Multiple Strictures Research Articles

Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures (supplement to the Clinical Practice Guidelines for Enteroscopy).

Balloon-assisted enteroscopy allows endoscopic treatments in the deeper segments of the small bowel. Endoscopic balloon dilation has become a popular minimally invasive alternative for the treatment of Crohn's disease-associated small intestinal strictures. As a supplement to the Clinical Practice Guidelines for Enteroscopy, the Japan Gastroenterological Endoscopy Society's Working Committee has developed the present "Guidelines for endoscopic balloon dilation in treating Crohn's disease-associated small intestinal strictures," based on new scientific techniques and evidence. The guidelines cover standard procedures for the insertion route of the balloon endoscope, bowel preparation, indications, procedure-related complications, efficacy, target diameter and duration, management of multiple strictures, and the current state of combined and alternative treatments. Unresolved future research questions are also listed in this guideline.

Primary sclerosing cholangitis-A long night's journey into day.

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The first experience of using autolipoaspirate in combined endoscopic treatment of severe cicatricial stricture of the esophagus

A 71-year-old patient with cicatricial stricture of the esophagus at the place of residence underwent bougienage, balloon dilatation and electric incision of the scar with a short-term effect.In March 2020, the patient applied to the Petrovsky National Research Center of Surgery with dysphagia grade 3 according to Bown. In the endoscopic department, multiple critical cicatricial strictures of presumably burn etiology were diagnosed, and therefore a long course of endoscopic bougienage was carried out, starting with Soehendra bougie with a diameter of 6 Fr to Savary bougie 45 Fr with an interval from 1–2 days to 2 weeks. Due to the tendency to rapid restenosis during this time, treatment was supplemented with 4 courses of intramural injections of dexamethasone solution. Despite the lack of a stable effect, the patient refused surgical treatment. Due to persistent restenosis, an innovative treatment was carried out—intramural injection of autologous lipoaspirate (nanofat) into the narrowed zone in order to reduce the density and rigidity of the scar tissue. At the final stage, in order to stabilize the lumen and prevent further restenosis, a course of intramural injections of triamcinolone was performed. This made it possible to successfully complete a two-year course of planned combined endoscopic treatment.

S3359 Diaphragm Disease: A Crohn's Mimicker?

Introduction: Diaphragm disease of the small bowel is a rare disease typically associated with NSAID use. The disease is characterized by multiple strictures appearing as ‘pinhole’ sized lumens caused by mucosal thickening. Often the condition goes misdiagnosed until the lumen is visualized, with clinical presentations initially consisting of recurrent bowel obstructions, anemia and/or protein loosing enteropathy. Case Description/Methods: A 50-year-old male with a history of hypertension, incarceration, and prior recurrent small bowel obstructions and prior exploratory laparotomy with lysis of adhesions, presented with recurrent abdominal pain, nausea, vomiting and constipation. A year prior to presentation, the patient was hospitalized for similar symptoms, with colonoscopy demonstrating a fibrotic stricture at the ileocecal valve, which was only able to be traversed after balloon dilation. The mucosa appeared endoscopically normal, however, biopsies of the terminal ileum demonstrated chronic active focal ileitis, suggestive of Crohn’s disease. The patient then experienced two more hospitalizations for small bowel obstruction, which resolved with supportive care and steroid administration. During this hospitalization, CT scan demonstrated a small bowel obstruction with several transition points in the mid small bowel. Intravenous corticosteroids were started, and nasogastric tube was placed with improvement. He adamantly denied any current or past prolonged NSAID use. It was decided that patient would benefit from a surgical small bowel exploration. Several strictures were seen in the proximal small bowel, and therefore proximal and distal resection of jejumum with a primary end-to-end enteroenterostomy anastomosis was performed. Histopathological evaluation of the resected specimen showed small bowel with circumferential membranes with submucosal neuromuscular and vascular hyperplasia, displaced mucosal glands, and associated mucosal active and chronic ileitis with ulceration, compatible with a diagnosis of diaphragm disease. (Figure) Discussion: NSAIDs can have deleterious effects on the small bowel including, ulceration, structuring, erosion formation, perforation and/or the formation of fibrous diaphragms that can lead to obstruction. Diaphragm disease is uncommon, especially in the absence of prior NSAID use. Clinically, it is important to recognize this group of patients as obstructive symptoms due to structuring/diaphragm disease are unlikely to resolve without some form of surgical intervention.Figure 1.: a + b) Submucosal fibrosis and neuromuscular and vascular hyperplasia. c) Focal narrowing and proximal dilation of a loop of small bowel with transition point within the mid small bowel.

