Efficacy and Safety of Variable Treatment Options in the Prevention of Hepatic Encephalopathy: A Systematic Review and Network Meta-Analysis.

There are no guidelines for the most effective medication to reduce hepatic encephalopathy (HE) or the associated mortality. The purpose of this study is to determine the most effective possible treatment among the single treatment options or the combined treatment options for decreasing the morbidity and mortality of HE. We evaluated the outcomes by various parameters such as the quality of life, reduction in ammonia, all causes of mortality, adverse events, reversal of minimal HE, and development of overt HE. We systematically searched PubMed, Cochrane, Web of Science, and Scopus till the 19th of January 2023 for studies that assess various treatment options for HE. Data were extracted from eligible studies and pooled in a frequentist network meta-analysis as standardized mean difference (SMD) and their 95% confidence interval (CI) using the MetaInsight web-based tool. The Cochrane Tool was used to assess the randomized controlled trials' quality (RCT), while the NIH tool was used to assess the quality of the included cohort studies. Utilizing the R software, the network meta-analysis was conducted. In addition to a significant variation in cases of (Lactulose and Rifaximin) compared with Rifaximin (RR= 0.39, 95% CI [0.17; 0.89]), the results demonstrated a significantly lower incidence of overt HE in (Lactulose and Rifaximin) compared with placebo (RR=0.19, 95% CI [0.09; 0.40]). Most arms demonstrated a statistically significant reduction in the incidence of overt HE compared to albumin and placebo. The results also demonstrated a significant reduction in ammonia between L-ornithine-L-aspartate (LOLA) and probiotics (MD= -19.17, 95% CI [-38.01; -0.32]), as well as a significant difference in the incidence of LOLA compared to placebo (MD= -22.62, 95% CI [-39.16; -6.07]). This network meta-analysis has significant data for managing subclinical HE in people without a history of overt HE. Our analysis showed that (Lactulose and Rifaximin), followed by (Rifaximin and L-carnitine), followed by (Lactulose and Rifaximin with zinc) were the best combinations regarding overt HE. LOLA reduced ammonia best, followed by Nitazoxanide and finally Lactulose. (Lactulose and Nitazoxanide) have the least adverse effects, followed by (Rifaximin and L-carnitine), then Probiotics. Yet, all mortality outcomes and quality of life changes yielded no useful findings. Future studies like RCTs must be done to compare our therapies directly.

Physician-scientists or celebrities? Kardashian-index of gastroenterologists.

BACKGROUND: The coronavirus disease 2019 pandemic unleashed a flood of untrustworthy information on social media platforms, resulting in the unfortunate consequence of expert scientists' opinions getting lost amidst the chaotic sea of misinformation. The question of how much influence these esteemed scientists hold on social media platforms remains elusive. To address this scientific quandary, we sought to explore the concept of the Kardashian index (K-index), a term introduced by Hall in 2014. This metric provides a rudimentary means of evaluating whether a physician scientist's popularity on social media aligns with their significant scientific contributions. AIM: To evaluate if a Gastroenterologist physician's popularity on social media is at par with their scientific contributions (research articles and publications). METHODS: We conducted an extensive search to identify all gastroenterologists actively practicing and associated with the top 100 hospitals as reported by the United States News. We collected specific data on a sub-group including their names, affiliations, degrees, and sub-specializations. To gauge their social media popularity, we utilized the K-index calculation which is determined by dividing the actual number of Twitter followers by the number of researcher's citations. The expected number of followers (F) is calculated using the formula F = 43.3 C ^ 0.32, where C represents the number of citations. RESULTS: Physicians affiliated with the Mayo Clinic emerged as the most prominent presence on Twitter, constituting 16% of the total. They were followed closely by physicians from Mount Sinai Hospital (9%) and the University of Michigan Hospital (9%). Surprisingly, 76% of the physicians evaluated exhibited a low K-index, falling within the range of 0 to less than 2. This suggests that a significant number of highly influential physician-scientists are not receiving due recognition, as indicated by their relatively low number of followers. On the other hand, 24% of the physicians had an inflated K-index, exceeding 5, which positioned them as the "Kardashians". These individuals enjoyed greater social media popularity than their actual scientific contributions. Interestingly, our analysis revealed no discernible association between sex and K-index (P value of 0.92). CONCLUSION: In the gastroenterology field, our study estimated that a majority (76%) of highly researched physicians are undervalued despite their significant scientific contributions.

