Comprehensive approach to esophageal variceal bleeding:From prevention to treatment

Esophageal variceal bleeding is a severe complication often associated with portal hypertension,commonly due to liver cirrhosis.Prevention and treatment of this condition are critical for patient outcomes.Preventive strategies focus on reducing portal hypertension to prevent varices from developing or enlarging.Primary prophylaxis involves the use of non-selective beta-blockers,such as propranolol or nadolol,which lower portal pressure by decreasing cardiac output and thereby reducing blood flow to the varices.Endoscopic variceal ligation(EVL)may also be employed as primary prophylaxis to prevent initial bleeding episodes.Once bleeding occurs,immediate treatment is essential.Initial management includes hemodynamic stabilization followed by pharmacological therapy with vasoactive drugs such as octreotide or terlipressin to control bleeding.Endoscopic intervention is the cornerstone of treatment,with techniques such as EVL or sclerotherapy applied to directly manage the bleeding varices.In cases where bleeding is refractory to endoscopic treatment,transjugular intrahepatic portosystemic shunt may be considered to effectively reduce portal pressure.Long-term management after an acute bleeding episode involves secondary prophylaxis using betablockers and repeated EVL sessions to prevent rebleeding,complemented by monitoring and managing liver function to address the underlying disease.In light of new scientific evidence,including the findings of the study by Peng et al,this editorial aims to review available strategies for the prevention and treatment of esophageal varices.

Role of endoscopic ultrasound-guided biliary drainage for palliation of malignant biliary obstruction

Endoscopic ultrasound-guided biliary drainage(EUS-BD)directs bile flow into the digestive tract and has been mostly used in patients with malignant biliary obstruction(MBO)where endoscopic retrograde cholangiopancreatography-guided biliary drainage was unsuccessful or was not feasible.Lumen apposing metal stents(LAMS)are deployed during EUS-BD,with the newer electrocautery-enhanced LAMS reducing procedure time and complication rates due to the inbuilt cautery at the catheter tip.EUS-BD with electrocautery-enhanced LAMS has high technical and clinical success rates for palliation of MBO,with bleeding,cholangitis,and stent occlusion being the most common adverse events.Recent studies have even suggested comparable efficacy between EUS-BD and endosc-opic retrograde cholangiopancreatography as the primary approach for distal MBO.In this editorial,we commented on the article by Peng et al published in the recent issue of the World Journal of Gastrointestinal Surgery in 2024.

Remimazolam for sedation in gastrointestinal endoscopy:A comprehensive review

Worldwide,a majority of routine endoscopic procedures are performed under some form of sedation to maximize patient comfort.Propofol,benzodiazepines and opioids continue to be widely used.However,in recent years,Remimazolam is gaining immense popularity for procedural sedation in gastrointestinal(GI)endoscopy.It is an ultra-short-acting benzodiazepine sedative which was approved by the Food and Drug Administration in July 2020 for use in procedural sedation.Remimazolam has shown a favorable pharmacokinetic and pharmacodynamic profile in terms of its non-specific metabolism by tissue esterase,volume of distribution,total body clearance,and negligible drug-drug interactions.It also has satisfactory efficacy and has achieved high rates of successful sedation in GI endoscopy.Furthermore,studies have demonstrated that the efficacy of Remimazolam is non-inferior to Propofol,which is currently a gold standard for procedural sedation in most parts of the world.However,the use of Propofol is associated with hemodynamic instability and respiratory depression.In contrast,Remimazolam has lower incidence of these adverse effects intra-procedurally and hence,may provide a safer alternative to Propofol in procedural sedation.In this comprehensive narrative review,highlight the pharmacologic characteristics,efficacy,and safety of Remimazolam for procedural sedation.We also discuss the potential of Remimazolam as a suitable alternative and how it can shape the future of procedural sedation in gastroenterology.

