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Mahmud Mahamid1,2, Tawfik Khoury2,3, Baker Mahamid1, Wisam Sbeit2,3, Amir Mari1, Wiliam Nseir2,4 1Gastroenterology and Hepatology Unit, Nazareth Hospital EMMS, Nazareth, Israel; 2Faculty of Medicine in the Galilee, Bar-Ilan University, Safed, Israel; 3Department of Gastroenterology, Galilee Medical Center, Nahariya, Israel; 4Internal Medicine Department, Nazareth Hospital EMMS, Nazareth, IsraelCorrespondence: Mahmud MahamidDivision of Internal Medicine, Gastroenterology and Endoscopy Unit, EMMS, the Nazareth Hospital, Nazareth 16100, IsraelTel +972 4 602 8851Fax +972 74 755 9051Email mahmudmahamid@yahoo.comBackground: Abdominal aortic aneurysm (AAA) and fatty liver disease are both associated with the metabolic syndrome (MS); the aim of this study was to investigate whether patients with AAA are also at a higher risk for fatty liver disease.Methods: A case-control retrospective study. Patients diagnosed with AAA were compared with age- and sex-matched controls regarding the prevalence of fatty liver disease. Extracted data include anthropometric parameters, clinical and laboratory data, and liver imaging.Results: 995 patients were enrolled in the final analysis, 495 patients with AAA and 500 age- and sex-matched controls. The prevalence of fatty liver disease among AAA subjects was 48.9% compared with 21.2% among the controls (P

This article compares the efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) versus endoscopic retrograde cholangiopancreatography (ERCP) for primary drainage in patients with distal malignant biliary obstruction (DMBO). The study analyzed five randomized controlled trials involving 519 patients. The results showed that EUS-BD had a higher technical success rate and 1-year stent patency compared to ERCP, with similar clinical success rates and safety profiles. The authors suggest that EUS-BD could be considered as a first-line approach for DMBO due to its good performance. [Extracted from the article]

This article, published in the journal Endoscopy, introduces a novel method for guiding ERCP (endoscopic retrograde cholangiopancreatography) navigation using multi-polar electrodes and electrochemical impedance spectroscopy (EIS). The study collected data from 10 patients to measure the electrical properties of bile and pancreatic juices during ERCP procedures. The results showed that the multi-pole sensors successfully differentiated between bile and pancreatic/mixed juices, indicating the potential for selective and safe biliary cannulation. Further research and validation are needed to establish the clinical applicability and benefits of this electrochemical navigation method. [Extracted from the article]

Objective: Endoscopic ultrasound guide fine needle biopsy (EUS-FNB) is the main diagnostic tool for pancreatic adenocarcinoma. In most instances, only histology is obtained via FNB, without sending cytological slides. The aim of our study was to assess the additive diagnostic yield of cytology performed through FNB., Methods: We conducted a retrospective study of all patients with histological diagnosis of pancreatic adenocarcinoma who were diagnosed by EUS-FNB., Results: Overall, 80 patients were included in the study period. The overall concordance between cytology and histology all FNB needles was 78.2%. Notably, cytological assessment improved the diagnostic yield for malignancy by 12.8%. The overall kappa coefficient correlation between histology and cytology was .501, 95% CI 0.361-0.641. However, the kappa correlation for suspicious of malignancy and malignant was excellent of .872, 95% CI 0.733-1, suggesting that cytology is crucial when histology is inconclusive. Further analysis showed that the Acquire and Sharkcore needles outperformed the Procore needle in term of concordance between cytology and histology (kappa correlation of .527, 95% CI 0.331-0.724, .515, 95% CI 0.265-0.764, and .297, 95% CI -0.051-0.646), respectively., Conclusion: Performing cytology specimen when using FNB improves the diagnostic yield in pancreatic adenocarcinoma., (© 2024 The Author(s). Diagnostic Cytopathology published by Wiley Periodicals LLC.)

Background:  We assessed efficacy and safety of endoscopic ultrasound-guided biliary drainage (EUS-BD) vs. endoscopic retrograde cholangiopancreatography (ERCP) as first-line intervention in malignant distal biliary obstruction (MDBO)., Methods:  PubMed/Medline, Embase, and Cochrane databases were searched until 01 /12 /2023 for randomized controlled trials of EUS-BD vs. ERCP for primary biliary drainage in patients with inoperable MDBO. The primary outcome was technical success. Secondary outcomes were clinical success, adverse events, mean procedure time, 1-year stent patency, and overall survival. Relative risk (RR) with 95 %CI were calculated using a random effects model., Results:  Five studies (519 patients) were included. RR (95 %CI) for EUS-BD was 1.06 (0.96 to 1.17; P = 0.27) for pooled technical success and 1.02 (0.97 to 1.08; P = 0.45) for clinical success. 1-year stent patency was similar between the groups (RR 1.15, 0.94 to 1.42; P = 0.17), with lower reintervention with EUS-BD (RR 0.58, 0.37 to 0.9; P = 0.01). The RR was 0.85 (0.49 to 1.46; P = 0.55) for adverse events and 0.97 (0.10 to 0.17; P = 0.98) for severe adverse events. On subgroup analysis, EUS-guided placement of lumen-apposing metal stent (LAMS) outperformed ERCP in terms of technical success (RR 1.17, 1.01 to 1.35; P = 0.03). Procedure time was lower with EUS-BD (standardized mean difference -2.36 minutes [-2.68 to -2.05; P < 0.001])., Conclusions:  EUS-BD showed a statistically significant lower reintervention rate than ERCP, but with similar technical success, stent patency, clinical success, and safety. Technical success of EUS-BD with LAMS was better than ERCP., Competing Interests: B. Napoléon has delivered a teaching session for Taewoong and is a consultant for Boston Scientific. A. Lisotti, P. Fusaroli, and F. Fumex are consultants for Boston Scientific. A.Y.B. Teoh is a consultant for Boston Scientific, Cook, Taewoong, Microtech, and MI Tech Medical. T. Khoury, W. Sbeit, G. Marasco, L.H. Eusebi, S.M. Chan, A. Shahin, M. Basheer, R. Gincul, S. Leblanc, and J. Jacques declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background: Dyspepsia is a very prevalent upper gastrointestinal tract symptoms complex. Some of these symptoms might arise from serious underlying diseases, so the promotion of evidence-based guidelines could potentially better align evaluation and treatment., Aim: To determine the value of alarm features as a predictive factor for significant endoscopic findings (SEFs) among hospitalized patients presenting with dyspepsia., Methods: We conducted a retrospective case-control study including information about 6208 endoscopic procedures performed for hospitalized patients. Patients were divided into two groups, with and without SEFs, and compared to elucidate the ability of the different alarm features to predict SEFs., Results: During the study, 605 patients fulfilled the inclusion criteria. When the demographics and clinical characteristics of the two groups were compared, tachycardia ( P < 0.05), normocytic anemia, ( P < 0.05), leukocytosis ( P < 0.05), and hypoalbuminemia ( P < 0.05) documented on admission prior to endoscopy were strong predictors of SEFs. Among the alarm features, upper gastrointestinal bleeding, persistent vomiting, odynophagia [odds ratio (OR) = 3.81, P < 0.05; OR = 1.75, P = 0.03; and OR = 7.81, P = 0.07, respectively] were associated with SEFs. Unexplained weight loss was strongly associated with malignancy as an endoscopic finding (OR = 2.05; P < 0.05). In addition, long-term use of anti-aggregate medications other than aspirin ( P < 0.05) was correlated to SEFs., Conclusion: Novel predictors of SEFs were elucidated in this study. These parameters could be used as an adjunctive in decision making regarding performing upper endoscopy in hospitalized patients with dyspepsia., Competing Interests: Conflict-of-interest statement: The authors have no conflicts of interest to declare., (©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.)

