Safety and efficacy of minimal biliary sphincterotomy with papillary balloon dilation (m-EBS+EPBD) in patients using clopidogrel or anticoagulation.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic biliary sphincterotomy (EBS) or endoscopic papillary balloon dilation (EPBD) are common techniques of biliary decompression. Potential risks include gastrointestinal hemorrhage, which can be increased by antiplatelet agents, anticoagulants (AC) and/or novel oral anticoagulants (NOACs) (ie. apixaban, dabigatran and rivaroxaban). The study aim is to evaluate the safety/efficacy of an alternative technique, minimal-EBS plus EPBD (m-EBS + EPBD), in individuals for whom clopidogrel, AC, and/or NOACs cannot be interrupted due to high cardiovascular or thromboembolic risk. Patients and methods Patients undergoing m-EBS + EPBD while taking clopidogrel and/or AC were retrospectively evaluated at two United States tertiary care centers for efficacy, GIB and procedure-related, cardiovascular and thromboembolic adverse events (AE). Results Ninety-five patients were identified [55 = clopidogrel and 45 = AC (31.1 % NOACs)]. The main indication for ERCP was choledocholithiasis (34 %). 100 % clinical improvement and 97.9 % endoscopic success were found. The incidence of AE was 5.3 %. There was a 4.2 % incidence of gastrointestinal hemorrhage (2 cases requiring endoscopic intervention). Both severe gastrointestinal hemorrhages also experienced the cases of post-ERCP pancreatitis, and 2 /3 of cholangitis (all aspirin + AC). There was 1cardiovascular event (non-ST elevation myocardial infarction), and no thromboembolic events. Conclusions Minimal-EBS + EPBD is an effective and safe therapy with an incidence of gastrointestinal hemorrhage of 4.2 %, (2.1 % requiring endoscopic intervention), for patients on clopidogrel and/or AC, with a high risk for cardiovascular/thromboembolic events.

Bleeding risk with clopidogrel and percutaneous endoscopic gastrostomy.

AIM: To compare bleeding within 48 h in patients undergoing percutaneous endoscopic gastrostomy (PEG) with or without clopidogrel. METHODS: After institutional review board approval, a retrospective study involving a single center was conducted on adult patients having PEG (1/08-1/14). Patients were divided into two groups: Clopidogrel group consisting of those patients taking clopidogrel within 5 d of PEG and the non-clopidogrel group including those patients not taking clopidogrel within 5 d of the PEG. RESULTS: Three hundred and nineteen PEG patients were found. One hundred and sixty-eight males and 151 females with mean body mass index 28.47 ± 9.75 kg/m(2) and mean age 65.03 ± 16.11 years were identified. Thirty-three patients were on clopidogrel prior to PEG with 286 patients not on clopidogrel. No patients in either group developed hematochezia, melena, or hematemesis within 48 h of percutaneous endoscopic gastrostomy (PEG). No statistical differences were observed between the two groups with 48 h for hemoglobin decrease of > 2 g/dL (2 vs 5 patients; P = 0.16), blood transfusions (2 vs 7 patients; P = 0.24), and repeat endoscopy for possible gastrointestinal bleeding (no patients in either group). CONCLUSION: Based on the results, no significant post-procedure bleeding was observed in patients undergoing PEG with recent use of clopidogrel.

Effect of precut sphincterotomy on post-endoscopic retrograde cholangiopancreatography pancreatitis: a systematic review and meta-analysis.

AIM: To conduct a systemic review and meta-analysis to investigate the role of early precut technique. Multiple randomized controlled trails (RCTs) have reported conflicting results of the early precut sphincterotomy. METHODS: MEDLINE/PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, and recent abstracts from major conference proceedings were searched (June 2013). Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included. Pooled estimates of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP), cannulation and adverse events were analyzed by using odds ratio (OR). Random and fixed effects models were used as appropriate. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I² measure of inconsistency. RESULTS: Seven randomized and seven non-randomized trials met inclusion criteria. Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant (OR = 0.58; 95%CI: 0.32-1.05; P = 0.07). No heterogeneity was noted among the studies with I² of 0%. CONCLUSION: Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.