Impact of frailty on endoscopic retrograde cholangiopancreatography outcomes in nonagenarians:A United States national experience

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is an essential therapeutic tool for biliary and pancreatic diseases.Frail and elderly patients,especially those aged≥90 years are generally considered a higher-risk population for ERCP-related complications.AIM To investigate outcomes of ERCP in the Non-agenarian population(≥90 years)concerning Frailty.METHODS This is a cohort study using the 2018-2020 National Readmission Database.Patients aged≥90 were identified who underwent ERCP,using the international classification of diseases-10 code with clinical modification.Johns Hopkins’s adjusted clinical groups frailty indicator was used to classify patients as frail and non-frail.The primary outcome was mortality,and the secondary outcomes were morbidity and the 30 d readmission rate related to ERCP.We used univariate and multivariate regression models for analysis.RESULTS A total of 9448 patients were admitted for any indications of ERCP.Frail and non-frail patients were 3445(36.46%)and 6003(63.53%)respectively.Indications for ERCP were Choledocholithiasis(74.84%),Biliary pancreatitis(9.19%),Pancreatico-biliary cancer(7.6%),Biliary stricture(4.84%),and Cholangitis(1.51%).Mortality rates were higher in frail group[adjusted odds ratio(aOR)=1.68,P=0.02].The Intra-procedural complications were insigni-ficant between the two groups which included bleeding(aOR=0.72,P=0.67),accidental punctures/lacerations(aOR=0.77,P=0.5),and mechanical ventilation rates(aOR=1.19,P=0.6).Post-ERCP complication rate was similar for bleeding(aOR=0.72,P=0.41)and post-ERCP pancreatitis(aOR=1.4,P=0.44).Frail patients had a longer length of stay(6.7 d vs 5.5 d)and higher mean total charges of hospitalization($78807 vs$71392)compared to controls(P<0.001).The 30 d all-cause readmission rates between frail and non-frail patients were similar(P=0.96).CONCLUSION There was a significantly higher mortality risk and healthcare burden amongst nonagenarian frail patients undergoing ERCP compared to non-frail.Larger studies are warranted to investigate and mitigate modifiable risk factors.

Peptic ulcer disease in non-alcoholic fatty liver disease hospitalizations:A new challenge on the horizon in the United States

BACKGROUND Peptic ulcer disease(PUD)is frequently seen in patients with liver cirrhosis.However,current literature lacks data on PUD in non-alcoholic fatty liver disease(NAFLD)hospitalizations.AIM To identify trends and clinical outcomes of PUD in NAFLD hospitalizations in the United States.METHODS The National Inpatient Sample was utilized to identify all adult(≥18 years old)NAFLD hospitalizations with PUD in the United States from 2009-2019.Hospitalization trends and outcomes were highlighted.Furthermore,a control group of adult PUD hospitalizations without NAFLD was also identified for a comparative analysis to assess the influence of NAFLD on PUD.RESULTS The total number of NAFLD hospitalizations with PUD increased from 3745 in 2009 to 3805 in 2019.We noted an increase in the mean age for the study population from 56 years in 2009 to 63 years in 2019(P<0.001).Racial differences were also prevalent as NAFLD hospitalizations with PUD increased for Whites and Hispanics,while a decline was observed for Blacks and Asians.The all-cause inpatient mortality for NAFLD hospitalizations with PUD increased from 2%in 2009 to 5%in 2019(P<0.001).However,rates of Helicobacter pylori(H.pylori)infection and upper endoscopy decreased from 5%in 2009 to 1%in 2019(P<0.001)and from 60%in 2009 to 19%in 2019(P<0.001),respectively.Interestingly,despite a significantly higher comorbidity burden,we observed lower inpatient mortality(2%vs 3%,P=0.0004),mean length of stay(LOS)(11.6 vs 12.1 d,P<0.001),and mean total healthcare cost(THC)($178598 vs$184727,P<0.001)for NAFLD hospitalizations with PUD compared to non-NAFLD PUD hospitalizations.Perforation of the gastrointestinal tract,coagulopathy,alcohol abuse,malnutrition,and fluid and electrolyte disorders were identified to be independent predictors of inpatient mortality for NAFLD hospitalizations with PUD.CONCLUSION Inpatient mortality for NAFLD hospitalizations with PUD increased for the study period.However,there was a significant decline in the rates of H.pylori infection and upper endoscopy for NAFLD hospitalizations with PUD.After a comparative analysis,NAFLD hospitalizations with PUD had lower inpatient mortality,mean LOS,and mean THC compared to the non-NAFLD cohort.