Background: Dilatation of common bile duct (CBD) is mostly pathological and mainly occurs secondary to mechanical causes. We aimed to explore the prevalence of CBD dilatation in Intraductal Papillary Mucinous Neoplasms of the pancreas (IPMN) among patients referred to EUS., Methods: A retrospective study of all patients who had an EUS diagnosis of IPMN from 2011 to 2019 at Galilee Medical Center were extracted. Control group including patients with other types of pancreatic cysts., Results: Overall, 2400 patients were included in the study, of them 158 patients were diagnosed with pancreatic cysts, 117 patients (74%) diagnosed with IPMN (group A), and 41 patients (26%) diagnosed with other pancreatic cysts (group B). Univariate analysis showed significant association of IPMN (OR 3.8, 95% CI 1.3-11.5), resected gallbladder (GB) (OR 7.75, 95% CI 3.19-18.84), and age (OR 1, 95% CI 1.01-1.08) with CBD dilatation. Classifying IPMN to sub-groups using adjusted multivariate logistic regression analysis, only main duct-IPMN (MD-IPMN) significantly correlated with CBD dilatation compared to branch duct (BD)-IPMN and mixed type-IPMN (OR 19.6, 95% CI 4.57-83.33, OR 16.3, 95% CI 3.02-88.08)., Conclusion: MD-IPMN was significantly correlated with dilated CBD. Assessment of the pancreas is warranted in encountered cases of dilated CBD without obvious mechanical cause., (© 2024. The Author(s).)

Objective: Endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) has been constantly increasing, particularly in the treatment of pancreatic neuroendocrine neoplasms (pNENs). While emerging data in this field are accumulating, we aimed to assess the pooled efficacy and safety of EUS-RFA for pNENs., Methods: The PubMed/Medline, Embase, and Cochrane Library databases search was conducted to identify studies reporting EUS-RFA of pNENs with outcomes of interest (efficacy and safety). The primary outcome was radiological response. Efficacy was assessed by the pooled clinical response rate, whereas safety was assessed by the pooled adverse events (AEs) rate. Heterogeneity was assessed using I 2 . Pooled estimates and the 95% confidence interval (CI) were calculated using a random-effect model., Results: Eleven studies involving 292 patients were included. The pooled technical success rate was 99.2% (95% CI 97.9-99.9%), with no heterogeneity. The pooled complete radiological response was 87.1% (95% CI 80.1-92.8%). The pooled partial response was 11.4% (95% CI 6.2-18.1%). The pooled clinical response rate for functional pNENs was 94.9% (95% CI 90.7-97.9%), with no heterogeneity. The pooled incidence of AEs was 20.0% (95% CI 14.0-26.7%); most AEs were mild to moderate in grade, while the pooled incidence of severe AEs was 0.9% (95% CI 0.2-2.3%). The most common AEs were transient mild abdominal pain in 19 patients (6.5%), and mild to moderate pancreatitis in 23 patients (7.9%). No cases of mortality were reported., Conclusion: Endoscopic ultrasound-guided radiofrequency ablation resulted on a feasible approach for pNENs treatment, with excellent technical success, high radiological and clinical response, and acceptable AE rate., (© 2023 The Authors. Digestive Endoscopy published by John Wiley & Sons Australia, Ltd on behalf of Japan Gastroenterological Endoscopy Society.)

Background: Foreign body ingestion in adults is commonly encountered in clinical practice. The therapeutic approach of whether to follow-up or extract is often controversial., Aim: We aimed to explore predictors for spontaneous passage of ingested foreign bodies by focusing on foreign body type, length, and location of impaction., Methods: We performed a 12-year retrospective single-center study. Logistic regression analysis was done to identify predictors of spontaneous passage., Results: Overall, 365 patients with foreign body ingestion were included. The rate of spontaneous passage was 53.7% in general, while the spontaneous passage rate was 47.9% in food impaction, 44.3% in sharp objects, 88.7% in blunt objects and only 22.2% in long blunt objects (> 6 cm). On regression analysis, esophageal location was associated with a higher impaction rate and lower spontaneous passage vs. stomach and small and large intestine (OR 0.15, 95% CI 0.07-0.31, OR 0.18, 95% CI 0.09-0.37 and OR 0.02, 95% CI 0.003-0.14), respectively. Performing Receiver operating characteristics (ROC) analysis found that the maximal length above which the foreign body will fail to pass spontaneously was 3.5 cm in the stomach and 3 cm in the small intestine, with area under the curve (AUC) of 0.8509 in stomach and 0.8073 in small intestine., Conclusion: Endoscopic removal was needed for all esophageal foreign bodies, and all foreign bodies more than 3.5 cm above the duodenum. Spontaneous passage of ingested foreign body in a selected cohort of patients depends on foreign body type, location, and length., (© 2024. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Ascites is the most common complication of liver cirrhosis. Spontaneous bacterial peritonitis (SBP) is a common complication of ascites. The diagnosis is made by an ascitic fluid polymorphonuclear (PMN) cell count of ≥ 250/mm 3 . However, no other diagnostic test is present for the diagnosis of SBP. The aim of the study present study is to assess the diagnostic yield of ascitic calprotectin in SBP, and to explore whether it can predict disease stage. We performed a single center proof-of-concept prospective study including all patients with cirrhosis and ascites who underwent paracentesis. Overall, 31 patients were included in the study. Eight patients had SBP vs. 23 patients without SBP. Ascitic calprotectin level was 77.4 ± 86.5 μg/mL in the SBP group, as compared to 16.1 ± 5.6 μg/mL in the non-SBP group (P = 0.001). An ascitic calprotectin cut-off value of > 21 μg/mL was associated with sensitivity and specificity of 85.7% and 89.5%, respectively, with ROC of 0.947 (95% CI 0.783 to 0.997, P < 0.0001). Notably, ascitic calprotectin did not had a prognostic value in cirrhosis stage and prognosis. Ascitic calprotectin was highly accurate in the diagnosis of SBP. It can be a serve as adjunct for indefinite cases of SBP., (© 2024. The Author(s).)

