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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.

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.)

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.

The management of dyspepsia in limited-resource areas has not been established. In 2017, key opinion leaders throughout Thailand gathered to review and evaluate the current clinical evidence regarding dyspepsia and to develop consensus statements, rationales, levels of evidence, and grades of recommendation for dyspepsia management in daily clinical practice based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. This guideline is mainly focused on the following 4 topics: (1) evaluation of patients with dyspepsia, (2) management, (3) special issues (overlapping gastroesophageal reflux disease/ irritable bowel syndrome and non-steroidal anti-inflammatory drug/aspirin use), and (4) long-term follow-up and management to provide guidance for physicians in Thailand and other limited-resource areas managing such patients. (J Neurogastroenterol Motil 2019;25:15-26)

Background Many bacteria and archaea possess a defense system called clustered regularly interspaced short palindromic repeats (CRISPR) associated proteins (CRISPR-Cas system) against invaders such as phages or plasmids. This system has not been demonstrated in Helicobacter pylori. The numbers of spacer in CRISPR array differ among bacterial strains and can be used as a genetic marker for bacterial typing. Results A total of 36 H. pylori isolates were collected from patients in three hospitals located in the central (PBH) and southern (SKH) regions of Thailand. It is of interest that CRISPR-like sequences of this bacterium were detected in vlpC encoded for VacA-like protein C. Virulence genes were investigated and the most pathogenic genotype (cagA vacA s1m1) was detected in 17 out of 29 (58.6%) isolates from PBH and 5 out of 7 (71.4%) from SKH. vapD gene was identified in each one isolate from PBH and SKH. CRISPR-like sequences and virulence genes of 20 isolates of H. pylori obtained in this study were analyzed and CRISPR-virulence typing was constructed and compared to profiles obtained by the random amplification of polymorphic DNA (RAPD) technique. The discriminatory power (DI) of CRISPR-virulence typing was not different from RAPD typing. Conclusion CRISPR-virulence typing in H. pylori is easy and reliable for epidemiology and can be used for inter-laboratory interpretation. Electronic supplementary material The online version of this article (10.1186/s13099-017-0215-8) contains supplementary material, which is available to authorized users.

Additional file 1: Figure S1. Clusters of DR assigned in H. pylori based on multiplex sequence alignment using MEGA7 software (highlight indicated the share sequences within the cluster).

Background Many bacteria and archaea possess a defense system called clustered regularly interspaced short palindromic repeats (CRISPR) associated proteins (CRISPR-Cas system) against invaders such as phages or plasmids. This system has not been demonstrated in Helicobacter pylori. The numbers of spacer in CRISPR array differ among bacterial strains and can be used as a genetic marker for bacterial typing. Results A total of 36 H. pylori isolates were collected from patients in three hospitals located in the central (PBH) and southern (SKH) regions of Thailand. It is of interest that CRISPR-like sequences of this bacterium were detected in vlpC encoded for VacA-like protein C. Virulence genes were investigated and the most pathogenic genotype (cagA vacA s1m1) was detected in 17 out of 29 (58.6%) isolates from PBH and 5 out of 7 (71.4%) from SKH. vapD gene was identified in each one isolate from PBH and SKH. CRISPR-like sequences and virulence genes of 20 isolates of H. pylori obtained in this study were analyzed and CRISPR-virulence typing was constructed and compared to profiles obtained by the random amplification of polymorphic DNA (RAPD) technique. The discriminatory power (DI) of CRISPR-virulence typing was not different from RAPD typing. Conclusion CRISPR-virulence typing in H. pylori is easy and reliable for epidemiology and can be used for inter-laboratory interpretation.

Management of Helicobacter pylori infection is an important aspect of many upper gastrointestinal tract diseases, such as chronic gastritis, peptic ulcer disease, gastric cancer and mucosa-associated lymphoid tissue (MALT) lymphoma. The Thailand Consensus on H. pylori treatment 2015 consisted of 22 national experts who took active roles, discussed all important clinical information and investigated clinical aspects in four workshops, focuising on: (1) Diagnosis (2) Treatment (3) Follow-up after eradication and (4) H. pylori infection and special conditions. Experts were invited to participate on the basis of their expertise and contribution to H. pylori works and/or consensus methodology. The results of each workshop were taken to a final consensus vote by all experts. Recommendations were developed from the best evidence and availability to guide clinicians in management of this specific infection associated with variety of clinical outcomes.

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

Aim. To study the efficacy and other treatment outcomes of Ovesco clip closure of iatrogenic perforation. Methods. Retrospective study from 3 tertiary-care hospitals in Thailand. Patients with iatrogenic perforation who underwent immediate endoscopic closure by Ovesco clip were included. Patients’ demographic data, perforation size, number of Ovesco clips used, fasting day, length of hospital stay, success rates, and complication rate were recorded. Technical success was defined as closure achievement during endoscopic procedure and clinical success was defined as the patient can be discharged without the need of additional surgical or radiological intervention. Results. There were 6 iatrogenic perforations in 2 male and 4 female patients. The median age was 59 years (range 39–78 years). The locations of perforation were 5 duodenal walls and 1 rectosigmoid junction. The median perforation size was 13 mm (range 10–40 mm). The technical success was 100% and the clinical success was 83.3%. The success rates per locations were 100% in colon and 80% in duodenum, respectively. The median fasting time was 5 days (range 1–10 days) and the median length of hospital stay was 10 days (range 2–22 days). There was no mortality in any. Conclusion. Ovesco clip seems to be an effective and safe tool for a closure of iatrogenic perforation.

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.

Objectives: The Asia-Pacific Colorectal Screening (APCS) scoring system was developed to identify high-risk subjects for advanced neoplasia. However, the appropriate fecal immunochemical test (FIT) cutoff for high-risk population may be different from that of average-risk population. We aimed to evaluate the FIT performance at different cutoffs in high-risk subjects undergoing colorectal cancer (CRC) screening. Methods: We prospectively enrolled asymptomatic subjects aged 50–75 years. Using the APCS score, subjects were stratified into either the average-risk or high-risk groups. All subjects were tested with one-time quantitative FIT and underwent colonoscopy. We compared the FIT performance for advanced neoplasia between two groups using different cutoffs (5 (FIT5), 10 (FIT10), 20 (FIT20), 30 (FIT30), and 40 (FIT40) μg Hb/g feces). Results: Overall, 1,713 subjects were recruited, and 1,222 (71.3%) and 491 (28.7%) were classified as average-risk and high-risk, respectively. Advanced neoplasia was detected in 90 (7.4%) of the average-risk subjects and 65 (13.2%) of the high-risk subjects. In the high-risk group, by decreasing the cutoff from FIT40 to FIT5, the sensitivity increased by 33.8 percentage points with decreased specificity by 11 percentage points. In the average-risk group, the sensitivity increased by 20 percentage points with decreased specificity by 9.6 percentage points. At the lowest cutoff (FIT5), the number of needed colonoscopies to find one advanced neoplasia was 2.8 and 6.1 for the high-risk and average-risk groups, respectively. Conclusions: Using an appropriate FIT cutoff for CRC screening in high-risk subjects could improve CRC screening performance and reduce the unnecessary colonoscopies. To maintain high sensitivity and specificity for advanced neoplasia, the optimal cutoff FIT in the high-risk subjects should be lower than that in the average-risk subjects.

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.