Pediatric stricturing Crohn's disease

Crohn’s disease(CD)is a chronic inflammatory disease of the digestive tract.The incidence of pediatric CD is increasing and is currently 2.5-11.4 per 100000 world-wide.Notably,approximately 25%of children with CD develop stricturing CD(SCD)that requires intervention.Symptomatic stricturing diseases refractory to pharmacological management frequently require non-pharmacological interventions.Non-pharmacological therapeutic strategies include endoscopic balloon dilatation,stricturoplasty,and surgical resection of the strictured seg-ment.However,strictures tend to recur postoperatively regardless of treatment modality.The lifetime risk of surgery in patients with childhood SCD remains at 50%-90%.Thus,new and emerging strategies,advanced diagnostic tools,and minimally invasive approaches are under investigation to improve the outcomes and overall quality of life of pediatric patients with SCD.

Population-based X-ray gastric cancer screening in Hiroshima prefecture, Japan

BACKGROUND X-ray gastric cancer(GC)screening has been shown to decrease mortality.Population-based X-ray GC screening has been performed in Hiroshima Prefe-cture,Japan,since 1983 but time trends and the efficacy of the method over 39 years have not been assessed.METHODS This was a population-based retrospective study.The data were derived from aggregated data of the Hiroshima Regional Health Medical Promotion Organization,including the number and rate of participants and those requiring esophagogastroduodenoscopies(EGDs),the number and rate of participants diagnosed as having GC,and the positive predictive value of the abnormal findings detected by X-ray and confirmed by EGDs.The number and rate of esophageal cancers were also collected.Further,the cost of detecting one GC was evaluated.RESULTS The number of participants has decreased during the last four decades,from 39925 in 1983 to 12923 in 2021.The rate of those requiring EGDs decreased significantly in recent years(P<0.001).The number of participants diagnosed as having GC has also declined,from 76 to 10 cases.However,the rate of cases diagnosed as GC among the participants remained around 0.1%.The positive predictive value increased significantly in recent years except during 1983-1991.The number and rate of accidentally detected esophageal cancers have risen recently,from 0%in 2008 to 0.02%in 2021,one-fifth of the diagnosis rate of GC.One GC diagnosis costs approximately 4200000 Japanese Yen(30000 United States Dollars)for the X-ray screenings and EGDs.CONCLUSION X-ray GC screening in Hiroshima has been efficient,but one challenge is the cost.Esophageal cancers may also need to be considered because they have gradually increased in recent years.

Eosinophilic esophagitis in Egyptian adult patients presenting with upper gastrointestinal symptoms

Background and Study Aim: Eosinophilic esophagitis (EoE) is a clinicopathological disease characterized by esophageal dysfunction and marked esophageal eosinophilic infiltration. It shows a marked increase in incidence and prevalence and has been associated with gastroesophageal reflux disease (GERD). The aim of this work was to detect the prevalence of EoE in Egyptian adult patients presenting with upper gastrointestinal symptoms and to clarify its clinical pattern and the possibility of its overlap with GERD. Patients and Methods: The study included 91 adult patients presenting with various upper gastrointestinal symptoms. Upper gastrointestinal endoscopy was done and esophageal biopsies were taken. The presence of >15 eosinophils per high power field together with a history of intake of proton pump inhibitors for at least 3 weeks without improvement was used as prerequisite diagnostic criteria for EoE. Results: Classification of the patients was based on both endoscopic and histo-pathological findings. Accordingly, out of the 91 patients, 70 had GERD (76.9%);58 of them had erosive reflux disease (ERD) and 12 had endoscopically normal esophagus but with histopathological changes compatible with reflux esophagitis and were classified as non erosive reflux disease (NERD). Eighteen patients had normal endoscopic and histopathological esophagus (19.8%), and 3 patients had EoE (3.3%), with an overlap between ERD and EoE in one patient. The mean age of EoE patients was 41.6 ± 11.7 years. Two of them were males and one was a female. All of the 3 patients complained of dysphagia and none complained of heartburn. The endoscopists did not report any endoscopic findings characteristic of EoE. Conclusion: The prevalence of EoE is low in adult Egyptian patients presenting with upper gastrointestinal symptoms. Dysphagia is the main presenting symptom of EoE while heartburn is not characteristic of the disease. Normal esophagus endoscopically does not exclude EoE.

