Post-ERCP cholecystitis: Incidence, characteristics, and outcomes from a prospective multicenter biliary endoscopy registry

BACKGROUND AND AIMS

The incidence, risk factors, and outcomes of post-ERCP cholecystitis are poorly described. We aimed to describe cases of post-ERCP cholecystitis from a prospective multicenter registry with protocolized 30-day follow-up.

METHODS

Patient- and procedure-related data from 7 centers were obtained. The primary outcome was post-ERCP cholecystitis, defined according to a Delphi-based criteria and causal attribution system. Risk factors and outcomes were described for all cases.

RESULTS

Seventeen cases of post-ERCP cholecystitis were identified among 4428 patients with gallbladders undergoing ERCP between 2018 and 2023 (incidence, 0.38%; 95% confidence interval, 0.20-0.57). In ERCPs with covered metal stenting, 7 of 467 resulted in cholecystitis (incidence, 1.50%; 95% confidence interval, 0.40-2.60). Patients had symptoms at a median of 5 days (interquartile range, 5) after ERCP. Management strategies included cholecystectomy, percutaneous cholecystostomy, and endoscopic stent removal/exchange.

CONCLUSIONS

Estimates of post-ERCP cholecystitis incidence can inform discussions around procedural risk.

A114 UNIFIED MAGNIFYING ENDOSCOPIC CLASSIFICATION (UMEC) FOR GASTROINTESTINAL LESIONS: A NORTH AMERICAN EDUCATION STUDY

Background

Magnification endoscopy and magnification narrow-band imaging are image enhanced endoscopy technologies that may allow for the diagnosis of advanced neoplasia in the GI tract on the basis of imaging characteristics. Recently, the Unified Magnifying Endoscopic Classification (UMEC) has been developed, which unified the criteria for the esophagus, stomach, and colon. UMEC divides optical diagnosis into one of the three categories: non-neoplastic, intramucosal neoplasia, and deep submucosal invasive cancer.

Purpose

The objective of this study is to educate North American endoscopists on the use of the UMEC schema, and to ascertain performance of the UMEC framework among North American endoscopists.

Method

Using UMEC, five North American endoscopists (>1000 procedures) without prior training in magnifying endoscopy independently diagnosed previously collected endoscopic image set of the esophagus, stomach, and colon. The endoscopists were trained on the use of UMEC via an eleven-minute training video with exemplars of each element of UMEC from esophagus, stomach, and colon. All endoscopists were blinded to white-light and non-magnifying NBI findings as well as histopathological diagnosis. The diagnostic performance of UMEC was assessed while using the gold standard histopathology as a reference.

Result(s)

A total of 299 gastrointestinal lesions (77 esophagus, 92 stomach, and 130 colon) were assessed using UMEC. For esophageal squamous cell carcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 65.2% (95% CI: 50.9–77.9) to 87.0% (95% CI: 75.3–94.6), 77.4% (95% CI: 60.9–89.6) to 96.8% (95% CI: 86.8–99.8), and 75.3% to 87.0%, respectively. For gastric adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 94.9% (95% CI: 85.0–99.1) to 100%, 52.9% (95% CI: 39.4–66.2) to 92.2% (95% CI: 82.7–97.5), and 73.3% to 93.3%, respectively. For colorectal adenocarcinoma, the sensitivity, specificity, and accuracy for all 5 endoscopists ranged from 76.2% (95% CI: 62.0–87.3) to 83.3% (95% CI: 70.3–92.5), 89.7% (95% CI: 82.1–94.9) to 97.7% (95% CI: 93.1–99.6), and 86.8% to 90.7%, respectively.

Image

Conclusion(s)

UMEC is a simple and practical classification that can be used to introduce and educate endoscopists to magnification narrow-band imaging and optical diagnosis.

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CAG

Disclosure of Interest

M. R. A. Fujiyoshi Grant / Research support from: 2022 CAG/AbbVie Education Research Grant, Y. Fujiyoshi: None Declared, N. Gimpaya: None Declared, R. Bechara: None Declared, T. Jeyalingam: None Declared, N. Calo: None Declared, N. Forbes: None Declared, R. Khan: None Declared, M. Atalla: None Declared, A. Toshimori: None Declared, Y. Shimamura: None Declared, M. Tanabe: None Declared, J. Mosko: None Declared, H. Inoue: None Declared, S. Grover: None Declared

Gluten-Free Diet Reduces Symptoms, Particularly Diarrhea, in Patients With Irritable Bowel Syndrome and Antigliadin IgG

BACKGROUND & AIMS

Many patients with irritable bowel syndrome (IBS) perceive that their symptoms are triggered by wheat-containing foods. We assessed symptoms and gastrointestinal transit before and after a gluten-free diet (GFD) in unselected patients with IBS and investigated biomarkers associated with symptoms.

METHODS

We performed a prospective study of 50 patients with IBS (ROME III, all subtypes), with and without serologic reactivity to gluten (antigliadin IgG and IgA), and 25 healthy subjects (controls) at a university hospital in Hamilton, Ontario, Canada, between 2012 and 2016. Gastrointestinal transit, gut symptoms, anxiety, depression, somatization, dietary habits, and microbiota composition were studied before and after 4 weeks of a GFD. HLA-DQ2/DQ8 status was determined. GFD compliance was assessed by a dietitian and by measuring gluten peptides in stool.