(1) Background: Pancreatic adenocarcinoma (PAC) is one of the most lethal types of cancer. Most cases of PAC occur in the head of the pancreas. Given the proximity of the pancreatic head to the bile duct, most patients present clinically during early stages of the disease, while distally located PAC could have delayed clinical presentation. (2) Aims: To assess predictors of non-head PAC. (3) Methods: A retrospective multicenter study was conducted, including all patients who had endoscopic ultrasound (EUS) for pancreatic masses and who had histologic confirmation of PAC. (4) Results: Of the 151 patients included, 92 (60.9%) had pancreatic head cancer, and 59 (39.1%) had distal pancreatic cancer. PAC at body was the most common location in the distal PAC group (31 patients (52.5%)). Logistic regression analysis demonstrated a significant association of obesity with distal migration of PAC (OR 4.44, 95% CI 1.15-17.19, p = 0.03), while none of the other assessed parameters showed a significant association. Notably, abdominal pain was more significantly associated with distal PAC vs. head location (OR 2.85, 95% CI 1.32-6.16, p = 0.008). (5) Conclusions: Obesity shows a significant association as a clinical predictor of distal PAC. Further studies are needed to better explore this association.

Introduction: Endoscopic ultrasound-guided fine needle aspiration and biopsy (EUS-FNA, -FNB) are the mainstay for tissue diagnosis of pancreatic lesions. Traditionally, FNA was performed for obtaining cytology and also histology if available from the puncture. Since their advent, however, FNB needles have been intended mainly to obtain core biopsies for histological specimens., Aims: We aimed to assess the yield of cytology obtained via both FNA and FNB needles., Methods: A retrospective study was performed including all patients who were diagnosed with pancreatic adenocarcinoma obtained via EUS-FNA/FNB needles., Results: Overall, 227 patients were included. Of them, 85 patients underwent FNB, versus 142 patients who had FNA. The average age in the FNB group was 70.46 ± 11.29 years, versus 71.44 ± 11.80 in the FNA group, P = 0.57. Notably, cytological analysis diagnosed malignancy equally in both groups (69.4% in the FNB group, vs. 65.5% in the FNA group). The compatibility rate of cytology with histology was 76.5% in the FNB group, versus 76.1% in the FNA group (P = 0.69). The agreement level between cytology obtained by FNA and FNB, versus histology obtained by both needles, was moderate (kappa = 0.48, 95% CI 0.39-0.57). Similarly, the agreement level between cytology and histology in the FNB group was moderate as well (kappa = 0.5, 95% CI 0.36-0.64)., Conclusion: Cytological assessment yielded an equal performance as compared to histological assessment with both needles. We recommend obtaining cytology specimens in pancreatic solid lesion puncture by FNB needle., (© 2023 John Wiley & Sons Ltd.)

Background: Acute gastrointestinal bleeding (GIB) is a commonly encountered medical emergency. In cases of negative endoscopic evaluations, computed tomography angiography (CTA) is usually the next diagnostic step. To date, data regarding positive CTA examinations are lacking. We aimed to assess the clinical and laboratory parameters that predict a positive CTA examination, as demonstrated by the extravasation of contrast material into the bowel lumen., Methods: We performed a single-center retrospective study, including all patients who were admitted with GIB and who underwent CTA. Analysis was performed to compare patients' characteristics, and logistic regression was used to explore parameters associated with a positive CTA., Results: We included 154 patients. Of them, 25 patients (16.2%) had active GIB on CTA vs. 129 patients (83.8%) who did not. On univariate analysis, several parameters were positively associated with active GIB, including congestive heart failure (OR 2.47, 95% CI 1.04-5.86, p = 0.04), warfarin use (OR 4.76, 95% CI 1.49-15.21, p = 0.008), higher INR (OR 1.33, 1.04-1.69, p = 0.02), and low albumin level (OR 0.37, 95% CI 0.17-0.79, p = 0.01). On multivariate logistic regression analysis, only high INR (OR 1.34, 95% CI 1.02-1.76, p = 0.03) and low albumin (OR 0.3, 95% CI 0.12-0.7, p = 0.005) kept their positive association with active bleeding, while a high ASA score was negatively associated with an active GIB., Conclusions: We could identify high INR and low albumin as strong predictors of active GIB, as demonstrated by positive CTA. On the other hand, comorbid patients classified by a high ASA score did not experience a higher rate of active GIB.

Background: Identification of pancreatic cancer (PC) local invasion is crucial to optimize patients' selection for surgery., Aims: To determine the diagnostic accuracy of contrast-enhanced computed tomography (CECT) and endoscopic ultrasound (EUS) in local staging of PC., Methods: We performed a multicenter study including all patients with PC who underwent surgery., Results: One hundred twelve patients were included. Surgical findings of peri-pancreatic lymph nodes (LN), vascular and adjacent organ involvement were seen in 67 (59.8%), 33 (29.5%) and 19 patients (17%), respectively. The diagnostic performance of EUS was better than CECT in peri-pancreatic LN. The sensitivity, specificity, positive predictive value (PPV) and negative predictive (NPV) of CECT vs. EUS were 28.4%, 80%, 67.9% and 42.9% vs. 70.2%, 75.6%, 81% and 63%, respectively. For vascular and adjacent organ involvement, the sensitivity, specificity, PPV and NPV were 45.5%, 93.7%, 75%, 80.4% and 31.6%, 89.2%, 37.5% and 86.5% for CECT, respectively, vs. 63.6%, 93.7%, 80.8%, 86.1% and 36.8%, 94.6%, 58.3% and 88% for EUS, respectively. Combining both CECT and EUS, the sensitivity for peri-pancreatic LN, vascular and adjacent organ involvement improved (76.1%, 78.8% and 42%), respectively., Conclusion: EUS was superior to CECT in local staging. Combined EUS and CECT had a higher sensitivity than either alone., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Pancreatic fat infiltration was shown to be linked with acute pancreatitis and probably its severity. These interesting findings merit more investigation to elucidate the effect of fatty pancreas on acute pancreatitis severity., Methods: We performed a retrospective study of patients hospitalized with documented acute pancreatitis. Pancreatic fat was determined according to pancreas attenuation on computed tomography. Patients were divided into two groups, with and without fatty pancreas. The Systemic Inflammatory Response Syndrome (SIRS) score was compared., Results: Overall, 409 patients were hospitalized with acute pancreatitis. Among them, 48 patients had fatty pancreas (group A), vs. 361 patients who did not (group B). The mean ± SD age in group A was 54.6 ± 21.3, vs. 57.6 ± 16.8 in group B ( P  = 0.51). Patients in group A, had a significantly higher rate of fatty liver, as compared to group B (85.4% vs. 35.5%, P  < 0.001). There was no significant difference in the medical history among the two groups. Fatty pancreas was associated with more severe acute pancreatitis as assessed by SIRS score at admission. The mean ± SD of SIRS score was significantly higher in group A (0.92 ± 0.87), as compared to 0.59 ± 0.74 in group B ( P  = 0.009). Positive SIRS score was present in a significantly higher proportion of patients with fatty pancreas (25%), as compared to only 11.4% in group B ( P  = 0.02)., Conclusion: The occurrence of acute pancreatitis with higher SIRS score was significantly associated with fatty pancreas. Fatty pancreas may represent a predictor of acute pancreatitis severity., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: One-anastomosis gastric bypass (OAGB) is a relatively simple surgical procedure for those afflicted with severe obesity. Studies reported symptomatic biliary reflux gastritis and esophagitis as predominant complications. Hepatobiliary scintigraphy (HIDA) is the least invasive test for the diagnosis of bile reflux, with good sensitivity, patient tolerability, and reproducibility. The aim of this study was to define an optimized HIDA scintigraphy protocol for demonstrating bile reflux in post-OAGB patients., Material and Methods: We conducted a prospective multicenter study. Patients after OAGB with dyspeptic complaints were included. All patients underwent HIDA scan with a dedicated protocol for demonstrating bile reflux; prevalence and severity were reported., Results: Nineteen patients were included, 18 females and one male, with mean age of 41.8 years and mean time of 22.4 months from operation to the scan. Bile reflux into the gastric pouch was documented in 11 patients (53%). Reflux to the stomach pouch was severe in three patients (27%), moderate in two patients (18%), and mild in six patients (55%). Bile reflux into the esophagus was documented in four patients (21%), severe reflux in one patient (25%), and mild in the other three (75%). A correlation was found between complaints of vomiting, heartburn and regurgitation, and findings of esophagitis on gastroscopy in patients with vs. without reflux., Conclusions: The tailored HIDA scan protocol detected bile reflux in more than half of the post-OAGB patients included in the study, with a high diagnostic sensitivity., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

