Efficacy of Vonoprazan vs. Intravenous Proton Pump Inhibitor in Prevention of Re-Bleeding of High-Risk Peptic Ulcers: A Randomized Controlled Pilot Study.

Background: Proton pump inhibitor (PPI) therapy is well-established for its effectiveness in reducing re-bleeding in high-risk peptic ulcer patients following endoscopic hemostasis. Vonoprazan (VPZ) has demonstrated the capacity to achieve gastric pH levels exceeding 4, comparable to PPIs. This study aims to evaluate the comparative efficacy of intravenous PPI infusion versus VPZ in preventing re-bleeding after endoscopic hemostasis in patients with high-risk peptic ulcers. Methods: A randomized, double-blind, controlled, and double-dummy design was employed. Patients with peptic ulcer bleeding (Forrest class IA/IB or IIA/IIB) who underwent endoscopic hemostasis were randomly assigned to either the PPI group or the VPZ group. Re-bleeding rates at 3, 7, and 30 days, the number of blood transfusions required, length of hospitalization, and ulcer healing rate at 56 days were assessed. Results: A total of 44 eligible patients were enrolled, including 20 patients (PPI group, n = 11; VPZ group, n = 9) with high-risk peptic ulcers. The mean age was 66 years, with 70% being male. Re-bleeding within 72 h occurred in 9.1% of the PPI group versus 0% in the VPZ group (p = 1.000). There was no significant difference in re-bleeding rates within 7 days and 30 days (18.2% vs. 11.1%, p = 1.000). Additionally, the ulcer healing rate did not significantly differ between the groups (87.5% vs. 77.8%). Conclusions: This pilot study demonstrates comparable efficacy between oral vonoprazan and continuous PPI infusion in preventing recurrent bleeding events among high-risk peptic ulcer patients following successful endoscopic hemostasis.

A smartphone application to enhance bowel preparation for first-time colonoscopy: a randomized controlled study.

Background and aims: Colonoscopy is an essential cancer screening tool; however, bowel preparation is a multifaceted process that involves several steps. Proper preparation is crucial for a successful colonoscopy in terms of diagnostic accuracy and procedural safety. We evaluated the performance of a smartphone application with bowel preparation instructions on individuals undergoing their first colonoscopy. Methods: In this randomized, prospective, endoscopist-blinded study, participants were scheduled to undergo their first colonoscopy between January 2020 and January 2022. The study protocol was registered at Thai Clinical Trials Registry (TCTR20190928002). They were randomly assigned to the smartphone education application (APP) or the standard education (control) group. The Boston Bowel Preparation Scale (BBPS) score, polyp detection rate (PDR), and adenoma detection rate (ADR) were compared. Factors associated with excellent bowel preparation were also evaluated. Results: In total, 119 patients (APP group, n = 57; control group, n = 62) underwent their first colonoscopy. The mean BBPS score and proportion of excellent bowel preparation (BBPS≥8) were significantly higher in the APP group than in the control group. Smartphone application-guided bowel preparation achieved a higher proportion of adequate and excellent bowel preparation scores, was associated with other quality indicators, and achieved the target ADR, cecal intubation rate, and adequate withdrawal time. Conclusion: This application may be a user-friendly option to improve the first-time colonoscopy experience, resulting in effective screening of colorectal cancer. Clinical trial registration: The study protocol was registered at Thai Clinical Trials Registry (TCTR20190928002).

Health-related quality of life in Thai patients with chronic hepatitis B.