S1787 Steroid-refractory IgG4-Related Disease Presenting as Sclerosing Cholangitis

Introduction: IgG4-related disease (IgG4-RD) is characterized by tumefactive infiltration of IgG4-bearing plasmablasts and other lymphocytes, along with storiform fibrosis, into one or multiple organs, with resultant organ enlargement, fibrosis, and dysfunction. Although initial reports of IgG4-RD concerned involvement of the pancreas, other organs such as the biliary tract can be involved. We present a case of steroid refractory IgG4- RD sclerosing cholangitis (IgG4-SC). Case Description/Methods: A 67-year-old man with hypertension presented with a 2-week history of unintentional weight loss, painless jaundice, and pruritus. Exam showed jaundice and scleral icterus. Laboratory revealed elevated liver tests with an obstructive pattern, with ALP, GGT, & Bilirubin of 431 U/L, 438 IU/L, 17.6mg/dL, respectively. MRCP, ERCP, and subsequent EUS demonstrated diffuse pancreatic parenchymal hypo-echogenicity, long segment strictures at the distal common bile duct with proximal duct dilation, dilated common hepatic duct, and multiple segmental intrahepatic biliary duct strictures. Biliary sphincterotomy and stent placement resolved symptoms. Biopsy of the Ampulla of Vater revealed chronic inflammation with ulceration. Further work-up uncovered an elevated serum IgG4 of 266 mg/dL with a negative ANA, SMA, AMA, and tumor markers. He was then diagnosed with IgG4-SC and completed a course of prednisone. Relapse of symptoms prompted a repeat ERCP which uncovered biliary tree pruning and irregularity, necessitating biliary stent replacement. Due to poor tolerance with rituximab infusion, he was treated with Mycophenolate Mofetil which accomplished a year of disease quiescence. Discussion: The prime gastrointestinal manifestations of IgG4-RD include type 1 Autoimmune Pancreatitis and less commonly, IgG4-SC. Management involves high dose steroids for 4 weeks with a slow taper over years to prevent permanent fibrosis. Patients are at highest risk of relapse during steroid taper or within 6 months of completion, with a relapse rate of 15-60%. Although our patient did not have the classic predictive factors of relapse, such as proximal strictures or serum IgG4 >280 mg/dL, he had a suboptimal response to steroids which prolonged his clinical course and exposed him to repeated procedures. There is still a need for further studies regarding the role for possible combination therapy (steroids & immunosuppressive therapy) to prevent relapse in high-risk individuals.

S2502 Gastrointestinal Kaposi Sarcoma: A Case Report

Introduction: Kaposi sarcoma (KS) in the gastrointestinal (GI) tract is an uncommon entity specially without any cutaneous manifestation since the introduction of HAART therapy in HIV patients. Most of the gastrointestinal KS, remains undiagnosed as majority of KS is asymptomatic. Here we present a case of GI- KS in a HIV-AIDS patient. Case Description/Methods: A 21-year-old male with history of HIV-AIDS came in for nausea, vomiting and hematochezia for 1 month. Lab showed; total CD4 of 10, elevated ALP 435 U/L, AST, ALT, total and direct bilirubin, lipase was normal. There was periodic increase in ALP hence MRCP was done, which revealed multiple hepatic and intrabiliary lesions. On EGD and colonoscopy, a large infiltrative mass, with recent stigmata of bleeding was found in the duodenum (Figure) to the ileum causing a partial obstruction. The biopsy showed extensive spindle cell proliferation with immunostains positive for HHV8 , ERG which was consistent with Kaposi Sarcoma. A liver biopsy was also done which showed non caseating granuloma with lymphocytic infiltrate with portal ductal proliferation and edema. He underwent ERCP revealing multiple segmental moderate biliary strictures in the common bile duct (CBD), left and right intrahepatic branches. A biliary sphincterotomy and a plastic stent in CBD was performed. He was on HAART therapy and anthracycline based chemotherapy was considered, but the patient passed away due to multiorgan failure from sepsis. Discussion: GI- KS can present as multiple GI symptoms including nausea, vomiting, GI bleeding as in our case or abdominal pain, anemia. (1) However, most of the time gastrointestinal KS remains asymptomatic. (1) Clinician should have high suspicion for GI-KS especially in patients with HIV- AIDS, not in therapy. This will help in the earlier diagnosis and management of GI-KS.Figure 1.: Large infiltrative mass of Kaposi Sarcoma found in duodenum.