Digital rectal examination versus spontaneous passage of stool for fecal occult blood testing.

BACKGROUND: The diagnostic value of a positive fecal occult blood test (FOBT) at the time of digital rectal examination (DRE) is disputed despite being used commonly by a significant number of physicians. A meta-analysis was conducted to evaluate FOBT by DRE for detecting neoplasia versus FOBT on stool passed spontaneously (SPS) in asymptomatic patients undergoing colorectal cancer screening. METHODS: MEDLINE, the Cochrane Central Register of Controlled Trials and the Cochrane database of systematic reviews, CINAHL, PubMed, and recent abstracts from major conferences were searched in August 2011. We included all of the studies that compared stool sampling techniques for FOBT. Separate analyses were performed for each main outcome (normal, nonadvanced adenoma, advanced adenoma, and colon cancer). RESULTS: Seven studies (N = 1835) met the inclusion criteria. The use of DRE for FOBT demonstrated statistically significant fewer advanced adenomas than SPS for FOBT. No statistically significant differences were noted for normal findings, neoplasia, nonadvanced adenoma, or colon cancer with DRE compared with SPS for FOBT. CONCLUSIONS: DRE for FOBT appears to be less effective at detecting advanced adenomas as compared with SPS despite cancer detection being similar. FOBT by SPS appears to be statistically superior to FOBT by DRE.

Warfarin Use During Fecal Occult Blood Testing: A Meta-Analysis.

BACKGROUND: Fecal occult blood testing (FOBT) is a widely used screening test for colorectal cancer (CRC). Given the limited data about the effects of warfarin on FOBT are inconclusive, current screening guidelines for CRC do not address whether warfarin should be discontinued before FOBT. Therefore, we conducted a meta-analysis to evaluate the influence of warfarin on the yield of FOBT. METHODS: Multiple medical databases were searched (April 2011). Studies examining the use of warfarin versus no warfarin for FOBT were included. Meta-analysis for the effect of warfarin or no warfarin for FOBT was performed by calculating pooled estimates of colonoscopy findings and detection of neoplasia, any adenoma, advanced adenoma, or colon cancer by odds ratio (OR) with fixed and random effects model. RevMan 5.1 was utilized for statistical analysis. RESULTS: Five studies (N = 11,244) met the inclusion criteria. No statistically significant difference was noted between FOBT with or without warfarin for colonoscopy findings (OR 0.88; 95% CI: 0.48 - 1.62, P = 0.67) or detection of neoplasia (OR 0.88; 95% CI: 0.58 - 1.35, P = 0.57), any adenoma (OR 1.08; 95% CI: 0.73 - 1.58, P = 0.71), advanced adenoma (OR 1.07; 95% CI: 0.69 - 1.65, P = 0.78), and colon cancer (OR 0.69; 95% CI: 0.38 - 1.23, P = 0.21). CONCLUSIONS: Among patients with positive FOBT, the yield of colonoscopy appears not to be altered by warfarin use.

Ursodeoxycholic acid in patients with ulcerative colitis and primary sclerosing cholangitis for prevention of colon cancer: a meta-analysis.

PURPOSE/AIM: Colon cancer risk is high in patients with ulcerative colitis (UC) and primary sclerosing cholangitis (PSC). Ursodeoxycholic acid has been shown to have some promise as a chemopreventive agent. A meta-analysis was performed to compare the efficacy of ursodeoxycholic acid in the prevention of colonic neoplasia in patients with UC and PSC. METHODS: Multiple databases were searched (January 2011). Studies examining the use of ursodeoxycholic acid vs. no ursodeoxycholic acid or placebo in adult patients with UC and PSC were included. Data were extracted in standard forms by two independent reviewers. Meta-analysis for the effect of ursodeoxycholic acid was performed by calculating pooled estimates of adenoma or colon cancer formation by odds ratio (OR) with random effects model. Heterogeneity was assessed by calculating the I (2) measure of inconsistency. RevMan 5 was utilized for statistical analysis. RESULTS: Four studies (n = 281) met the inclusion criteria. The studies were of adequate quality. Ursodeoxycholic acid demonstrated no overall improvement in adenoma (OR 0.53; 95 % CI: 0.19-1.48, p = 0.23) or colon cancer occurrence (OR 0.50; 95 % CI: 0.18-1.43, p = 0.20) as compared to no ursodeoxycholic acid or placebo in patients with UC and PSC. CONCLUSION: Ursodeoxycholic acid use in patients with UC and PSC does not appear to decrease the risk of adenomas or colon cancer.

