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Background: Helicobacter pylori (H. pylori) is one of the most common chronic infections. It is linked to the development of peptic ulcers and is considered an important factor in the development of gastric cancer. With an appropriate therapeutic regimen, the eradication of H. pylori infection can be achieved, gastritis can be cured, and we can alter its progression to the complications. In this study, we aimed to measure medical staff knowledge about the different regimens and treatment plans for H. pylori infection in Buraydah, Saudi Arabia. Methods: A 23-item questionnaire was filled out by 60 internal medicine physicians in the private sector to assess different variables regarding H. pylori knowledge and treatment. Results: A total of 40 responses were included [30 (75%) men, 26 (68%) < 45 years]. We found that a higher knowledge score was more associated with being a male (T = 2.397; p = 0.002) and those having sources of H. pylori's information such as national meetings (T = 2.418; p = 0.020) and internet (T = 2.063; p = 0.046), while the differences in the score of knowledge among age (p = 0.992) and degree/title (p = 0.547) were not significantly different. Conclusion: There are knowledge discrepancies among the participants with a wide spread of data sources regarding H. pylori management, screening, and diagnosis. There was also a statistically valuable difference regarding physicians' choice of information source. Those who obtained their information through national meetings and internet sources were more knowledgeable than those who obtained it in another way. For future research, we suggest exploring the connection between information sources and the knowledge level and attitude concerning treatment plans.

Background and Aims Digital single-operator cholangioscopy (DSOC) allows direct visualization of the biliary tree for evaluation of biliary strictures. Our objective was to assess the interobserver agreement (IOA) of DSOC interpretation for indeterminate biliary strictures using newly refined criteria. Methods Fourteen endoscopists were asked to review an atlas of reference clips and images of 5 criteria derived from expert consensus. They then proceeded to score 50 deidentified DSOC video clips based on the visualization of the following: (1) tortuous and dilated vessels, (2) irregular nodulations, (3) raised intraductal lesion, (4) irregular surface with or without ulcerations, and (5) friability. The endoscopists then diagnosed the clips as neoplastic or non-neoplastic. Intraclass correlation (ICC) analysis was done to evaluate interrater agreement for both criteria sets and final diagnosis. Results Clips of 41 malignant lesions and 9 benign lesions were scored. Three out of 5 revised criteria had almost perfect agreement. ICC was almost perfect for presence of tortuous and dilated vessels (0.86), raised intraductal lesions (0.90), and presence of friability (0.83); substantial agreement for presence of irregular nodulations (0.71); and moderate agreement for presence of irregular surface with or without ulcerations (0.44). The diagnostic ICC was almost perfect for neoplastic diagnosis (0.90) and non-neoplastic (0.90). The overall diagnostic accuracy using revised criteria was 77%, ranging from 64% to 88%. Conclusion The IOA and accuracy rate of DSOC using the new Mendoza criteria shows a significant increase of 16% and 20% compared with previous criteria. The reference atlas helps with formal training and may improve diagnostic accuracy.

Introduction Celiac disease is an immune-mediated systemic disease. It is prevalent and has diverse clinical manifestations; gastrointestinal symptoms are more common in children, including failure to thrive, chronic diarrhea, vomiting, and abdominal distention. The diagnosis should be made at a precise time to evade severe irreversible complications, especially for pediatric patients. This study aimed to determine the clinical presentation and diagnosis, including laboratory, serological tests, and histopathological findings, in pediatric celiac disease patients. Patients and methods From January 2019 to August 2021, all children with a confirmed celiac disease diagnosis at Maternity and Children's Hospital in Buraydah, Qassim region, Saudi Arabia, were studied retrospectively. Information was collected, including demographics, clinical presentation, and diagnostic modalities with serology and small intestinal histology reported by Marsh grading. Results Fourteen patients were reviewed, with a mean age of 8.64 years. Marsh grading of those who underwent biopsy revealed that half of the patients had type 3a, and the rest had either type 1 or 3b celiac disease. Clinical manifestations included abdominal distention and chronic diarrhea, and some patients were asymptomatic. Conclusion Abdominal distention, chronic diarrhea, constipation, and nausea were the most common clinical features. Patients with a family history of celiac disease, longer symptom duration, and higher tissue transglutaminase immunoglobulin A

Background Peroral endoscopic myotomy (POEM) was proposed in 2010 as a minimally invasive procedure for the treatment of achalasia. In this article, we describe the Middle Eastern experience with the procedure in terms of efficacy, length of admission, and short- and long-term complications. Methods A retrospective analysis of our prospectively collected data on patients who underwent a POEM procedure was conducted between March 2019 and May 2020. The primary outcome was clinical success rate, defined as a postprocedure Eckardt score ≤3 at ≥3 months. Secondary outcomes included the length of hospital stay, presence of reflux symptoms or need for proton pump inhibitors (PPIs) ≥3 months, and adverse events. Results During the study period, 67 patients (35 females) underwent the procedure for achalasia. The participants' ages ranged from 11 to 80 years (mean 41 ± 18 years). Eckardt scores before the treatment ranged between 4 and 12 (mean 8.85 ± 1.75). Sixty-four patients (95.5%) achieved Eckardt scores of ≤3 at ≥3 months after the procedure (95% confidence interval [CI]: 91%-100%). The difference between pre- and post-procedural Eckardt scores averaged around -8 points (95% CI: -7.5 to -8.5 P < 0.0001). Adverse events were reported in 24 patients (35.8%) and included pneumoperitoneum (32.8%), reflux symptoms at 3 months (29.9%), and surgical emphysema (3%). Six patients had adverse events that led to prolongation of admission; 3% of whom had aspiration pneumonia, 3% had pneumoperitoneum, 1.5% had both, and 1.5% had an esophageal tear. Conclusions POEM is a promising procedure for the treatment of achalasia with a high clinical success rate, short hospital admission, and a reassuring safety profile.