S2374 Recurrent Strictures in a Patient With Missed Diagnosis of Eosinophilic Esophagitis

Introduction: EoE is an antigen-mediated inflammatory disorder of the esophagus that affects both children and adults. Diagnosis requires symptoms related to esophageal dysfunction and esophageal biopsy showing >15 eosinophils/hpf is confirmatory for diagnosis. Proton pump inhibitors (PPIs) are considered the first line agents for the treatment of EoE, together with elimination diet and topical corticosteroids. Nonadherence to therapy and undiagnosed disease can increase the risk of fibro-stricturing disease and food impactions. Practicing evidence-based guidelines in diagnosing and managing patients with EoE can allow standardization of care and prevent complications in patients with EoE. Case Description/Methods: A 34-year-old man presented with a longstanding history of intermittent dysphagia to solids. He had an emergent esophagogastroduodenoscopy (EGD) for food impaction about 3 years prior to presentation. No biopsies were obtained at that time, and he was prescribed a short course of PPI before discharge. On current presentation, the patient underwent an EGD which showed multiple untraversable strictures requiring dilation (Figure). Biopsy from multiple sites showed >200 eosinophils/hpf, consistent with a diagnosis of eosinophilic esophagitis (EoE). Thereafter, the patient was initiated on PPIs but had to undergo further dilations for recurrent strictures. Topical steroids were subsequently added to the therapy with satisfactory response. Discussion: Once considered rare, EoE is now a well-known entity, with an estimated prevalence of 51.6/100000 in the US. However, variability and deviations from standard therapy continues to persist among gastroenterologists. According to a national survey conducted in 2020 among 240 gastroenterologists, only 24 % were “very familiar” with the EoE guidelines and only 12 % followed EoE guidelines in their clinical practice. The current case underscores the need to standardize clinical practice related to the care of patients with EoE in order to provide quality and evidence-based care and improve overall outcomes.Figure 1.: EGD showed trachealization of the esophagus.

Diagnostic predicaments in a case of Intestinal obstruction with strictures to distinguish intestinal Koch’s and Crohn’s disease

Intestinal Tuberculosis (Koch’s) has become a very common disease which pose a great diagnostic challenge because of its non- specific presentation and broad-spectrum features and lead to delays in diagnosis along with developments of complications. This 70 years old female patient presented with intestinal obstruction with multiple strictures. It was very tough to distinguish Tuberculosis from Crohn’s Disease in this case as the sections for histology were continuously negative for Acid fast bacilli. This case demonstrates the diagnostic predicaments encountered to arrive at a diagnosis of Intestinal Tuberculosis.

Primary sclerosing cholangitis - an insidious enemy of the liver - case report

Background and introduction
 Primary sclerosing cholangitis (PSC) is a chronic liver disease with features of cholestasis as a result of inflammation and damage to the bile ducts, which can eventually lead to liver fibrosis and parenchymal failure at an advanced stage.
 Case Report
 A 22-year-old man was admitted urgently to the Department of Gastroenterology for complaints of abdominal pain, weakness and tarry stools. A panel of detailed examinations was performed to establish the diagnosis. An abdominal ultrasound scan showed significant enlargement of the liver and spleen. Gastroscopy revealed variceal columns of II degree in the lower esophagus, which were cauterized. Laboratory tests confirmed anemia, reduced platelet and white blood cell counts, increased activity of ALT, ASP, GTP, ALP and slight elevation of total bilirubin in the blood. Based on the clinical disease manifestation and the results of diagnostic tests, cirrhosis of unknown origin was suspected. Subsequent magnetic resonance cholangiopancreatography (MRCP) revealed the presence of multiple strictures in the intra- and extrahepatic bile ducts and gave rise to the diagnosis of PSC. Pharmacological treatment was administered. Currently, the patient remains under the close care of the Transplant Clinic, where he undergoes regular checks of liver function, and endoscopic variceal ligation (EVL) as required.
 Discussion with conclusions
 The case presented here shows that the course of PSC can be insidious and asymptomatic. Despite the absence of clinical symptoms, the disease can lead to the development of advanced cirrhosis even in patients of young age and be diagnosed as late as at the decompensated stage, when the only treatment option remains organ transplantation.