A Rare Cause of Massive Upper Gastrointestinal Hemorrhage in Immunocompromised Host.

Mucormycosis is an invasive and aggressive opportunistic fungal infection that usually presents with rhinocerebral or pulmonary involvement and rarely involves the gastrointestinal tract. The disease is acute with mortality rate up to 100%. A 68-year-old male was undergoing treatment at a local hospital for COPD exacerbation with IV steroids and antibiotics. Two weeks into his treatment he suddenly developed massive upper GI bleeding and hemodynamic instability that necessitated transfer to our tertiary care hospital for further treatment and management. An urgent upper endoscopy revealed multiple large and deep gastric and duodenal bulb ulcers with stigmata of recent bleeding. The ulcers were treated endoscopically. Biopsies showed fibrinopurulent debris with fungal organisms. Stains highlighted slightly irregular hyphae with rare septa and yeast suspicious for Candida. The patient was subsequently placed on fluconazole. Unfortunately, the patient's general condition continued to worsen and he developed multiorgan failure and died. Autopsy revealed disseminated systemic mucormycosis. Most of the cases of gastrointestinal mucormycosis were reported from the tropics and few were reported in the United States. The disease occurs most frequently in immunocompromised individuals. The rare incidence of GI involvement, acute nature, severity and the problematic identification of the organisms on biopsies make antemortem diagnosis challenging. Treatment includes parenteral antifungals and debridement of the infected tissues. Gastroenterologists should be aware of this rare cause of gastrointestinal bleeding and understand the importance of communication with the reviewing pathologist so that appropriate, and often lifesaving, therapies can be administered in a timely manner.

Erythromycin prior to endoscopy in acute upper gastrointestinal bleeding: a meta-analysis.

OBJECTIVE: Upper gastrointestinal bleeding (UGIB) is a medical emergency requiring urgent endoscopy and diagnosis. However, adequate visualization is a necessity. Studies have been performed evaluating the efficacy of erythromycin infusion prior to endoscopy to improve visibility and therapeutic potential of esophagogastroduodenoscopy (EGD) with varied results. Therefore, a meta-analysis was performed comparing the efficacy of erythromycin infusion prior to endoscopy in acute UGIB. MATERIALS AND METHODS: Multiple databases were searched. Meta-analysis for the effect of erythromycin prior to endoscopy in UGIB was analyzed by calculating pooled estimates of visualization of gastric mucosa, need for second endoscopy, and units of blood transfused using odds ratio (OR) and weighted mean difference (WMD). RESULTS: Four studies (N = 269) met the inclusion criteria. Erythromycin prior to endoscopy in UGIB demonstrated a statistically significant improvement in visualization of the gastric mucosa (OR 4.89; 95% CI 2.85-8.38, p < 0.01), a decrease in the need for a second endoscopy (OR 0.42; 95% CI 0.24-0.74, p < 0.01), and a trend for less units of blood transfused (WMD -0.48; 95% CI -0.97 to 0.01, p = 0.05) with erythromycin as compared with no erythromycin. CONCLUSIONS: Erythromycin infusion prior to endoscopy in acute UGIB significantly improves visualization of gastric mucosa while decreasing the need for a second endoscopy. Based upon these results, erythromycin should be strongly considered prior to endoscopy in patients with UGIB.

Pancreatic stents for prophylaxis against post-ERCP pancreatitis: a meta-analysis and systematic review.

