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The effectiveness of the hemostatic powder TC-325 as a single endoscopic treatment for acute nonvariceal upper gastrointestinal bleeding is uncertain.To compare TC-325 with standard endoscopic hemostatic treatments in the control of active bleeding from nonvariceal upper gastrointestinal causes.One-sided, noninferiority, randomized, controlled trial. (ClinicalTrials.gov: NCT02534571).University teaching hospitals in the Asia-Pacific region.224 adult patients with acute bleeding from a nonvariceal cause on upper gastrointestinal endoscopy.TC-325 (The primary outcome was control of bleeding within 30 days. Other outcomes included failure to control bleeding during index endoscopy, recurrent bleeding after initial hemostasis, further interventions, blood transfusion, hospitalization, and death.224 patients were enrolled (136 with gastroduodenal ulcers [60.7%], 33 with tumors [14.7%], and 55 with other causes of bleeding [24.6%]). Bleeding was controlled within 30 days in 100 of 111 patients (90.1%) in the TC-325 group and 92 of 113 (81.4%) in the standard treatment group (risk difference, 8.7 percentage points [1-sided 95% CI, 0.95 percentage point]). There were fewer failures of hemostasis during index endoscopy with TC-325 (3 [2.7%] vs. 11 [9.7%]; odds ratio, 0.26 [CI, 0.07 to 0.95]). Recurrent bleeding within 30 days did not differ between groups (9 [8.1%] vs. 10 [8.8%]). The need for further interventions also did not differ between groups (further endoscopic treatment: 8 [7.2%] vs. 10 [8.8%]; angiography: 2 [1.8%] vs. 4 [3.5%]; surgery: 1 [0.9%] vs. 0). There were 14 deaths in each group (12.6% vs. 12.4%).Clinicians were not blinded to treatment.TC-325 is not inferior to standard treatment in the endoscopic control of bleeding from nonvariceal upper gastrointestinal causes.General Research Fund to the University Grants Committee, Hong Kong SAR Government.

BACKGROUND The fecal immunochemical test (FIT) is a cost-effective colorectal cancer (CRC) screening tool. However, longitudinal adherence, a factor that is critical to the success to any FIT-based screening program, often is poor. The authors hypothesized that reminders sent via mobile messengers, such as WhatsApp, improve such adherence. METHODS In the current single-blind, randomized study, subjects from an opportunistic FIT screening program who had a negative FIT result the year prior were randomly allocated (1:1) to receive either a 1-off reminder via the WhatsApp messenger (WR) 1 month prior to the due appointments or no reminder (NR). All subjects were blinded to study participation and group allocation. At 24 months after randomization, a crossover of intervention was performed among those individuals who remained in the FIT program. The primary outcome was FIT adherence, defined as the pick-up and on-time return of the FIT. The secondary outcome was FIT adherence after the crossover. RESULTS A total of 500 subjects were randomized to receive WR (250 subjects) or NR (250 subjects). Three individuals were excluded from analysis (1 died and 2 underwent colonoscopy). Both the FIT pick-up rate (80.3% vs 59.3%; P < .001) and return rate (79.9% vs 57.3%; P < .001) were significantly higher in the WR group compared with the NR group. After crossover of intervention (452 subjects), the WR group again was found to have a higher FIT pick-up rate (79.1% vs 52.9%; P < .001) and return rate (78.2% vs 52.4%; P < .001). CONCLUSIONS Text reminders sent via mobile messenger appear to improve the longitudinal adherence to FIT-based opportunistic CRC screening programs. The routine use of this technology in CRC screening should be considered.

Background and aim Secondary prophylaxis (SP) of variceal rebleeding was reported to improve outcomes of hepatocellular carcinoma (HCC) patients, but the optimal endoscopic approach is not well defined. We compared outcomes in HCC patients who underwent SP by endoscopic ultrasound-guided cyanoacrylate obturation (EUS-CYA) versus no SP. Methods Between 2014 and 2018, 30 consecutive patients with inoperable HCC and recent endoscopically controlled variceal bleeding were prospectively recruited. Twenty-seven patients with persistent varices ≥ 3 mm on endoscopic ultrasound underwent EUS-CYA for SP. Thirty-three HCC patients treated by esophagogastroduodenoscopy-guided CYA obturation (EGD-CYA) alone for acute variceal bleeding between 2009 and 2013 were identified from a prospective gastrointestinal bleed registry as standard of care controls for comparison. Outcome measures were death-adjusted cumulative incidence of rebleeding, bleeding-free survival, technical success, and procedure-related adverse events of EUS-CYA. Results The majority of patients in both groups had advanced HCC, portal vein thrombosis, and Child-Pugh B cirrhosis. EUS-CYA was successful in all 27 patients with no radiographic evidence of cyanoacrylate-lipiodol embolization. Significantly lower 30- and 90-day death-adjusted cumulative incidence of rebleeding (14.8% vs 42.4%, P = 0.023 and 18.5% vs 60.6%, P = 0.002, respectively) and significantly higher variceal bleeding-free survival at 3 and 6 months (51.9% vs 21.2%, P = 0.009, 40.7% vs 15.2%, P = 0.010, respectively) were observed in the EUS-CYA group when compared with standard of care group. Conclusions Secondary prophylaxis by EUS-CYA reduced rebleeding rate and improved variceal bleeding-free survival in patients with inoperable HCC and variceal bleeding when compared with no SP. Randomized studies are needed to confirm the benefits of EUS-CYA for this difficult-to-treat population.