The role of endoscopic ultrasound (EUS) in the last two decades has shifted from a diagnostic tool to an important therapeutic tool treating mainly pancreato-biliary disorders. In recent years, its applications for treating pancreatic diseases have broadened, including the implementation of radiofrequency ablation (RFA), which has been traditionally used for treating solid tumors. In this critical in-depth review, we summarized all the papers throughout the literature regarding EUS-RFA for pancreatic neuroendocrine neoplasms, adenocarcinoma, and pancreatic cystic lesions. Overall, for pancreatic neuroendocrine neoplasms we identified 16 papers that reported 96 patients who underwent EUS-RFA, with acceptable adverse events that were rated mild to moderate and a high complete radiological resolution rate of 90%. For pancreatic adenocarcinoma, we identified 8 papers with 121 patients. Adverse events occurred in 13% of patients, mostly rated mild. However, no clear survival benefit was demonstrated. For pancreatic cystic lesions, we identified 4 papers with 38 patients. The adverse events were mostly mild and occurred in 9.1% of patients, and complete or partial radiological resolution of the cysts was reported in 36.8%. Notably, the procedure was technically feasible for most of the patients. Nevertheless, a long road remains before this technique finds its definite place in guidelines due to several controversies. EUS-RFA for pancreatic tumors seems to be safe and effective, especially for pancreatic neuroendocrine neoplasms, but multicenter prospective trials are needed to consider this treatment as a gold standard., Competing Interests: Conflict-of-interest statement: All the authors report having no relevant conflicts of interest for this article., (©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.)

Introduction: Currently, the rate of bile duct injury and leak following laparoscopic cholecystectomy (LC) is still higher than for open surgery. Diverse investigative algorithms were suggested for bile leak, shifting from hepatobiliary scintigraphy (HBS) toward invasive and more sophisticated means. We aimed to analyze the use of biliary scan as the initial modality to investigate significant bile leak in the drain following LC, attempting to avoid potential unnecessary invasive means when the scan demonstrate fair passage of nuclear substance to the intestine, without leak., Methods: We have conducted a prospective non-randomized study, mandating hepatobiliary scintigraphy first, for asymptomatic patients harboring drain in the gallbladder fossa, leaking more than 50 mL/day following LC. Analysis was done based on medical data from the surgical, gastroenterology, and the nuclear medicine departments., Results: Among 3,124 patients undergoing LC, significant bile leak in the drain was seen in 67 subjects, of whom we started with HBS in 50 patients, presenting our study group. In 27 of whom, biliary scan was the only investigative modality, showing fair passage of the nuclear isotope to the duodenum and absence of leak in the majority. The leak stopped spontaneously within a mean of 3.6 days, and convalescence as well as outpatient clinic follow-up was uneventful. In 23 patients, biliary scan that was interpreted as abnormal was followed by endoscopic retrograde cholangio-pancreatography (ERCP). However, ERCP did not demonstrate any bile leak in 13 subjects. In 17 patients, ERCP was used initially, without biliary scan, suggesting the possibility of avoiding invasive modalities in 7 patients., Conclusions: Based on a negative predictive value of 91%, we suggest that in cases of asymptomatic significant bile leak through a drain following LC, a normal HBS as the initial modality can safely decrease the rate of using invasive modalities., (© 2023 The Author(s). Published by S. Karger AG, Basel.)

Background: Gallstone disease is common worldwide and can lead to severe complications, including cholangitis; thus, it is important to identify modifiable risk factors for cholangitis. Proton pump inhibitors (PPIs) are commonly prescribed to treat gastroenterological disorders. We aimed to explore whether PPI use is associated with an increased risk of acute cholangitis in patients with gallstone disease., Methods: This retrospective multicenter study included all patients arriving to the hospital over a 10-year period with various presentations of choledocholithiasis. We compared active PPI use in two groups: those with cholangitis (group A) vs. without cholangitis (group B)., Results: Overall, 811 patients were included, 161 in group A and 650 in group B. The average age ± standard deviation (SD) in groups A and B was 74.5 ± 20.6 vs. 61.6 ± 20.9 years, respectively. PPI use in group A was higher vs. group B (42.9% vs. 29.1%, p  = 0.001). On univariate analysis, male gender (OR 1.47, 95% confidence interval (CI) 1.04-2.08), age (OR 1.04, 95% CI 1.03-1.05), ischemic heart disease (IHD) (OR 1.68, 95% CI 1.07-2.64), hyperlipidemia (OR 1.59, 95% CI 1.11-2.29), hypertension (OR 1.81, 95% CI 1.28-2.57) and PPI use (OR 1.83, 95% CI 1.28-2.61), all were associated with acute cholangitis. On multivariate analysis, only PPI use kept its association after adjustment for age (OR 1.64, 95% CI 1.2-3.7)., Conclusions: Active PPI use was associated with a higher rate of cholangitis among patients with choledocholithiasis. We advocate considering this risk before prescribing PPIs to patients with gallstones., Trial Registration Number: NHR-0263-20 received on 14/01/2021 date 'retrospectively registered'.