P7.06: Endovascular Thrombectomy in a Chronic Upper Cava Syndrome Due to Long Term Home Parenteral Nutrition. New Hope to Extend Life Support

Introduction: Chronic Intestinal Pseudo Obstruction(CIPO) refers to a heterogeneous group of disorders characterized by symptoms of intestinal obstruction, without evidence of mechanical lesion and is a cause of chronic intestinal failure. Loss of vascular accesses by thrombosis has become the current main indication for intestinal transplant. Materials and Methods: A 28-year-old female patient with a history of myopathic CIPO received Home Parenteral Nutrition(HPN) for 25 years, developing central venous accesses thrombosis. As a consequence of a chronic upper cava syndrome with occlusion of the right jugular and subclavian-axillary vein, an invalidating headache and inability to maintain dorsal decubitus due to retroocular pain evolves overtime, but worsen with HPN infusion, limiting the volume and calories provided. A multidisciplinary case discussion concluded that although chronic, an endovascular thrombectomy should be attempted to improve quality of life and to satisfy nutritional needs. Results: A vascular computer tomography(CT) scan with 3D reconstruction and a digital venography were performed showing complete occlusion of the right jugular, axillary and subclavian(where a picc-line was placed as last access) veins and a partial occlusion of the proximal superior vena cava(SVC) and occlusion of the right iliac vein. An angioplasty trough the right humeral, axillary, innominate trunk axis and superior vena cava using 6 & 9mm balloons was performed. Balloon dilatation of multiple venous strictures was done, followed by placement of two stents, one into the right subclavian vein and SVC, and the other into left subclavian vein, with restitution of venous blood flow. Anticoagulation with Rivaroxaban and Clopidrogel was started. On the 5th postoperative day a new onset of acute pain, paresthesia were reported, followed by edema in the right upper limb. A Doppler ultrasound was positive for an acute thrombosis, confirmed by CT scan. A new phlebography and mechanical thrombectomy using the ASPIREX device followed by a new angioplasty of a partial distal stenosis was done. A new stent implantation into humeral, axillary, and subclavian veins was performed. Outcome was favorable with complete resolution of the symptoms; being discharged on day 6. The patient currently is asymptomatic, receiving HPN without complications. Conclusion: This case is an example of the management of deep venous thrombosis secondary to the chronic use of HPN. A comprehensive multidisciplinary approach is mandatory due to its complexity, requiring to be performed by trained and expert interventionists, to successfully provide new alternatives to extend the possibility for their life support or avoid contraindications to transplant. Peripheral venous hemodynamic is not a common procedure however, is the cornerstone to treat this complication achieving in many cases the recovery of venous blood flow delaying the need of intestinal transplantation.

Imaging features of COVID-19-associated secondary sclerosing cholangitis on magnetic resonance cholangiopancreatography: a retrospective analysis

BackgroundDespite emerging reports of secondary sclerosing cholangitis (SSC) in critically ill COVID-19 patients little is known about its imaging findings. It presents as delayed progressive cholestatic liver injury with risk of progression to cirrhosis. Diagnosis cannot be made based on clinical presentation and laboratory markers alone. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) can aid in the diagnosis. The aim of this study was to describe MRI/MRCP imaging features of COVID-19-associated SSC.ResultsSeventeen patients (mean age 60.5 years, 15 male) who underwent MRI/MRCP were included. All had been admitted to intensive care unit (ICU) (median duration of ICU stay 10 weeks, range, 2–28 weeks) and developed acute respiratory distress syndrome requiring mechanical ventilation. On imaging, all patients had intrahepatic bile duct strictures and 10 (58.8%) had associated upstream dilatation. Intrahepatic bile duct beading was seen in 14 cases (82.3%). Only one patient (5.9%) had extrahepatic bile duct stricturing. Patchy arterial phase hyperenhancement and high signal on T2- and diffusion-weighted images were seen in 7 cases (53.8%) and 9 cases (52.9%), respectively. Biliary casts were seen in 2 cases (11.8%). Periportal lymphadenopathy and vascular complications were not seen.ConclusionOn MRI/MRCP, COVID-19-associated SSC presents with multiple intrahepatic bile duct strictures with or without upstream dilatation and intrahepatic bile duct beading. Surrounding hepatic parenchymal changes including alterations in enhancement and T2 signal are common. The extrahepatic biliary tree was typically spared and periportal lymphadenopathy was missing in all patients.

