Predicting need for intervention in acute necrotizing pancreatitis following discharge- A single center experience in 525 patients.

BACKGROUND AND AIMS: The clinical course of necrotizing pancreatitis (NP) is variable and unpredictable, with some patients managed conservatively, but a significant proportion become symptomatic and needing intervention for drainage and/or necrosectomy. The aim of this study was to identify patients based on baseline clinical and imaging metrics who will likely need intervention and therefore closer follow-up. METHODS: All NP patients managed in our institution between 2010 and 2019 were identified from a prospective database and those who did not undergo intervention during initial hospitalization were followed longitudinally post discharge until clinical and imaging resolution of necrosis. Patients were categorized into a conservative arm or intervention arm (endoscopic/percutaneous/surgical drainage and/or necrosectomy) for criteria defined according to IAP/APA guidelines. Clinical and imaging characteristics during initial presentation were analyzed between the two groups to identify independent predictors for eventual intervention using multivariable logistic regression. A nomogram was designed based on factors that were significant as defined by P value < 0.05. RESULTS: Among 525 patients, 340 who did not meet criteria for intervention during initial admission were included for study and followed for an average 7.4 ± 11.3 months. 140 were managed conservatively and 200 needed intervention (168 within 6 months and 32 after 6 months). Independent predictors of need for eventual intervention were white race [OR 3.43 (1.11-10.62)], transferred status [OR 3.37 (1.81-6.27)], and need for TPN [OR 6.86 (1.63-28.9)], necrotic collection greater than 6 cm [OR 8.66 (4.10-18.32)] and necrotic collection with greater than 75% encapsulation [OR 41.3 (8.29-205.5)]. A prediction model incorporating these factors demonstrated an area under the curve of 0.88. CONCLUSIONS: Majority of NP patients do not need intervention during initial admission but may require drainage/necrosectomy mostly in the first 6 months following discharge. Need for subsequent intervention can be accurately predicted by a combination of clinical and imaging features on index admission.

Endoscopic Management of Complications in Chronic Pancreatitis.

PURPOSE OF REVIEW: Management of complications in patients with chronic pancreatitis is often suboptimal. This review discusses detailed endoscopic approaches for managing complications in CP. LITERATURE FINDINGS: CP is characterized by progressive and irreversible destruction of pancreatic parenchyma and ductal system resulting in fibrosis, scarring, and loss of glandular function. Abdominal pain remains is the most common symptom of the disease and the main aim of medical, endoscopic, and surgical therapy is to help relieve symptoms, prevent disease progression, and manage complications related to CP. In fact, advances in our understanding of CP have improved medical care and quality of life in these patients. With significant sequela, morbidity and a progressive nature, a thorough understanding of the pathophysiology, natural course, diagnostic approaches, and optimal management strategies for this disease is warranted. The existing modalities and new innovations in this field are safe, effective, and likely to have a positive impact on management of complication in CP whenever used in the right context.

EUS-guided versus percutaneous transhepatic cholangiography biliary drainage for obstructed distal malignant biliary strictures in patients who have failed endoscopic retrograde cholangiopancreatography: A systematic review and meta-analysis.

EUS-guided biliary drainage (EUS-BD) and percutaneous transhepatic cholangiography biliary drainage (PTC) are the two alternate methods for biliary decompression in cases where ERCP fails. We conducted a systematic review and meta-analysis of studies to compare the efficacy and safety of endoscopic and percutaneous biliary drainage for malignant biliary obstruction in patients with failed ERCP. A total of ten studies were included, fulfilling the inclusion criteria, including four retrospective studies and six randomized controlled trials. We compared the technical and clinical success rates and the acute, delayed, and total adverse events of EUS-BD with PTC. The odds ratios (ORs) and confidence intervals (CIs) were calculated. There was no difference between technical (OR: 0.47 [95% CI: 0.20-1.07]; P = 0.27) and clinical (OR: 2.24 [95% CI: 1.10-4.55]; P = 0.51) success rates between EUS-PD and PTC groups. Procedural adverse events (OR: 0.17 [95% CI: 0.09-0.31]; P = 0.03) and total adverse events (OR: 0.09 [95% CI: 0.02-0.38]; P < 0.01) were significantly different between the two groups; however, delayed adverse events were nonsignificantly different (OR: 0.73 [95% CI: 0.34-1.57]; P = 0.97). This meta-analysis indicates that endoscopic biliary drainage (EUS-BD) is equally effective but safer in terms of acute and total adverse events than percutaneous transhepatic biliary drainage (PTC) for biliary decompression in patients with malignant biliary strictures who have failed an ERCP.

