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Primary sclerosing cholangitis (PSC) is a progressive liver disease for which there is no effective therapy. Hepatocytes and cholangiocytes from a PSC patient were cocultured with mesenchymal stem cells (MSCs) to assess in vitro change. A single patient with progressive PSC was treated with 150 million MSCs via direct injection into the common bile duct. Coculture of MSCs with cholangiocytes and hepatocytes showed in vitro improvement. Local delivery of MSCs into a single patient with progressive PSC was safe. Radiographic and endoscopic evaluation showed stable distribution of multifocal structuring in the early postoperative period. MSCs may be effective for the treatment of PSC.

Our aim was to compare the diagnostic yield of endoscopic ultrasound guided fine needle aspiration (EUS-FNA) versus combined fine needle aspiration and fine needle biopsy (EUS-FNA + FNB) in the evaluation of solid pancreatic masses (SPMs).EUS-FNA and EUS-FNB are established methods to diagnose SPMs. No studies have evaluated the efficacy of combination of both (EUS-FNA + FNB). Our senior author (MRS) hypothesized that combining the two techniques by using a single FNB needle improves diagnostic yield and started combination technique in October 2016.Patients who underwent EUS for SPMs by MRS during January 2014-September 2019 were included. They were divided into the EUS-FNA group and EUS-FNA + FNB group. EUS-FNA was performed using a 22 or 25 gauge Expect Slimline needle (Boston Scientific, Marlborough, MA) and EUS-FNA + FNB was performed using a single 22 or 25 gauge Shark-core needle (Medtronics, Minneapolis, MN, USA). Our primary outcome was to compare the diagnostic yield in the two groups.Among 105 patients included, 58 were in the EUS-FNA group and 47 were in the EUS-FNA + FNB group. EUS-FNA + FNB group had significantly higher diagnostic yield and required fewer needle passes compared to EUS-FNA group, 95.7% vs. 77.6%,Our study showed that combined EUS-FNA + FNB had higher diagnostic yield compared to EUS-FNA in SPMs along with less number of needle passes and needles required. Further prospective studies are needed to validate these findings and cost-effectiveness of this strategy.

Cholecystokinin cholescintigraphy is used clinically to quantify gallbladder ejection fraction as an indicator of functional gallbladder disorder. It can also provide the opportunity to quantify an individual's responsiveness to the physiologic stimulant of gallbladder contraction, cholecystokinin, which is a major regulator of appetite and postprandial satiety. Methods: In the current work, we use cholecystokinin cholescintigraphy to quantify the kinetics of gallbladder emptying, including average and peak rates, in response to a standard cholecystokinin infusion. Results: We demonstrated that patients with no gallstones or biliary obstruction who empty their gallbladders completely in response to cholecystokinin, having an ejection fraction greater than 80%, exhibit a broad range of sensitivity to this hormone. Three distinct kinetic profiles were observed, with those most sensitive to cholecystokinin achieving the earliest peak and the fastest rate of gallbladder emptying, whereas those least sensitive to cholecystokinin have the latest peak and the slowest rate of emptying. Conclusion: Patients can have abnormal cholecystokinin stimulus-activity coupling as an effect of endogenous negative allosteric modulation by membrane cholesterol. This was predicted in ex vivo studies but has not, to our knowledge, previously been demonstrated in vivo. This type of kinetic analysis provides a tool to quantify cholecystokinin responsiveness in patients and identify patients who might benefit from a drug that would positively modulate cholecystokinin action to improve their appetite regulation and to better control their weight.

Video Video 1 Treatment of refractory benign gastroenteral strictures with fully covered metal stents.