Background: Chronic hepatitis B (CHB) significantly impacts the health-related quality of life (HRQoL), but remains underexplored in the Thai population. Health state utilities (HSU) are indicators reflecting HRQoL which serve as fundamental inputs for economic evaluation analyses. This study aimed at assessing differences in HRQoL across five CHB stages in Thai patients, including non-cirrhotic CHB, compensated cirrhosis, decompensated cirrhosis, early-/intermediate-stage hepatocellular carcinoma (HCC) and advanced-/terminal-stage HCC. Methods: We conducted a cross-sectional study to collect HRQoL data from patients with CHB at five stages. The study included patients with CHB who were followed up at a super-tertiary care centre between March 2021 and February 2022. The participants completed the EQ-5D-5L questionnaire and provided demographic data. Disease stage and relevant data were obtained from medical records. HSU and Euroqol-visual analogue scale (EQ-VAS) scores, calculated using Thai-specific conversion coefficients, were assessed. Results: Among 422 patients, 236 did not have cirrhosis, 92 had compensated cirrhosis, 13 had decompensated cirrhosis, 55 had early-/intermediate-stage HCC, and 26 had advanced-/terminal-stage HCC. The HSU scores for non-cirrhotic, compensated cirrhosis, decompensated cirrhosis, early-/intermediate-stage HCC and advanced-/terminal-stage HCC were 0.95 ± 0.08, 0.89 ± 0.16, 0.79 ± 0.19, 0.89 ± 0.12 and 0.52 ± 0.39, respectively. Similarly, the EQ-VAS scores for various CHB stages were 83.56 ± 12.90, 80.48 ± 13.03, 68.76 ± 17.40, 79.00 ± 14.38 and 62.92 ± 20.62, respectively. A significant correlation (r = 0.469, P < 0.001) was observed between the HSU and EQ-VAS scores. The disease progression led to a notable HSU decline, particularly in the advanced-/terminal-stage HCC group (regression coefficient: -0.436, P < 0.001). The EQ-VAS scores indicated reduced quality of life in advanced liver disease. Conclusions: Later CHB stages compromise the HRQoL. Decompensated cirrhosis and advanced-/terminal-stage HCC profoundly affect physical health and quality of life, whereas patients with compensated cirrhosis and early-/intermediate-stage HCC report better HRQoL.

Predictive Factors Correlated with Successful Early Endoscopic Removal of Pancreaticolithiasis in Chronic Pancreatitis after Extracorporeal Shock Wave Lithotripsy.

BACKGROUND: The treatment of chronic pancreatitis (CP) and symptomatic pancreatic duct (PD) calculi often involves techniques like endoscopic retrograde cholangiopancreatography (ERCP), extracorporeal shock wave lithotripsy (ESWL), or a combination of both. However, identifying predictive factors for the successful removal of these calculi remains variable. This study aimed to determine the factors predicting successful ESWL and endoscopic removal in CP and PD calculi patients. METHODS: We examined data from CP patients who underwent complete PD calculi removal via ESWL combined with ERCP between July 2012 and 2022, and assessed baseline characteristics, imaging findings, and treatment details. Patients were categorized into early- and late-endoscopic complete removal groups (EER and LER groups, respectively). RESULTS: Of the 27 patients analyzed, 74.1% were male with an average age of 44 ± 9.6 years. EER was achieved in 74% of the patients. Patients in the EER group exhibited smaller PD calculi diameter (8.5 vs. 19 mm, p = 0.012) and lower calculus density (964.6 vs. 1313.3 HU, p = 0.041) compared to the LER group. Notably, PD stricture and the rate of PD stent insertion were not different between the groups. A calculus density threshold of 1300 HU on non-contrast CT demonstrated 71% sensitivity and 80% specificity in predicting EER. CONCLUSIONS: Smaller and low-density PD calculi may serve as predictors for successful EER, potentially aiding in the management of CP patients with PD calculi.

Clinical Outcomes of the Endoscopic Step-Up Approach with or without Radiology-Guided Percutaneous Drainage for Symptomatic Walled-Off Pancreatic Necrosis.

Background and objectives: Symptomatic walled-off pancreatic necrosis is a serious local complication of acute necrotising pancreatitis. The endoscopic step-up approach is the standard treatment for symptomatic walled-off pancreatic necrosis; however, adjunctive radiologic percutaneous drainage for this condition is controversial. This study compared the clinical and radiologic resolution of walled-off pancreatic necrosis achieved with the endoscopic step-up approach with or without radiology-guided percutaneous drainage. Material and Methods: This retrospective, single-centre cohort study enrolled patients with symptomatic walled-off pancreatic necrosis who underwent endoscopic transmural drainage (ETD) followed by directed endoscopic necrosectomy (DEN) with or without radiology-guided drainage. A total of 34 patients (endoscopic approach, n = 22; combined modality approach, n = 12) underwent the endoscopic step-up approach (ETD followed by DEN). Baseline characteristics, clinical success, and resolution of necrosis were compared between groups. Results: All patients achieved symptom resolution from walled-off pancreatic necrosis. The mean patient age was 58.4 years, and 21 (61.8%) were men. Following treatment with the endoscopic approach and combined modality approach, clinical success was achieved in 90.9% of patients within 11.5 days, and 66.7% of patients within 16.5 days, respectively. Both length of hospital stay (55 days vs. 71 days; p = 0.071) and time to complete radiologic resolution were shorter (93 days vs. 124 days; p = 0.23) in the endoscopic approach group. Conclusion: Both the endoscopic step-up approach and the CMD approach resulted in a favourably high clinical resolution rates in patients with symptomatic WON. However, clinical success rates seemed to be higher, and the length of hospital stay tended to be shorter in the endoscopic approach than in the CMD approach, as well as the significantly shorter necrosectomy time in each procedure was observed. Of note, these findings might be from some inherited differences in baseline characteristics of the patients between the two groups, and a randomized controlled trial with a larger sample size to verify these results is warranted.

