Maximizing success in single-session EUS-directed transgastric ERCP: a retrospective cohort study to identify predictive factors of stent migration.

BACKGROUND AND AIMS: EUS-directed transgastric ERCP (the EDGE procedure) is a simplified method of performing ERCP in Roux-en-Y gastric bypass patients. The EDGE procedure involves placement of a lumen-apposing metal stent (LAMS) into the excluded stomach to serve as a conduit for passage of the duodenoscope for pancreatobiliary intervention. Originally a multistep process, urgent indications for ERCP have led to the development of single-session EDGE (SS-EDGE) with LAMS placement and ERCP performed in the same session. The goal of this study was to identify predictive factors of intraprocedural LAMS migration in SS-EDGE. METHODS: We conducted a multicenter retrospective review that included 9 tertiary medical centers across the United States. Data were collected and analyzed from 128 SS-EDGE procedures. The primary outcome was intraprocedural LAMS migration. Secondary outcomes were other procedural adverse events such as bleeding and perforation. RESULTS: Eleven LAMS migrations were observed in 128 procedures (8.6%). Univariate analysis of clinically relevant variables was performed, as was a binary logistic regression analysis of stent diameter and stent dilation. This revealed that use of a smaller (15 mm) diameter LAMS was an independent predictor of intraprocedural stent migration (odds ratio, 5.36; 95% confidence interval, 1.29-22.24; P = .021). Adverse events included 3 patients who required surgery and 2 who experienced intraprocedural bleeding. CONCLUSIONS: Use of a larger-diameter LAMS is a predictive factor for a nonmigrated stent and improved procedural success in SS-EDGE. Although larger patient cohorts are needed to adequately assess these findings, performance of LAMS dilation and fixation may also decrease risk of intraprocedural LAMS migration and improve procedural success.

Management of Severe and Severe/Complicated Clostridoides difficile Infection Using Sequential Fecal Microbiota Transplant by Retention Enema.

We evaluated serial fecal microbiota transplant (FMT) by retention enema in patients with severe or severe/complicated Clostridoides difficile infection (CDI) unresponsive to at least 48 hours of standard antibiotic therapy. Of the 15 patients included, despite initial improvement in most patients, only 5 patients sustained cure at 30 days, and serious adverse events occurred in 4 patients.

Heparin bridge is associated with more post-polypectomy bleeding and emergency department visits among anticoagulated patients.

BACKGROUND: Among patients undergoing colonoscopy, anticoagulants are usually stopped and are sometimes substituted by a heparin bridge (hep-bridge). We aimed to assess adverse events associated with hep-bridge compared to temporary cessation of anticoagulants (no-bridge). METHODS: This was a single-center, retrospective cohort study that included anticoagulated patients undergoing colonoscopy between 2013 and 2016 at a Veterans Affairs Medical Center. In the no-bridge cohort, warfarin was stopped for 5 days and novel anticoagulants for 2 days pre-procedure. In the hep-bridge cohort, anticoagulants were stopped and were substituted by subcutaneous enoxaparin. The primary outcome was post-polypectomy bleeding. Secondary outcomes included cardiovascular events, all-cause adverse events and emergency department or unscheduled ambulatory office visits within 30 days. The predictive values of the HAS-BLED and CHADS2 scores were evaluated. RESULTS: A total of 662 patients were included, of whom 551 underwent polypectomy (mean age 68.6 years; 97.6% male). Four hundred seventy colonoscopies were performed with no-bridge and 192 with hep-bridge. Post-polypectomy bleeding occurred in 6.0% of procedures: 5.7% in the no-bridge cohort compared to 13.0% of hep-bridge procedures (P=0.0038). Cardiovascular or thrombotic events occurred after 2.6% of the no-bridge and 5.2% of the hep-bridge procedures (P=0.1176). Emergency department or unscheduled office visits within 30 days were reported after 18.7% of the no-bridge procedures and 29.7% of the hep-bridge procedures (P<0.0001). Neither CHADS2 nor HASBLED scores predicted bleeding. CONCLUSION: The use of hep-bridge was associated with a greater incidence of post-polypectomy bleeding and more emergency department and unscheduled office visits compared with cessation of all anticoagulants.

Analysis of Accredited Gastroenterology Fellowship Internet-Available Content: Twenty-Nine Steps Toward a Better Program Website.

GOAL: To assess publicly available content derived from official websites of accredited gastroenterology fellowship programs, specifically evaluating data pertinent to prospective applicants. BACKGROUND: The Internet provides access to key information for applicants applying to gastroenterology fellowship, particularly as competition drives applicants to apply to a large number of programs. Thus, it is important for fellowship program websites to be up to date and contain accurate and pertinent information. METHODS: Twenty-nine variables, determined as important website content on the basis of prior published website analyses and from surveys of preferences, were extracted from the relevant websites of all accredited gastroenterology fellowships in the USA. Results were binary-i.e., a website either contained or did not contain each item. RESULTS: A total of 178 websites were evaluated. The mean number of online content items was 14.1(± 3.2 SD) out of a possible 29 (47.1%). Program coordinator contact information, application information, and the number of current fellows were accessible on > 80% of websites. In contrast, the typical number and types of procedures performed by fellows and number of hospitals covered by fellows on call were found on < 10% of websites. Analysis revealed that 23.2% of lifestyle, 48.3% of training, and 59.6% of program variables were met. CONCLUSIONS: Gastroenterology fellowship websites lacked important content. Websites had a lower mean percentage of lifestyle content compared to training and program-related items. An organized website containing relevant information may not only attract qualified applicants but also avert unnecessary email inquiries and inappropriate applications. This study may provide guidance to gastroenterology fellowship programs seeking to improve their websites for applicants.