Multiple Strictures of Small Intestine: Is It Crohn’s Disease?

Question: A previously healthy 43-year-old woman presented with epigastric pain and intermittent postprandial vomiting for 1 year. The patient denied any fever, night sweats, extraintestinal symptoms, and perianal disease. Physical examination was unremarkable. Initial laboratory values were within normal limits except for increased erythrocyte sedimentation rate (46 mm/h) and positive fecal calprotectin. Ileocolonoscopy revealed erosions in the terminal ileum. Biopsy specimens showed unspecific alterations with acute and chronic inflammation. Computed tomography enterography showed circumferential thickening and enhancement of the multiple segmental small intestinal walls, with luminal stricture and enlarged peripheral lymph nodes (Figure A). Subsequent interferon-γ release assay for Mycobacterium tuberculosis was negative and no tuberculous lesions were found on a computed tomography scan of the chest. What is the most likely diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. Owing to the symptoms of mechanical obstruction and diagnostic uncertainty, a decision was made to undertake a surgical approach. Laparoscopy confirmed 8 segments of thickened intestinal wall between 5 and 200 cm proximal to the ileocecal valve, accompanied by numerous white, miliary nodules on the mesenterium and intestinal wall (Video). Focally stenosis was found (Figure B) and partial intestinal resection was obtained followed by end-to-side anastomosis. Macroscopic examination showed a circumferential ulcer (Figure C, arrows). Pathology revealed numerous caseating granulomas throughout intestinal tissue, characterized by confluent granuloma, large granuloma, and granuloma with surrounding cuffing lymphocytes (Figure D). Additionally, the results of acid-fast staining (Figure E, circle) and polymerase chain reaction testing for M tuberculosis were positive. Hence, a firm diagnose of intestinal tuberculosis was made. HIV testing was negative. The patient is on a 1-year course of antituberculosis treatment with good response. Multiple diagnostic models have been developed regarding the differentiation of intestinal tuberculosis from Crohn’s disease.1He Y. Zhu Z. Chen Y. et al.Development and validation of a novel diagnostic nomogram to differentiate between intestinal tuberculosis and Crohn's disease: a 6-year prospective multicenter study.Am J Gastroenterol. 2019; 114: 490-499Crossref PubMed Scopus (33) Google Scholar An interferon-γ release assay is the most commonly used tool. Although this assay has very high specificity (>95%), the sensitivity is only approximately 80%, as in our case.2Pai M. Zwerling A. Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update.Ann Intern Med. 2008; 149: 177-184Crossref PubMed Scopus (1150) Google Scholar Persons with tuberculosis in high incidence countries (like China) often have advanced disease and are likely to be malnourished or infected with HIV. Anergy owing to advanced disease (which may be applicable to our patient), malnutrition, and HIV-associated immune suppression may decrease the sensitivity of interferon-γ release assays. Hence, it is a challenge to make the differential diagnosis between intestinal tuberculosis and Crohn’s disease. Multiple segmental involvement at small intestine, especially with a normal-appearing ileocecal valve are very unusual in intestinal tuberculosis.3Bae J.H. Park S.H. Ye B.D. et al.Development and validation of a novel prediction model for differential diagnosis between Crohn's disease and intestinal tuberculosis.Inflamm Bowel Dis. 2017; 23: 1614-1623Crossref PubMed Scopus (24) Google Scholar It is frequently misdiagnosed as Crohn’s disease preoperatively. As seen in this patient, exploratory abdominal surgery was usually required for the final diagnosis. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI3MmVmM2EzMDEyNjRiZGU1NmI2Y2JmZDZiZGQ5NTliOSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjcwOTExMjExfQ.isWS2Gk2qOguY5qIEWij4OJBJJuDXzRct5FoY4d49ZTUqfOvNyjzd1PuZwASlAVJpvWR_qEgLYpzjYhehlCMN4gTvH8mTzg_UwEDnoLexdCTsH7vGKnT_xuoZGKwhtNfM0gn4I4Egq4qkollG2UzWKHjesnMvmGKA4ConZhyqLtNlvkqdKFhWR5lW_6KLRIGLvHJqjRC6CcZlJyw1eaIBWQIyTRIqRLoQptMipd4z30ZuvX4XeDx6KNv8KIovkFSqXtDAPflPunRAUETprl6ZY0Gsakyh79bWf9_SLhN1jIiQnIqC_4AAE-EolCxqQA-zFICCCfw8QlB48Y4ITISHA Download .mp4 (16.47 MB) Help with .mp4 files Video