Background The use of macroscopic on-site evaluation (MOSE) to estimate the adequacy of a specimen for histological diagnosis during endoscopic ultrasound (EUS)-guided fine-needle tissue acquisition (FNTA) has recently been advocated. This study aimed to evaluate the diagnostic yield of MOSE compared with conventional EUS-FNTA without rapid on-site evaluation (ROSE).Methods This was an international, multicenter, prospective, randomized controlled study. After providing informed consent, consecutive adult patients referred for EUS-FNTA for solid lesions larger than 2 cm were randomized to a MOSE arm or to a conventional arm without ROSE. A designated cytopathologist from each center performed all cytopathological examinations for that center and was blinded to the randomization results. The primary outcome measure was the diagnostic yield, and the secondary outcomes included sensitivity, specificity, positive predictive value, negative predictive value, diagnostic accuracy, and the rate of procedure-related complications.Results 244 patients (122 conventional, 122 MOSE) were enrolled during the study period. No significant differences between the two arms were found in procedure time or rate of procedure-related adverse events. The diagnostic yield for the MOSE technique (92.6 %) was similar to that for the conventional technique (89.3 %; P = 0.37), with significantly fewer passes made (median: conventional 3, MOSE 2; P Conclusions EUS-FNTA with the MOSE technique provided a similar diagnostic yield to conventional EUS-FNTA technique in the absence of ROSE but with fewer passes. This technique can be used when ROSE is not available.

Background Peroral cholangioscopy (POCS) can be useful for difficult bile duct stone clearance. Large prospective multinational data on POCS-guided lithotripsy for clearing difficult bile duct stones in a single session of endoscopic retrograde cholangiopancreatography (ERCP) are missing. Methods Patients with difficult bile duct stones (defined as one or more of: largest stone diameter ≥ 15 mm, failed prior attempt at stone clearance, impacted, multiple, hepatic duct location, or located above a stricture) were enrolled at 17 centers in 10 countries. The principal endpoint was stone clearance in a single ERCP procedure using POCS. Results 156 patients underwent 174 sessions of POCS-guided electrohydraulic or laser lithotripsy. Stone clearance had failed in a previous ERCP using traditional techniques in 124/156 patients (80 %), while 32 /156 patients (21 %) were referred directly to POCS-guided therapy based on preprocedural assessment of the difficulty of stone clearance. In 101/156 patients (65 %), there were impacted stones. POCS-guided stone clearance was achieved in a single POCS procedure in 125 /156 patients (80 %, 95 % confidence interval [CI] 73 % – 86 %), and was significantly more likely for stones ≤ 30 mm compared with > 30 mm (odds ratio 7.9, 95 %CI 2.4 – 26.2; P = 0.002). Serious adverse events occurred in 3/156 patients (1.9 %, 95 %CI 0.4 % – 5.5 %), and included pancreatitis, perforation due to laser lithotripsy, and cholangitis (n = 1 each), all resolved within 1 week. Conclusion POCS-guided lithotripsy is highly effective for clearance of difficult bile duct stones in a single procedure and successfully salvages most prior treatment failures. It may also be considered first-line therapy for patients with difficult choledocholithiasis to avoid serial procedures.

Although the association between fatty pancreas and metabolic syndrome has been suggested in retrospective studies, long-term prospective data on the effect of fatty pancreas on various metabolic outcomes are lacking. We aimed to prospectively investigate the association between fatty pancreas and the development of major metabolic outcomes.A total of 631 subjects from a population study using fat-water magnetic resonance imaging to quantify pancreatic and liver fat content during 2008 to 2010 were followed up prospectively until December 2020 (mean follow-up time, 11.1 ± 1.1 y). Subjects with significant alcohol intake and diabetes mellitus (DM) at baseline were excluded. Incidence of newly diagnosed DM, hypertension, dyslipidemia, ischemic heart disease, cardiovascular accidents, pancreatic cancer, and mortality were evaluated.Among the 631 subjects (mean age, 48 ± 11 y), 93 (14.7%) had fatty pancreas. The fatty pancreas group had a higher incidence of DM (33.3% vs 10.4%; P.001), hypertension (37.7% vs 22.7%; P = .003), and dyslipidemia (37.7% vs 14.6%; P.001) during long-term follow-up evaluation. Individuals with both fatty liver and pancreas had the highest DM incidence, followed by fatty liver only and fatty pancreas only groups (P.001). Fatty pancreas was associated independently with DM (adjusted hazard ratio, 1.81; 95% CI, 1.10-3.00; P = .020), but not hypertension or dyslipidemia on multivariate analysis. Each percentage increase of pancreatic fat increased the risk of incident DM by 7% (adjusted hazard ratio, 1.07; 95% CI, 1.01-1.13; P = .016). No participants developed pancreatic cancer during the follow-up period.Fatty pancreas is associated independently with subsequent DM development, but not hypertension or dyslipidemia.

Rice bran exhibits chemopreventive properties that may help to prevent colorectal cancer (CRC), and a short-term rice bran dietary intervention may promote intestinal health via modification of the intestinal microbiota. We conducted a pilot, double-blind, randomised placebo-controlled trial to assess the feasibility of implementing a long-term (24-week) rice bran dietary intervention in Chinese subjects with a high risk of CRC, and to examine its effects on the composition of their intestinal microbiota. Forty subjects were randomised into the intervention group (n = 19) or the control group (n = 20). The intervention participants consumed 30 g of rice bran over 24-h intervals for 24 weeks, whilst the control participants consumed 30 g of rice powder on the same schedule. High rates of retention (97.5%) and compliance (≥91.3%) were observed. No adverse effects were reported. The intervention significantly enhanced the intestinal abundance of Firmicutes and Lactobacillus, and tended to increase the Firmicutes/Bacteroidetes ratio and the intestinal abundance of Prevotella_9 and the health-promoting Lactobacillales and Bifidobacteria, but had no effect on bacterial diversity. Overall, a 24-week rice bran dietary intervention was feasible, and may increase intestinal health by inducing health-promoting modification of the intestinal microbiota. Further larger-scale studies involving a longer intervention duration and multiple follow-up outcome assessments are recommended.