Proton pump inhibitors reduce phlebotomy burden in patients with HFE-related hemochromatosis: a systematic review and meta-analysis.

BACKGROUND AND AIMS: Proton pump inhibitors (PPIs) may reduce iron absorption and serum ferritin levels in patients with homeostatic iron regulator (HFE)-related hemochromatosis, reducing the need for frequent phlebotomies. Our study aimed to perform for the first time a meta-analysis of existing observational and randomized controlled studies to ascertain the overall effect of PPI use in patients with HFE-related hemochromatosis. METHODS: Studies in adults reporting the outcomes of PPIs use in hereditary hemochromatosis patients from Medline, Embase, Scopus and Google Scholar databases from inception to December 2019 were systematically searched. The study outcomes were the serum ferritin levels and annual requirement for phlebotomies. Pooled mean difference, and 95% confidence intervals (CIs) were obtained by the random-effects model. Forrest plots were constructed to show the summary pooled estimate. Heterogeneity was assessed by using I2 measure of inconsistency. RESULTS: Following an initial search of 202 manuscripts, a total of three studies involving 68 patients with hemochromatosis (34 in the PPIs group and 34 in the placebo or non-PPI group) were included. A minimum duration of PPI use was 1 year. Patients who received PPIs therapy did not have a statistically significant lower serum ferritin levels (mean difference: -18.86, 95% CI: -60.44, 22.72, P = 0.37, I2 = 88%) but required significantly less sessions of phlebotomies annually (mean difference: -3.10, 95% CI: -4.46, -3.08, P < 0.00001, I2 = 93%). No publication bias was found on Egger (P = 0.94) or Begg (P = 0.98) tests. CONCLUSION: PPIs can be used as an adjuvant therapy to reduce phlebotomy burden in patients with HFE-related hemochromatosis.

A Case of False-Positive HIV Test in a Patient With Newly Diagnosed Hodgkin Lymphoma and Literature Review.

Hodgkin lymphoma (HL) is one of the non-acquired immunodeficiency syndrome (AIDS)-defining cancers (NADCs). HIV testing has become a part of routine testing in HL because of commonly anticipated association. Here we report an unusual case where the need for HIV screening in a newly diagnosed case of HL raised an ethical dilemma and a medical challenge due to false-positive HIV test results. In literature, pregnancy, autoimmune disorders, some viral infections, and the presence of hypergammopathy of hematologic malignancy have all been linked with false-positive HIV screening. The reactive results require additional testing with an HIV-1/HIV-2 antibody differentiation assay. The specimens show reactivity on the initial screening immunoassay, but negative or indeterminate antibody differentiation assay should undergo nucleic acid testing. Nevertheless, several instances of discordance between screening and confirmatory techniques have been described. It is speculated that this might be due to coincidental cross-reaction of subtypes of polyclonal gamma globulin with the HIV p24 antigen. In conclusion, this case signifies the understanding of the HIV testing algorithm and the use of reflex testing in the context of a positive HIV test before disclosing such preliminary results to patients and/or physicians.

Pre-operative Sarcopenia Predicts Low Islet Cell Yield Following Total Pancreatectomy with Islet Autotransplantation for Chronic Pancreatitis.