BACKGROUND AND AIM Gastroparesis is a potentially debilitating gastric motility disorder with limited treatment options. Highest efficacy treatments include gastric per-oral endoscopic myotomy (GPOEM) and surgical pyloromyotomy. This study compares the efficacy and safety of GPOEM versus laparoscopic pyloromyotomy for refractory gastroparesis. METHODS Patients who underwent GPOEM or laparoscopic pyloromyotomy for refractory gastroparesis from four centers across the USA and Latin America were included in a dedicated registry. Data collected included patient demographics, imaging, laboratory values, clinical success, gastroparesis cardinal symptom index, procedure time, pre-op and post-op gastric emptying times, adverse events, and hospital length of stay. RESULTS A total of 102 patients were included (mean age 47; 32.4% male): GPOEM n = 39, surgical pyloromyotomy n = 63.Technical success was 100% in both groups. Clinical success was 92.3% in the GPOEM group and 82.5% in the surgery group (P = 0.164). The GPOEM group had a significantly higher post-op GSCI score reduction by 1.3 units (P

Management of pancreatic duct strictures is a challenging task. Different modalities can be offered based on available tools and expertise. Options include endoscopic pancreatic duct stenting using conventional ERCP, EUS-guided pancreatic drainage, and finally surgery. This chapter explores the different options we dispose for treating this difficult condition.

Benign pancreatic duct strictures remain a challenging diagnosis. Etiology are multiple and diverse, but recent novel techniques has permitted to make progress in this field and offer the possibility to exclude a neoplastic etiology in the majority of cases. This chapter explore the different diagnostic tools we dispose for the workup of this difficult condition.

Diabetes is often poorly managed in hospitals. This study assessed the level of adherence to current Canadian practice guidelines for inpatient pharmacologic management of type 2 diabetes and whether it affected the frequency of hyperglycemia or hypoglycemia.Retrospectively, we assessed the first 3 days of routine inpatient capillary blood glucose measurement (CBGM) records for hyperglycemia (8 mmol/L fasting,10 mmol/L nonfasting) and hypoglycemia (4 mmol/L) in adults with drug-treated type 2 diabetes admitted to internal medicine without metabolic decompensation or nil per os (NPO) status at 2 hospitals during October through December 2014. Patients, divided according to their admission orders into guideline-adherent versus guideline-nonadherent groups were compared for frequency of hyperglycemia and hypoglycemia. Factors predicting guideline adherence were assessed.Of 150 patients with diabetes who were admitted, 108 met entry criteria. A total of 89 patients received guideline-based care (82%), whereas 19 patients did not (18%). Charlson index and preadmission medications did not predict guideline-based care, but admitting physicians' seniority did (junior, senior resident, attending physician; p=0.05). In the adherent group, 43% of CBGMs were hyperglycemic, versus 64% in the nonadherent group (p=0.01). For hypoglycemia, proportions were 2% versus 1%, respectively (p=0.21).Adherence to guidelines for inpatient type 2 diabetes management is good and may be greater with more training. Hyperglycemia was more common in patients who did not receive guideline-based care. Hypoglycemia was uncommon and did not appear to be more common in the guideline-adherent group, although numbers were small. These results may alleviate physicians' fear that providing adequate insulin to hospitalized patients may cause hypoglycemia.

With the global pandemic due to coronavirus disease 2019 (COVID-19), there has been a significant strain on healthcare facilities. The infectivity rate, as well as the rate of healthcare workers who have fallen ill to the disease, has raised concerns globally on the proper management of patients as well as the role of safe healthcare provision utilizing personal protective equipment (PPE). Furthermore, the limited supply of PPEs has mandated rationing their use to achieve maximum utility and preservation. Multiple gastroenterology associations have issued guidance and statements that would help healthcare providers in navigating these unprecedented and difficult times, and the Saudi Gastroenterology Association has provided this statement in an effort to bring the most up to date information for the management of endoscopy units in terms of resources, manpower planning, scheduling, as well as infection control policies and leadership.