Perivascular epithelioid cell tumors of the liver misdiagnosed as hepatocellular carcinoma:Three case reports

BACKGROUND Hepatic perivascular epithelioid cell neoplasms(PEComas)are rare.Diagnostic and treatment experience with hepatic PEComa remains insufficient.CASE SUMMARY Three hepatic PEComa cases are reported in this paper:One case of primary malignant hepatic PEComa,one case of benign hepatic PEComa,and one case of hepatic PEComa with an ovarian mature cystic teratoma.During preoperative imaging and pathological assessment of intraoperative frozen samples,patients were diagnosed with hepatocellular carcinoma(HCC),while postoperative pathology and immunohistochemistry subsequently revealed hepatic PEComa.Patients with hepatic PEComa which is misdiagnosed as HCC often require a wider surgical resection.It is easy to mistake them for distant metastases of hepatic PEComa and misdiagnosed as HCC,especially when it’s combined with tumors in other organs.Three patients eventually underwent partial hepatectomy.After 1-4 years of follow-up,none of the patients experienced recurrence or metastases.CONCLUSION A clear preoperative diagnosis of hepatic PEComa can reduce the scope of resection and prevent unnecessary injuries during surgery.

Pancreatitis after endoscopic retrograde cholangiopancreatography:A narrative review

Acute post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP)is a feared and potentially fatal complication that can be as high as up to 30%in high-risk patients.Pre-examination measures,during the examination and after the examination are the key to technical and clinical success with a decrease in adverse events.Several studies have debated on the subject,however,numerous topics remain controversial,such as the effectiveness of prophylactic medications and the amylase dosage time.This review was designed to provide an update on the current scientific evidence regarding PEP available in the literature.

Expression of pyruvate dehydrogenase is an independent prognostic marker in gastric cancer

AIM:To investigate the expression and prognostic role of pyruvate dehydrogenase(PDH) in gastric cancer(GC).METHODS:This study included 265 patients(194 male,71 female,mean age 59 years(range,29-81 years) with GC who underwent curative surgery at the First Affiliated Hospital of China Medical University from January 2006 to May 2007.All patients were followed up for more than 5 years.Patient-derived paraffin embedded GC specimens were collected for tissue microarrays(TMAs).We examined PDH expression by immunohistochemistry in TMAs containing tumor tissue and matched nonneoplastic mucosa.Immunoreactivity was evaluated independently by two researchers.Overall survival(OS) rates were determined using the Kaplan-Meier estimator.Correlations with other clinicopathologic factors were evaluated by two-tailed χ2 tests or a two-tailed t-test.The Cox proportional-hazard model was used in univariate analysis and multivariate analysis to identify factors significantly correlated with prognosis.RESULTS:Immunohistochemistry showed that 35.47% of total cancer tissue specimens had cytoplasmic PDH staining.PDH expression was much higher in normal mucosa specimens(75.09%;P = 0.001).PDH expression was correlated with Lauren grade(70.77% in intestinal type vs 40.0% in diffuse type;P = 0.001),lymph node metastasis(65.43% with no metastasis vs 51.09% with metastasis;P = 0.033),lymphatic invasion(61.62% with no invasion vs 38.81% with invasion;P = 0.002),histologic subtypes(70.77% in intestinal type vs 40.0% in diffuse type;P = 0.001) and tumor-node-metastasis(TNM) stage(39% in poorly differentiated vs 65.91% in well differentiated and 67.11% in moderately differentiated;P = 0.001) in GC.PDH expression in cancer tissue was significantly associated with higher OS(P < 0.001).The multivariate analysis adjusted for age,Lauren classification,TNM stage,lymph node metastasis,histological type,tumor size,depth of invasion and lymphatic invasion showed that the PDH expression in GC was an independent prognostic factor for higher OS(HR = 0.608,95%CI:0.504-0.734,P < 0.001).CONCLUSION:Our study indicated that PDH expression is an independent prognostic factor in GC patients and that positive expression of PDH may be predictive of favorable outcomes.