BACKGROUND AND AIM: Sarcopenia defined as degenerative loss of skeletal muscle mass associated with aging, represents an objective parameter to measure frailty and to estimate patient's physiologic reserves. It is a robust predictor of post-operative complications in transplantation and major oncologic surgeries. There is no data regarding the prevalence of sarcopenia in chronic pancreatitis or its impact on the outcome of patients undergoing TPIAT for CP. We sought to estimate the prevalence of sarcopenia, its impact on post-operative morbidity and prediction of islet yield and metabolic outcomes in patients undergoing TPIAT. METHODS: Adult patients undergoing TPIAT between 2008 and 2018 were identified from our prospectively maintained database and were included if they had CT within 6 months before TPIAT. Skeletal muscle index (SMI) was evaluated by pre-operative CT at the level of L3 vertebra. Sarcopenia was defined as SMI < 52.4 in males and < 38.5 in females. Post-operative morbidity occurring within 90 days after TPIAT was graded as per the validated Clavien-Dindo score. Major post-surgical morbidity was defined as Clavien-Dindo score of IIIa or more. The yield of islets was quantified as islet equivalents (IEQ) and IEQ/kg recipient body weight was calculated. RESULTS: One hundred and thirty-eight patients underwent TPIAT, with 46 (one-third) being classified as having pre-operative sarcopenia based on CT. No significant differences were observed in the incidence of any major surgical complications, length of hospital stay (median (range in days) 111-8 vs. 122-9; p = 0.6) and 30-day readmission rate (7 (15.2%) vs, 2 (2.2%); p = 0.5) between sarcopenic and non-sarcopenic patients. More patients with sarcopenia needed to be discharged to residential rehabilitation facility compared with non-sarcopenic patients (7 (15.2%) vs. 2 (2.2%), p = 0.007). Sarcopenia (OR 7.4 (95% CI 1.32-41.24); p = 0.023) and presence of calcification (OR 5.5 (95% CI 0.94-32.19); p = 0.05) were independent predictors of low islet yield (< 2500 IEQ/kg) on multivariate analysis. CONCLUSION: Sarcopenia is frequent in CP patients undergoing TPIAT, but not readily recognized by standard anthropometric measurement. Sarcopenia was associated with increased chance of discharge to a residential rehabilitation facility and with a poor islet yield during TPIAT. It is therefore critical to optimize nutrition prior to TPIAT surgery in CP patients.

Effectiveness of Helicobacter pylori eradication in preventing metachronous gastric cancer and preneoplastic lesions. A systematic review and meta-analysis.

BACKGROUND: Helicobacter pylori is a significant risk factor for gastric cancer. Recent trials show eradication decreases the incidence of gastric cancer in patients with early-stage gastric cancer. However, data on gastric cancer prevention are inconsistent for patients with precancerous lesions such as atrophic gastritis and intestinal metaplasia. AIM: The aim of the study is to assess the efficacy of H. pylori eradication in gastric cancer prevention in patients with varying risk factors for gastric cancer at baseline. METHODS: A systematic review and meta-analysis were performed according to Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, Medline, and Google Scholar were searched from inception through March 2019 for randomized controlled trials (RCTs) studying H. pylori eradication on gastric cancer prevention. We estimated the odds ratio (OR) with 95% confidence interval (CI) for each outcome using a random-effects model. P values of less than 0.05 were considered significant. RESULTS: Nine RCTs with total of 6967 patient were included in the analysis. There was significant reduction in gastric cancer incidence in the H. pylori group for patients with early gastric cancer status post endoscopic mucosal resection OR, 0.47; 95% CI, 0.33-0.67; P < 0.0001; I = 0%. There was no difference in gastric cancer incidence in patients with atrophic gastritis and intestinal metaplasia at baseline for H. pylori arm OR, 0.67; 95% CI, 0.42-1.07; P = 0.09; I = 0%). Atrophic gastritis and intestinal metaplasia improved from baseline in the H. pylori arm compared to placebo OR, 2.61; 95% CI, 1.41-4.81; P = 0.002; I = 88 and OR, 2.61; 95% CI, 1.66-4.11; P ≤ 0.0001; I = 0%, respectively. CONCLUSIONS: H. pylori eradication is associated with reduced gastric cancer incidence in patients with early-stage gastric cancer and improvement in atrophic gastritis and intestinal metaplasia. There was no difference in gastric cancer incidence in patients with atrophic gastritis and intestinal metaplasia at baseline.