Antibioprohylaxis (ABP) for pancreatic cystic lesion is still a debated clinical indication. Although professional societies guidelines still recommend ABP in endoscopic ultrasound-fine needle aspiration (EUS-FNA) for pancreatic cystic lesions (PCL), this standard of care recommendation was based on old and weakly planned studies with a small number of patients. Herein, in this work, we provide a critical review with pooled data analysis of the available literature. Overall, the studies reported are weak and limited with small number of patients, the absence of exact definition of infection and the heterogenicity of the type and the duration of the ABP used. Pooled data analysis showed that the effect of ABP on the rate of cyst infection was not significant (OR 0.56, 95% CI 0.17-1.2), with no significant heterogenicity between the results of the studies reviewed and reported (as assessed by Breslow Day test for homogeneity of OR's [P = 0.15]). The pooled infection rate without ABP was 0.89% and 0.36% in the ABP group. Moreover, according to the pooled data infection rate, sample size calculation demonstrated that 6954 patients are needed to show superiority of ABP, with a number needed to treat of 179 patients to prevent single infection. However, through the literature only six studies (1660 patients) reported the cyst infection rate among ABP versus control, making these results scarce and biased by a small number of patients. Therefore, we suggest the need to revise the guidelines, until performing well organized large international study to solve this controversy., (© 2022 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.)

Background: Patients with acute idiopathic pancreatitis (AIP) should undergo further imaging tests such as endoscopic ultrasound (EUS) for further investigation. The time interval between an episode of AIP and EUS performance is still controversial., Aims: We aimed to explore the optimal timing for performing EUS and to reveal parameters that might predict longer intervals needed for performing EUS., Methods: We performed a single-center retrospective study at Galilee Medical Center from January 2015 to January 2020, at which point we included all patients who underwent EUS for further investigation of AIP., Results: Overall, we included 50 patients. The average age of all patients was 54.2 ± 17.6 years (range 22-69 years), and more than half of the study cohort were males (58%). Classifying patients as inflamed vs. normal pancreatic tissue on EUS, we found that among patients with normal pancreatic tissue, EUS was performed 44.7 ± 28.3 days from discharge, while for patients with inflamed pancreatic tissue, it was 48.1 ± 22.3 days ( p = 0.37) after discharge. Notably, the CT severity index was significantly associated with inflamed pancreatic tissue on EUS, as it was 2.4 ± 0.74 vs. 1.5 ± 1.3 in the normal pancreatic tissue group ( p = 0.03). There were no differences in the Bedside index for severity in acute pancreatitis (BISAP) scores, and there were no differences in the average American Society of Anesthesiologist Physical Status (ASA) scores between the two groups. Notably, 26.3% of patients had inflamed pancreatic tissue when performing EUS at 4 weeks, as compared to 16% who had inflamed pancreatic tissue at EUS performed after 6 weeks., Conclusion: Radiological severity score was the only important factor in determining the time interval of performing EUS after an episode of AIP. Intervals greater than six weeks seem to be needed among patients with higher Balthazar scores.

Background: Choledocholithiasis is a commonly encountered disease that is associated with various clinical presentations ranging from mild form of biliary colic to severe life-threatening acute cholangitis. Recently, peri-ampullary diverticulum (PAD) has been linked to the development of biliary diseases; however, data regarding its association with the development of acute cholangitis in the setting of choledocholithiasis are scarce., Aims: We aimed to identify predictors, specifically PAD, for the development of acute cholangitis in patients with choledocholithiasis., Methods: We performed a retrospective cross-sectional study of all patients admitted to Galilee Medical Center from 1 January 2010 to 31 December 2019 with different clinical presentations of documented choledocholithiasis including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes., Results: Overall, 651 patients were included in the final analysis. Among them, 88 patients (13.5%) had choledocholithiasis associated with acute cholangitis (group A), as compared to 563 patients (86.5%) without acute cholangitis (group B). The average ages in groups A and B were 77.8 ± 13.6 and 62.4 ± 20.4 years, respectively (P < 0.0001). The rate of PAD was significantly higher in group A as compared to group B (35.2% vs. 19%, P = 0.0002). However, the rate of smoking, chronic liver diseases, hemolytic anemia, and post-cholecystectomy status were not different between the groups (P = 0.3, P = 0.3, P = 0.2, and P = 0.3), respectively. On univariate analysis, age (OR 1.05, P < 0.0001) and PAD (OR 2.32, P = 0.0006) were significantly associated with acute cholangitis. On multivariate logistic regression analysis, the effects of age and PAD were preserved (OR 1.05, 95% CI 1.03-1.07, P < 0.0001 and OR 1.64, 95% CI 1.02-2.72, P = 0.049), respectively., Conclusion: PAD showed a significant association with the development of acute cholangitis among patients with choledocholithiasis. Identification of gallbladder and biliary stones in patients with PAD is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Dominant stricture (DS) is a main cause of complication among patients with Primary Sclerosing Cholangitis (PSC). Endoscopic treatment options include dilation and plastic stenting, each with its own benefits and drawbacks., Aims: The aim of the current study is to assess the safety and efficacy of fully-covered metal stent (FCMS) in these patients., Methods: A retrospective study of PSC patients with refractory DS, defined as strictures resistance to conventional therapy (balloon dilatation, plastic biliary stent insertion or both) and who underwent FCMS insertion for 3 months were included. The primary outcome was defined as clinical and laboratory improvement, while secondary outcomes were DS resolution upon stent removal and cholangiographic DS recurrence at 12-months after FCMS extraction., Results: Twenty patients were enrolled from January 2016 through January 2020. Improvement in weakness and pruritus were seen in 80% and 35%, 75% and 65%, 75% and 35% of patients at 1-3 and 6 months following FCMS removal, respectively. Similarly, consistent improvement in all liver enzymes and total bilirubin were seen in up to 6 month following stent removal. Only one patient (5%) needed premature FCMS removal due to cholangitis 1 week after stent placement and 2 cases (10%) of stent related pancreatitis were encountered. At 3-months all remaining stents were softly removed. Cholangiographic DS resolution was demonstrated in 13 patients (65%) after stent removal at 3-months, and DS recurred in 4 patients (4/13 = 30.7%) at 12-months following stent removal. Notably, only proximal biliary DS location showed a trend for DS recurrence (OR 28.6, P = 0.06)., Conclusion: Temporary 3 months duration FCMS was feasible, safe and effective treatment option among patients with PSC related refractory DS., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Introduction: The prevalence of colonic diverticulosis and diverticulitis has significantly increased in recent years. Obesity is a well‑known risk factor for diverticulitis, but far less is known about the association between diverticulitis and overweight., Objective: We aimed to examine the association between overweight and diverticulitis and to study the potential relationship between body mass index (BMI) and disease severity., Patients and Methods: We conducted a retrospective, multicenter study. Patients diagnosed with diverticulosis confirmed by colonoscopy were included. The diagnosis of diverticulitis was confirmed by computed tomography. Weight status was defined as normal in the case of BMI in the range of 18.5- 24.9 kg/m2, overweight when BMI was 25-29.9 kg/m2, and obesity with BMI equal or above 30 kg/m2., Results: The study included 592 patients. Among them, 157 (26.5%) had normal BMI, 191 (32.3%) were overweight, and 244 (41.2%) were obese. Patients with BMI above the normal range, overweight and obese were at higher odds of acute diverticulitis as compared with those with normal BMI. This was evidenced by the values of odds ratio (OR) 3.10 (95% CI, 2.00-4.73; P <0.001) for weight above the normal range, OR 1.85 (95% CI, 1.14-3.00; P = 0.01) for overweight, and OR 4.50 (95% CI, 2.84-7.12; P <0.001) for obese patients., Conclusions: Overweight was associated with an increased risk of diverticulitis among patients with diverticulosis. Since overweight is a modifiable factor, this observation has preventive importance.

