Jonathan Love

Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.

Twenty patients with chronic pancreatitis and signs of biliary obstruction were treated by endoscopic placement of self expandable metal mesh stents, and followed up prospectively. Eleven had been treated previously with plastic endoprostheses. All had persistent cholestasis, seven patients had jaundice, and three overt cholangitis. Endoscopic stent placement was successful in all cases. No early clinical complication was seen and cholestasis, jaundice or cholangitis rapidly resolved in all patients. Mean follow up was 33 months (range 24 to 42) and consisted of clinical evaluation, ultrasonography, and endoscopic retrograde cholangiopancreatography (ERCP). In 18 patients, successive ERCPs and cholangioscopies have shown that the metal mesh initially embeds in the bile duct wall and is rapidly covered by a continuous tissue by three months. The stent lumen remained patent and functional throughout the follow up period except in two patients who developed epithelial hyperplasia within the stent resulting in recurrent biliary obstruction, three and six months after placement. They were treated endoscopically with standard plastic stents with one of these patients ultimately requiring surgical drainage. No patient free of clinical or radiological signs of epithelial hyperplasia after six months developed obstruction later. This new treatment could become an effective alternative to surgical biliary diversion if further controlled follow up studies confirm the initial impression that self expandable metal mesh stents offer a low morbidity alternative for longterm biliary drainage in chronic pancreatitis without the inconvenience associated with plastic stents.

Complete disruption of the main pancreatic duct: endoscopic management.

BACKGROUND Complete disruption of the main pancreatic duct is an unusual event in the course of acute or chronic pancreatitis. Endoscopic management has already proven effective in the treatment of partial ruptures. METHODS Thirteen patients presented over a 7-year period with acute (9 patients) or chronic (4 patients) pancreatitis complicated by complete disruption of the main pancreatic duct and cyst formation. Endoscopic treatment was attempted in 12. Treatment varied depending on the site of the rupture and accessibility of the pseudocyst and consisted either of transpapillary drainage (3), cystogastrostomy (3), cystoduodenostomy (2), or combined procedures (4) when one of these procedures did not induce significant decrease in collection size. Long-term results were obtained by observing the patients with ultrasound, CT, ERCP, and clinical evaluation. RESULTS Short-term results were excellent with complete cyst resolution and clinical recovery in all but one patient treated by endoscopy. Two patients had pseudocyst infection successfully treated by drainage and antibiotics. Long-term follow-up was available for 11 patients (mean duration, 30.2 months; range, 12 to 72 months) without relapsing clinical symptoms or pseudocyst. CONCLUSIONS Endoscopic management is effective and safe for treating patients with complete main pancreatic duct disruption. A double drainage combining transpapillary drainage and cystoenterostomy must be done in selected instances, especially when rupture occurs in the setting of chronic pancreatitis with stricture or stone distal to the rupture.

Endoscopic sphincterotomy by using pure-cut electrosurgical current and the risk of post-ERCP pancreatitis: a prospective randomized trial.

BACKGROUND It has been suggested that the use of pure-cut electrosurgical current for endoscopic sphincterotomy may reduce the risk of post-ERCP pancreatitis. The aim of this study was to determine whether pure-cut current reduces the risk of pancreatitis compared with blend current. METHODS Patients were randomly assigned to undergo sphincterotomy over a non-conductive guidewire with 30 W/sec pure-cut current or 30 W/sec blend-2 current by a blinded endoscopist. Serum amylase and lipase levels were determined 1 day before and within 24 hours after ERCP. Post-ERCP pancreatitis was the primary outcome of interest. Secondary outcomes were as follows: severity of immediate bleeding, as graded by a 3-point scale from 1 (no bleeding) to 3 (injection or balloon tamponade therapy required to stop bleeding) and evidence of delayed bleeding 24 hours after ERCP. Analyses were performed in intention-to-treat fashion. RESULTS A total of 246 patients were randomized (116 pure-cut current, 130 blend current). There were no differences in baseline characteristics between the groups. The overall frequency of post-ERCP pancreatitis was 6.9%, with no significant difference in frequency between treatment arms (pure cut, 7.8% vs. blend, 6.1%; p = 0.62). The difference in rates of pancreatitis between the two groups was 1.7%: 95% CI[-4.8%, 8.2%]. Six patients (2.4%) had delayed bleeding after ERCP, of which two required transfusion. There was a significant increase in minor bleeding episodes (grade 2) in the pure-cut group (p < 0.0001). Delayed episodes of bleeding were equal (n = 3) in each arm. CONCLUSIONS The type of current used when performing endoscopic sphincterotomy does not appear to alter the risk of post-ERCP pancreatitis. The selection of electrosurgical current for biliary endoscopic sphincterotomy should be based on endoscopist preference.

Endoscopic Management of Gastric Varices: Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate in a North American Patient Population

BACKGROUND: Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America.