Postoperative outcomes of resectable periampullary cancer accompanied by obstructive jaundice with and without preoperative endoscopic biliary drainage.

Background: Preoperative biliary drainage (PBD) is useful in resectable periampullary cancer with obstructive jaundice. Whether it is better than direct surgery (DS) in terms of postoperative complications and mortality is controversial. Methods: All cases of successful pancreaticoduodenectomy (PD) in patients with periampullary cancer with obstructive jaundice performed between January 2016 and January 2021 were retrospectively reviewed. Endoscopic PBD was performed; data pertaining to serum bilirubin level, procedural technique, and duration before surgery were obtained. The incidence of postoperative complications and survival rate were compared between the PBD and DS group. Results: A total of 104 patients (PBD, n = 58; DS, n = 46) underwent curative PD. The mean age was 63.8 ± 10 years and 53 (51%) were male. Age, body mass index (BMI), sex, Eastern Cooperative Oncology Group status, presence of comorbid disease, initial laboratory results, and pathological diagnoses were not significantly different between the two groups. The incidence of postoperative complications was 58.6% in the PBD group while 73.9% in the DS group (relative risk [RR] 1.26, 95% confidence interval [CI] 0.92, 1.73, p=0.155) and the difference was not significant except in bile leakage (RR 8.83, 95% CI 1.26, 61.79, p = 0.021) and intraoperative bleeding (RR 3.97, 95% CI 0.88, 17.85, p = 0.049) which were higher in the DS group. The one-year survival rate was slightly less in the DS group but the difference was not statistically significant. The independent predictors for death within 1-year were intraoperative bleeding and preoperative total bilirubin > 14.6 mg/dL. Conclusions: PBD in resectable malignant distal biliary obstruction showed no benefit in terms of 1-year survival over DS approach. But it demonstrated the benefit of lower risks of intraoperative bleeding, and bile leakage. Additionally, the level of pre-operative bilirubin level of over 14.6 mg/dL and having intraoperative bleeding were associated with a lower 1-year survival in such patients. Overall, PBD may be not necessary for all resectable periampullary cancer patients, but there might be a role in those with severely jaundice (>14.6 mg/dL), as it helps lower risk of intraoperative bleeding, and might lead to a better survival outcome.

Optical diagnosis by near-focus versus normal-focus narrow band imaging colonoscopy in colorectal polyps based on combined NICE and WASP classification: a randomized controlled trial.

BACKGROUND/AIMS: Narrow Band Imaging (NBI) International Colorectal Endoscopic (NICE) and Workgroup Serrated Polyps and Polyposis (WASP) classifications were developed for optical diagnosis of neoplastic and sessile serrated polyps, respectively. Near-focus NBI with NICE combined with WASP criteria for optical diagnosis of colonic polyps has not yet been evaluated. We aimed to compare the accuracy of near-focus NBI (group A) with normal-focus NBI (group B) in real-time optical diagnosis of colorectal polyps using combined NICE and WASP criteria. METHODS: Among 362 patients, 118 with 227 polyps were recruited. Groups A and B included 62 patients with 130 polyps (three lost polyps) and 56 patients with 106 polyps (six lost polyps), respectively. Optical diagnoses were compared with pathological reports. RESULTS: The accuracy of optical diagnosis of neoplastic polyps in groups A and B was not significantly different (76% vs. 71%, p=0.52). WASP criteria provided all false positive diagnoses of sessile polyps as serrated polyps in 31 (16.2%) patients. CONCLUSION: Near-focus NBI was not superior to normal-focus NBI in optical diagnostics of neoplastic polyps using NICE criteria. In our study, WASP classification yielded all false positives in the diagnosis of sessile serrated adenomas/polyps. Routine real-life optical diagnosis of polyps is still unadvisable.

Diagnostic performance of endoscopic ultrasound-guided tissue acquisition by EUS-FNA versus EUS-FNB for solid pancreatic mass without ROSE: a retrospective study.

