Endoscopic Ultrasound View of Pneumatosis Cystoides Intestinalis.

Pneumatosis cystoid intestinalis (PCI) is a rare condition, with a worldwide incidence of 0.3-1.2%. PCI is classified into primary (idiopathic) and secondary forms, with 15% and 85% of presentations, respectively. This pathology was associated with a wide variety of underlining etiologies to explain the abnormal accumulation of gas within the submucosa (69.9%), subserosa (25.5%), or both layers (4.6%). Many patients endure misdiagnosis, mistreatment, or even inadequate surgical exploration. In this case, a patient presented acute diverticulitis, after treatment, a control colonoscopy was performed that found multiple rounds and elevated lesions. To further study the subepithelial lesion (SEL), a colorectal endoscopic ultrasound (EUS) was performed with an overtube in the same procedure. For safe insertion of the curvilinear array EUS, an overtube with colonoscopy was positioned through the sigmoid as described by Cheng et al. The EUS evaluation evidenced air reverberation in the submucosal layer. The pathological analysis was consistent with PCI's diagnosis. The diagnosis of PCI is usually made by colonoscopy (51.9%), surgery (40.6%), and radiological findings (10.9%). Although the diagnosis can be made by radiological studies, a colorectal EUS and colonoscopy can be made in the same section without radiation and with high precision. As it is a rare disease, there are not enough studies to define the best approach, although colorectal EUS should be preferred for a reliable diagnosis.

A case of esophageal histoplasmosis mimicking carcinoma on endoscopy.

A 54-year-old woman with progressive and non-acute dysphagia to solid foods, post-feeding vomiting, and weight loss of 10 kg in 1 year. As personal history, she was a former smoker of 60 pack-year, heart transplant for idiopathic dilated cardiomyopathy, and type 2 diabetes. She was on daily use of metformin and immunosuppressive drugs. The laboratory tests were all normal. Upper digestive endoscopy (UDE) revealed in the middle third of the esophagus a lesion of 3 cm presenting atypical rectified vessels, covering 50% of the esophageal lumen, suggestive type 0-IIc+IIa1 (A). The chromoendoscopy with Lugol iodine at 1.25% showed a positive pink sign (B). Biopsies showed esophagitis with mixed inflammatory infiltrate and numerous macrophages (C-upper panel). The Periodic Acid-Schiff staining showed small yeasts compatible with Histoplasma capsulatum, measuring 0.5 to 2.5 µm, within the cytoplasm of macrophages (arrows), with a clear halo (inset, arrows) (C-lower panel). These findings were compatible with esophageal histoplasmosis. Treatment was started with oral Itraconazole 400mg/day. After 3 months, a new UDE with biopsies showed complete esophageal healing. Gastrointestinal histoplasmosis manifests mainly in the small bowel and colon, related to a great amount of lymphoid tissue in these areas. Patients can present with fever, weight loss, abdominal pain and diarrhea. In endoscopy, we may find ulcerations, thickened wall, plaques and pseudopolyps2. It is considered a rare condition, and in only 3% of cases, there is esophageal involvement. This manifestation is mainly in immunosuppressed patients. It can be related to direct involvement of the esophagus or secondary to infiltration of mediastinal nodes2. In endoscopy, ulcerations, inflammatory masses, strictures, and external compressions can be found. This case illustrated the difficulty in differentiating early cancer from an esophageal histoplasmosis.

The Effectiveness and Safety of the Duodenal-Jejunal Bypass Liner (DJBL) for the Management of Obesity and Glycaemic Control: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.

INTRODUCTION: The duodenal-jejunal bypass liner (DJBL) is a less-invasive treatment of obesity and type 2 diabetes mellitus (T2DM). METHODS: This is a systematic review and meta-analysis including randomized clinical trials (RCTs) comparing DJBL versus sham or pharmacotherapies aiming to evaluate the effectiveness and safety of DJBL. RESULTS: Ten RCTs (681 patients) were included. The DJBL group showed superior excess weight loss (+ 11.4% [+ 7.75 to + 15.03%], p < 0.00001) and higher decrease in HbA1c compared to the control group (- 2.73 ± 0.5 vs. - 1.73 ± 0.4, p = 0.0001). Severe adverse events (SAEs) occurred in 19.7%. CONCLUSION: The DJBL did not reach the ASGE/ASMBS thresholds for the treatment of obesity. However, it is important to state that many SAEs were not really severe. Therefore, we believe this therapy plays an important role in the management obesity and T2DM.

Endoscopic ultrasound (EUS)-guided cholecystostomy versus percutaneous cholecystostomy (PTC) in the management of acute cholecystitis in patients unfit for surgery: a systematic review and meta-analysis.

BACKGROUND AND AIM: Surgical cholecystectomy is the gold standard strategy for the management of acute cholecystitis (AC). However, some patients are considered unfit for surgery due to certain comorbid conditions. As such, we aimed to compare less invasive treatment strategies such as endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and percutaneous gallbladder drainage (PT-GBD) for the management of patients with AC who are suboptimal candidates for surgical cholecystectomy. METHODS: A comprehensive search of multiple electronic databases was performed to identify all the studies comparing EUS-GBD versus PT-GBD for patients with AC who were unfit for surgery. A subgroup analysis was also performed for comparison of the group undergoing drainage via cautery-enhanced lumen-apposing metal stents (LAMS) versus PT-GBD. The outcomes included technical and clinical success, adverse events (AEs), recurrent cholecystitis, reintervention, and hospital readmission. RESULTS: Eleven studies including 1155 patients were included in the statistical analysis. There was no difference between PT-GBD and EUS-GBD in all the evaluated outcomes. On the subgroup analysis, the endoscopic approach with cautery-enhanced LAMS was associated with lower rates of adverse events (RD = - 0.33 (95% CI - 0.52 to - 0.14; p = 0.0006), recurrent cholecystitis (- 0.05 RD (95% CI - 0.09 to - 0.02; p = 0.02), and hospital readmission (- 0.36 RD (95% CI-0.70 to - 0.03; p = 0.03) when compared to PT-GBD. All other outcomes were similar in the subgroup analyses. CONCLUSIONS: EUS-GBD using cautery-enhanced LAMS is superior to PT-GBD in terms of safety profile, recurrent cholecystitis, and hospital readmission rates in the management of patients with acute cholecystitis who are suboptimal candidates for cholecystectomy. However, when cautery-enhanced LAMS are not used, the outcomes of EUS-GBD and PT-GBD are similar. Thus, EUS-GBD with cautery-enhanced LAMS should be considered the preferable approach for gallbladder drainage for this challenging population.

SARS-CoV-2 leading to acute pancreatitis: an unusual presentation.

During SARS-CoV-2 (severe acute respiratory syndrome coronavirus-2) pandemic, the etiologic agent of COVID-19, several studies described the involvement of other tissues besides the respiratory tract, such as the gastrointestinal tract. Angiotensin-converting enzyme-2, the functional virus host cell receptor expressed by organs and tissues, seems to have an important role in the pathophysiology and presentation of this disease. In pancreas, this receptor is expressed in both exocrine glands and islets, being a potential target for the virus and subsequent pancreatic injury. There are few articles reporting pancreatic injury in COVID-19 patients but most of them do not report acute pancreatitis. Diagnosing acute pancreatitis secondary to SARS-CoV-2 infection is challenging due to the need to rule out other etiologies as well the notable heterogeneous presentations. Herein we report the case of a patient with COVID-19 who developed severe acute pancreatitis.