Acute pancreatitis in liver transplant hospitalizations:Identifying national trends,clinical outcomes and healthcare burden in the United States

BACKGROUND Acute pancreatitis(AP)in liver transplant(LT)recipients may lead to poor clinical outcomes and development of severe complications.AIM We aimed to assess national trends,clinical outcomes,and the healthcare burden of LT hospitalizations with AP in the United States(US).METHODS The National Inpatient Sample was utilized to identify all adult(≥18 years old)LT hospitalizations with AP in the US from 2007–2019.Non-LT AP hospitalizations served as controls for comparative analysis.National trends of hospitalization characteristics,clinical outcomes,complications,and healthcare burden for LT hospitalizations with AP were highlighted.Hospitalization characteristics,clinical outcomes,complications,and healthcare burden were also compared between the LT and non-LT cohorts.Furthermore,predictors of inpatient mortality for LT hospitalizations with AP were identified.All P values≤0.05 were considered statistically significant.RESULTS The total number of LT hospitalizations with AP increased from 305 in 2007 to 610 in 2019.There was a rising trend of Hispanic(16.5%in 2007 to 21.1%in 2018,P-trend=0.0009)and Asian(4.3%in 2007 to 7.4%in 2019,p-trend=0.0002)LT hospitalizations with AP,while a decline was noted for Blacks(11%in 2007 to 8.3%in 2019,P-trend=0.0004).Furthermore,LT hospitalizations with AP had an increasing comorbidity burden as the Charlson Comorbidity Index(CCI)score≥3 increased from 41.64%in 2007 to 62.30%in 2019(P-trend<0.0001).We did not find statistically significant trends in inpatient mortality,mean length of stay(LOS),and mean total healthcare charge(THC)for LT hospitalizations with AP despite rising trends of complications such as sepsis,acute kidney failure(AKF),acute respiratory failure(ARF),abdominal abscesses,portal vein thrombosis(PVT),and venous thromboembolism(VTE).Between 2007–2019,6863 LT hospitalizations with AP were compared to 5649980 non-LT AP hospitalizations.LT hospitalizations with AP were slightly older(53.5 vs 52.6 years,P=0.017)and had a higher proportion of patients with CCI≥3(51.5%vs 19.8%,P<0.0001)compared to the non-LT cohort.Additionally,LT hospitalizations with AP had a higher proportion of Whites(67.9%vs 64.6%,P<0.0001)and Asians(4%vs 2.3%,P<0.0001),while the non-LT cohort had a higher proportion of Blacks and Hispanics.Interestingly,LT hospitalizations with AP had lower inpatient mortality(1.37%vs 2.16%,P=0.0479)compared to the non-LT cohort despite having a higher mean age,CCI scores,and complications such as AKF,PVT,VTE,and the need for blood transfusion.However,LT hospitalizations with AP had a higher mean THC($59596 vs$50466,P=0.0429)than the non-LT cohort.CONCLUSION In the US,LT hospitalizations with AP were on the rise,particularly for Hispanics and Asians.However,LT hospitalizations with AP had lower inpatient mortality compared to non-LT AP hospitalizations.