BACKGROUND: Endoscopic ultrasound-guided tissue acquisition (EUS-TA) is an established diagnostic procedure for solid pancreatic mass. However, the diagnostic yield between fine-needle aspiration (FNA) and fine-needle biopsy (FNB) remains unclear. We aimed to evaluate and compare the diagnostic yields between FNA and FNB using conventional FNA and Franseen needles of the same size 22-gauge needle, in patients with solid pancreatic mass who underwent EUS-TA without rapid onsite cytopathology evaluation (ROSE). METHODS: All cases of EUS-TA by FNA or FNB for solid pancreatic mass between January 2017 and October 2020 in a single-centre university hospital were retrospectively reviewed. All procedures were performed without an onsite cytologist. Before the endoscopist finished the procedure, macroscopic onsite evaluation (MOSE) was confirmed. The diagnostic yield and the average number of needle passes between FNB and FNA were then compared. RESULTS: A total of 151 patients (FNA, n = 77; FNB, n = 74) with solid pancreatic mass detected by cross-sectional imaging underwent EUS-TA. The mean age was 62.3 ± 12.8 years, with 88 (58.3%) males. Age, sex, mass location, tumour size and disease stage from imaging were not significantly different between the two groups. The diagnostic performance was higher in EUS-FNB (94.6%) than in EUS-FNA (89.6%). The mean number of needle passes was clearly fewer in FNB than in FNA (2.8 vs. 3.8, p < 0.001). The total procedure time was shorter in FNB (34.7 min) than in FNA (41 min). The adverse event rate between FNB and FNA was not significantly different. CONCLUSIONS: The diagnostic yield of solid pancreatic mass was higher in FNB using the Franseen needle than in FNA using the conventional FNA needle in a centre where ROSE is unavailable, without serious adverse event. In addition, FNB had fewer needle passes and shorter total procedure time.

Multiple Esophageal Leiomyoma Presenting with Clinical Dysphagia from Mechanical Obstruction and Motility Disorder.

Esophageal leiomyoma is uncommon. However, this tumor is the most common subepithelial tumor affecting the esophagus, comprising approximately two-thirds of benign esophageal tumors. Leiomyomas of the esophagus rarely cause symptoms when they are single and <5 cm. The mainstay of treatment is esophagectomy for symptomatic patients. A 68-year-old male patient presented with progressive dysphagia for 4 months. The degree of dysphagia and chest discomfort was more severe on solid rather than liquid diet. The CT scan of the chest showed multiple well-defined, submucosal nodules, up to 1.9 cm in diameter located at the middle esophagus. The barium swallow study illustrated multiple, well-defined, smooth, semilunar filling defects along the mid to distal esophagus. Meanwhile, esophagogastroduodenoscopy revealed 8 smooth subepithelial masses. Moreover, the radial EUS showed multiple hypoechoic masses arising from the 4th layer, with some of the tumors connected to others as a horseshoe-like shape causing narrowed lumen. Last, high-resolution esophageal manometry revealed ineffective esophageal motility. We report a rare case of numerous esophageal leiomyomas which caused dysphagia as a result of both mechanical obstruction and hypomotility disorder. The histopathology confirmed the diagnosis of esophageal leiomyoma. Symptoms improved significantly after lifestyle modifications and adherence to dietary advice on the part of the patient.

Amoxycillin-Clavulanic Acid-Induced Esophageal Ulcer: An Unusual Cause.

Pill-induced esophagitis or esophageal ulcers are considered when patients have retrosternal chest pain or odynophagia following the ingestion of suspicious medications. Various drugs have been reported to induce esophageal ulcers. However, amoxycillin-clavulanic acid-induced esophagitis or esophageal ulcer has not been reported in literature. Hence, we report the case of a 30-year-old Thai male who presented with acute, severe odynophagia and retrosternal chest pain. He had a history of taking amoxycillin-clavulanic acid for 12 days. An esophagogastroduodenoscopy was performed and revealed geographic clean-based ulcers, with a kissing-ulcer appearance at the level of the mid-esophagus. A biopsy was taken and revealed inflamed granulation tissue and an ulcer with neither infection nor malignancy. Thus, the diagnosis of an amoxycillin-clavulanic acid-induced esophageal ulcer was made according to the clinicopathologic report.

Biliary Fascioliasis in Chronic Calcific Pancreatitis Presenting with Ascending Cholangitis and Biliary Stricture.