Antioxidant drugs to prevent post-endoscopic retrograde cholangiopancreatography pancreatitis:What does evidence suggest?

AIM:To determine whether or not the use of antioxidant supplementation aids in the prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis.METHODS:A systematic review of randomized controlled trials(RCTs) was made to evaluate the preventive effect of prophylactic antioxidant supplementation in post-endoscopic retrograde cholangiopancreatography pancreatitis(PEP).The inclusion criteria included:acute post-endoscopic retrograde cholangiopancreatography pancreatitis in adults; randomized clinical trials with the use of any antioxidant as an intervention compared with placebo,to reduce PEP.The outcome measure was the incidence and severity of PEP.Twelve RCTs involving 3110 patients since 1999 wereincluded.The antioxidants used were selenite,β-carotene,and pentoxifylline(each one in one trial),N-acetylcysteine(NAC) in three trials,and allopurinol in six trials.The group of patients treated with NAC received different doses; either oral or intravenous,and allopurinol-treated patients received five different oral doses in two different administration periods.The results are expressed with raw numbers,proportions,as well as mean and standard deviations.The incidence of pancreatitis between groups was analyzed with Pearson's χ2 test or Fisher's exact test(F).The main outcome is expressed as relative risks and 95%CI.RESULTS:The incidence of pancreatitis in all antioxidant treatment groups was 8.6%,whereas it was 9.7% in the control group.The antioxidants used were selenite,β-carotene,and pentoxifylline(each one in one trial),NAC in three trials,and allopurinol in six trials.In allopurinol trials,three different dosifications were used; two trials reported a low dosage(of less than 400 mg),two trials reported a moderate dose(600 mg) and the remaining two employed higher doses(more than 900 mg).Supplementation was not associated with a significant reduction in the incidence of PEP [relative risk(RR) = 0.93; 95%CI:0.82-1.06; P = 0.28].In addition,the incidences of PEP in patients treated with allopurinol and those treated with other antioxidants were similar to that observed in patients who received the placebo(RR for trials with allopurinol,0.92; 95%CI:0.78-1.08; P = 0.31) and,with the use of other antioxidants,the incidence of PEP was 8.9%,whereas it was 9.7% in the control group(RR = 0.95; 95%CI:0.77-1.18; P = 0.19).CONCLUSION:Antioxidant supplementation shows no beneficial effect on the incidence of PEP.There is a lack of robust trials to support the use of antioxidants for prevention.

Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife:A pilot animal study

AIM:To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model.METHODS:Pure natural orifice transluminal endoscopic surgery(NOTES) cholecystectomy was performed on three non-survival pigs,by transumbilical approach,using a water-jet hybrid-knife. Under general anesthesia,the following steps detailed the procedure:(1) incision of the umbilicus followed by the passage of a double-channel flexible endsocope through an overtube into the peritoneal cavity;(2) establishment of pneumoperitoneum;(3) abdominal exploration;(4)endoscopic cholecystectomy:dissection of the gallbladder performed using water jet equipment,ligation of the cystic artery and duct conducted using nylon loops;and(5) necropsy with macroscopic evaluation.RESULTS:Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig,with minor bleedings. The dissection times were 137and 42 min,respectively. The total operation times were 167 and 69 min,respectively. And the lengths of resected specimen were 6.5 and 6.1 cm,respectively.Instillation of the fluid into the gallbladder bed produced edematous,distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops.There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case,leading to the operation failure.CONCLUSION:Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