Efficacy of pancreatoscopy for pancreatic duct stones:A systematic review and meta-analysis

BACKGROUND Pancreatic duct stones can lead to significant abdominal pain for patients.Per oral pancreatoscopy(POP)-guided intracorporal lithotripsy is being increasingly used for the management of main pancreatic duct calculi(PDC)in chronic pancreatitis.POP uses two techniques:Electrohydraulic lithotripsy(EHL)and laser lithotripsy(LL).Data on the safety and efficacy are limited for this procedure.We performed a systematic review and meta-analysis with a primary aim to calculate the pooled technical and clinical success rates of POP.The secondary aim was to assess pooled rates of technical success,clinical success for the two individual techniques,and adverse event rates.AIM To perform a systematic review and meta-analysis of POP,EHL and LL for management of PDC in chronic pancreatitis.METHODS We conducted a comprehensive search of multiple electronic databases and conference proceedings including PubMed,EMBASE,Cochrane,Google Scholar and Web of Science databases(from 1999 to October 2019)to identify studies with patient age greater than 17 and any gender that reported on outcomes of POP,EHL and LL.The primary outcome assessed involved the pooled technical success and clinical success rate of POP.The secondary outcome included the pooled technical success and clinical success rate for EHL and LL.We also assessed the pooled rate of adverse events for POP,EHL and LL including a subgroup analysis for the rate of adverse event subtypes for POP:Hemorrhage,post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP),perforation,abdominal pain,fever and infections.Technical success was defined as the rate of clearing pancreatic duct stones and clinical success as the improvement in pain.Randomeffects model was used for analysis.Heterogeneity between study-specific estimates was calculated using the Cochran Q statistical test and I2 statistics.Publication bias was ascertained,qualitatively by visual inspection of funnel plot and quantitatively by the Egger test.RESULTS A total of 16 studies including 383 patients met the inclusion criteria.The technical success rate of POP was 76.4%(95%CI:65.9-84.5;I2=64%)and clinical success rate was 76.8%(95%CI:65.2-85.4;I2=66%).The technical success rate of EHL was 70.3%(95%CI:57.8-80.3;I2=36%)and clinical success rate of EHL was 66.5%(95%CI:55.2-76.2;I2=19%).The technical success rate of LL was 89.3%(95%CI:70.5-96.7;I2=70%)and clinical success rate of LL was 88.2%(95%CI:66.4-96.6;I2=77%).The incidence of pooled adverse events for POP was 14.9%(95%CI:9.2-23.2;I2=49%),for EHL was 11.2%(95%CI:5.9-20.3;I2=15%)and for LL was 13.1%(95%CI:6.3-25.4;I2=31%).Subgroup analysis of adverse events showed rates of PEP at 7%(95%CI:3.5-13.6;I2=38%),fever at 3.7%(95%CI:2-6.9;I2=0),abdominal pain at 4.7%(95%CI:2.7-7.8;I2=0),perforation at 4.3%(95%CI:2.1-8.4;I2=0),hemorrhage at 3.4%(95%CI:1.7-6.6;I2=0)and no mortality.There was evidence of publication bias based on funnel plot analysis and Egger’s test.CONCLUSION Our study highlights the high technical and clinical success rates for POP,EHL and LL.POP-guided lithotripsy could be a viable option for management of chronic pancreatitis with PDC.

Sarcopenia in hepatocellular carcinoma:Current knowledge and future directions

Liver cancer is the second most occurring cancer worldwide and is one of the leading causes of cancer-related deaths.Hepatocellular carcinoma(HCC)is the most common(80%-90%)type among malignant liver cancers.Sarcopenia occurs very early in HCC and can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional,systemic,and transplant management.Multiple prognostic stating systems have been developed in HCC,such as Barcelona Clinic Liver Cancer,Child-Pugh score and Albumin-Bilirubin grade.However,the evaluation of patients’performance status is a major limitation of these scoring systems.In this review,we aim to summarize the current knowledge and recent advances about the role of sarcopenia in cirrhosis in general,while focusing specifically on HCC.Additionally,the role of sarcopenia in predicting clinical outcomes and prognostication in HCC patients undergoing loco-regional therapies,liver resection,liver transplantation and systematic therapy has been discussed.A literature review was performed using databases PubMed/MEDLINE,EMBASE,Cochrane,Web of Science,and CINAHL on April 1,2021,to identify published reports on sarcopenia in HCC.Sarcopenia can independently predict HCC-related mortality especially in patients undergoing treatments such as loco-regional,surgical liver transplantation and systemic therapies.Basic research is focused on evaluating a balance of anabolic and catabolic pathways responsible for muscle health.Early clinical studies have shown promising results in methods to improve sarcopenia in HCC which can potentially increase prognosis in these patients.As sarcopenia occurs very early in HCC,it can predict and provide an opportunity to improve muscle health before engaging in the treatment options such as loco-regional,systemic,and transplant management.Further,sarcopenia measurement can obviate the confounding caused by the abdominal ascites in these patients.The use of sarcopenia can add to the existing scoring systems to better prognosticate the HCC.