Biliary fascioliasis is a rare infection of the hepatobiliary system. In human, it is known to present with two main phases; acute phase (hepatic phase) presenting with abdominal pain or abnormal liver biochemistry then chronic phase (biliary phase) presenting with biliary obstruction or cholangitis. Optimal treatment of biliary fascioliasis consists of endoscopic retrograde cholangiography with removal of the parasite and single oral dose of triclabendazole. We report a rare case of biliary fascioliasis in chronic calcified pancreatitis who presented with ascending cholangitis and biliary stricture. A 63-years-old Thai man was referred to our hospital for treatment of clinical symptoms severe cholangitis. Magnetic resonance cholangiopancreatography showed evidence of distal common bile duct stricture associated with chronic calcific pancreatitis. ERCP was performed, that found a few amorphous filling defects in the common bile duct and distal biliary stricture. After removal of the foreign body of what seems to be a fluke parasite followed with single oral dose triclabendazole thereafter, the clinical symptom was improved dramatically.

Mucinous cystic neoplasm of the liver with extrahepatic growth presenting with ascending cholangitis diagnosed by endoscopic ultrasound features: a case report.

BACKGROUND: Mucinous cystic neoplasm of the liver with extrahepatic growth is a rare benign epithelial neoplasm of the biliary system that presents with a mass effect or is incidentally found on imaging. The tumor affects mostly the common hepatic duct, which is difficult to diagnose preoperatively by radiology, endoscopy, or cystic fluid analysis. Endoscopic ultrasound is a noninvasive tool for the evaluation of features of a cystic lesion and the extent of disease. Optimal treatment is complete tumor resection. CASE PRESENTATION: A 27-year-old Thai woman was referred to our hospital for investigation and treatment of clinical symptoms of obstructive jaundice and ascending cholangitis, as well as an unknown cause of obstruction. Multiple investigations were performed, including endoscopic retrograde cholangiography and magnetic resonance imaging. Endoscopic ultrasound showed a multiloculated cystic lesion with internal septations without communication to the bile duct, which helped to support a diagnosis of mucinous cystic neoplasm. Eventually, the pathological diagnosis made was mucinous cystic neoplasm of the bile duct. A follow-up clinical examination with imaging at 6 months revealed that the patient was asymptomatic and without recurrence. CONCLUSIONS: We report a rare case of a patient with a large mucinous cystic neoplasm of the liver with extrahepatic growth causing biliary obstruction, which was diagnosed on the basis of endoscopic ultrasound features. Following definitive diagnosis, treatment with complete surgical resection using a multidisciplinary approach was successful.

Prospective randomized trial of EUS-assisted ERCP without fluoroscopy versus ERCP in common bile duct stones.

BACKGROUND AND AIMS: ERCP with stone removal is the standard treatment for common bile duct stones (CBDSs). Radiation exposure is a risk to the endoscopist and patient. EUS-guided ERCP without fluoroscopy (EGEWF) in patients with CBDSs is feasible, but the efficacy and safety compared with ERCP is unknown. We aimed to compare the efficacy and safety of EGEWF with ERCP in CBDS removal. METHODS: A prospective randomized study was done in 114 patients with CBDSs who met inclusion criteria. These patients were equally randomized into the EGEWF and ERCP groups. In the EGEWF group, ERCP was performed by cannulation without fluoroscopy. Balloon sweeping was done after sphincterotomy to clear the stones until the number of stones matched the number detected by EUS and the stone clearance (SC) was confirmed by cholangiography. In the ERCP group, ERCP was performed in the standard manner. The cannulation rates, SC rates, total procedure and fluoroscopic times, and adverse event rates were analyzed. RESULTS: After exclusion of 3 patients, 55 were in the EGEWF group and 56 in the ERCP group. Demographic data, laboratory data, stone characteristics, CBD diameter, and number of patients with periampullary diverticulum were not different between the 2 groups. The cannulation success rates in the EGEWF (96.35%) and ERCP (100%) groups were similar (P = .243). The SC rate in the EGEWF group (85.5%) was inferior to the ERCP group (100%) (P = .002). The SC rate based on the number of stones retrieved that matched the number by EUS was correct in 94%. More than 2 stones may increase the failure rate of SC in EGEWF. The adverse event rates and the total procedure times were not different between the groups. CONCLUSIONS: EGEWF was inferior to ERCP in terms of SC; however, no radiation exposure is beneficial for selected patients. (Clinical trial registration number: NCT02870686.).