Bile Acid Malabsorption in Chronic Diarrhea: Pathophysiology and Treatment

BACKGROUND Bile acid malabsorption (BAM) is a common but frequently under-recognized cause of chronic diarrhea, with an estimated prevalence of 4% to 5%. METHODS The published literature for the period 1965 to 2012 was examined for articles regarding the pathophysiology and treatment of BAM to provide an overview of the management of BAM in gastroenterology practice. RESULTS BAM is classified as type 1 (secondary to ileal dysfunction), type 2 (idiopathic) or type 3 (secondary to gastrointestinal disorders not associated with ileal dysfunction). The estimated prevalence of BAM is >90% in patients with resected Crohn disease (CD) and 11% to 52% of unresected CD patients (type 1); 33% in diarrhea-predominant irritable bowel syndrome (type 2); and is a frequent finding postcholecystectomy or postvagotomy (type 3). Investigations include BAM fecal bile acid assay, 23-seleno-25-homo-tauro-cholic acid (SeHCAT) testing and high-performance liquid chromatography of serum 7-α-OH-4-cholesten-3-one (C4), to determine the level of bile acid synthesis. A less time-consuming and expensive alternative in practice is an empirical trial of the bile acid sequestering agent cholestyramine. An estimated 70% to 96% of chronic diarrhea patients with BAM respond to short-course cholestyramine. Adverse effects include constipation, nausea, borborygmi, flatulence, bloating and abdominal pain. Other bile acid sequestering agents, such as colestipol and colesevelam, are currently being investigated for the treatment of BAM-associated diarrhea. CONCLUSIONS BAM is a common cause of chronic diarrhea presenting in gastroenterology practice. In accordance with current guidelines, an empirical trial of a bile acid sequestering agent is warranted as part of the clinical workup to rule out BAM.

31 Patchy Histologic Changes in Symptomatic Celiac Disease Despite Gluten Free Diet Is Accurately Reflected by Confocal Laser Endomicroscopy

and High Fat Diet). Four weeks later, anxiety-like behavior was assessed using the light preference and the step-down tests. Microbiota composition profiles were analyzed by 16S DNA based DGGE and Illumina techniques. The profile of microbiota from mice colonized with human microbiota bore strong similarity with that of the donor. Diet had a significant impact on bacterial composition in both healthy and IBS microbiota-colonized mice as increasing lipid content in the diet improved similarity between mouse and human donor microbiota. Moreover, higher lipid content better separated IBS and healthy profiles. In addition, the increased lipid content led to a decrease on the exploratory behavior of the mice with healthy microbiota. This effect, however, was not observed in mice with IBS microbiota. Our data demonstrate that the degree of success of human microbiota transfer into gnotobiotic mice is influenced by diet composition. Furthermore, the interaction between diet and microbiota has significant impact on mouse behavioral phenotypes.

Endoscopic Management of Gastric Varices; Efficacy and Outcomes of Gluing with N-Butyl-2-Cyanoacrylate

BACKGROUND Gastric variceal bleeding is associated with significant morbidity and mortality in patients with portal hypertension. Outside of North America, gastric variceal injection of N-butyl-2-cyanoacrylate has been shown to be safe and effective. The majority of studies on this mode of therapy are in Asian populations in which the etiology of portal hypertension differs from North America. AIM To assess the safety and efficacy of gastric variceal glue injection in a North American population. METHODS Consecutive patients that underwent glue injection of gastric varices in the Calgary Health Region from 2001 to 2006 were assessed. RESULTS Thirty-four patients (19 men, 15 women) underwent a total of 47 separate gluing procedures. Of those presenting with active bleeding at endoscopy, immediate hemostasis was achieved in 93.8% of patients. Rebleeding within 48 h of gluing was observed after four procedures. Gastric varices were eradicated in 84.0% of cases. Complications included superior mesenteric vein thrombosis in one patient. Twenty-eight (82.4%) patients were alive at the end of follow-up. The treatment failure-related mortality rate was 2.1%. CONCLUSIONS The present study is one of the few to assess the role of gastric variceal gluing in a North American population. Glue injection with cyanoacrylate is safe and effective in the treatment of bleeding gastric varices.

The Effectiveness of Ciprofloxacin in Prolonging Plastic Biliary Stent Patency: A Randomized Controlled Trial

The Effectiveness of Ciprofloxacin in Prolonging Plastic Biliary Stent Patency: A Randomized Controlled Trial Gabriel Chan, Jeffrey Barkun, Neena Abraham, Alan Barkun, Eric Valois, Albert Cohen, Gad Friedman, Jose Parent, Robert Enns, Jonathan R. Love, Vicky Baffis, Mansour Jabbari, Peter Szego, Larry Stein Background: Endoscopically-placed stents are the mainstay of the palliation of malignant biliary obstruction, but are complicated by obstruction, return of jaundice and cholangitis. Several trials have failed to consistently demonstrate an improvement in the duration of polyethylene stent patencywith ongoing antibiotic treatment. Generally, these studies have lacked sufficient statistical power. Aim: To study the effect of ciprofloxacin treatment on stent patency and on the perceived patient’s quality of life. Methods: Patients with obstructive jaundice from an unresectable malignancy were randomized in a double-masked fashion after successful polyethylene biliary stent insertion, to receive ciprofloxacin (500 mg PO BID) or placebo (one tablet PO BID) until stent blockage. Results: A total of 135 patients were recruited from three tertiary care institutions. The two groups were comparable in terms of age (72.7 6 10.4 yrs.), gender (54% F), initial symptomatology, diagnosis, staging of the tumor, site of obstruction, liver enzymes, and bilirubin (265.6 6 147.0 lmol/L). Thirty-four were excluded from final analysis because of: drop-out prior to the 7-day follow-up (16), inadequate early drop in bilirubin (18). Therewere 26 episodes of stent occlusion in the placebo group (43%) and 20 episodes in the Ciprofloxacin group (34%). The mean time to blockage was 61.2 6 68.0 days in the placebo group and 83.3 6 117.9 days in the treatment group. On survival analysis, there was no significant difference in the duration of patency between the two groups by log-rank test, (p=0.17). SF-36 Health Survey at baseline and one month were used to quantify any change in patient quality of life. The ciprofloxacin group demonstrated a significant decrease in the Social Function domain at one month compared to the placebo group (p=0.03). Conclusion:We conclude that the use of ciprofloxacin does not prolong biliary stent patency in malignant obstruction, and may even be associated with a decrease in the quality of life of these patients.