Background Although endoscopic ultrasound (EUS) features and criteria have been described in chronic pancreatitis, challenges remain with interoperator variability and ease of adoption. The aim of this study was to define and validate the EUS features of chronic pancreatitis in a multicenter prospective study in Asia. Method The study was divided into two parts: the first part was conducted to derive the EUS features of chronic pancreatitis with adequate interoperator agreement; the second was to prospectively evaluate these features in a multicenter cross-sectional study and determine the optimal combination of features for the diagnosis of chronic pancreatitis. Prospectively enrolled cases had standard internationally validated radiologic or histologic features of chronic pancreatitis, and controls were patients without chronic pancreatitis who underwent EUS examination. Results The top six EUS features that had good interobserver agreement (mean kappa 0.73, range 0.60 – 0.90) were selected to be further evaluated in part II of the study. These included: hyperechoic foci with shadowing, lobularity with honeycombing, cysts, dilated main pancreatic duct, dilated side branches, and calculi in the main pancreatic duct. A total of 284 subjects (132 cases, 152 controls) were enrolled from 12 centers in Asia. All six features had high accuracy ranging from 63.3 % to 89.1 %. Two or more of these six EUS features accurately defined chronic pancreatitis (sensitivity 94.7 %, specificity 98.0 %), with an area under the receiver operating curve of 0.986. Conclusion This multicenter Asian study characterized and defined the EUS features of chronic pancreatitis. This provides a useful tool in clinical practice and further research in pancreatic cancer surveillance.

It is recommended that patients with acute upper gastrointestinal bleeding undergo endoscopy within 24 hours after gastroenterologic consultation. The role of endoscopy performed within time frames shorter than 24 hours has not been adequately defined.To evaluate whether urgent endoscopy improves outcomes in patients predicted to be at high risk for further bleeding or death, we randomly assigned patients with overt signs of acute upper gastrointestinal bleeding and a Glasgow-Blatchford score of 12 or higher (scores range from 0 to 23, with higher scores indicating a higher risk of further bleeding or death) to undergo endoscopy within 6 hours (urgent-endoscopy group) or between 6 and 24 hours (early-endoscopy group) after gastroenterologic consultation. The primary end point was death from any cause within 30 days after randomization.A total of 516 patients were enrolled. The 30-day mortality was 8.9% (23 of 258 patients) in the urgent-endoscopy group and 6.6% (17 of 258) in the early-endoscopy group (difference, 2.3 percentage points; 95% confidence interval [CI], -2.3 to 6.9). Further bleeding within 30 days occurred in 28 patients (10.9%) in the urgent-endoscopy group and in 20 (7.8%) in the early-endoscopy group (difference, 3.1 percentage points; 95% CI, -1.9 to 8.1). Ulcers with active bleeding or visible vessels were found on initial endoscopy in 105 of the 158 patients (66.4%) with peptic ulcers in the urgent-endoscopy group and in 76 of 159 (47.8%) in the early-endoscopy group. Endoscopic hemostatic treatment was administered at initial endoscopy for 155 patients (60.1%) in the urgent-endoscopy group and for 125 (48.4%) in the early-endoscopy group.In patients with acute upper gastrointestinal bleeding who were at high risk for further bleeding or death, endoscopy performed within 6 hours after gastroenterologic consultation was not associated with lower 30-day mortality than endoscopy performed between 6 and 24 hours after consultation. (Funded by the Health and Medical Fund of the Food and Health Bureau, Government of Hong Kong Special Administrative Region; ClinicalTrials.gov number, NCT01675856.).

Second forward view (SFV) examination of the right colon (RC) in colonoscopy was suggested to improve the adenoma detection rate (ADR), but multicenter data to inform its routine use remain limited. We performed an international multicenter randomized trial comparing SFV vs a standard single forward view examination of the RC on adenoma detection.Asymptomatic individuals undergoing screening or surveillance colonoscopies from 6 Asia Pacific regions were invited for study. A forward view examination of the RC was first performed in all patients, followed by randomization at the hepatic flexure to either SFV examination of the RC and standard withdrawal examination from the hepatic flexure to rectum, or a standard withdrawal colonoscopy (SWC) examination from the hepatic flexure to rectum. The primary outcome was RC ADR.Between 2016 and 2019, there were 1011 patients randomized (SFV group, 502 patients; SWC group, 509 patients). Forty-five endoscopists performed the colonoscopies. The RC ADR was significantly higher in the SFV group than in the SWC group (27.1% vs 21.6%; P = .042). The whole-colon ADR was high in both groups (49.0% vs 45.0%; P =.201). The SFV examination identified 58 additional adenomas in 49 patients (9.8%), leading to a change in surveillance recommendations in 15 patients (3.0%). The median overall withdrawal time was 1.5 minutes longer in the SFV group (12.0 vs 10.5 min; P.001). Older age, male sex, ever smoking, and longer RC withdrawal time were independent predictors of right-sided adenoma detection.In this multicenter trial, SFV examination significantly increased the RC ADR in screening and surveillance colonoscopies. Routine RC SFV examination should be considered. ClinicalTrials.gov ID: NCT03121495.

