Combination of diclofenac plus somatostatin in the prevention of post-ERCP pancreatitis: a randomized, double-blind, placebo-controlled trial.

BACKGROUND AND STUDY AIMS: Pancreatitis is the most common complication of therapeutic endoscopic retrograde cholangiopancreatography (ERCP), and many pharmacoprophylactic approaches have been suggested, though not without controversy. The aim was to investigate the impact of combined therapy with diclofenac plus somatostatin on reducing the frequency and severity of post-ERCP pancreatitis (PEP). PATIENTS AND METHODS: A prospective, double-blind, placebo-controlled trial was conducted in two tertiary referral centers, with 540 eligible patients randomized to receive either combined therapy with diclofenac 100 mg rectally 30 to 60 minutes before ERCP plus somatostatin 0.25 mg/h for 6 hours (group A), or a placebo suppository identical in appearance to the diclofenac along with saline solution (group B). Patients were clinically evaluated and serum amylase levels were determined before ERCP and at 6 and 24 hours post-procedure. Standardized criteria were used to diagnose and grade the severity of PEP. Adverse events were recorded prospectively. RESULTS: There were no statistical differences between the groups regarding demographic data, ERCP findings, and procedure risk factors for PEP. The overall incidence of acute pancreatitis was 7.2 %. The PEP rate was significantly lower in the patients who received the combination therapy than in controls (4.7 % vs. 10.4 %, P = 0.015). Previous history of acute pancreatitis (P = 0.001), pancreatic opacification of first-class branches and beyond (P = 0.008), and absence of pharmacoprophylaxis (P = 0.023) were identified as independent risk factors for PEP in multivariate analysis. CONCLUSION: Although combined prophylactic therapy with diclofenac plus somatostatin was promising in reducing frequency of PEP, further comparative large-scale studies are needed to confirm our findings before definitive conclusions can be drawn.

Capsule endoscopy findings in congenital afibrinogenemia-associated angiopathy.

Congenital afibrinogenemia is a rare genetic disorder characterized by the complete absence of functional fibrinogen. We report a 22-year-old female who developed nephrogenic arterial hypertension and intestinal ischemia due to congenital afibrinogenemia-associated angiopathy of large abdominal arteries. We describe, for the first time, the capsule findings and discuss the pathophysiology of this unusual condition.

Endoscopic mucosal resection for recurrent gastric antral vascular ectasia.

Gastric antral vascular ectasia (GAVE) is an overt or occult source of gastrointestinal bleeding. Despite several therapeutic approaches have been successfully tested for preventing chronic bleeding, some patients present recurrence of GAVE lesions. To the best of our knowledge, we report the first case, of a 86-year-old woman who presented severe iron-deficiency anemia due to GAVE and showed recurrence of GAVE lesion despite the intensive argon plasma coagulation treatment. We performed endoscopic mucosal resection of bleeding GAVE with resolution of anemia.

Endoscopic sphincterotomy for acute relapsing pancreatitis associated with periampullary diverticula: a long-term follow-up.

BACKGROUND AND STUDY AIMS: Periampullary diverticula (PAD) are extraluminal outpouchings of the duodenum arising within a radius of 2-3 cm from the ampulla of Vater. Data concerning the association of PAD with biliopancreatic disease are inconsistent, but an association between acute pancreatitis and PAD has been reported. The aim of this retrospective study was to evaluate the outcome of endoscopic sphincterotomy (ES) in a Greek cohort of patients with acute relapsing pancreatitis associated with PAD. PATIENTS AND METHODS: A total of 344 patients who had undergone ERCP between 1994 and 2005 for investigation of acute pancreatitis were retrospectively entered into a database. Of these patients, 11 (3.19% ; median age: 69 years; range: 58-78; 3 men, 8 women) were found to have acute relapsing pancreatitis associated with PAD. All patients underwent ES and were followed for new episodes of acute pancreatitis or other complications. RESULTS: No further episodes of acute pancreatitis occurred after ES, during a long-term follow-up (median: 4.3 years, range: 1.9-10.4). Two patients (18.2%) presented post-procedure mild pancreatitis and one patient (9.1%) post-ES stenosis with two small common bile duct stones and was treated with ES and extraction of stones. CONCLUSION: ES is the treatment of choice for patients with acute relapsing pancreatitis associated with PAD.

Gastric predominant hereditary hemorrhagic telangiectasia.

Hereditary hemorrhagic telangiectasia (HHT) or Rendu-Osler-Weber disease is an autosomal-dominant disorder that frequently presents with epistaxis and gastrointestinal bleeding which may be a diagnostic and therapeutic challenge. We describe a 48-year-old monk with familiar history of HHT, who presented with frequent epistaxes and symptoms of ferropenic anemia. Upper gastrointestinal endoscopy revealed innumerable telangiectasias in the stomach. The patient underwent three sessions with argon plasma coagulation treatment but the results were poor. We also review the literature on the pathophysiology of the disease and discuss the suggested treatment.

Endoloop-assisted polypectomy for large pedunculated colorectal polyps.

BACKGROUND: The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful. METHODS: This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps. RESULTS: Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients). CONCLUSION: Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.

Takayasu's arteritis and ulcerative colitis in a young non-Asian woman: a rare association.

The association between ulcerative colitis and Takayasu's arteritis has been well described in patients of Asian ethnicity. We present the third non-Asian case reported in the English literature, of a 37-year-old woman with a 4-year history of Takayasu's arteritis, who developed idiopathic ulcerative colitis. She was found to carry the human leucocyte antigens HLA-B52 and DR2, which have been previously noted to be associated with these inflammatory conditions, mainly in the Japanese population. Ulcerative colitis was steroid-dependent despite simultaneous administration of mesalazine. Azathioprime achieved remission of both diseases. The possible pathogenic association of the disorders is discussed.