Gallstone ileus,clinical presentation,diagnostic and treatment approach

Gallstone ileus is a mechanical intestinal obstruction due to gallstone impaction within the gastrointestinal tract. Less than 1% of cases of intestinal obstruction are derived from this etiology. The symptoms and signs of gallstone ileus are mostly nonspecific. This entity has been observed with a higher frequency among the elderly, the majority of which have concomitant medical illness. Cardiovascular, pulmonary, and metabolic diseases should be considered as they may affect the prognosis. Surgical relief of gastrointestinal obstruction remains the mainstay of operative treatment. The current surgical procedures are:(1) simple enterolithotomy;(2) enterolithotomy, cholecystectomy and fistula closure(one-stage procedure); and(3) enterolithotomy with cholecystectomy performed later(two-stage procedure). Bowel resection is necessary in certain cases after enterolithotomy is performed. Large prospective laparoscopic and endoscopic trials are expected.

Papillary fistulotomy vs conventional cannulation for endoscopic biliary access:A prospective randomized trial

AIM To compare the cannulation success, biochemical profile, and complications of the papillary fistulotomy technique vs catheter and guidewire standard access.METHODS From July 2010 to May 2017, patients were prospectively randomized into two groups: Cannulation with a catheter and guidewire(Group Ⅰ) and papillary fistulotomy(Group Ⅱ). Amylase, lipase and C-reactive protein at T0, as well as 12 h and 24 h after endoscopic retrograde cholangiopancreatography, and complications(pancreatitis, bleeding, perforation) were recorded.RESULTS We included 102 patients(66 females and 36 males, mean age 59.11 ± 18.7 years). Group Ⅰ and Group Ⅱ had 51 patients each. The successful cannulation rates were 76.5% and 100%, respectively(P = 0.0002). Twelve patients(23.5%) in Group Ⅰ had a difficult cannulation and underwent fistulotomy, which led to successful secondary biliary access(Failure Group). The complication rate was 13.7%(2 perforations and 5 mild pancreatitis) vs 2.0%(1 patient with perforation and pancreatitis) in Groups Ⅰ and Ⅱ, respectively(P = 0.0597). CONCLUSION Papillary fistulotomy was more effective than guidewire cannulation, and it was associated with a lower profile of amylase and lipase. Complications were similar in both groups.

Transgastric endoscopic gastrojejunostomy using holing followed by interrupted suture technique in a porcine model

AIM: To demonstrate the feasibility and reproducibility of a pure natural orifice transluminal endoscopic surgery(NOTES) gastrojejunostomy using holing followed by interrupted suture technique using a single endoloop matched with a pair of clips in a non-survival porcine model.METHODS: NOTES gastrojejunostomy was performed on three female domestic pigs as follows: Gastrostomy, selection and retrieval of a free-floating loop of the small bowel into the stomach pouch, hold and exposure of the loop in the gastric cavity using a submucosal inflation technique, execution of a gastro-jejunal mucosal-seromuscular layer approximation using holing followed by interrupted suture technique with endoloop/clips, and full-thickness incision of the loop with a Dual knife.RESULTS: Pure NOTES side-to-side gastrojejunostomy was successfully performed in all three animals. No leakage was identified via methylene blue evaluation following surgery.CONCLUSION: This novel technique for preforming a gastrointestinal anastomosis exclusively by NOTES is technically feasible and reproducible in an animal model but warrants further improvement.

Otilonium bromide in irritable bowel syndrome:A dose-ranging randomized double-blind placebo-controlled trial

AIM: To examine the efficacy and safety of otilonium bromide (OB) in treatment-sensitive functional irritable bowel syndrome (IBS) clinical parameters.