Objectives: The project is aimed to compare the tissue sampling rate and the diagnostic accuracy rate of EUS-FNA using 22G nitinol and reverse bevel-tipped needles. Subjects and Methods: This was a prospective, randomized, crossover study in a tertiary academic hospital. All consecutive adult patients undergoing EUS-guided FNA for lesions > 2 cm were recruited. Patients fulfilling the inclusion and exclusion criteria underwent EUS-guided FNA using both needles in sequence. They were randomized on a 1:1 basis to determine whether EUS-FNA would be performed first using the 22G reverse bevel-tipped (ProCore) needle followed by the nitinol needle or vice versa. The patients and the pathologists were blinded to the type of needle used. Results: Forty patients with suspected malignant neoplasms were recruited to the study. No significant differences were found in the diagnostic yield (76.9% vs. 84.6%, P = 0.389), accuracy (71.8% vs. 84.6%, P = 0.170), sensitivity (77.8% vs. 86.1%, P = 0.358), specificity (100% vs. 100%, P = 1), positive predictive value (100% vs. 100%, P = 1), and negative predictive value (20.0% vs. 28.6%, P = 1). The percentage of obtained tissue for histological assessment was also similar (41.0% vs. 46.2%, P = 0.648). In terms of the quantity of tissue obtained with the needles, a larger proportion of patients in the nitinol group obtained more tissue for assessment (P = 0.003). Conclusion: The tissue-sampling rate and the diagnostic accuracy of the new 22G ProCore needle were comparable to the conventional 22G FNA needle in the absence of an on-site cytopathologist.

ObjectiveWhile it is recommended that patients presenting with acute upper gastrointestinal bleeding (AUGIB) should receive endoscopic intervention within 24 hours, the optimal timing is still uncertain. We aimed to assess whether endoscopy timing postadmission would affect outcomes.DesignWe conducted a retrospective, territory-wide, cohort study with healthcare data from all public hospitals in Hong Kong. Adult patients (age ≥18) that presented with AUGIB between 2013 and 2019 and received therapeutic endoscopy within 48 hours (n=6474) were recruited. Patients were classified based on endoscopic timing postadmission: urgent (t≤6), early (6ResultsResults showed that urgent timing (n=1008) had worse outcomes compared with early endoscopy (n=3865), with higher 30-day all-cause mortality (pConclusionCompared with urgent and late endoscopy among patients who have received therapeutic endoscopies, early endoscopy was associated with superior outcomes especially among patients with non-variceal bleeding. This supports the notion that non-variceal AUGIB patients should receive endoscopy within 24 hours, but also emphasises the importance of prior resuscitation and pharmacotherapy.

As endoscopic ultrasound (EUS) equipment improves, the diagnostic and therapeutic applications of EUS in patients with portal hypertension (pHTN) have been increasingly explored. Various EUS-guided vascular interventions for pHTN have been evaluated in human or animal studies. EUS has been shown to be useful in variceal and perforating feeding veins identification, prediction of variceal recurrence/rebleeding, and assessment of response to pharmacological therapy for pHTN. When compared to conventional endoscopic therapies, EUS-guided therapy for varices and/or perforating feeding veins can ensure intra-variceal delivery of injection therapy, allow real-time monitoring of variceal obliteration, and provide injection therapy under pure EUS guidance when the target varix is endoscopically obscured. While the feasibility of EUS-guided assessment of portal hemodynamics and creation of intrahepatic portosystemic shunt has been evaluated, further studies would be needed to assess the long term outcomes before routine application.

Contains fulltext : 220059.pdf (Publisher’s version ) (Closed access) BACKGROUND AND AIMS: Accurately diagnosing indeterminate biliary strictures is challenging but important for patient prognostication and further management. Biopsy sampling under direct cholangioscopic vision might be superior to standard ERCP techniques such as brushing or biopsy sampling. Our aim was to investigate whether digital single-operator cholangioscopy (DSOC) compared with standard ERCP workup improves the diagnostic yield in patients with indeterminate biliary strictures. METHODS: Patients with an indeterminate biliary stricture on the basis of MRCP were randomized to standard ERCP visualization with tissue brushing (control arm [CA]) or DSOC visualization and DSOC-guided biopsy sampling (study arm [SA]). This was a prospective, international, multicenter trial with a procedure-blinded pathologist. RESULTS: The first sample sensitivity of DSOC-guided biopsy samples was significantly higher than ERCP-guided brushing (SA 68.2% vs CA 21.4%, P < .01). The sensitivity of visualization (SA 95.5% vs CA 66.7%, P = .02) and overall accuracy (SA 87.1% vs CA 65.5%, P = .05) were significantly higher in the SA compared with the CA, whereas specificity, positive predictive value, and negative predictive value showed no significant difference. Adverse events were equally low in both arms. CONCLUSIONS: DSOC-guided biopsy sampling was shown to be safe and effective with a higher sensitivity compared with standard ERCP techniques in the visual and histopathologic diagnosis of indeterminate biliary strictures. (Clinical trial registration number: NCT03140007.).