A Rare Case of Severe Jaundice in a Panhypopituitarism Patient.

Hyperbilirubinemia and transaminitis are rarely associated with a disorder of endocrine function. It mostly manifests as a cholestatic pattern of liver injury. Herein, a 25-year-old female patient with a past medical history of congenital hypopituitarism due to pituitary ectopia presented with serum direct bilirubin level of 9.9 mg/dL and aspartate transaminase (AST)/alanine transaminase (ALT) of 60/47 U/L. All tests for chronic liver disease imaging and liver biopsy were normal. She was found to have central hypothyroidism and low cortisol level. She was started on intravenous (IV) levothyroxine 75 µg daily and IV hydrocortisone 10-5 mg AM/PM. She was discharged on oral levothyroxine 88 µg daily and hydrocortisone orally 10 mg twice daily. Follow-up labs 1 month later showed completely normal liver function test. In conclusion, hyperbilirubinemia due to congenital hypopituitarism can occur in adults. Delayed recognition of underlying endocrine disorder as a cause of hyperbilirubinemia and hepatocellular inflammation can result in end-stage liver damage due to prolonged cholestasis.

A Rare Case of Anterograde Gastroduodenal Intussusception Caused by Migrated Percutaneous Endoscopic Gastrostomy Feeding Tube.

Gastroduodenal intussusception is a critical condition in which stomach protrudes into the duodenum. It is a very rare condition in adults. Most common causes include intra luminal lesions in the stomach including benign or malignant tumors of the stomach. Most common tumors included are gastrointestinal stromal tumors (GISTs), gastric carcinoma, gastric lipoma, gastric leiomyoma, and gastric schwannoma. It is extremely rare to be caused by migration of percutaneous feeding tube. A 50-year-old woman with a past medical history (PMH) of dysphagia status post percutaneous endoscopic gastrostomy (PEG) tube, history of spastic quadriplegia, presented with acute nausea, vomiting and abdominal distention, and was found to have gastroduodenal intussusception in computed tomography (CT) scan. Condition resolved after retracting PEG tube. Endoscopy did not reveal any intra luminal lesions. External fixation using Avanos Saf-T-Pexy T-fasteners was performed to prevent recurrence of this condition. Most common of causes of gastroduodenal intussusception are GIST tumors of stomach. CT abdomen is the most accurate test and upper endoscopy is needed to rule out any intra luminal causes. Treatment of choice is either endoscopic or surgical resection. External fixation is essential to prevent recurrence.

Trends in Hospitalizations of Esophageal Varices From 2011 to 2018: A United States Nationwide Study.