The Chicago Classification version 3.0 (CC v 3.0) defines hypercontractile peristalsis as Jackhammer esophagus (JE); Nutcracker esophagus (NE) is no longer recognized. Data regarding patient characteristics and treatment response for JE versus NE are limited. We aimed to compare demographic characteristics, high resolution manometry (HRM) features, clinical presentation, management strategies, and treatment outcomes in patients with JE versus NE. We performed a retrospective analysis of adult patients diagnosed with NE (CC v 2.0) or JE (CC v 3.0) by HRM from January 2012 to August 2015. Demographics, symptoms, treatments, and response to therapy (none or partial/complete) were ascertained by chart review, for statistical comparisons. In 45 patients with JE and 29 with NE, there was no significant difference in rate of dysphagia (73% and 59%) or chest pain (44% and 59%). Treatment data were available in 29 JE (smooth muscle relaxants in 4, pain modulators in 3, botulinum toxin injection (BTX) in 10, endoscopic dilation in 5, multimodal treatment in 7), and 20 NE patients (smooth muscle relaxants in 2, pain modulators in 2, (BTX) in 6, endoscopic dilation in 3, multimodal treatment in 7). Follow-up data on 26/29 JE and 20/20 NE patients showed similar treatment response (96.4% vs. 82.1%, p= 0.08) after mean follow-up of 11.2 and 11 months, respectively. There were no major differences for JE versus NE in demographics, symptoms, or type of and response to therapy. Larger prospective, controlled trials are needed to clarify the clinical significance and response to treatment in JE and NE.

Acute cholangitis (AC) can be associated with significant mortality and high risk of readmissions, if not managed promptly. We used national readmission database (NRD) to identify trends and risk factors associated with 30-day readmissions in patients with AC. We conducted a retrospective cohort study of adult patients admitted with AC from 2010–2014 and Q1-Q3 of 2015 by extracting data from NRD. Initial admission with a primary diagnosis of acute cholangitis (ICD-9 code: 576.1) was considered as the index admission and any admission after index admission was considered a readmission regardless of the primary diagnosis. Multivariable regression analyses were performed to assess the association. From 52,906 AC index admissions, overall 30-day readmission rate was 21.48% without significant differences in the readmission rates across the study period. There was significant increase in the overall hospital charges for readmissions, while a significant reduction in the death rate was observed during the first readmission. Recurrent cholangitis (14%), septicemia (6.4%), and mechanical complication of bile duct prosthesis (3%) were the most common reasons for readmissions. The risk of readmission was significantly higher in patients with pancreatic neoplasm (OR 1.6, 95% CI 1.4–1.8), those who underwent percutaneous biliary procedures (OR 1.4, 95% CI 1.2–1.6), and who had an acute respiratory failure (OR 1.2, 95% CI 1.0–1.15). Other factors contributing to increased risk of readmissions included patients with Charleston comorbidity index > 3, diabetes, and length of stay > 3 days. Readmission risk was significantly lower in patients who underwent ERCP (OR 0.80, 95% CI 0.73–0.88) or cholecystectomy (OR 0.54, 95% CI 0.43–0.69). AC is associated with a high 30-day readmission rate of over 21%. Patients with malignant biliary obstruction, increased comorbidities, and those who undergo percutaneous drainage rather than ERCP seem to be at the highest risk.

Background and Aims There is controversy about finding intestinal metaplasia (IM) of the gastric cardia on biopsy. The most recent American College of Gastroenterology guideline comments that IM cardia is not more common in patients with Barrett’s esophagus (BE). It provides limited guidance on whether the cardia should be treated when patients with BE undergo endoscopic eradication therapy (EET) and whether the cardia should undergo biopsy after ablation. The aims of our study were to determine the frequency in the proximal stomach of (1) histologic gastric cardia mucosa and (2) IM cardia. A third aim was to explore the frequency of advanced pathology (dysplasia and adenocarcinoma) in the cardia after patients with BE have undergone EET. Methods Consecutive patients undergoing esophagogastroduodenoscopy between January 2008 and December 2014 who had proximal stomach biopsies were included. Patients who had histologically confirmed BE were compared with those without BE. Results Four hundred sixty-two patients, 289 with BE and 173 without BE, were included. Histologically confirmed cardiac mucosa was found in 81.6% of all patients. This was more frequent in those with versus without BE (86% vs 75%; odds ratio [OR], 2.06; 95% confidence interval [CI], 1.28-3.32; P = .003). IM cardia was more common in the BE group (17% vs 7%; OR, 2.67; 95% CI, 1.38-5.19; P = .004). Advanced pathology was more likely in the patients with BE who had undergone EET. Conclusions Cardiac mucosa is present in most patients who undergo endoscopy for upper GI symptoms. IM cardia is more common in patients with BE than those without. Advanced histologic changes in the cardia were seen only in the subgroup of patients with BE who had undergone EET.