BACKGROUND AND AIM Colorectal cancer (CRC) incidence is rising among

Endoscopic ultrasound (EUS), with or without fine needle aspiration (FNA), has become an essential tool in the evaluation of pancreatobiliary diseases. Although conventional EUS is superior to multidetector computed tomography in tumor detection and staging, there are situations when characterization of various pancreatobiliary lesions remains difficult. Contrast-enhanced EUS (CE EUS) can further improve the detection and characterization of pancreatic solid lesions such as ductal adenocarcinoma, neuroendocrine tumor, or mass-forming autoimmune pancreatitis based on differences in the enhancement pattern of the target lesions. It is also useful in differentiating between mural nodules and mucous clots in pancreatic cystic neoplasms, and characterizing various lesions in the gallbladder and bile duct. CE EUS is complementary to FNA and has the potential to increase the diagnostic yield on the first FNA needle pass.

Background and study aims: Submucosal tunnelling endoscopic resection (STER) is a novel endoscopic technique to remove submucosal tumour (SMT). We propose a novel, low cost simulator for training of techniques for STER. Patients and methods: The model consisted of an ex-planted porcine oesophagus, stomach and duodenum with marbles embedded surgically in the submucosal plane. Two expert endoscopists with experience in submucosal tunnelling and 5 board-certified endoscopists with no experience in submucosal tunnelling were recruited. Participants were asked to perform a diagnostic endoscopy and 2 STER procedures, 1 in the oesophagus and 1 in the stomach. They also answered a structured questionnaire. Factors including operative time, mucosal and muscular injury rate, injection volume and accuracy of endoscopic closure were assessed. Results: The median time for localization of all SMTs was 40.1 seconds for experts and 38.5 seconds for novices (P = 1.000). For esophageal STER, the length of mucosal incisions and tunnelling distances were comparable between the 2 groups. The median volume injected by the novice group was significantly lower than the experts (15 mL vs 42.5 mL (P = 0.05). The median tunnelling time per length was 25.9 seconds/mm for the experts and 40.8 seconds/mm for the novice group (P = 0.38). There was a higher rate of mucosal injury and muscular perforation in the novice group (8 vs 0; P = 0.05). For gastric STER, the length of mucosal incisions and tunnel distances were comparable between the 2 groups. The median tunnelling time per length for the experts was 23.3 seconds/mm and 34.6 seconds/mm for the novice group (P = 0.38). One mucosal injury was incurred by a novice. The rate of dissection in the stomach and the oesophagus was not statistically different (P = 0.620). All participants voted that the model provides a realistic simulation and recommended it for training. Conclusions: STER is an advanced endoscopic technique where its indication is currently explored. Experienced and novice STER endoscopists have expressed the usefulness of this model as a training tool. This low-cost model can be used for future research in STER.

Background: The incidence of Crohn’s disease (CD) is increasing in Asia and Eastern Europe. Limited studies have reported on the frequency of upper gastrointestinal (GI) involvement in patients with CD in non-Western countries. This prospective study compared the rate of macroscopic and microscopic upper GI manifestations and Helicobacter pylori (H. pylori) positivity in asymptomatic CD patients in Asia and Eastern Europe. Methods: Consecutive asymptomatic CD patients were prospectively recruited for upper GI endoscopy between 2013 and 2015 in Hong Kong and in Hungary. Endoscopy and biopsy findings were recorded and histology was performed to assess for H. pylori and microscopic signs characteristic for CD, using standardized diagnostic criteria. Results: One hundred and eighty CD patients (100 Hong Kong; 80 Hungary; 70.6% male; mean age, 38.5 years) and 189 controls (100 Hong Kong; 89 Hungary; 57.7% male; mean age 41 years) were included. Gastroduodenal involvement of CD was significantly higher in Hungary than in Hong Kong (16.5% vs 2.0%, p≤0.001). H. pylori positivity was significantly higher in Hungarian than Chinese CD patients (13.9% vs. 4.0%, p≤0.001). Granulomas were detected in 1% in Hong Kong and 7.6% in Hungary (p≤0.001). Chinese CD subjects had a significantly lower H. pylori positivity compared with controls (6% vs. 15%; p≤0.001). Conclusion: Upper GI CD was significantly higher in Eastern Europe compared with Asia. The detection of granuloma in Hungary was similar to the literature data, whereas focal gastritis was lower than expected in both cohorts.

Background & Aims The 2015 American Gastroenterological Association guidelines recommend discontinuation of surveillance of pancreatic cysts after 5 years, although there are limited data to support this recommendation. We aimed to determine the rate of pancreatic cancer development from neoplastic pancreatic cysts after 5 years of surveillance. Methods We performed a retrospective multicenter study, collecting data from 310 patients with asymptomatic suspected neoplastic pancreatic cysts, identified by endoscopic ultrasound from January 2002 to June 2010 at 4 medical centers in California. All patients were followed up for 5 years or more (median, 87 mo; range, 60–189 mo). Data were used to calculate the risk for pancreatic cancer and all-cause mortality. Results Three patients (1%) developed invasive pancreatic adenocarcinoma. Based on American Gastroenterological Association high-risk features (cyst size > 3 cm, dilated pancreatic duct, mural nodule), risks for cancer were 0%, 1%, and 15% for patients with 0, 1, or 2 high-risk features, respectively. Mortality from nonpancreatic causes was 8-fold higher than mortality from pancreatic cancer after more than 5 years of surveillance. Conclusions There is a very low risk of malignant transformation of asymptomatic neoplastic pancreatic cysts after 5 years. Patients with pancreatic lesions and 0 or 1 high-risk feature have a less than 1% risk of developing pancreatic cancer, therefore discontinuation of surveillance can be considered for select patients. Patients with neoplastic pancreatic cysts with 2 high-risk features have a 15% risk of subsequent pancreatic cancer, therefore surgery or continued surveillance should be considered.