Background: Prevalence of gastroesophageal varices is around 50% of patients with cirrhosis. In compensated cirrhosis they are present in 30-40%. Progression from small to large varices occurs at rate of 10-12% annually. That percentage increases significantly in decompensated liver cirrhosis with gastroesophageal varices found in 85% of patients. Variceal hemorrhage occurs at a rate around 10-15% per year. The outcome of variceal hemorrhage depends on the severity of liver disease, size of varices, and presence of stigmata of recent bleeding (red whale sign). Six-week mortality of variceal hemorrhage ranges between 15% and 25%. Without treatment, variceal hemorrhage tends to recur in 60% of patients within 1 - 2 years. The aim of the study was to assess demographics of esophageal varices with and without bleeding, geographic distribution, comorbidities, outcomes, main payers, and cost of hospitalizations. Methods: The National Inpatient Sample (NIS) database from year 2011 to 2018 was used. Patients who had a primary diagnosis of esophageal varices with or without bleeding were identified using the International Classification of Diseases, Ninth Revision (ICD-9) codes (456.0 for esophageal varices with bleeding, and 456.1 for esophageal varices without bleeding), and International Classification of Diseases, 10th Revision (ICD-10) codes (I85.01 for esophageal varices with bleeding, and I85.00 for esophageal varices without bleeding) in the first two discharge diagnoses. The propensity score to calculate the inverse probability treatment weighting (IPTW) to adjust between the differences of the compared groups was implemented. Two groups were compared in terms of their hospitalization outcomes, including LOS, hospital charges, hospital mortality, and disposition. Results: A total of 322,761 patients were admitted with esophageal varices between 2011 and 2018, with 236,802 (73.6%) had bleeding esophageal varices and 85,959 (26.4%) had nonbleeding esophageal varices. The majority of the patients from both groups were white (66%), covered with Medicare (38% in the esophageal varices with bleeding vs. 41% in the nonbleeding group). There was a steady increase of patients admitted with nonbleeding esophageal varices. Most common comorbidities were liver diseases, alcohol abuse, uncomplicated hypertension and depression in both groups. There were no significant changes in OLS over the years in both groups, but there was a significant increase in hospital charges, especially in the patients with bleeding esophageal varices starting in 2015, and no change in mortality throughout the years. Regarding hospital disposition, there was a notable decline in rehab discharge in the bleeding esophageal varices group. Conclusions: Esophageal varices with and without bleeding have been steadily increasing since the beginning of this century. This may result in a substantial impact on increasing health care costs and utilization due to acute variceal hemorrhage. Odds of death, transfer to urban hospital, and transfer to visiting nursing assistance remained unchanged.

Two Patients With Difficulty in Swallowing due to Dysphagia Lusoria.

Dysphagia lusoria (DL) is a rare clinical entity caused by compression of the esophagus by an aberrant right subclavian artery. It is coined from the Latin word meaning freak or jest of nature, with an estimated prevalence of approximately 0.5%. Before the term DL was known, the artery abnormality was referred to as luxus nature. Most patients are asymptomatic. In 30-40% of cases, DL results in tracheoesophageal symptoms like dysphagia to solid foods, chest pain, cough, and Horner's syndrome. Symptoms presenting later in life have been linked to arteriosclerosis and diminishing esophageal compliance resulting in compression. Another reason why people become symptomatic is due to Kommerell's diverticulum, a disorder that was first described by Kommerell, a German radiologist in 1936. It is also known as lusoria diverticulum, remnant diverticulum or lusoria root. This disorder represents a remnant of the left dorsal arch which forms a vascular ring behind the esophagus, leading to external compression. The key to diagnosis of DL is a barium esophagogram which may show extrinsic compression. Computed tomography or magnetic resonance imaging can be used for definite delineation of the vascular anatomy. Treatment approach is dietary modification or surgical intervention for unresponsive cases. Here, we present cases of dysphagia in two middle-aged women caused by compression effect on the esophagus by an aberrant right subclavian artery who did not respond to dietary modification.

The Tale of a Bleeding Tree: A Rare Case of Peripancreatic Variceal Hemorrhage Causing Hemosuccus Pancreaticus.

Hemosuccus pancreaticus (HP) is a rare cause of upper gastrointestinal bleeding. It was described by Lawal and Farrel in 1931. This disorder has also been referred to as pseudohemobilia or wirsungorrhagia, caused by bleeding into the pancreatic duct. The rarity of this condition can pose a diagnostic challenge. HP is life-threatening and requires immediate attention. The commonly used treatment modality is coil embolization. Surgery is considered in the case of failed embolization or uncontrolled bleeding. Described below, is a case of a 72-year-old female with a history of chronic pancreatitis who presented with anemia secondary to bleeding peripancreatic varices.

Endoscopic stricturotomy with pulsed argon plasma and balloon dilation for refractory benign colorectal strictures: a case series.