Split dose bowel preparations (SDP) have superior outcomes for colonoscopy as compared to evening before regimens. However, the association of the actual volume of the SDP to colonoscopy outcome measures has not been well studied. Compare adenoma detection rate (ADR), sessile serrated polyp detection rate (SDR), mean bowel cleanse score, and predictors of inadequate exams between small volume SDP and large volume SDP. We have conducted a retrospective study in patients undergoing colonoscopy with small volume SDP versus large volume SDP between July 2014 and December 2014. Basic demographics (age, gender and BMI) along with clinical co-morbidities were recorded. Quality of the bowel preparation, ADR and SDR was compared between these groups. Univariate and multivariable logistic regressions were used to assess the determinants of inadequate exams in each group. 1573 patients with split dose preparation were included in this retrospective study. 58.4% (920/1573) patients took small volume SDP. There was no difference in ADR (37.9 vs. 38.8%, p = 0.2); however, SDR was higher for small volume SDP compared to large volume SDP (11.9 vs. 7.9% p = 0.005). There was no difference in the rate of inadequate exams between the two groups (p = 0.7). A history of diabetes and constipation was associated with inadequate exams only in the small volume SDP. SDR was higher in small volume SDP. There was no difference in rate of inadequate exams between the two groups. A history of diabetes and constipation was associated with inadequate exams only in patients with the small volume SDP.

Background: Computed tomographic enterography (CTE) has been shown to have a high sensitivity and specificity for active small bowel inflammation. There are only sparse data on the effect of CTE results on Crohn's disease (CD) patient care. Methods: We prospectively assessed 273 patients with established or suspected CD undergoing a clinically indicated CTE. Providers were asked to complete pre- and postimaging questionnaires regarding proposed clinical management plans and physician level of confidence (LOC) for the presence or absence of active small bowel disease, fistula(s), abscess(es), or stricturing disease. Correlative clinical, serologic, and histologic data were recorded. Following revelation of CTE results, providers were questioned if CTE altered their management plans, and whether LOC changes were due to CTE findings (on a 5-point scale). Results: CTE altered management plans in 139 cases (51%). CTE changed management in 70 (48%) of those with established disease, prompting medication changes in 35 (24%). Management changes were made post-CTE in 69 (54%) of those with suspected CD, predominantly due to excluding CD (36%). CTE-perceived changes in management were independent of clinical, serologic, and histologic findings (P < 0.0001). Clinically meaningful LOC changes (2 or more points) were observed in 212 (78%). Conclusions: CTE is a clinically useful examination, altering management plans in nearly half of patients with CD, while increasing physician LOC for the detection of small bowel inflammation and penetrating disease. These findings further support the use of CTE in CD management algorithms. (Inflamm Bowel Dis 2011;)

To determine the computed tomographic (CT) detector configuration, patient size, and image noise limitations that will result in acceptable image quality of 80-kV images obtained at abdominal dual-energy CT.The Institutional Review Board approved this HIPAA-compliant retrospective study from archival material from patients consenting to the use of medical records for research purposes. A retrospective review of contrast material-enhanced abdominal dual-energy CT scans in 116 consecutive patients was performed. Three gastrointestinal radiologists noted detector configuration and graded image quality and artifacts at specified levels-midliver, midpancreas, midkidneys, and terminal ileum-by using two five-point scales. In addition, an organ-specific enhancement-to-noise ratio and background noise were measured in each patient. Patient size was measured by using the longest linear dimension at the level of interest, weight, lean body weight, body mass index, and body surface area. Detector configuration, patient sizes, and image noise levels that resulted in unacceptable image quality and artifact rankings (score of 4 or higher) were determined by using multivariate logistic regression.A 14 × 1.2-mm detector configuration resulted in fewer images with unacceptable quality than did the 64 × 0.6-mm configuration at all anatomic levels (P = .004, .01, and .02 for liver, pancreas, and kidneys, respectively). Image acceptability for the kidneys and ileum was significantly greater than that for the liver for all readers and detector configurations (P.001). For the 14 × 1.2-mm detector configuration, patient longest linear dimensions yielding acceptable image quality across readers ranged from 34.9 to 35.8 cm at the four anatomic levels.An 80-kV abdominal CT can be performed with appropriate diagnostic quality in a substantial percentage of the population, but it is not recommended beyond the described patient size for each anatomic level. The 14 × 1.2-mm detector configuration should be preferred.