Management of patients on antithrombotic therapy undergoing endoscopic procedures can be challenging. Although guidelines from major gastrointestinal endoscopy societies provide useful recommendations in this regard, data are limited concerning the bleeding risk of new complex endoscopic procedures and the management of novel anticoagulants in patients needing invasive procedures. The approach to the management of antithrombotic therapy often needs to be formulated on an individual basis, especially in patients with high thrombotic risk undergoing a high-risk endoscopic procedure. In addition to the procedure-related bleeding risk, endoscopists also need to consider the urgency of the endoscopic procedure, the thromboembolic risk of the patient if antithrombotic therapy is temporarily withheld, and the timing of discontinuation/resumption of antithrombotic therapy in the decision-making process. Diagnostic endoscopic procedures with or without biopsy can often be done without interruption of antithrombotic therapy. If possible, elective procedures with high bleeding risk should be delayed in patients on antithrombotic therapy for conditions with high thrombotic risk. If high-risk procedures cannot be delayed in these patients, thienopyridines, traditional and novel anticoagulants are usually withheld, whereas aspirin withdrawal is decided on a case by case basis. In patients with high thrombotic risk, communication with the prescribing clinician before proceeding to procedures with high bleeding risk is particularly important in optimizing the peri-procedural management plan of antithrombotic therapy.

The majority of branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) are recommended for surveillance imaging based on consensus guidelines. However, growth rates that should prompt concern for malignant transformation of BD-IPMN are unknown. To determine whether BD-IPMN growth can predict an increased risk of malignancy and define growth rates concerning for malignant BD-IPMN. The study is a retrospective, multicenter study of suspected BD-IPMN patients undergoing imaging surveillance. All patients underwent EUS evaluation followed by surveillance imaging. Two hundred and eighty-four patients with suspected BD-IPMN without worrisome features or high-risk stigmata were followed for a median 56 months and underwent a median of four imaging studies. Nine patients (3.2 %) developed malignant BD-IPMN. Malignant BD-IPMN grew at a faster rate (18.6 vs. 0.8 mm/year; P = 0.05) compared to benign BD-IPMN. BD-IPMN growth rate between 2 and 5 mm/year was associated with an increased risk of malignancy with hazard ratio (HR) of 11.4 (95 % CI 2.2–58.6) when compared to subjects with BD-IPMN growth rate

Endoscopic ultrasonography (EUS) is currently an integral tool for work-up of pancreaticobiliary neoplasms. Tissue acquisition by EUS is possible with fine-needle aspiration (FNA) cytology and histology. However, FNA still carries some limitations and risks of complications. The use of image-enhanced EUS may improve detection and characterization of pancreaticobiliary neoplasms and complement FNA. The present article aims to provide an overview of the current development of contrast-enhanced imaging and elastography in EUS and their potential application in the diagnosis of pancreaticobiliary diseases.

ObjectivesInterventional endoscopic ultrasonography (EUS) procedures are gaining popularity and the most commonly performed procedures include EUS-guided drainage of pancreatic pseudocyst, EUS-guided biliary drainage, EUS-guided pancreatic duct drainage and EUS-guided celiac plexus ablation. The aim of this paper is to formulate a set of practice guidelines addressing various aspects of the above procedures.MethodsFormulation of the guidelines was based on the best scientific evidence available. The RAND/UCLA appropriateness methodology (RAM) was used. Panellists recruited comprised experts in surgery, interventional EUS, interventional radiology and oncology from 11 countries. Between June 2014 and October 2016, the panellists met in meetings to discuss and vote on the clinical scenarios for each of the interventional EUS procedures in question.ResultsA total of 15 statements on EUS-guided drainage of pancreatic pseudocyst, 15 statements on EUS-guided biliary drainage, 12 statements on EUS-guided pancreatic duct drainage and 14 statements on EUS-guided celiac plexus ablation were formulated. The statements addressed the indications for the procedures, technical aspects, pre- and post-procedural management, management of complications, and competency and training in the procedures. All statements except one were found to be appropriate. Randomised studies to address clinical questions in a number of aspects of the procedures are urgently required.ConclusionsThe current guidelines on interventional EUS procedures are the first published by an endoscopic society. These guidelines provide an in-depth review of the current evidence and standardise the management of the procedures.

Mucosal healing is the goal for ulcerative colitis (UC) therapy, but it needs to be confirmed via colonoscopy. Colon capsule endoscopy (CCE) is a noninvasive technique for colon investigation. Our study investigated the accuracy of second-generation CCE (CCE-2) in assessing mucosal lesions and disease activity in UC.In this prospective study, CCE-2 and conventional colonoscopy were performed on the same day. CCE-2 reviewers and colonoscopists used the Mayo endoscopic subscore (MES) and the Ulcerative Colitis Endoscopic Index of Severity (UCEIS) to assess disease activity, and they were blinded to each other's findings. Diagnostic parameters of CCE-2 for identifying mucosal lesions were evaluated by using colonoscopy as the reference.A total of 150 patients were enrolled. Of the 150 patients, 108 were included for per-patient analysis. CCE-2 and colonoscopy showed substantial agreement in measuring MES (intraclass correlation coefficient [ICC] 0.69; 95% confidence interval [CI], 0.46-0.81; P .001) and UCEIS (ICC 0.64; 95% CI, 0.38-0.78; P .001). CCE-2 had a sensitivity of 97% and 94% to detect mucosal inflammation (MES0) and moderate to severe inflammation (MES1), respectively. In per-segment analysis, the negative predictive values of CCE-2 to detect mucosal inflammation, including vascular pattern loss, bleeding, and erosions reached 94% to 95%. Interobserver agreement between 2 independent CCE-2 readers for both scoring systems was good (ICC .80). The sensitivity and specificity of CCE-2 in detecting postinflammatory polyps were 100% and 91%, respectively. CCE-2 was better tolerated and preferred by patients than was colonoscopy.CCE-2 yields high accuracy in detecting mucosal lesions and determining disease severity in UC. It represents a well-tolerated and reliable tool for disease monitoring in UC. (Clinical trial registration number: NCT02469103.).