Percutaneous Transhepatic Biliary Intervention in Adult Biliary Atresia Patients After Kasai Portoenterostomy.

Kasai portoenterostomy (KP) is a standard treatment for patients with biliary atresia (BA). After KP, patients with BA occasionally develop biliary complications, such as recurrent cholangitis, biliary stricture, and cystic dilatation of the intrahepatic bile duct. Percutaneous transhepatic biliary drainage is one of the treatment options for these biliary complications. However, limited information is available on percutaneous transhepatic biliary drainage performed after KP in adult BA patients with native livers. Herein, we describe 8 cases of percutaneous transhepatic biliary interventions performed after KP in 7 adult BA patients with native livers. Cholangiography showed multiple cystic dilatation of the intrahepatic bile ducts. Advancing a guidewire and catheter was difficult due to the multiple dilatations and strictures of the bile duct. Successful biliary drainage tube placement and clinical improvement was achieved in 5 and 3 cases, respectively. Because of its technical difficulty and limited clinical effectiveness, it is not recommended that it be performed easily.

Systematic review and meta-analysis of MRI features for differentiating autoimmune pancreatitis from pancreatic adenocarcinoma.

To identify reliable MRI features for differentiating autoimmune pancreatitis (AIP) from pancreatic ductal adenocarcinoma (PDAC) and to summarize their diagnostic accuracy. We conducted a systematic literature review and meta-analysis using PubMed, EMBASE, and the Cochrane Library to identify original articles published between January 2006 and July 2021. The pooled diagnostic accuracy, including the diagnostic odds ratios (DORs) with 95% confidence intervals (CIs) of the identified features, was calculated using a bivariate random effects model. Twelve studies were included, and 92 overlapping descriptors were subsumed under 16 MRI features. Ten features favoring AIP were diffuse enlargement (DOR, 75; 95% CI, 9-594), capsule-like rim (DOR, 52; 95% CI, 20-131), multiple main pancreatic duct (MPD) strictures (DOR, 47; 95% CI, 17-129), homogeneous delayed enhancement (DOR, 46; 95% CI, 21-104), low apparent diffusion coefficient value (DOR, 30), speckled enhancement (DOR, 30), multiple pancreatic masses (DOR, 29), tapered narrowing of MPD (DOR, 15), penetrating duct sign (DOR, 14), and delayed enhancement (DOR, 13). Six features favoring PDAC were target type enhancement (DOR, 41; 95% CI, 11-158), discrete pancreatic mass (DOR, 35; 95% CI, 15-80), upstream MPD dilatation (DOR, 13), peripancreatic fat infiltration (DOR, 10), upstream parenchymal atrophy (DOR, 5), and vascular involvement (DOR, 3). This study identified 16 informative MRI features to differentiate AIP from PDAC. Among them, diffuse enlargement, capsule-like rim, multiple MPD strictures, and homogeneous delayed enhancement favored AIP with the highest DORs, whereas discrete mass and target type enhancement favored PDAC. • The MRI features with the highest pooled diagnostic odds ratios (DORs) for autoimmune pancreatitis were diffuse enlargement of the pancreas (75), capsule-like rim (52), multiple strictures of the main pancreatic duct (47), and homogeneous delayed enhancement (46). • The MRI features with the highest pooled DORs for pancreatic ductal adenocarcinoma were target type enhancement (41) and discrete pancreatic mass (35).