BACKGROUND: Acute pancreatitis is a common complication of ERCP. Several randomized, controlled trials (RCTs) have evaluated the use of pancreatic stents in the prevention of post-ERCP pancreatitis with varying results. OBJECTIVE: We conducted a meta-analysis and systematic review to assess the role of prophylactic pancreatic stents for prevention of post-ERCP pancreatitis. DESIGN: MEDLINE, Cochrane Central Register of Controlled Trials and Database of Systematic Reviews, PubMed, and recent abstracts from major conference proceedings were searched. RCTs and retrospective or prospective, nonrandomized studies comparing prophylactic stent with placebo or no stent for post-ERCP pancreatitis were included for the meta-analysis and systematic review. Standard forms were used to extract data by 2 independent reviewers. The effect of stents (for RCTs) was analyzed by calculating pooled estimates of post-ERCP pancreatitis, hyperamylasemia, and grade of pancreatitis. Separate analyses were performed for each outcome by using the odds ratio (OR) or weighted mean difference. Random- or fixed-effects models were used. Publication bias was assessed by funnel plots. Heterogeneity among studies was assessed by calculating I(2) measure of inconsistency. SETTING: Systematic review and meta-analysis of patients undergoing pancreatic stent placement for prophylaxis against post-ERCP pancreatitis. PATIENTS: Adult patients undergoing ERCP. INTERVENTIONS: Pancreatic stent placement for the prevention of post-ERCP pancreatitis. MAIN OUTCOME MEASUREMENTS: Post-ERCP pancreatitis, hyperamylasemia, and complications after pancreatic stent placement. RESULTS: Eight RCTs (656 subjects) and 10 nonrandomized studies met the inclusion criteria (4904 subjects). Meta-analysis of the RCTs showed that prophylactic pancreatic stents decreased the odds of post-ERCP pancreatitis (odds ratio, 0.22; 95% CI, 0.12-0.38; P<.01). The absolute risk difference was 13.3% (95% CI, 8.8%-17.8%). The number needed to treat was 8 (95% CI, 6-11). Stents also decreased the level of hyperamylasemia (WMD, -309.22; 95% CI, -350.95 to -267.49; P≤.01). Similar findings were also noted from the nonrandomized studies. LIMITATIONS: Small sample size of some trials, different types of stents used, inclusion of low-risk patients in some studies, and lack of adequate study of long-term complications of pancreatic stent placement. CONCLUSIONS: Pancreatic stent placement decreases the risk of post-ERCP pancreatitis and hyperamylasemia in high-risk patients.

Enteral feeding within three hours after percutaneous endoscopic gastrostomy placement: a meta-analysis.

BACKGROUND: Traditionally, tube feedings have been delayed after gastrostomy placement to the next day and up to 24 hours postprocedure. However, results from various randomized clinical trials (RCTs) indicate earlier feeding may be an option. Therefore, we conducted a meta-analysis to analyze the effect of earlier feedings (≤3 h) after percutaneous endoscopic gastrostomy (PEG) placement. METHODS: Various medical databases and recent abstracts from major conference proceedings were searched (8/09). Only RCTs on adult subjects that compared early (≤3 h) versus delayed or next-day feedings after PEG placement were included. Meta-analysis was performed using pooled estimates of complications, death ≤72 hours, and significant increases in the number of postprocedural gastric residual volume during day 1 using odds ratio (OR) with the fixed and random effects models. Heterogeneity was assessed by calculating the I2 measure of inconsistency. RevMan 5.0 was utilized for statistical analysis. RESULTS: Five studies (N=355) met the inclusion criteria. No significant differences were noted between early (≤3 h) and delayed or next day feedings for patient complications [OR 0.78; 95% confidence interval (CI), 0.39-1.53; P=0.47], death in ≤72 hours (OR 0.60; 95% CI, 0.18-1.99; P=0.40), and number of significant gastric residual volume during day 1 (OR 1.46; 95% CI, 0.75-2.84; P=0.27). No publication bias and no significant heterogeneity were noted. CONCLUSIONS: Early tube feeding ≤3 hours after PEG placement has no significant differences to delayed or next-day feeding in respect to complications, death in ≤72 hours, or number of significant gastric residual volumes at day 1.