Benign strictures of the colon and rectum affect a sizable portion of patients who have an underlying inflammatory disease or who have undergone recent surgery. Etiologies include inflammatory bowel disease (IBD), post-surgical ischemia, anastomotic strictures, non-steroidal anti-inflammatory drugs (NSAIDs), and complicated diverticulitis. Refractory colorectal strictures are very difficult to manage and often require repeated and different treatment options. We report a novel technique using argon plasma coagulation (APC) with endoscopic balloon dilation (EBD) as a safe and effective treatment modality for refractory benign colorectal strictures. Four patients with symptomatic benign colorectal strictures were referred for endoscopic treatment. In all cases (two females and two males; average age 62 years), the endoscopic and radiographic assessment showed significant strictures (diameter, 4-13 mm). The stricture was secondary to Crohn's disease in one patient and anastomotic strictures in the other three patients. Endoscopic stricturotomy through fulguration and tissue destruction using argon plasma at 1.5 liters/minute, effect 2, and 40 watts was performed, followed by EBD. All patients were treated by one advanced endoscopist. The primary outcomes were the efficiency and safety of endoscopic stricturotomy with pulsed argon plasma and balloon dilation. The resolution of stricture was achieved in all patients. No complications were reported. We believe that combined APC with EBD is a safe and effective technique in the treatment of benign colonic stricture.

Closure of recurrent colovaginal fistulas using AMPLATZER occluder device.

A 79-year-old woman and a 92-year-old woman were referred to the gastroenterology department for management of persistent colovaginal fistula despite surgical and non-surgical management. Both patients had several hospitalisations for recurrent urinary tract infections. After failed surgical management and endoscopy using over-the-scope clipping, both patients underwent endoscopic closure using the Amplatzer cardiac septal occluder device. Both patients underwent successful closure and had no recurrence of symptoms at 6-month follow-up. Although there are several therapies available for persistent colovaginal fistulas, most involve multiple sessions and have high recurrence rate. There have been reports in the literature of cardiac septal occluders being used in the management of upper gastrointestinal tract fistulas, but few cases exist explaining their role in the management of colovaginal fistulas. Our cases demonstrate that cardiac septal occluders may be a viable option for management of fistulas and warrants further studies to reproduce its effectiveness and safety.

A Complicated Parenchymal-Esophageal Fistula in Non-Small Cell Lung Cancer.

Respiratory digestive fistula (RDF) is an abnormal communication between the airway and the digestive tract. Only 3-11% of RDF communications are parenchymal-esophageal fistulas. We present a case of a 58-year-old male who presented to the emergency department with dysphagia and cough after swallowing. He was diagnosed with stage III/B non-small cell lung cancer. The patient was previously treated with chemotherapy, radiation, and immunotherapy. Computed tomography (CT) scan of the chest with contrast showed a chronic cavitary right upper lobe lesion in the previously treated malignancy area. New right paratracheal adenopathy, right esophageal wall thickening, and bilateral lung infiltrates were also shown. Upper endoscopy with bronchoscopy and endobronchial ultrasound (EBUS) was done to evaluate mediastinal lymphadenopathy as well as dysphagia. A tract was found extending from the right lung cavity into the esophagus through the mediastinum. Esophagoscopy was subsequently performed, and a fistula was observed on the right wall of the mid-esophagus. The defect was favorable for clipping, which was successfully closed with an 11/6 traumatic over the scope clip, followed by a fully covered esophageal stent. The patient's respiratory and gastrointestinal symptoms improved after the procedure. Follow-up barium swallow was negative for any esophageal leak. At three-month follow-up, the patient was free of recurrent pulmonary and gastrointestinal symptoms that he presented with. Palliative therapy is the targeted therapy for RDF management. RDF is either managed conservatively or with radiation, chemotherapy, or surgery to obliterate the connection. Surgical correction usually is not an option since patients typically have a poor functional status at the time of diagnosis. Considering the survival and recurrence rate medical intervention is the mainstay of treatment. Parallel dual (esophageal-bronchial) stenting has been proven to provide the best outcomes. Self-expanding metal stents (SEMS), either covered or partially covered, are used extensively to manage malignant RDF.

Imaging Negative Hepatic Lesions: A Rare Case of Infiltrative Hepatocellular Carcinoma Diagnosed With Endoscopic Ultrasound.