Background: This study was conducted to determine the prevalence of penetrating disease and extraintestinal manifestations of Crohn's disease (CD) identified by computed tomography enterography (CTE). We also sought to examine the percentage of clinically significant new noninflammatory bowel disease (IBD) related findings in these patients. Methods: We analyzed the records of 357 consecutive patients with previously diagnosed CD evaluated at our institution who underwent a CTE between August 2004 and October 2005. Radiology reports were reviewed for the presence of penetrating disease (abscess, fistula, or phlegmon) or extraintestinal IBD manifestations (nephrolithiasis, cholelithiasis, sacroiliitis, avascular necrosis, deep vein thrombosis, or primary sclerosing cholangitis). Additional non-IBD-related abnormalities were also recorded, including any mass or cystic lesion. Urgent findings were defined as those that were deemed by the radiologist or ordering physician to require medical follow-up within 3 months. Results: Of 357 patients identified (51% female) the median age was 41.6 years and median disease duration was 9.9 years. Of this cohort, 20.7% had penetrating disease (new finding in 58.1%) and 18.8% had extraintestinal IBD manifestations (new finding in 67.2%). Six patients had primary sclerosing cholangitis and portal/mesenteric vein thrombosis, respectively. In addition, 45.1% had non-IBD findings including 2 unsuspected malignancies. Most of these extraenteric non-IBD abnormalities were benign, with only 13.0% requiring urgent follow-up. Conclusions: CT enterography is a valuable diagnostic modality for detecting both penetrating disease and extraintestinal IBD manifestations. These data add to a growing body of evidence that supports the use of CTE in CD diagnostic and management algorithms. (Inflamm Bowel Dis 2008)

Dual-energy CT scanning has significant potential for disease identification and classification. However, it dramatically increases the amount of data collected and therefore impacts the clinical workflow. One way to simplify image review is to fuse CT datasets of different tube energies into a unique blended dataset with desirable properties. A non-linear blending method based on a modified sigmoid function was compared to a standard 0.3 linear blending method. The methods were evaluated in both a liver phantom and patient study. The liver phantom contained six syringes of known CT contrast which were placed in a bovine liver. After scanning at multiple tube currents (45, 55, 65, 75, 85, 95, 105, and 115 mAs for the 140-kV tube), the datasets were blended using both methods. A contrast-to-noise (CNR) measure was calculated for each syringe. In addition, all eight scans were normalized using the effective dose and statistically compared. In the patient study, 45 dual-energy CT scans were retrospectively mixed using the 0.3 linear blending and modified sigmoid blending functions. The scans were compared visually by two radiologists. For the 15, 45, and 64 HU syringes, the non-linear blended images exhibited similar CNR to the linear blended images; however, for the 79, 116, and 145 HU syringes, the non-linear blended images consistently had a higher CNR across dose settings. The radiologists qualitatively preferred the non-linear blended images of the phantom. In the patient study, the radiologists preferred non-linear blending in 31 of 45 cases with a strong preference in bowel and liver cases. Non-linear blending of dual energy data can provide an improvement in CNR over linear blending and is accompanied by a visual preference for non-linear blended images. Further study on selection of blending parameters and lesion conspicuity in non-linear blended images is being pursued.