Vanishing bile duct syndrome in Hodgkin's lymphoma: A case report and literature review.

Vanishing bile duct syndrome (VBDS) has been described in different pathologic conditions including infection, ischemia, adverse drug reactions, autoimmune diseases, allograft rejection, and humoral factors associated with malignancy. It is an acquired condition characterized by progressive destruction and loss of the intra-hepatic bile ducts leading to cholestasis. Prognosis is variable and partially dependent upon the etiology of bile duct injury. Irreversible bile duct loss leads to significant ductopenia, biliary cirrhosis, liver failure, and death. If biliary epithelial regeneration occurs, clinical recovery may occur over a period of months to years. VBDS has been described in a number of cases of patients with Hodgkin's lymphoma (HL) where it is thought to be a paraneoplastic phenomenon. This case describes a 25-year-old man found on liver biopsy to have VBDS. Given poor response to medical treatment, the patient underwent transplant evaluation at that time and was found to have classical stage IIB HL. Early recognition of this underlying cause or association of VBDS, including laboratory screening, and physical exam for lymphadenopathy are paramount to identifying potential underlying VBDS-associated malignancy. Here we review the literature of HL-associated VBDS and report a case of diagnosed HL with biopsy proven VBDS.

Hepatic sarcoidosis: pathogenesis, clinical context, and treatment options.

Sarcoidosis is typically characterized as a non-caseating granulomatous disease that has the ability to affect multiple different organ systems. Although extra-thoracic sarcoidosis can occur in the presence and also without lung involvement, isolated extra-pulmonary disease is rare. The liver is the third most commonly affected organ system after the lungs and lymph nodes. When discussing hepatic sarcoidosis it is important to keep in mind that many patients in this population may not present as one would typically expect since most of the patients are asymptomatic or have mild presentations. Therefore, the diagnosis can be difficult at times since no single laboratory or imaging study can definitively diagnose this systemic disease. In the rare case of some patients where there is difficulty in discerning between different pathologies, the use of image-guided tissue biopsy may be necessary to establish a diagnosis. At the current time, there are no clear guidelines for the management of hepatic sarcoidosis and are mostly dependent on a patient's clinical status at time of presentation. The current body of research in regard to treatment suggests steroids to be the mainstay of therapy. However, there is a role for additional immunosuppressive therapy in cases where the initial treatment is refractory to steroids. In this manuscript, we discussed the pathogenesis of liver sarcoidosis and context of its presentation. In addition, the differential diagnosis and imaging evaluation in this population is discussed. Finally, treatment options are reviewed in setting of previous studies for liver sarcoidosis.

Isolated Gastric Varices and Use of Balloon-occlusive Retrograde Transvenous Obliteration: A Case Report and Literature Review.

Isolated gastric varices are far less prevalent in Western countries where the rate of splenic thrombosis is much lower. However, in Asian countries the entity is more common and therefore a more robust treatment approach has been developed. Balloon-occlusive retrograde transvenous obliteration (BRTO) was first described in 1984 and then revived in 1996. The procedure, while uncommon in the U.S. and not recognized by the AASLD practice guidelines, allows for direct exclusion from the portosystemic system. Here we describe the case of a patient with alcoholic cirrhosis decompensated by bleeding gastric varices treated with BRTO.

Topical androgen antagonism promotes cutaneous wound healing without systemic androgen deprivation by blocking ß-catenin nuclear translocation and cross-talk with TGF-ß signaling in keratinocytes.

Orchidectomy in rodents and lower testosterone levels in men are associated with improved cutaneous wound healing. However, due to the adverse effects on skeletal and sexual tissues, systemic androgen blockade is not a viable therapeutic intervention. Accordingly, we tested the hypothesis that topical application of an androgen antagonist would elicit accelerated wound healing without systemic androgen antagonism. Full-thickness cutaneous wounds were created on adult C57BL6/J mice. Daily topical application of androgen receptor antagonist, flutamide, resulted in improved gap closure similar to orchiectomized controls and faster than orchidectomized mice treated with topical testosterone. In vivo data showed that the effects of androgen antagonism on wound closure primarily accelerate keratinocytes migration without effecting wound contraction. Consequently, mechanisms of testosterone action on reepithelialization were investigated in vitro by scratch wounding assays in confluent keratinocytes. Testosterone inhibited keratinocyte migration and this effect was in part mediated through promotion of nuclear translocation of ß-catenin and by attenuating transforming growth factor-ß (TGF-ß) signaling through ß-catenin. The link between Wnt and TGF beta signaling was confirmed by blocking ß-catenin and by following TGF-ß-induced transcription of a luciferase reporter gene. Together, these data show that blockade of ß-catenin can, as a potential target for novel therapeutic interventions, accelerate cutaneous wound healing.