Comparison of He/icobacter py/ori infection and gastric mucosal histological features of gastric ulcer patients with chronic gastritis patients

AIM: To compare Helicobacter pyloriinfection and gastric mucosal histological features of gastric ulcer patients with chronic gastritis patients in different age groups and from different biopsy sites.METHODS: The biopsy specimens were taken from the antrum, corpus and upper angulus of gastric ulcer and chronic gastritis patients. Giemsa staining, improved Toluidine-blue staining and H pylori-specific antibody immune staining were performed as appropriate for the histological diagnosis of H pylori infection. Hematoxylineosin staining was used for the histological diagnosis of activity of H pylori infection, mucosal inflammation,glandular atrophy and intestinal metaplasia and scored into four grades according to the Updated Sydney System.RESULTS: Total rate of H pylori infection, mucosal inflammation, activity of H pylori infection, glandular atrophy and intestinal metaplasia in 3 839 gastric ulcer patients (78.5%, 97.4%, 82.1%, 61.1% and 64.2%,respectively) were significantly higher than those in 4 102chronic gastritis patients (55.0%, 90.3%, 56.2%, 36.8%,and 37.0%, respectively, P＜0.05). The rate of H pylori colonization of chronic gastritis in ＜30 years, 31-40 years,41-50 years, 51-60 years, 61-70 years and ＞70 years age groups in antrum was 33.3%, 41.7%, 53.6%, 57.3%,50.7%, 43.5%, respectively; in corpus, it was 32.6%,41.9%, 53.8%, 60.2%, 58.0%, 54.8%, respectively; in angulus, it was 32.4%, 42.1%, 51.6%, 54.5%, 49.7%,43.5%, respectively. The rate of Hpyloricolonization of gastric ulcer in ＜30 years, 31-40 years, 41-50 years,51-60 years, 61-70 years and ＞70 years age groups in antrum was 60.5%, 79.9%, 80.9%, 66.8%, 59.6%, 45.6%,respectively; in corpus, it was 59.7%, 79.6%, 83.6%,80.1%, 70.6%, 59.1%, respectively; in angulus, it was61.3%, 77.8%, 75.3%, 68.8%, 59.7%, 45.8%,respectively. The rate of H pylori colonization at antrum was similar to corpus and angulus in patients, below50 years, with chronic gastritis and in patients, below40 years, with gastric ulcer. In the other age- groups,the rate of H pylori colonization was highest in corpus,lower in antrum and lowest in angulus (all P＜0.05). The rates of glandular atrophy and intestinal metaplasia were higher and earlier in H pylori-positive patients than those without H pylori infection (both P＜0.01). In comparison of gastric ulcer patients with chronic gastritis patients,the rate of glandular atrophy and intestinal metaplasia was higher in H pylori-positive patients with gastric ulcer than in H pylori-positive patients with chronic gastritis(both P＜0.01); the rate of glandular atrophy and intestinal metaplasia were also higher in H pylori-negative patients with gastric ulcer than in H pylori-negative patients with chronic gastritis (both P＜0.01). Both glandular atrophy and intestinal metaplasia were much more commonly identified in the angulus than in the antrum, lowest in corpus (all P＜0.01).CONCLUSION: Rate of H pylori infection, glandular atrophy and intestinal metaplasia in gastric ulcer were higher than in chronic gastritis in all-different age -groups. Distribution of H pylori colonization is pangastric in the younger patients. It is highest in corpus, lower in antrum and lowest in angulus in the older age groups. Progression of glandular atrophy and intestinal metaplasia seem to have a key role in the distribution of H pylori colonization. H pylori appears to be the most important risk factor for the development of glandular atrophy and intestinal metaplasia, but it is not the only risk.

Submucosal injection of platelet-rich plasma in endoscopic resection of large sessile lesions

AIM To prospectively evaluate the efficacy of submucosal injection of platelet-rich plasma(PRP) on endoscopic resection of large sessile lesions.METHODS Eleven patients were submitted to endoscopic mucosal resection(EMR) with prior injection of PRP, obtained at the time of endoscopy. Patients were followed during 1 mo. The incidence of adverse events(delayed bleeding or perforation) and the percentage of mucosal healing(MHR) after 4 wk were registered. RESULTS EMR was performed in 11 lesions(46.4 mm ± 4 mm, range 40-70 mm). Delayed bleeding or perforation was not observed in any patient. Mean ulcerated area atbaseline was 22.7 cm^2 ± 11.7 cm^2 whereas at week 4 were 2.9 cm^2 ± 1.5 cm^2. Patients treated with PRP showed a very high MHR after 4 wk(87.5%). CONCLUSION PRP is an easy-to-obtain solution with proven and favourable biological activities that could be used in advanced endoscopic resection.