Vanishing bile duct syndrome (VBDS) is a rare acquired disorder associated with progressive destruction and disappearance of intrahepatic bile ducts which eventually leads to cholestasis. VBDS has been linked to a variety of etiologies, including autoimmune disorders, infectious diseases, primary neoplasms, genetic abnormalities, and many classes of medications, including antibiotics, nonsteroidal anti-inflamatories (NSAIDs), anticonvulsants, antipsychotics and others. We present the case of VBDS associated with anabolic androgenic steroid (AAS) exposure in an otherwise healthy 29-year-old male. Resume Le syndrome de disparition des canaux biliaires (SDCB) est une affection acquise rare caractérisée par la destruction progressive et la disparition des canaux biliaires intrahépatiques entrainant une cholestase. Le SDCB a été associé à diverses étiologies, dont des affections auto-immunes, des maladies infectieuses, des néoplasmes primaires, des anomalies génétiques et de nombreuses classes de médicaments, incluant des antibiotiques, des anti-inflammatoires non stéroïdiens, des anticonvulsivants, des antipsychotiques et autres. Nous présentons un cas de SDCB associé à la prise d’un stéroïde androgénique anabolisant chez un homme de 29 ans par ailleurs en bonne santé.

Adrenal hemorrhage (AH) is a rare condition with an estimated prevalence of 1% among hospital-based autopsies. It is usually discovered incidentally on computed tomography.1 Most cases are associated with the use of anticoagulation, especially in the setting of heparin-induced thrombocytopenia, anti-phospholipid antibody syndrome, trauma, metastatic disease, sepsis, and critical illness.5-7 We report a case of acute unilateral adrenal hemorrhage associated with Escherichia coli pyelonephritis in the context of recent prolonged steroid use.

1Department of Medicine, McMaster University, Hamilton; 2Department of Gastroenterology, Sunnybrook Health Science, Toronto, Ontario Correspondence: Dr Lawrence Cohen, Department of Gastroenterology, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, HG-63, Toronto, Ontario M4N 3N5. Telephone 416-480-4725, fax 416-480-5977, e-mail lawrence.cohen@sunnybrook.ca Received for publication June 21, 2014. Accepted July 1, 2014 CASE PRESENTATION A 67-year-old woman was brought to the endoscopy unit in May 2014 for removal of a covered self-expanding metal stent (SEMS) from the common bile duct (CBD), initially placed in May 2013 to manage recurrent cholangitis. The patient developed idiopathic pancreaticobiliary dysmotility following cholecystectomy in 2001. She experienced recurrent episodes of pancreatitis and cholangitis for which she required numerous endoscopic retrograde cholangiopancreatograms, including the insertion of biliary plastic stents to facilitate drainage, extraction of CBD stones and/or clearing debris from the biliary tree. Her most recent intervention had been the insertion of a SEMS, which was effective in preventing recurrent cholangitis over the year. On physical examination, she appeared to be fit, well-nourished and in no distress, with no pallor, jaundice or lymphadenopathy. An abdominal examination was unremarkable. Laboratory investigations were within normal limits, without any contraindications to endoscopy.

1Department of Medicine, McMaster University, Hamilton, Ontario; 2Department of Medicine, University of Calgary, Calgary, Alberta; 3Division of Gastroenterology, McMaster University, Hamilton, Ontario; 4Harvard School of Public Health, Harvard University, Boston, Massachusetts, USA Correspondence: Dr Frances Tse, Division of Gastroenterology, McMaster University, Room 2F53, 1200 Main Street West, Hamilton, Ontario L8N 3Z5. Telephone 905-521-2100 ext 76733, fax 905-523-6048, e-mail tsef@mcmaster.ca Received for publication April 21, 2013. Accepted May 12, 2013 Case presentation A 53-year-old man admitted for stem cell transplantation in the context of acute myeloid leukemia was referred for gastric content leakage from a persistent gastrocutaneous fistula. A percutaneous endoscopic gastrostomy (PEG) tube had been placed for four months due to suboptimal nutrition. The PEG tube was subsequently removed due to improvement in caloric intake and nutritional status. Unfortunately, drainage of gastric contents (approximately 250 mL/day) from the gastrocutaneous fistula after removal of the PEG tube persisted. This led to peristomal skin maceration and breakdown resulting in local cutaneous bleeding from the PEG tube site. Despite conservative management with bowel rest, proton pump inhibitor therapy, wound care and parenteral nutrition, drainage and bleeding from the gastrocutaneous fistula site persisted. The remainder of his medical history was noncontributory. Physical examination using subjective global assessment revealed a hemodynamically stable man with adequate nutritional status, without any examination or laboratory contraindications to endoscopy. Informed consent was obtained to proceed with an attempt to close the gastrocutaneous fistula via endoscopic hemoclips before considering surgical closure. During endoscopy, the opening of the fistula was identified in the antrum (Figure 1). Single-modality therapy was used and three hemoclips were placed in an attempt to close the fistula site (Figure 2). A stoma bag was placed over the pre-existing fistula site; no air leakage was observed at the time of endoscopy. The fistula tract closed within 24 h after the procedure with no further leakage noted. The patient was closely followed over the ensuing week. Daily clinical assessments were conducted and no evidence of gastric content was noted at the previous fistula site. The patient was kept nil per os for three days and proton pump inhibitor therapy was continued. His diet was then advanced. The lack of gastric output from the fistula tract postendoclip placement, even after the initiation of oral feeds, confirmed the successful outcome of the procedure (Figure 3).