Background: Recurrent common bile duct (CBD) stone is a long-term sequalae among patients who underwent endoscopic retrograde cholangiopancreatography (ERCP) with CBD stone extraction. Data regarding risk factors for recurrent CBD stone are scarce. We aimed to identify predictors of recurrent CBD stone., Methods: We performed a retrospective case-controlled study from January 2010 to December 2019. Inclusion criteria included patients who had recurrent CBD stone at least 6 months after the index ERCP, in which complete stone extraction was performed and normal cholangiogram was obtained. Overall, 457 patients were included. Forty-two patients (9.2%) had recurrent CBD stone, and 415 patients (90.8%) did not have recurrent CBD stone., Results: In univariate analysis, male sex [odds ratio (OR) = 0.49, P = 0.033] was a protective factor, while endoscopic stone extraction by basket vs. balloon (OR = 2.55, P = 0.005), older age (OR = 1.03, P = 0.003), number of CBD stones (OR = 1.99, P = 0.037), size of CBD stone (OR = 4.06, P = 0.003) and mechanical lithotripsy (OR = 9.22, P = 0.004) were risk factors for recurrent CBD stone. In multivariate logistic regression analysis, mechanical lithotripsy [OR = 9.73, 95% confidence interval (CI): 1.69-55.89, P = 0.010], basket clearance vs. combined basket and balloon (OR = 18.25, 95% CI: 1.05-318.35, P = 0.046) and older age (OR = 1.02, 95% CI: 1.00-1.05, P = 0.023) were risk factors, and male sex (OR = 0.39, 95% CI: 0.19-0.81, P = 0.012) was a protective factor., Conclusions: We identified modifiable and non-modifiable risk factors for recurrent CBD stone. Taking into consideration those factors might aid in minimizing the CBD stone recurrence risk., Competing Interests: Competing interest No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article., (Copyright © 2021. Published by Elsevier B.V.)

Background: fatty pancreas (FP) is an old observation, but a new disease with clinical implications and several associated comorbid conditions, ranging from mild to life-threatening diseases. Herein, we aimed to assess the association between FP and pancreatic cancer (PC) development., Methods: we performed a retrospective cross-sectional study including all patients who underwent endoscopic ultrasound (EUS) for hepatobiliary indications. The study cohort was divided into patients with and without PC. Univariate and multivariate analysis were used to assess the association of several parameters with PC., Results: overall, 519 patients were included in the study. Of them, 48 had PC (PC group), and 471 did not (non-PC group). In univariate analysis, age (OR 1.04, 95% CI 1.01-1.07, p = 0.004), congestive heart failure (CHF) (OR 3.89, 95% CI 1.72-8.79, p = 0.001), ischemic heart disease (IHD) (OR 3.36, 95% CI 1.59-7.05, p = 0.001), hypertension (OR 2.42, 95% CI 1.33-4.41, p = 0.004) and fatty pancreas (FP) (OR 2.62, 95% CI 1.23-5.57, p = 0.01) were significantly associated with PC. In multivariate logistic regression analysis, only FP kept its association (OR 2.35, 95% CI 1.04-5.33, p = 0.04)., Conclusion: FP was significantly associated with PC. A follow-up plan should be considered for individuals with FP.

Abstract: Common bile duct (CBD) stone is a commonly encountered disease that is associated with various clinical presentations ranging from the mild form of biliary colic to the severe complication of acute cholangitis. Recently, diabetes mellitus (DM) has been linked to the development of biliary diseases; however, no data regarding the association of DM with acute cholangitis development in the setting of CBD stone exist. The aim of the current study was to investigate whether DM represents a risk factor for acute cholangitis in patients with CBD stone. We performed a retrospective cross-sectional study from January 1, 2010 till June 1, 2020 of all patients presenting to Galilee Medical Center with various clinical presentations of documented CBD stone, including cholangitis, biliary pancreatitis, and biliary colic with abnormal liver enzymes. Overall, 687 patients were included in the final analysis. Among them, 101 patients (14.7%) had CBD stone associated with acute cholangitis (group A), as compared to 586 patients (85.3%) without acute cholangitis (group B). The average ages in groups A and B were 77.7 ± 13.6 and 62.5 ± 20.5 years, respectively (P < .0001). The prevalence of DM was significantly higher in group A as compared to group B (52.5% vs 36.3%, P = .001). On univariate analysis, age (odds ratio [OR] 1.05, P < .0001), male gender (OR 1.54, P = .04), and DM (OR 1.92, P = .002) were associated with acute cholangitis development, and on multivariate logistic regression analysis, the correlation was preserved for DM (OR 1.93, 95% confidence interval 1.26-2.96, P = .002). DM showed a significant association with acute cholangitis development among patients with CBD stone. Identification of bile duct stones in diabetic patients is of paramount importance since early diagnosis and treatment might prevent further life-threatening complications., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2022 the Author(s). Published by Wolters Kluwer Health, Inc.)

The impressive technological advances in recent years have rapidly translated into the shift of endoscopic ultrasound (EUS) from diagnostic modality into an interventional and therapeutic tool. Despite the great advance in its diagnosis, the majority of pancreatic adenocarcinoma cases are inoperable when diagnosed, thus demanding alternative optional therapies. EUS has emerged as an easy, minimally invasive modality targeting this carcinoma with different interventions that have been reported recently. In this review we summarize the evolving role of interventional therapeutic EUS in pancreatic adenocarcinoma management., Competing Interests: Conflict-of-interest statement: The authors declare no conflict of interest., (©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.)

