Is it necessary to stop glucagon-like peptide-1 receptor agonists prior to endoscopic procedure? A retrospective study

BACKGROUND Glucagon-like peptide-1 receptor agonists(GLP-1 RA)are effective in diabetes and obesity,reducing hyperglycemia by increasing insulin release and delaying gastric emptying.However,they can cause gastroparesis,raising concerns about aspiration during procedures.Recent guidelines advise discontinuing GLP-1 RA before surgery to reduce the risk of pulmonary aspiration.AIM To evaluate the effect of GLP-1 RAs on gastric residual contents during endosco-pic procedures.METHODS A retrospective chart review at BronxCare Health System,New York,from January 2019 to October 2023,assessed gastric residue and aspiration in GLP-1 RA patients undergoing endoscopic procedures.Two groups were compared based on dietary status before the procedure.Data included demographics,symptoms of gastroparesis,opiate use,hemoglobin A1c,GLP-1 agonist indication,endo-scopic details,and aspiration occurrence.IBM SPSS was used for analysis,cal-culating means,standard deviations,and applying Pearson’s chi-square and t-tests for associations,with P<0.05 as being significant.RESULTS During the study,306 patients were included,with 41.2%on a clear liquid/low residue diet and 58.8%on a regular diet before endoscopy.Most patients(63.1%)were male,with a mean age of 60±12 years.The majority(85.6%)were on GLP-1 RAs for diabetes,and 10.1%reported digestive symptoms before endoscopy.Among those on a clear liquid diet,1.5%had residual food at endoscopy compared to 10%on a regular diet,which was statistically significant(P=0.03).Out of 31 patients with digestive symptoms,13%had residual food,all from the regular diet group(P=0.130).No complications were reported during or after the procedures.CONCLUSION The study reflects a significant rise in GLP-1 RA use for diabetes and obesity.A 24-hour liquid diet seems safe for endoscopic procedures without aspiration.Patients with upper gastrointestinal symptoms might have a higher residual food risk,though not statistically significant.Further research is needed to assess risks based on diabetes duration,gastroparesis,and GLP-1 RA dosing,aiming to minimize interruptions in therapy during procedures.

Staining for p53 and Ki-67 increases the sensitivity of EUS-FNA to detect pancreatic malignancy

AIM:To investigate whether tumor marker staining can improve the sensitivity of endoscopic ultrasound-guided fine needle aspiration(EUS-FNA)to diagnose pancreatic malignancy. METHODS:Patients who underwent EUS-FNA were retrospectively identified.Each EUS-FNA specimen was evaluated by routine cytology and stained for tumor markers p53,Ki-67,carcinoembryonic antigen(CEA) and CA19-9.Sensitivity,specificity,positive and negative predictive values(PPV and NPV),and positive and negative likelihood ratios(PLR and NLR)were calculated in order to evaluate the performance of each test to detect malignancy. RESULTS:Sixty-one specimens had complete sets of stains,yielding 49 and 12 specimens from pancreatic adenocarcinomas and benign pancreatic lesions due to pancreatitis,respectively.Cytology alone had sensitivity and specificity of 41%and 100%to detect malignancy, respectively.In 46%of the specimens,routine cytology alone was deemed indeterminate.The addition of either p53 or Ki-67 increased the sensitivity to 51%and 53%,respectively,with perfect specificity,PPV and PLR (100%,100%and infinite).Both stains in combination increased the sensitivity to 57%.While additional staining with CEA and CA19-9 further increased the sensitivity to 86%,the specificity,PPV and PLR were significantly reduced(at minimum 42%,84%and 1,respectively).Markers in all combinations performed poorly as a negative test(NPV 26%to 47%,and NLR 0.27 and 0.70).CONCLUSION:Immunohistochemical staining for p53 and Ki-67 can improve the sensitivity of EUS-FNA to diagnose pancreatic adenocarcinoma.

Gallstone ileus with multiple stones:Where Rigler triad meets Bouveret's syndrome

A 53-year-old man with multiple medical conditions presented to the emergency department with complaints of vomiting, anorexia and diffuse colicky abdominal pain for 3 d. A computed tomography scan of the abdomen and pelvis showed radiographic findings consistent with Rigler triad seen in small proportion of patients with small bowel obstruction secondary to gallstone impaction. In addition there was a gastric outlet obstruction, consistent with Bouveret's syndrome. The patient underwent an exploratory laparotomy and enterotomy with multiple stones extracted. The patient had an uneventful post-surgical clinical course and was discharged home.

Incidental finding of esophageal pneumatosis

Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall.Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum,however it is most commonly reported in the small intestine.Despite multiple case reports in literature,its pathogenesis still remains unclear.Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease,jejunoileal bypass,intestinal obstruction and non-gastrointestinal disorders like asthma,chronic obstructive pulmonary disease,systemic lupus erythematosus,infectious enteritis,etc.We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy(EGD).A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia.Few months prior to EGD,she had undergone excision of laryngocele at our hospital.EGD revealed extensive submucosal blebs distributed throughout the esophagus,otherwise unremarkable stomach and duodenum.Colonoscopy showed a tubular adenomatous polyp.Since our patient was asymptomatic she did not require any surgical intervention.Management of pneumatosis depends on the underlying cause.