Raman spectroscopy for early real-time endoscopic optical diagnosis based on biochemical changes during the carcinogenesis of Barrett's esophagus

Raman spectroscopy is a spectroscopic technique based on the inelastic scattering of monochromatic light that represents the molecular composition of the interrogated volume to provide a direct molecular fingerprint. Several investigations have revealed that confocal Raman spectroscopy can differentiate non-dysplastic Barrett&rsquo;s esophagus from esophageal high-grade dysplasia and adenocarcinoma with high sensitivity and specificity. An automated on-line Raman spectral diagnostic system has made it possible to use Raman spectroscopy to guide accurate target biopsy instead of multiple random forceps-biopsies, this novel system is expected to improve in vivo precancerous diagnosis and tissue characterization of Barrett&rsquo;s esophagus.

rate of adverse events of gastroduodenal snare polypectomy for non-flat polyp is low: A prospective and multicenter study

AIM To evaluate the rate of adverse events(AEs) during consecutive gastric and duodenal polypectomies in several Spanish centers. METHODS Polypectomies of protruded gastric or duodenal polyps ≥ 5 mm using hot snare were prospectively included. Prophylactic measures of hemorrhage were allowed in predefined cases. AEs were defined and graded according to the lexicon recommended by the American Society for Gastrointestinal Endoscopy. Patients were followed for 48 h, one week and 1 mo after theprocedure. RESULTS308 patients were included and a single polypectomy was performed in 205. Only 36(11.7%) were on prior anticoagulant therapy. Mean polyp size was 15 ± 8.9 mm(5-60) and in 294 cases(95.4%) were located in the stomach. Hemorrhage prophylaxis was performed in 219(71.1%) patients. Nine patients presented AEs(2.9%), and 6 of them were bleeding(n = 6, 1.9%)(in 5 out of 6 AE, different types of endoscopic treatment were performed). Other 24 hemorrhagic episodes could be managed without any change in the outcome of the endoscopy and, consequently, were considered incidents. We did not find any independent risk factor of bleeding.CONCLUSION Gastroduodenal polypectomy using prophylactic measures has a rate of AEs small enough to consider this procedure a safe and effective method for polyp resection independently of the polyp size and location.

Gastric infiltration of diffuse large B-cell lymphoma: Endoscopic diagnosis and improvement of lesions after chemotherapy

Diffuse large B-cell lymphoma (DLBCL) is the most common histologic subtype of the non-Hodgkin’s lymphoma (NHL) accounting for about 40% of all NHLs. This is a case report about the endoscopic appearance of a DLBCL with infiltration to the stomach in a 39-year-old female. She had a 6-mo history of lumbar and left upper quadrant pain with intermittent episodes of melena. A computer tomograghy (CT) scan showed mural thickening of the gastric antrum. Endoscopic examination revealed multiple gastric ulcers. Definite diagnosis could be made by endoscopic biopsies and the patient had a good response to chemotherapy. This response correlated well with a further endoscopic follow-up. A follow-up endoscopic examination could be considered to evaluate a good response to chemotherapy in DLBCL patients with secondary gastric dissemination.

Nonsteroidal anti-inflammatory drug effectivity in preventing postendoscopic retrograde cholangiopancreatography pancreatitis: A systematic review and meta-analysis

BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP)is the primary therapeutic procedure for the treatment of diseases affecting the biliary tree and pancreatic duct.Although the therapeutic success rate of ERCP is high,the procedure can cause complications,such as acute pancreatitis[post-ERCP pancreatitis(PEP)],bleeding and perforation.AIM To assess the efficacy of non-steroidal anti-inflammatory drugs(NSAIDs)in preventing PEP during follow-up.METHODS Databases such as MEDLINE,EMBASE and Cochrane Central Library were searched.Only randomized controlled trials(RCTs)comparing the efficacy of NSAIDs and placebo for the prevention of PEP were included.Outcomes evaluated included the incidence of PEP,severity of pancreatitis,route of administration,types,dose,and timing of administration of NSAIDs.RESULTS Twenty-six RCTs were considered eligible with a total of 8143 patients analyzed.Overall,4020 patients used NSAIDs before ERCP and 4123 did not use NSAIDs(control group).Ultimately,298 cases of post-ERCP acute pancreatitis were diagnosed in the NSAID group and 484 cases in the placebo group.The risk of PEP was lower in the NSAID group risk difference(RD):-0.04;95%confidence interval(CI):-0.07 to-0.03;number needed to treat(NNT),25;P<0.05.NSAID use effectively prevented mild pancreatitis compared to placebo use(2.5%vs 4.1%;95%CI:-0.05 to-0.01;NNT,33;P<0.05),but information on moderate PEP and severe PEP could not be fully elucidated.Only rectal administration reduced the incidence of PEP with RD:-0.06;95%CI:-0.08 to-0.04;NNT,17;P<0.05).Furthermore,only the use of diclofenac or indomethacin was effective in preventing PEP,at a dose of 100 mg,which must be administered before performing ERCP.CONCLUSION Rectal administration of diclofenac and indomethacin significantly reduced the risk of developing mild PEP.Additional RCTs are needed to compare the efficacy between NSAID routes of administration in preventing PEP.

Upfront surgery of small intestinal neuroendocrine tumors. Time to reconsider?

Small intestinal neuroendocrine tumors(SI-NETs) may demonstrate a widely variable clinical behavior but usually it is indolent. In cases with localized disease, locoregional resective surgery(LRS) is generally indicated with a curative intent. LRS of SI-NETs is also the recommended treatment when symptoms are present, regardless of the disease stage. Concerning asymptomatic patients with distant metastases, prophylactic LRS has been traditionally suggested to avoid possible future complications. Even the current European Neuroendocrine Tumor Society guidelines emphasize a possible effect of LRS in Stage IV SINETs with unresectable liver metastases. On the contrary, the 2017 National Comprehensive Cancer Network Guidelines on carcinoid tumors do not support the resection of a small, asymptomatic, relatively stable primary tumor in the presence of unresectable metastatic disease. Furthermore, a recent study revealed no survival advantage for asymptomatic patients with distant-stage disease who underwent upfront LRS. At the aforementioned paper, it was suggested that delayed surgery as needed was comparable with the upfront surgical approach in terms of postoperative morbidity and mortality, the length of the hospital stay and the rate of incisional hernia repairs but was associated with fewer reoperations for bowel obstruction. On the other hand, it is also important to note that some patients might benefit from a prophylactic surgical approach and our attention should focus on identifying this patient population.

Unexplained septic shock after colonoscopy with polyethylene glycol preparation in a young adult:A case report

BACKGROUND Colonoscopy has become a routine physical examination as people’s health awareness has increased.Polyethylene glycol(PEG)is greatly used in bowel preparation before colonoscopy due to its price and safety advantages.Septic shock after colonoscopy with PEG preparation is extremely rare,with only very few cases in critically ill patients.Herein,we describe a case of septic shock in a healthy young adult immediately following colonoscopy with PEG preparation.CASE SUMMARY A 33-year-old young adult presented to our hospital for colonoscopy with PEG bowel preparation due to recurrent diarrhea for 7 years.The male's previous physical examination showed no abnormal indicators,and colonoscopy results were normal;however,he exhibited septic shock and markedly elevated white blood cell,C-reactive protein,and procalcitonin levels on the second day after colonoscopy.Immediate resuscitation and intensive care with appropriate antibiotics improved his condition.However,the blood and stool cultures did not detect the pathogen CONCLUSION Septic shock after colonoscopy is rare,especially in young adults.The authors considered the possibility of opportunistic infections after PEG bowel preparation,and clinicians should monitor patients for the possibility of such complications.