Non-alcoholic fatty liver disease (NAFLD) is increasingly encountered. It is associated with several comorbid diseases. However, its association with infectious biliary diseases is still unknown. Aims: We aimed to assess whether NAFLD is a risk factor for the development of acute cholangitis among patients with common bile duct (CBD) stones. Methods: We performed a retrospective study, including all patients with a documented diagnosis of CBD stone that had available data on the presence or absence of NAFLD. Descriptive analysis using univariate and multivariate models was used to assess whether an association existed between NAFLD and acute cholangitis. Results: We included 811 patients. Of them, 161 patients presented with acute cholangitis, vs. 650 patients who presented with symptomatic CBD stone without cholangitis. NAFLD was significantly more common in the cholangitis group compared to the non-cholangitis group (15.5% vs. 8.3%, p = 0.01). In univariate analysis, age (Odds ratio (OR) 1.04, p < 0.0001), male gender (OR 1.47, p = 0.03), hypertension (OR 1.81, p = 0.0008), hyperlipidemia (OR 1.59, p = 0.01), and NAFLD (OR 2.04, p = 0.006) were significantly associated with acute cholangitis. In multivariate analysis, NAFLD kept its association with acute cholangitis irrespective of age (OR 2.15, p = 0.005). Conclusions: NALFD showed a significant association with acute cholangitis among patients with a CBD stone. Clinicians should encourage treatment of NAFLD in general, and especially in the setting of gallstone disease.

Background: Fatty pancreas (FP) has become an increasingly encountered entity in recent years. Several studies have shown an association with several disease states., Aims: we aimed to generate a simple non-invasive scoring model to predict the presence of FP., Method: We performed a retrospective cross-sectional analysis at Galilee Medical Center. Inclusion criteria included patients who underwent endoscopic ultrasound (EUS) for hepatobiliary indications and who had either hyperechogenic pancreas consistent with FP or no sonographic evidence of fatty pancreas., Results: We included 569 patients. Among them, 78 patients had FP by EUS and 491 patients did not have FP. On univariate analysis, obesity (odds ratio (OR) 5.11, p < 0.0001), hyperlipidemia (OR 2.86, p = 0.0005), smoking (OR 2.02, p = 0.04), hypertension (OR 2.58, p = 0.0001) and fatty liver (OR 5.94, p < 0.0001) were predictive of FP. On multivariate analysis, obesity (OR 4.02, p < 0.0001), hyperlipidemia (OR 2.22, p = 0.01) and fatty liver (OR 4.80, p < 0.0001) remained significantly associated with FP. We developed a diagnostic score which included three parameters that were significant on multivariate regression analysis, with assignment of weights for each variable according to the OR estimate. A low cut-off score of ≤1 was associated with a negative predictive value (NPV) of 98.1% for FP, whereas a high cut-off score of ≥2 was associated with a positive predictive value (PPV) of 35-56%., Conclusion: We recommend incorporating this simple score as an aid to identify individuals with FP.

Background and Objectives : The initial diagnostic test required to evaluate esophageal dysphagia is upper endoscopy (EGD) to assess the structure of the esophagus and the esophageo-gastric junction (EGJ). Taking biopsies during EGD has become a common practice in patients with dysphagia to rule out eosinophilic esophagitis (EoE). The aims of this study were to evaluate the endoscopic findings of patients who underwent EGD for esophageal dysphagia, to assess the rate of biopsy taking from the esophagus to diagnose/exclude EoE, and to report histology outcomes of these biopsies. Materials and Methods : This was a retrospective multicenter study that included individuals ≥18 years who underwent EGD due to esophageal dysphagia between the years 2015 and2020, (with no other alarm signs, such as weight loss, new iron deficiency anemia, and lymphadenopathy). We obtained data from patients' electronic files. The endoscopy and histology findings were obtained from endoscopy reports saved in our electronic files. Results : A total of 209 patients were included in the study. The average age was 57.1 ± 17.1 years. The most common endoscopic findings were normal endoscopy in 76 patients (36.4%) and erosive esophagitis in 75 patients (35.9%). Barrett's esophagus and esophageal malignancy were encountered in 11 patients (5.3%) and 2 patients (0.95%), respectively. Esophageal biopsies were taken in 50.2% of patients, and one patient had histological evidence of EoE (0.5%). On univariate analysis, there was a trend for association between proton pump inhibitors (PPIs) use and a normal EGD, but it was not statistically significant (OR 0.28, 95% CI 0.07-1.11, p = 0.07). Conclusions : Endoscopic findings were prevalent in dysphagia patients even when no other alarm symptoms exist. Neoplastic lesions and EOE were rare in our study.