To test the hypothesis that trained nurse endoscopists are not inferior to medical endoscopists in finding adenomas during colonoscopy.This is a prospective, randomised, single-blind, non-inferiority study comparing nurses with medical endoscopists in performing screening colonoscopy. The nurse endoscopists had been trained according to the British Joint Advisory Group on GI Endoscopy curriculum and had completed at least 140 colonoscopic procedures prior to the study. The primary endpoint was the adenoma detection rate. Secondary endpoints included the caecal intubation rate, intubation time, complication rate, patient pain and satisfaction scores.We enrolled and analysed a total of 731 patients over a 15-month period. At least one adenoma was found in 159 (43.8%) of 363 patients by nurse endoscopists and 120 (32.7%) of 367 patients by medical endoscopists and a proportion difference of +11.1% compared with the medical endoscopists (95% CI 4.1% to 18.1%). The withdrawal time was, however, significantly longer among nurses (998 vs 575 s, p0.001). After adjusting for differences in a regression analysis, colonoscopy by nurses was associated with a lower adenoma detection rate (OR 0.475: 95% CI 0.311 to 0.725). Nurse endoscopists had a lower caecal intubation rate (97.3% vs 100%), received better pain and satisfaction scores and had a high rate of patient acceptance.In this pragmatic trial, nurses can perform screening colonoscopy but require a longer procedural time to achieve a comparable adenoma detection rate as medical endoscopists.NCT01923155.

Summary Background Serrated polyps of the colorectum have distinct histological features and malignant potential. Aim To assess the association between the presence of serrated polyps and synchronous advanced colorectal neoplasia. Methods Among 4989 asymptomatic Chinese individuals aged 50–70 years who underwent screening colonoscopy, 281 cases with advanced neoplasia (adenoma ≥1 cm, with tubulovillous/villous histology, with high-grade dysplasia, or invasive adenocarcinoma) were compared with 4708 controls without advanced neoplasia for age, sex, smoking history, body mass index, family history of colorectal cancer and the presence of serrated polyps. Independent predictors of advanced neoplasia were determined by multivariate logistic regression analysis. Results The prevalence of advanced neoplasia and serrated polyps (excluding small distal hyperplastic polyps) was 5.7% and 5.6%, respectively. 3.7% and 0.4% subjects had proximal and large (≥10 mm) serrated polyps, respectively. Independent predictors of synchronous advanced colorectal neoplasia were the presence of sessile serrated adenomas (OR: 4.52; 95% CI: 2.40–8.49), proximal serrated polyps (OR: 2.23, 95% CI: 1.38–3.60), large serrated polyps (OR: 59.25; 95% CI: 18.85–186.21), hyperplastic polyps (OR: 1.66; 95% CI: 1.03–2.67), three or more serrated polyps (OR: 4.86; 95% CI: 1.24–19.15) and one or more non-advanced tubular adenomas (OR: 3.58, 95% CI: 2.59–4.96). Conclusion Detection of proximal, sessile and/or large serrated polyps at screening colonoscopy is independently associated with an increased risk for synchronous advanced neoplasia.

Background and Aims: Upper GI bleeding (UGIB) still constitutes one of the major hospital admissions\ud through emergency departments (EDs). This feasibility study aims to test whether capsule endoscopy (CE)\ud can reduce unnecessary hospital admissions in patients with suspected UGIB.\ud Methods: This was a prospective randomized controlled trial in which patients who presented with symptoms or\ud signs suggestive of UGIB were randomized to receive either the standard treatment (ST) of hospital management\ud or receive CE, after which hospital admission was determined by the findings of CE. Patients were also graded by\ud Glasgow Blatchford score (GBS) at the ED for assessment of need of hospital admission.\ud Results: Seventy-one patients fulfilled the recruitment criteria, with 37 subjects enrolled into the CE group and\ud 34 subjects into the ST group. Seven CE patients with active bleeding or significant endoscopic findings were\ud admitted to the hospital compared with the ST group in which all 34 patients were admitted. There was no difference\ud in the clinical outcome in terms of recurrent bleeding and 30-day mortality. Hospital admission was also\ud greatly reduced if CE instead of GBS was used to triage patients in the ED.\ud Conclusions: This feasibility study shows that CE offers a safe and effective method in triaging patients presenting\ud with symptoms of UGIB that do not require hospital admission. (Clinical trial registration number:\ud NCT02446678.)