RESULTS

There was no difference in symptoms among patients at baseline, but after the GFD, patients with antigliadin IgG and IgA reported less diarrhea than patients without these antibodies (P = .03). Compared with baseline, IBS symptoms improved in 18 of 24 patients (75%) with antigliadin IgG and IgA and in 8 of 21 patients (38%) without the antibodies. Although constipation, diarrhea, and abdominal pain were reduced in patients with antigliadin IgG and IgA, only pain decreased in patients without these antibodies. Gastrointestinal transit normalized in a higher proportion of patients with antigliadin IgG and IgA. Anxiety, depression, somatization, and well-being increased in both groups. The presence of antigliadin IgG was associated with overall reductions in symptoms (adjusted odds ratio compared with patients without this antibody, 128.9; 95% CI, 1.16-1427.8; P = .04). Symptoms were reduced even in patients with antigliadin IgG and IgA who reduced gluten intake but were not strictly compliant with the GFD. In controls, a GFD had no effect on gastrointestinal symptoms or gut function.

CONCLUSIONS

Antigliadin IgG can be used as a biomarker to identify patients with IBS who might have reductions in symptoms, particularly diarrhea, on a GFD. Larger studies are needed to validate these findings. ClinicalTrials.gov: NCT03492333.

Comparative Effectiveness of Lumen-Apposing Metal Stents and Plastic Stents for the Treatment of Pancreatic Walled-Off Necrosis: A Meta-analysis

Background

Plastic stents (PS), lumen-apposing metal stents (LAMS) and biflanged metal stents (BFMS) are used for initial drainage of pancreatic walled-off necrosis (WON). There are no strong evidence to support the use of LAMS/BFMS over PS, and prior systematic reviews lack comparative analyses and also lack both trial data and observational studies for WON efficacy outcomes. The aim of this study is to compare the efficacy and adverse events (AEs) in LAMS/BFMS versus PS in patients with pancreatic WON.

Methods

A comprehensive search up to December 1, 2020, was performed. The primary outcome was clinical improvement after drainage. Secondary outcomes included AEs and technical failure. Pooled odds ratios (OR) with 95% confidence intervals (CI) were reported using random effects models. Heterogeneity was evaluated with the Cochrane I  2 statistic. Subgroup and sensitivity analyses were performed. The quality of the evidence was assessed using Grading of Recommendations, Assessment, Development and Evaluations (GRADE).

Results

Nine studies (one randomized controlled trial and eight observational) were included for the primary outcome including 493 patients treated with LAMS/BFMS and 514 with PS. LAMS/BFMS were associated with higher odds of clinical improvement compared with PS (OR 2.58; 95% CI 1.81, 3.68; I  2 = 1%). This association remained robust in sensitivity analyses. The use of LAMS/BFMS was not associated with higher AEs (OR 1.22; 0.61, 2.46; I2 = 71%). There was no difference in technical failure (OR 1.06; 0.19, 6.00; I2 = 12%).

Conclusions

LAMS/BFMS seem to result in better clinical outcomes compared with PS in patients with pancreatic WON, with comparable AEs and technical failure. Larger randomized controlled trials for this comparison are warranted.

Anxiety But Not Depression Predicts Poor Outcomes in Inflammatory Bowel Disease

BACKGROUND AND AIMS

Patients with inflammatory bowel disease (IBD) have high rates of psychiatric comorbidities, but it is not clear whether those with comorbidities are at higher risk of poor outcomes. We aimed to determine whether patients with IBD who have co-existing anxiety and/or depression are more likely to have poor IBD-related outcomes compared with IBD patients without anxiety and/or depression.

METHODS

This was a prospective longitudinal follow-up study in Ontario, Canada, from 2008 to 2016. Patients were asked to complete questionnaires at the time of initial assessment, including the Hospital Anxiety and Depression Scale (HADS). We selected a number of clinical variables at the time of presentation and tested their ability to predict subsequent poor IBD-related outcomes, such as IBD-related hospitalization, emergency room visits, and recurrent courses of corticosteroids over the duration of follow-up. Logistic regression was used for multivariate analysis.

RESULTS

Four hundred fourteen IBD patients completed the baseline questionnaire. Among them, 125 had anxiety and/or depression at baseline. Factors that predicted poor IBD-related outcomes during longitudinal follow-up included increased severity of disease at initial presentation, prior IBD-related surgery, longer duration of follow-up, and elevated C-reactive protein at time of initial presentation. After adjustment for potential covariates, IBD patients with abnormal anxiety subscores had poor IBD-related outcomes compared with those without elevated anxiety subscores (odds ratio [OR] 3.36, 95% CI, 1.51-7.48). No difference in IBD-related outcomes were observed in those with abnormal depression subscores compared with those without elevated depression scores (OR 0.43, 95% CI, 0.14-1.32).

CONCLUSIONS

Severe disease, anxiety, and previous IBD-related surgery predict poor IBD-related outcomes in patients in the future. Closer monitoring with regular follow-up may be appropriate for patients with these risk factors.

Huge Pulmonary Arteriovenous Malformation, Venous Thromboembolism and Anticoagulation Treatment in a Patient with Hereditary Hemorrhagic Telangiectasia

Hereditary hemorrhagic telangiectasia (HHT) usually presents in association with pulmonary arteriovenous malformations (PAVMs). In addition, the incidence of venous thromboembolism tends to be increased in these patients. A 74-year-old female with HHT presented with cyanosis and hypoxemia. Contrast-enhanced multislice computed tomography (MSCT) revealed two left PAVMs and one in the right upper lobe. Both left PAVMs were treated with embolotherapy. Follow-up MSCT revealed an incidental pulmonary embolism in the right pulmonary branches. Deep venous thrombosis was confirmed and anticoagulation was initiated. Follow-up MSCT revealed the resolution of thromboembolism. Finally, embolotherapy was performed. This case illustrates the chronic adaptation to hypoxemia and adds further evidence to the relative safety of anticoagulation treatment in these patients.