Rendezvous transgastric and percutaneous sinus tract endoscopy (STE) for debridement of necrotic collections with deep retroperitoneal extension: a case series (with video): Meeting presentations: Digestive Disease Week 2018.

Background and study aims Infected necrotic collections extending deep into the retroperitoneum may not be amenable solely to endoscopic necrosectomy. Rendezvous transgastric and percutaneous sinus tract endoscopic necrosectomy was conceived to maximize debridement and obviate the need for open necrosectomy or video-assisted retroperitoneal debridement. Patients and methods Patients who underwent simultaneous rendezvous transgastric and sinus tract endoscopic transluminal necrosectomy at the same session were identified from a prospectively maintained database. Demographic data, clinical outcomes, immediate and late complications were evaluated. Results Among 415 patients with necrotizing pancreatitis, four patients (three males, median age 47 years) underwent this intervention after a median 29.5 days following placement of percutaneous drain. Intra-procedural bleeding following dilation of percutaneous tract required placement of esophageal stent for tamponade. No patients required rescue open necrosectomy or video assisted retroperitoneal debridement. Complete removal of percutaneous drains was accomplished in all patients after a median of 78.5 days. Conclusions Our novel approach is safe and effective and can expand the available armamentarium for management of large necrotic collection with deep retroperitoneal extension.

Isolated peripancreatic necrosis (PPN) is associated with better clinical outcomes compared with combined pancreatic and peripancreatic involvement (CPN)- a systematic review and meta-analysis.

BACKGROUND AND AIMS: Peripancreatic necrosis (PPN) is considered as a distinct entity with a better outcome when compared with combined pancreatic and peripancreatic necrosis (CPN), but there is no systematic review to summarize the evidence. Our study aimed to perform a meta-analysis of existing observational studies comparing the outcomes of PPN with CPN. METHODS: Studies in adult patients comparing the outcomes of PPN and CPN from PubMed, Medline, and Scopus databases from inception to November 2018 were systematically searched. The primary outcome was mortality, and secondary outcomes included multi-organ failure, persistent organ failure, infected necrosis, need for interventions including open necrosectomy. Pooled adjusted odds ratios, and 95% confidence intervals (CI) were obtained by the random-effects model. Forrest plots were constructed to show the summary pooled estimate. Heterogeneity was assessed by using I2 measure of inconsistency. RESULTS: A total of 6 studies involving 1851 patients (1295 (70%) with CPN and 556 (30%) with PPN) were included. Patients with CPN had a significantly higher mortality (OR 2.49, 95% CI: 1.61-3.87), risk for multi-organ failure (OR 3.24, 95% CI: 2.38-4.43), persistent organ failure (OR 2.79, 95% CI: 1.53-5.08), and infected necrosis (OR 6.21, 95% CI: 3.85-10.03). They underwent more interventions (OR 5.86, 95% CI: 3.69-9.32), including open necrosectomy (OR 5.04, 95% CI: 3.33-7.63). Heterogeneity was low (I2 = 18.1, p = 0.296), and there was no publication bias. CONCLUSION: Isolated peripancreatic necrosis portends an overall better prognosis when compared to necrosis involves pancreatic parenchyma. Clinicians should recognize this distinction for management decisions.

Adherence to the United States Preventative Services Task Force Female Screening Guidelines: An Internal Medicine Residency Program Experience.

Background Various guidelines exist for female preventative screening tests and medical resident physician adherence to the United States Preventive Services Task Force (USPSTF) guidelines varies. National screening rates for breast cancer and osteoporosis have improved but they are still below the expected target. Material and methods Ambulatory medical clinic records of female patients from the period July 2015 to December 2017 were reviewed for breast cancer and osteoporosis screening. Resident performance and commitment with regards to ordering the aforementioned screening tests according to the USPSTF guidelines were compared to the most recent national screening rates for mammograms and dual-energy X-ray absorptiometry (DXA) scans. Results Of the 1327 charts reviewed, 1025 was included in the study. Of the 545 mammograms performed, 93% of them were indicated according to the USPSTF guidelines (P < 0.0001, 95% CI: 125.9-342.0). A total of 480 mammograms were not ordered, of which 6% were indicated and 93.9% were not indicated. Out of a total of 107 DXA scans performed, 88.7% were correctly indicated (P < 0.0001, 95% CI: 37.11-132.9). Conclusion Resident physician adherence to the USPSTF screening guidelines for breast cancer and DXA scans were higher than the national and state screening rates. Our well-structured educational project (strong faculty mentorship, resident to patient continuity of care and the reasonable resident-clinic load) resulted in higher screening rates.