Hepatocellular carcinoma is a common malignancy with male predominance. It is further classified into different subtypes, among which the infiltrative subtype is the most difficult to diagnose with imaging because of its inherently ill-defined micro nodules involving a segment or entire hepatic parenchyma without a distinguishable mass. Owing to the aggressive nature and decreased survival expectations in most patients with infiltrative hepatocellular carcinoma, liver transplants and surgical resections are not recommended. Our case describes a middle-aged woman presenting with alpha-fetoprotein >20,000 and imagings negative for hepatic mass, thereby necessitating the use of endoscopic ultrasound with fine-needle aspiration.

Ascending Cholangitis Caused by Methicillin-Resistant Staphylococcus aureus Species in a Patient With Cystic Fibrosis.

Ascending cholangitis is a bacterial infection of the extra-hepatic biliary system and presents as a life-threatening systemic condition. Increased bacterial loads and biliary obstruction favor bacterial translocation into the vascular and lymphatic systems. Common organisms isolated are Escherichia Coli, Klebsiella, Enterococcus species, and Enterobacter species. Methicillin-resistant Staphylococcus aureus (MRSA) is a rare isolate in ascending cholangitis. We present a case of a 24-year-old patient with cystic fibrosis who presented with epigastric abdominal pain, low-grade fever, jaundice, dark urine, and nausea for two days. Initial workup revealed elevated liver enzymes, hyperbilirubinemia, leukocytosis, and an ultrasound which showed common bile duct dilation to 14 mm with choledocholithiasis. He underwent endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction and bile fluid culture. Cultures grew out MRSA and the patient was treated with appropriate antibiotic therapy. The mainstay of therapy for ascending cholangitis is adequate hydration, antibiotics, and biliary decompression. Early recognition of the offending organism is critical in guiding therapy. Current guidelines focus on the empiric treatment of Gram-negative and anaerobic bacteria. Clinicians should be aware of the possibility of less common pathogens (such as MRSA), especially in a patient who is decompensating despite antibiotic therapy.

A Benign Ulcerating Gastric Mass Presenting as Acute Gastrointestinal Hemorrhage.

Gastrointestinal lipomas are rare, often colonic tumors. The stomach is an unusual site of involvement of lipomas, accounting for less than 5% of all gastrointestinal lipomas and less than 3% of all benign gastric neoplasms. They are usually asymptomatic, and symptoms develop as the tumor grows. Gastric lipomas can present with massive bleeding from an ulcerating tumor and can be life-threatening if left untreated. We present a case of an ulcerating gastric lipoma that presented as an acute upper gastrointestinal hemorrhage. The patient was treated with Billroth II procedure and final pathology showed an ulcerating submucosal lipoma. The diagnosis of gastric lipoma is often suspected incidentally on imaging, then confirmed via biopsy. Definitive treatment of large lesions typically requires surgery, however, newer endoscopic techniques are being utilized for resection of these benign tumors.

Assessing the utility, findings, and outcomes of percutaneous transhepatic cholangioscopy with SpyglassTM Direct visualization system: a case series.

Bile duct stones, indeterminate biliary strictures and other biliary duct pathologies represent a significant surgical and endoscopic challenge in patients with altered luminal or biliary anatomy. Traditional endoscopic retrograde cholangiopancreatography (ERCP) is not feasible and alternative approach is usually required. A novel alternative approach of addressing these challenging cases is assessed by this case series. All patients who underwent percutaneous transhepatic cholangioscopy (PTCS) and SpyglassTM Direct visualization system (SDVS) between December 2016 and February 2018 were studied. The indications for procedure, interventions performed, outcomes and complications were reviewed for each case. SpyglassTM marketed by Boston Scientific Corporation, Marlborough, Massachusetts was utilized by interventional endoscopists and radiologists through a 12 French (Fr) percutaneous vascular sheath. Five patients had altered biliary and/or luminal anatomy: two with Roux-en-Y gastric bypass and three with Roux-en-Y hepaticojejunostomy. All patients had unsuccessful previous ERCP attempts. All PTCS with SDVS procedures were technically successful. Indications for this unusual approach were: ascending cholangitis, abnormal liver function tests and biliary dilation on imaging. SDVS was utilized to conduct electrohydraulic lithotripsy (EHL) for biliary stone management in four patients and intraductal biopsies for indeterminate strictures in two of them. PTCS with SDVS can be beneficial for multiple diagnostic and therapeutic indications in patients with altered biliary or luminal anatomy. SDVS allows direct evaluation and management of different biliary pathologies in challenging cases where traditional ERCP is not feasible. Some indications for PTCS with SDVS include evaluation of biliary strictures and biliary stasis, biliary tract biopsy and lithotripsy for management of biliary stones.

