. Although the epithelium can withstand prolonged exposure to physiologically relevant concentrations of acid, the presence of pepsin or bile salts may overcome the permeability barrier, which probably resides in the superficial layers of epithelial cells. Focal destruction of these cells allows access of luminal acid and other aggressive agents to the vulnerable basolateral cell membranes and to the submucosa. The result is lesion production, although an efflux of alkaline plasma may protect the underlying submucosa and allow healing. Salivary-derived epidermal growth factor (EGF) is present in the luminal fluid, and lesion development may also provide access of EGF to receptors within the epithelium and in the underlying vasculature. Accelerated cell proliferation would then contribute to healing. Inflammation and healing should also be viewed as defensive responses, as can the development of Barrett's esophagus, in which the stratified squamous epithelium is replaced by a potentially acid-resistant columnar epithelium. Chronic inflammation and esophagitis only result when this multilayered set of defences is overcome. The challenge for research is to identify those components of the defensive repertoire that are defective in individuals who suffer from chronic esophagitis.

In previous studies we have demonstrated that microvascular permeability increases early in the course of experimental acid-induced esophageal mucosal injury. This is associated with an increase in the intraluminal appearance of histamine, suggesting a possible role for mast cells in this form of injury. In the present study, quantitative analysis of esophageal mast cells was undertaken using both light and electron microscopy in opossums undergoing intraluminal esophageal acid perfusion or normal saline control perfusion. Light microscopy showed that animals perfused with either 50 or 100 mM hydrochloric acid had an approximate 50% decrease in the number of stainable esophageal mast cells. Stereologic analysis of electron micrographs revealed that within the mucosa, the mean area of the mast cells as well as nuclear area and area of intact granules were also significantly reduced in acid perfused animals. Taken together these quantitative morphological analyses suggest that intraluminal acid exposure is associated with degranulation and/or lysis of esophageal mast cells and that released mediators from esophageal mast cells may play a role in the pathophysiology of reflux esophagitis.

Total calcium content of both human and porcine MHS skeletal muscle is significantly less than normal. This data is consistent with the concept that some organelle (probably the sarcoplasmic reticulum, the mitochondrion or even the sarcolemma) within the MHS muscle stores less than normal amounts of calcium. The large variability between muscle specimens rules out measurement of total calcium content of skeletal muscle as a routine diagnostic test for malignant hyperthermia susceptibility.

In this study of nonpregnant women were compared with pregnant women. A set of feelings and attitudes along with questions relevant to the anatomy and physiology of parturition were the measures of comparison. The pregnant women and the nonpregnant women had almost identical feelings and attitudes. There were, however, three exceptions to this general condordance. They were: (1) the nonpregnant women's regard of pregnancy as a depressive and withdrawing experience, (2) a greater fear for the fetus among the nonpregnant women, and (3) higher scores on a pregnancy information inventory among the pregnant women.