Peri-Ampullary Metastasis From Endometrial Adenocarcinoma: A Rare Etiology of Obstructive Jaundice.

Endometrial cancer is the commonest gynecologic malignancy, of which adenocarcinoma is the most common histologic type. While most women who relapse present with local symptoms within 3 years of the initial diagnosis, metastatic disease usually involves the abdominal cavity and liver. Herein we present a rare case of a patient with a remote history of endometrial adenocarcinoma status-post curative surgical resection and adjuvant therapy who presented with obstructive jaundice proved to be secondary to peri-ampullary metastasis of uterine adenocarcinoma.

Impact of Hyoscine Bromide Use on Polyp Detection Rate During Colonoscopy: A Systematic Review and Meta-Analysis.

BACKGROUND: Colorectal cancer (CRC) is a leading cause of death worldwide. Polyp detection rate (PDR) and adenoma detection rate (ADR) are key focus in endoscopic research for CRC screening and prevention. Use of anti-spasmodic agents during colonoscopy to help identify adenomas and polyps has remained a controversial topic. Hyoscine butyl bromide (HBB) is the most commonly used anti-spasmodic agent in patients undergoing colonoscopy. Some randomized controlled trials (RCTs) have questioned the clinical efficacy and safety of routine use of HBB for polyp and adenoma detection rates. METHODS: We conducted a systematic search in PubMed and MEDLINE from inception until February 10, 2018, for studies which compared HBB with placebo. We used RevMan version 5.3 for analysis. Procedural end-points were polyps, adenomas, and advanced adenoma detection rates, mean number of polyps detected and cecal intubation time. RESULTS: We included seven RCTs with 2,588 patients in our analysis. A total of 1,301 patients were randomized to HBB arm and 1,287 to the placebo arm. There was no significant difference in the primary outcome of polyp detection rate, 654 in HBB group vs. 616 in the placebo group, (odds ratio (OR) = 1.11, confidence interval (CI) = 0.93 - 1.34, P = 0.25). There was no difference in secondary outcomes of adenoma detection rate, 430 in HBB group vs. 396 in the placebo group, (OR = 1.06, CI = 0.89 - 1.26, P = 0.51), advanced adenoma detection rate, 92 in HBB vs. 95 in placebo group (OR = 0.95, CI = 0.70 - 1.30, P = 0.76), mean number of polyps detected (point estimate = 0.12, CI = 0.00 - 0.23, P = 0.05), adenomatous polyps (OR = 0.84, CI = 0.39 - 1.81, P = 0.65) and cecal intubation time (point estimate = 0.73, CI = -1.98 - 0.52, P = 0.25) between the two groups. CONCLUSIONS: The use of HBB in patients undergoing colonoscopy does not appear to improve polyp or adenoma detection rates. It showed a non-significant trend of increased mean number of polyps detected with HBB.

Comparing fecal microbiota transplantation to standard-of-care treatment for recurrent Clostridium difficile infection: a systematic review and meta-analysis.