Anesthetic effect of ultrasound-guided block of the musculocutaneous nerve during endovascular treatment of dysfunctional radiocephalic arteriovenous fistulas.

Delivering requisite and minimal anesthesia for endovascular treatment (EVT) of dysfunctional arteriovenous fistulas (AVFs) under the target nerve block can achieve reasonable analgesia. We evaluated the anesthetic efficacy of ultrasound (US)-guided selective block of the musculocutaneous nerve (MCN) during the EVT of runoff venous strictures in the forearm through the radiocephalic (RC)-AVF at the wrist or the anatomical snuff box and analyzed the factors inhibiting the analgesia achieved under the MCN block. We enrolled 30 adult patients undergoing hemodialysis who had received 78 EVT sessions in an outpatient clinic mainly for long and/or multiple outflow-venous strictures in the forearm under US-guided blocks of the MCN, which provides sensory innervation to the anterolateral forearm where the cephalic vein courses. We assessed patients' pain during balloon dilations using the Wong-Baker FACES® Pain Rating Scale (WBFRS) and evaluated the factors increasing the pain (WBFRS score ⩾4), including patient characteristics, dilated strictures, additional nerve blocks, and types of balloon catheters. In 25 EVT sessions (32.1%) out of 78 sessions, patients complained of stronger pain (WBFRS score ⩾4), while in the other 53 sessions (67.9%), presented with no pain and slight pain (WBFRS score = 0 or 2). Univariate analysis clarified that dilation of the AVF anastomosis, presence of dilated stenosis >4 cm, and a single block of the MCN or its sensory terminal significantly triggered more pain (p < 0.05). Consequently, multivariate analysis of all the factors with p < 0.1 in the univariate analysis, including multiple dilated stenosis sites, demonstrated that dilation of the AVF anastomosis significantly caused severe pain despite the anesthesia of the MCN block (p < 0.05). US-guided selective block of the MCN could be a leading anesthetic option for EVT for multiple long stenoses of the cephalic vein draining through the RC-AVF in the wrist or anatomical snuff box.

The surgical outcomes of reconstruction for the treatment of ureteral stricture after holmium laser lithotripsy: The comprehensive experiences

ObjectiveTo analyze the characteristics of ureteral stricture after ureteroscopic holmium laser lithotripsy and summarize our experience with the reconstructive strategies. MethodsThis study retrospectively reviewed 42 patients with ureteral stricture after ureteroscopic holmium laser lithotripsy between December 2009 and December 2019. Patient demographics, laboratory data, imaging studies, perioperative variables, complications, and follow-up data were recorded. Surgical success was defined as relief of symptoms, improved/stabilized hydronephrosis, and stable renal function. ResultsThe upper, middle, and lower thirds of the ureter were affected in 27, 6, and 7 cases, respectively. Multiple ureteral strictures were found in 2 patients. The median length of the stricture was 3.5 cm (range 1–30 cm). In the upper ureteral strictures, lingual mucosal ureteroplasty (8/27, 29.6%) is the most commonly used treatment method for stricture longer than 3 cm but shorter than 6 cm, followed by appendiceal onlay ureteroplasty (5/27, 18.5%). Four lower ureteral strictures ranging from 3 to 8 cm were repaired with Boari flap. Reconstructive strategies of the middle ureteral strictures included Boari flap, appendiceal onlay ureteroplasty and ureteroureterostomy. Patients with the length of the stricture longer than 8 cm or multiple strictures underwent ileal ureter replacement. The median follow-up was 27.3 ± 17.2 months. The overall success rate was 97.6%. ConclusionUpper ureter is more vulnerable in ureteroscopic holmium laser lithotripsy. Sufficient follow-up and appropriate examination are necessary for diagnosis. Different treatment strategies need to be flexibly selected according to the location and length of the injury.

Efficacy and tolerability of hyperbaric oxygen therapy in small bowel stricturing Crohn's disease: a pilot study.