Aim: Coronavirus disease 2019 (COVID-19) is a recently encountered disease that was declared a pandemic by WHO in 2020. Obesity and other components of the metabolic syndrome may aggravate the severity of COVID-19. Nonalcoholic fatty liver disease (NAFLD) represents the hepatic manifestation of metabolic syndrome. The aim of this study was to investigate a possible association between MAFLD and COVID-19 severity., Methods: We performed a retrospective, case-control study, enrolling 71 consecutive COVID-19 patients who were divided into two groups according to the presence or absence of fatty liver by computed tomography scan. All medical records of eligible patients were reviewed including demographic, clinical, laboratory parameters and data regarding the presence of NAFLD and COVID-19 severity., Results: NAFLD was identified in 22/71 (31%) of the study group. Out of 71, thirteen suffered from severe COVID-19. NAFLD patients had more severe COVID-19 compared with non-NAFLD subjects, 8/22 (36.3%) vs. 5/49(10.2%), (P < 0.005), respectively. Multiple logistic regression analysis showed that NAFLD subjects were more likely to have severe COVID-19 disease (odds ratio 3.57, 95% confidence interval: 1.22, 14.48, P = 0.0031)., Conclusion: NAFLD represents a high risk for severe COVID-19 irrespective to gender, and independent of metabolic syndrome specifically in male gender. Moreover, obesity, hypertension and metabolic syndrome were also significantly associated with severe COVID-19., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Liver diseases are among the most common diseases worldwide accounting for substantial morbidity and mortality. Most liver diseases necessitate radiological evaluation or accurate diagnosis and recently for management as well. In the last decade, the application of therapeutic endoscopic ultrasound (EUS) procedure has been increasingly utilized for the management of various liver diseases. In this comprehensive narrative review article, we provide systematic overview on EUS-guided therapeutic interventions in various liver diseases summarizing most updated data regarding technical success, outcomes and safety profiles. Overall, 35 articles have reported on the use of EUS in the treatment of liver diseases with excellent technical success, favorable radiological response and high safety profiles for EUS-guided treatment of solid and cystic liver lesion and for EUS-guided angiotherapy for gastric varices, except for EUS-guided cyanoacrylate glue injection which was associated with life-threatening fatal systemic embolization adverse events. This suggests that EUS-guided intervention is a new promising therapeutic intervention for the treatment of various liver diseases with durable effect and a limited potential for adverse events., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Nonalcoholic fatty pancreatic disease (NAFPD) is an increasingly recognized disease with accumulating evidence of associated co-morbidities. However, data linked with other pancreatic and hepatobiliary disorders are still being studied., Aims: To investigate the association of pancreato-hepato-biliary disorders with NAFPD., Methods: At two Israeli medical centers, a total of 569 patients were analyzed who underwent endoscopic ultrasound for hepatobiliary indications. They were divided into groups depending on the presence or absence of NAFPD., Results: Seventy-eight patients (13.7%) had NAFPD (NAFPD group) vs. 491 patients (86.3%) without (non-NAFPD group). NAFPD was significantly associated with obesity [odds ratio (OR) 4.98, 95% confidence interval (CI) 3.02-8.24, P < 0.0001], hypertension (OR 2.55, 95% CI 1.57-4.15, P = 0.0002), active smoking (OR 2.02, 95% CI 1.04-3.93, P = 0.03), and hyperlipidemia (OR 2.86, 95% CI 1.58-5.18, P = 0.0005). On multivariate regression analysis: fatty liver (OR 5.49, 95% CI 2.88-10.49, P < 0.0001), main duct intraductal papillary mucinous neoplasm (M-IPMN) (OR 2.69, 95% CI 1.05-6.9, P = 0.04), and gallstones (OR 1.93, 95% CI 1.1-3.38, P = 0.02) were the most endoscopically and ultrasonographically detected diseases that significantly correlated with NAFPD., Conclusion: NAFPD was associated with several diseases, most importantly the premalignant M-IPMN. Further investigation for these coexisting diseases should be considered., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Achalasia is not uncommonly diagnosed in elderly patients and its incidence and prevalence are growing in this population. However, a scarcity of studies has assessed the typical pathophysiological and clinical features of the disease as well as the effectiveness and safety of the various therapeutic options in elderly populations. Botulinum toxin injection has been used for achalasia treatment since 1994 and is traditionally considered the preferred treatment for fragile elder patients. However, recently more evidence has become available regarding the safety and effectiveness of pneumatic balloon dilation (BD), laparoscopic Heller myotomy (LHM) and per-oral endoscopic myotomy (POEM) in elderly patients with achalasia. In the current review we present the current literature on this topic with a focus on the clinical presentation of achalasia in the elderly and manometric features thereof, as well as summarize the effectiveness and safety of the various therapeutic options. Furthermore, we propose a practical management algorithm as a means to guide the treatment of future cases. We recommend that a conservative/BTI approach should be adopted in the fragile unfit patient. In the elderly fit patient, the treatment decision should be based on the achalasia type, patient preference and the available expertise, similar to the approach adopted for the non-elderly population.

Background: Percutaneous endoscopic gastrostomy (PEG) tube insertion is used for enteral nutrition. Each manufacturer has its own instructions for planned tube replacement. Accordingly, caregivers have adopted the policy of elective change at a fixed period of time (3-6 months)., Aim: The current study aimed to assess whether retained PEG for more than 6 months was associated with a higher rate of PEG-related complications., Methods: A retrospective single-center study included all patients who underwent PEG insertion were included in the study., Results: Overall, 303 patients were included, 48 patients (16.2%) had PEG tube replacement. Peristomal PEG tube leak was the commonest complication, occurring in 20 patients (41.7%), followed by dislodgement in 18 patients (37.5%) and obstruction in 10 patients (20.8%). Among the patients with a leak, it occurred within and beyond 6 months from PEG insertion in 40 and 60% of patients, respectively (OR 0.68, 95% CI 0.21-2.18, p  = .57). Similarly, 50% of patients had PEG tube obstruction within 6 months and 50% had it beyond 6 months from insertion (OR 1.46, 95% CI 0.34-6.26, p  = .72). Moreover, there was no difference in PEG dislodgement after PEG insertion within or beyond 6 months (nine patients, 50% vs. nine patients, 50%), respectively, (OR 1.37, 95% CI 0.42-4.47, p  = .76)., Conclusion: Retained PEG tubes for more than 6-months were not associated with more PEG-tube-related complications.

Background: Patients with suspected choledocholithiasis should undergo further confirmatory imaging test by endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) before performing definite extraction by endoscopic retrograde cholangiopancreatography (ERCP). Usually, those procedures are performed at a separate session., Aim: The aim of our study is to report the safety, efficacy and cost-effectiveness of same day EUS and ERCP., Methods: A retrospective study including all patients who underwent EUS and ERCP for choledocholithiasis from 1st January 2020 through 1st January 2021. Patients were categorized into same day EUS and ERCP (group A) and separate day procedures (group B). Univariate descriptive analysis was done to compare between the groups and cost-effectiveness analysis was based on the length of hospitalization., Results: Sixty-one patients (57.5%) underwent same day EUS and ERCP (group A), as compared to 45 patients (42.5%) who had separate sessions (group B). The average ages in groups A and B were 66.1 ± 20.7 years and 65.8 ± 19.3 years, respectively ( p  = .47). There was no difference in the mean doses of midazolam, propofol and fentanyl in EUS and ERCP examinations in both groups. Notably, group A had a significantly lower hospitalization length as compared to group B (7.4 ± 2.9 vs. 9.7 ± 3.9 days, p  = .0003). Consequently, same day EUS and ERCP was associated with a significant cost saving as compared to group B (7680.9$ ± 3071.4$vs 10089.4$±4053.4$, p  = .0003), respectively. There was no serious anesthesia related adverse events., Conclusion: Same day EUS and ERCP for choledocholithiasis was safe and cost-effective with significant lower hospitalization length.

Objectives: Fatty pancreas (FP), previously believed to be without clinical significance, recently has been shown to be associated with comorbid diseases. We aimed to explore whether FP predispose to acute pancreatitis., Methods: Patients who underwent endoscopic ultrasound for hepatobiliary indications were included. Patients with pathological pancreato-biliary findings other than FP were excluded. The cohort was divided into patients with a history of pancreatitis (within 6 months of endoscopic ultrasound, group A) and patients without (group B)., Results: Overall, 189 patients were included. Sixty-one (32.3%) patients were in group A, and 128 (67.7%) patients were in group B. The average age in group A was 55.5 (standard deviation, 17.7) versus 58.5 (standard deviation, 13.5) in group B. The prevalence of FP in group A (37.7%) was higher compared with group B (4.7%) (P = 0.001). On univariate analysis, FP showed significant correlation with a history of acute pancreatitis [odds ratio (OR), 5.14, P = 0.006] and hyperlipidemia (OR, 4.19; P = 0.002). On multivariate analysis, FP remained significantly associated with a history of acute pancreatitis after stratification for obesity and hyperlipidemia (OR, 10.78; 95% confidence interval, 3.75-30.89; P < 0.0001)., Conclusions: Fatty pancreas was associated with acute pancreatitis. Clinicians should be aware of this association., Competing Interests: The authors declare no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)