BACKGROUND: The use of fecal microbiota transplantation (FMT) as a treatment option for recurrent Clostridium difficile infection (rCDI) is well established. Various studies have used different forms and administration routes for FMT. We performed a systemic review and meta-analysis to update the clinical knowledge about different FMT modalities for curing rCDI compared with medical treatment (MT). PATIENTS AND METHODS: We searched PubMed and Medline from inception through 10 May 2018 for randomized control trials (RCTs) comparing FMT (fresh or frozen) versus MT. We used Cochrane Collaboration's Risk of Bias tool to assess bias in the RCTs. We estimated odds ratio (OR) with 95% confidence interval (CI) for each outcome using a random effects model. P values of less than 0.05 were considered significant. RESULTS: We included seven RCTs comprising a total of 543 patients with recurrent CDI. There was a nonsignificant trend toward resolution of diarrhea following a single fresh FMT infusion compared with frozen FMT and MT (OR=2.45, 95% CI=0.78-7.71, P=0.12, I=69%). Subgroup analysis of fresh FMT vs. frozen FMT showed no difference between the two groups (OR=2.13, 95% CI=0.22-20.41, P=0.51, I=61%). Frozen FMT infusion through upper route versus lower route showed no difference (OR=0.62, 95% CI=0.15-2.54, P=0.51, I=0%). There was a nonsignificant trend favoring multiple treatments with FMT versus multiple courses of MT (OR=3.68, 95% CI=0.74-18.22, P=0.11, I=0%). CONCLUSION: FMT is a promising treatment modality for rCDI compared with MT alone. Different forms and routes of FMT administration seem to be equally efficacious. In future, more well-designed RCTs directed at homogenous FMT preparation and delivery methods are required to validate these findings.

Concurrent Primary Gastric and Pulmonary Diffuse Large B-Cell Lymphoma: A Case Report and Literature Review.

The primary pulmonary diffuse large B-cell lymphoma (PPDLBCL), a kind of non-Hodgkin's lymphomas, itself is a rare entity. Its association with primary B-cell gastric lymphoma has not been established yet. Herein we present a case of PPDLBCL along with a literature review. This case is special and extremely rare as it has concurrent primary gastric B-cell lymphoma.

Syndrome of inappropriate secretion of anti-diuretic hormone (SIADH) as an initial presenting sign of non small cell lung cancer-case report and literature review.

Association of SIADH with malignancy was first reported in 1957, when it was described in two patients with bronchogenic carcinoma. While the association with small cell lung cancer (SCLC) is well known, that with non small cell lung cancer (NSCLC) has been rarely reported. We report a case of 70 year old male who was found to have hyponatremia secondary to SIADH. Radiological tests revealed right hilar lung mass with mediastinal adenopathy. Bronchoscopic biopsy revealed non-small cell lung cancer of type squamous cell. Magnetic resonance imaging (MRI) of brain showed metastatic lesions, thereby confirming diagnosis of metastatic lung cancer. Paraneoplastic syndromes occur in 10% of lung cancer cases and they represent a group of disorders related to secretion of functional polypeptides or hormones from tumor cells. SIADH is more commonly described in conjunction with small cell lung cancer but there are a few case reports describing it's occurrence after initiation of therapy for NSCLC such as radiation and chemotherapy. The mechanism for this phenomenon is not known. Unlike infectious causes, hyponatremia as initial presentation is an uncommon feature of malignancy-associated SIADH. In the lung cancer population, hyponatremia has been identified as a negative prognostic factor in hospitalized patients and those with advanced-stage disease. Malignancy should be a consideration in the diagnostic evaluation of SIADH, irrespective of the time of presentation.

Lance-Adams syndrome associated with cerebellar pathology.

Lance-Adams syndrome (LAS) is an uncommon neurological disorder characterized by the development of chronic post-hypoxic myoclonus. There are relatively few cases described following successful cardiopulmonary resuscitation. We report a patient who developed LAS 3 months after successful resuscitation. Cerebral imaging studies indicate that brain pathology in LAS patients is not uniform, suggesting that the pathophysiology of myoclonus may vary from patient to patient. Our patient adds to this etiological heterogeneity by demonstrating the unusual feature of cerebellar pathology by both cerebral magnetic resonance imaging and single-photon emission computed tomography scans. There is also heterogeneity of these patients in their response to therapy. Unlike some patients described in the literature, our patient has not responded to drug treatment. Studies of these rare patients with LAS are important as they provide insight into the pathophysiology of this condition which, it is hopefully, will facilitate the development of more effective therapy.