Endoscopic ultrasound-guided vascular interventions: Current insights and emerging techniques

Endoscopic ultrasound(EUS)is one of the significant breakthroughs in the field of advanced endoscopy.In the last two decades,EUS has evolved from a diagnostic tool to a real-time therapeutic modality.The luminal gastrointestinal(GI)tract provides a unique opportunity to access multiple vascular structures,especially in the mediastinum and abdomen,thus permitting a variety of EUS-guided vascular interventions.The addition of the doppler and contrast-enhanced capability to EUS has further helped provide real-time visualization of blood flow in vessels through the GI tract.EUS-guided vascular interventions rely on standard endoscopic accessories and interventional tools such as fine-needle aspiration needles and fine-needle biopsy.EUS allows the visualization of various structures in real-time by differentiating tissue densities and vascularity,thus,avoiding radiation exposure.EUS-guided techniques also allow real-time microscopic examination after target biopsy.Furthermore,many necessary interventions can be done during the same procedure after diagnosis.This article provides an overview of EUS-guided vascular interventions such as variceal,non-variceal bleeding interventions,EUSguided portal vein(PV)access with the formation of an intrahepatic portosystemic shunt,and techniques related to diagnosis of GI malignancies.Furthermore,we discuss current insights and future outlook of therapeutic modalities like PV embolization,PV sampling,angiography,drug administration,and portal pressure measurement.

Impact of utilization of hepatitis C positive organs in liver transplant:Analysis of united network for organ sharing database

BACKGROUND The utility of hepatitis C virus(HCV)organs has increased after the Food and Drug Administration approval of direct acting anti-viral(DAA)medications for the HCV treatment.The efficacy of DAA in treating HCV is nearly 100%.AIM To analyze the United Network for Organ Sharing(UNOS)database to compare the survival rates between the hepatitis C positive donors and negative recipients and hepatitis C negative donors and recipients.METHODS We analyzed the adult patients in UNOS database who underwent deceased donor liver transplant from January 2014 to December 2017.The primary endpoint was to compare the survival rates among the four groups with different hepatitis C donor and recipient status:(Group 1)Both donor and recipient negative for HCV(Group 2)Negative donor and positive recipient for HCV(Group 3)Positive donor and negative recipient for HCV(Group 4)Both positive donor and recipient for HCV.SAS 9.4 software was used for the data analysis.Kaplan Meier log rank test was used to analyze the estimated survival rates among the four groups.RESULTS A total of 24512 patients were included:Group 1:16436,Group 2:6174,Group 3:253 and Group 4:1649.The 1-year(Group 1:91.8%,Group 2:92.12%,Group 3:87%,Group 4:92.8%),2-year(Group 1:88.4%,Group 2:88.1%,Group 3:84.3%,Group 4:87.5%),3-year(Group 1:84.9%,Group 2:84.3%,Group 3:75.9%,Group 4:83.2%)survival rates showed no statistical significance among the four groups.Kaplan Meier log rank test did not show any statistical significance difference in the estimated survival rates between Group 3 vs all the other groups.CONCLUSION The survival rates in hepatitis C positive donors and negative recipients are similar as compared to both hepatitis C negative donors and recipients.This could be due to the use of DAA therapy with cure rates of nearly 100%.This study supports the use of hepatitis C positive organs in the selected group of recipients with and without HCV infection.Further long-term studies are needed to further validate these findings.