Background & Aims It is not clear whether H2-receptor antagonists (H2RAs) reduce the risk of gastrointestinal (GI) bleeding in aspirin users at high risk. We performed a double-blind randomized trial to compare the effects of a proton pump inhibitor (PPI) vs a H2RA antagonist in preventing recurrent upper GI bleeding and ulcers in high-risk aspirin users. Methods We studied 270 users of low-dose aspirin (≤325 mg/day) with a history of endoscopically confirmed ulcer bleeding at 8 sites in Hong Kong and Japan. After healing of ulcers, subjects with negative results from tests for Helicobacter pylori resumed aspirin (80 mg) daily and were assigned randomly to groups given a once-daily PPI (rabeprazole, 20 mg; n = 138) or H2RA (famotidine, 40 mg; n = 132) for up to 12 months. Subjects were evaluated every 2 months; endoscopy was repeated if they developed symptoms of upper GI bleeding or had a reduction in hemoglobin level greater than 2 g/dL and after 12 months of follow-up evaluation. The adequacy of upper GI protection was assessed by end points of recurrent upper GI bleeding and a composite of recurrent upper GI bleeding or recurrent endoscopic ulcers at month 12. Results During the 12-month study period, upper GI bleeding recurred in 1 patient receiving rabeprazole (0.7%; 95% confidence interval [CI], 0.1%–5.1%) and in 4 patients receiving famotidine (3.1%; 95% CI, 1.2%–8.1%) (P = .16). The composite end point of recurrent bleeding or endoscopic ulcers at month 12 was reached by 9 patients receiving rabeprazole (7.9%; 95% CI, 4.2%–14.7%) and 13 patients receiving famotidine (12.4%; 95% CI, 7.4%–20.4%) (P = .26). Conclusions In a randomized controlled trial of users of low-dose aspirin at risk for recurrent GI bleeding, a slightly lower proportion of patients receiving a PPI along with aspirin developed recurrent bleeding or ulcer than of patients receiving an H2RA with the aspirin, although this difference was not statistically significant. ClincialTrials.gov no: NCT01408186.

Endoscopic ultrasound (EUS) is a well-established tool for the evaluation of pancreatic lesions. Due to the closer proximity of EUS to the pancreas, EUS offers a high sensitivity for detection of small pancreatic mass and is the preferred modality for obtaining tissue for diagnosis of pancreatic mass. Contrast-enhanced EUS and/or elastography provide additional information to the fundamental B—mode ultrasound images, leading to more accurate diagnosis. The aim of this video-article is to show the different steps in performing EUS on pancreatic lesions and to provide some tips and tricks to improve and facilitate the execution of EUS on pancreatic lesions.

The epidemiology of peptic ulcer disease (PUD) has undergone significant changes since the discovery of Helicobacter pylori. Various aetiologies contribute to recurrent PUD. Ulcers related to untreated H. pylori infection tend to recur. Use of NSAIDs, low-dose aspirin and dual anti-platelet therapy have become important risk factors for recurrent ulcers and their complications as the proportion of H. pylori-related ulcers declines. Recent data have shown that H. pylori-negative, NSAID-negative idiopathic peptic ulcers are on the rise and carry a higher risk of recurrent ulcer bleeding and mortality. Effective management of recurrent PUD relies on identification and modification of treatable risk factors. Persistent H. pylori infection should be carefully ruled out. Choice of an effective H. pylori eradication regimen should be based on local antibacterial resistance patterns. For patients who need long-term NSAID therapy, the initial choice of an NSAID relates to a patient's cardiovascular risk, and the need for therapy to decrease gastrointestinal (GI) complications is determined by the severity and number of GI risk factors. For patients on dual anti-platelet therapy, strategies to prevent recurrent ulcer disease and its complications centre on balancing the bleeding and thrombotic risks of individual patients. Long-term proton pump inhibitor maintenance therapy may be necessary to prevent recurrent ulcer bleeding for patients with ulcer bleeding from H. pylori-negative, NSAID-negative ulcers, and for patients who require NSAID or aspirin maintenance therapy.

Background Studies suggest that endoscopist-related factors such as colonoscopy withdrawal time are important in determining the adenoma detection rate (ADR). Objective To determine the importance of withdrawal technique in differentiating among endoscopists with varying ADRs. Design Prospective, multicenter study. Setting Five academic tertiary-care medical centers. Participants This study involved 11 gastroenterology faculty endoscopists. Intervention A retrospective review of screening colonoscopies was performed to categorize endoscopists into low, moderate, and high ADR groups. Video recordings were randomly obtained for each endoscopist on 20 (10 real, 10 sham) withdrawals during colonoscopies performed for average-risk colorectal cancer screening. Three blinded reviewers assigned withdrawal technique scores (total of 75 points) on 110 video recordings. A separate reviewer recorded withdrawal times. Main Outcome Measurements Withdrawal technique scores and withdrawal times. Results Mean (± standard deviation [SD]) withdrawal technique scores were higher in the moderate (62 ± 2.5) and high (59.5 ± 3) ADR groups compared with the low (40.8±3) ADR group ( P = .002). Mean (± SD) withdrawal times were 6.3 ± 1.8 minutes (low ADR), 10.2 ± 1.5 minutes (moderate ADR), and 8.2 ± 1.8 minutes (high ADR) ( P = .29). A comparison of the withdrawal times and technique scores of the two individual endoscopists with the lowest and highest ADRs did not find a significant difference in withdrawal times (6.6 ± 1.7 vs 7.4 ± 1.7 minutes) ( P = .36) but did find a nearly 2-fold difference in technique scores (36.2 ± 9 vs 62.8 ± 9.9) ( P = .0001). Limitations Not adequately powered to detect small differences in withdrawal times. Conclusion Withdrawal technique is an important indicator that differentiates between endoscopists with varying ADRs. It is possible that withdrawal technique is equal to, if not more important than, withdrawal time in determining ADRs.