Anchoring lumen-apposing metal stent with coaxial plastic stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: any benefit?

BACKGROUND: Anchoring double-pigtail plastic stents (DPSs) within lumen-apposing metal stents (LAMSs) has been proposed to prevent adverse events during endoscopic drainage of pancreatic fluid collections (PFCs). We sought to compare the outcomes of patients who received LAMSs alone and those who received both LAMSs and anchoring DPSs for drainage of PFCs. METHODS: A retrospective study was conducted at the University of Kentucky. Patients with PFCs who underwent endoscopic ultrasound-guided drainage using LAMSs, with or without DPSs, between January 2016 and March 2018 were included. Categorical data were analyzed using chi-square tests, and continuous variables using 2-sample t-tests. Adverse events were defined according to the American Society for Gastrointestinal Endoscopy's Lexicon. The primary outcome was to evaluate the efficacy (PFC resolution), and safety (adverse events) of LAMSs with or without DPSs used to drain PFCs. RESULTS: Fifty-seven patients with PFCs were treated by 2 experienced endoscopists over 26 months. Twenty-one (37%) patients received LAMSs alone, and 36 (63%) received LAMSs plus DPSs. Forty-three patients had walled-off pancreatic necrosis, and 14 patients had pancreatic pseudocyst. Clinical success (resolution of PFCs) was achieved in 15 patients (71.4%) in the LAMSs alone group, and 21 patients (58.3%) with LAMSs plus DPSs (P=0.32). In patients with LAMSs alone, 6 patients (28.6%) had adverse events, while in those with LAMSs plus DPSs, 14 (38.9%) patients had adverse events (P=0.43). CONCLUSION: No significant difference was identified in fluid resolution or adverse events between patients with LAMSs alone and those with LAMSs plus DPSs.

Duodenal variceal bleeding with large spontaneous portosystemic shunt treated with transjugular intrahepatic portosystemic shunt and embolization: A case report.

BACKGROUND: Duodenal variceal bleeding is a rare cause of gastrointestinal bleeding. The most common site is the duodenal bulb. It is usually detected endoscopically but it can be very challenging to diagnose if it is located distal to the second part od duodenum. The pre- transjugular intrahepatic portosystemic shunt (TIPS) presence of spontaneous portosystemic shunt (SPSS) was found to be associated with an increased risk of early morbidity and mortality after TIPS placement. CASE SUMMARY: A 43-year-old cirrhotic male presented with melena for three days. Upper endoscopy was performed and showed active blood oozing from the distal duodenum concerning for ectopic duodenal varix. A computed tomography (CT) angiogram was performed and showed an enlarged cluster of venous collaterals around the distal duodenum. He underwent TIPS placement. He had another episode of melena three days later. Push enteroscopy with injection sclerotherapy into the duodenal varices was performed with no success. A repeat CT angiogram showed occluded TIPS shunt. Therefore, a TIPS revision was performed and there was an extensive portal venous thrombosis with a large shunt between the inferior mesenteric vein and left renal vein via the left gonadal vein. Thrombectomy and TIPS shunt balloon angioplasty was performed, followed by embolization of the portosystemic. The melena was resolved, and patient was discharged with arranged hepatology follow up. CONCLUSION: It importance to look and embolize the SPSS shunts in patients with early TIPS dysfunction and recurrent duodenal variceal bleeding.