Gastrointestinal manifestations,risk factors,and management in patients with post-transplant lymphoproliferative disorder:A systematic review

BACKGROUND Patients with a history of solid organ transplantation(SOT)or hematopoietic stem cell transplantation(HSCT)are at an increased risk of developing post-transplant lymphoproliferative disorder(PTLD).The gastrointestinal(GI)tract is commonly affected as it has an abundance of B and T cells.AIM To determine typical GI-manifestations,risk factors for developing PTLD,and management.METHODS Major databases were searched until November 2021.RESULTS Non-case report studies that described GI manifestations of PTLD,risk factors for developing PTLD,and management of PTLD were included.Nine articles written within the last 20 years were included in the review.All articles found that patients with a history of SOT,regardless of transplanted organ,have a propensity to develop GI-PTLD.CONCLUSION GI tract manifestations may be nonspecific;therefore,consideration of risk factors is crucial for identifying GI-PTLD.Like other lymphoma variants,PTLD is very aggressive making early diagnosis key to prognosis.Initial treatment is reduction of immunosuppression which is effective in more than 50%of cases;however,additional therapy including rituximab,chemotherapy,and surgery may also be required.

Spontaneous bacterial empyema in cirrhosis:A systematic review and meta-analysis

BACKGROUND Spontaneous bacterial empyema(SBE)occurs when a hepatic hydrothorax becomes infected and runs a course similar to spontaneous bacterial peritonitis(SBP).It remains underdiagnosed as patients with cirrhosis do not routinely undergo diagnostic thoracentesis.Current understanding is limited by small cohorts,while studies reporting its association with ascites/SBP are conflicting.AIM To explore the incidence of SBE,to determine its association with ascites,and to summarize what is known regarding treatment and outcomes for patients with SBE.METHODS Major databases were searched until June 2021.Outcomes include the incidence of SBE in pleural effusions,SBP in peritoneal fluid,and SBE in patients without ascites within our cohort of patients with cirrhosis.We performed a meta-analysis using a randomeffects model with pooled proportions and 95%confidence intervals(CI).We assessed heterogeneity using I^(2)and classic fail-safe to determine bias.RESULTS Eight studies with 8899 cirrhosis patients were included.The median age ranged between 41.2 to 69.7 years.The majority of the patients were Child-Pugh B and C.Mean MELD score was 18.6±8.09.A total of 1334 patients had pleural effusions and the pooled incidence of SBE was 15.6%(CI 12.6-19;I^(2)50).Amongst patients diagnosed with SBE,the most common locations included right(202),left(64),and bilateral(8).Amongst our cohort,a total of 2636 patients had ascites with a pooled incidence of SBP of 22.2%(CI 9.9-42.7;I^(2)97.8).The pooled incidence of SBE in patients with cirrhosis but without concomitant ascites was 9.5%(CI 3.6-22.8;I^(2)82.5).CONCLUSION SBE frequently occurs with concurrent ascites/SBP;our results suggest high incidence rates of SBE even in the absence of ascites.The pleura can be an unrecognized nidus and our findings support the use of diagnostic thoracentesis in patients with decompensated cirrhosis after exclusion of other causes of pleural effusion.Thoracentesis should be considered particularly in patients without ascites and when there is a high suspicion of infection.The need for diagnostic thoracentesis will continue to be important as rates of multi-drug resistant bacterial infections increase and antibiotic susceptibility information is required for adequate treatment.

Understanding evidence-based clinical practice guidelines for cholelithiasis 2021

Cholelithiasis is characterized by impaired metabolism of bile acids,cholesterol and bilirubin resulting in deposition of gallstones within the gallbladder(1).The article by Fujita et al.outlines the third revision of the evidence-based practice guidelines issued by the Japanese Society of Gastroenterology(JSGE)on cholelithiasis(2).For these current guidelines,52 questions were adopted through discussions among committee members,covering epidemiology,pathogenesis,diagnosis,treatments,complications,and prognostic aspects of cholelithiasis in Japan(2).The strengths of recommendations were determined by voting by committee members after assessing current available literature,patient preferences,and cost-benefit balance(2).Similar to the previous guideline(second revision),consensus among committee members was defined as the acquisition of 70%votes or over(2).