Background/AimsExisting therapeutic options for complicated Crohn’s disease (CD) like biologics and surgery are limited by inadequate long-term efficacy, cost, and adverse effects. Tissue hypoxia is important in CD pathogenesis and may be ameliorated with hyperbaric oxygen therapy (HBOT). We assessed the efficacy and tolerability of HBOT in small bowel stricturing CD.MethodsThis pilot study included patients of small bowel stricturing CD (from April 2019 to January 2020) who underwent HBOT. These patients were refractory to conventional medical treatment or had multiple strictures not amenable to resection. Each session of HBOT was given for 60 minutes with a pressure of 1.5–2.5 atm. Clinical, biochemical responses and Short Inflammatory Bowel Disease (SIBD) questionnaire were evaluated at 2 and 6 months, and radiological response was evaluated at 6 months.ResultsFourteen patients (mean age, 42.9±15.7 years; male, 50%) were subjected to 168 HBOT sessions. Thirteen patients (92.7%) had strictures and 1 patient had enterocutaneous fistula in addition. Median number of HBOT sessions was 11 (range, 3–20) which were administered over a median of 4 weeks. Most patients tolerated it well except 1 who had hemotympanum. At 2 and 6 months of follow-up, 64.2% of patients had a clinical response, 50% and 64.2% of patients had clinical remission respectively. Steroid-free clinical remission was seen in 8 (57%) of patients with radiological improvement in 50%. There was a significant improvement in SIBD scores at 2-month follow-up (59.4 vs. 44.5, P=0.03).ConclusionsHBOT can be a safe and effective therapeutic option in patients with stricturing small bowel CD refractory to conventional medical treatment.

Percutaneous transhepatic treatment for biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation: a 9-year single-center experience.

To investigate clinical outcomes of percutaneous transhepatic treatment for biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation (LDLT). This retrospective study examined baseline characteristics, procedural details, clinical outcomes, drainage catheter removal rate within 8 months, and recurrence after catheter removal using patients' medical records and images. Risk factors for failure of drainage catheter removal within 8 months and recurrence of biliary stricture after drainage catheter removal were assessed via univariable and multivariable analyses. A total of 112 patients (53.4 ± 8.79 years, 91 men) were evaluated. Multiple drainage catheters were placed in 75 patients (70.0%). Drainage catheters were successfully removed in 107 patients (95.5%). Failure of drainage catheter removal within 8 months was associated with hepatic artery complications (p= 0.034) and strictures requiring alternative passage techniques (p= 0.034). The cumulative primary patency rates after drainage catheter removal at 1, 2, 3, and 5 years were 85.4%, 79.8%, 75.8%, and 68.4%, respectively. Recurrence of biliary stricture was associated with the presence of an untreated isolated sectoral duct (aHR, 3.632; 95% CI, 1.086-12.150, p= 0.037) and with concurrent bile leaks (aHR, 2.475; 95% CI, 1.090-5.621, p= 0.031). Percutaneous transhepatic treatment was effective for the treatment of biliary strictures after duct-to-duct biliary anastomosis in LDLT. Multiple drainage catheter maintenance was needed because multiple strictures often occurred in these patients. • Percutaneous transhepatic treatments are useful and effective for the treatment of biliary stricture after duct-to-duct biliary anastomosis in living donor liver transplantation (LDLT), although an endoscopic approach is available for this type of reconstruction. • Multiple drainage catheters were frequently placed in these patients because of multiple complex strictures. • We found that recurrence after drainage catheter removal was associated with isolation of the sectoral duct and with concurrent bile leaks.

Critical Illness Cholangiopathy in COVID-19 Long-haulers

Critical Illness Cholangiopathy in COVID-19 Long-haulers

'Short' pancreaticojejunostomy might be a valid option for treatment of chronic pancreatitis in many cases.

BACKGROUNDThe Partington-Rochelle pancreaticojejunostomy (PJ) is an essential management option for patients with chronic pancreatitis (CP) associated with intractable pain and a dilated pancreatic duct (PD). Wide ductotomy and long PJ (L-PJ) have been advocated as the standard of care to ensure full PD decompression. However, the role of short PJ (S-PJ) in a uniformly dilated PD has not yet been evaluated.AIMTo evaluate the possible advantages and disadvantages of S-PJ and L-PJ and to interpret the perspective of S-PJ in the treatment of CP.METHODSA retrospective review of prospectively collected cohort data was conducted on surgically treated CP patients subjected to side-to-side PJ. The length of the PJ was adapted to anatomical alterations in PD. A comparison was made of S-PJ (< 50 mm) for uniformly dilated PD and L-PJ (50-100 mm) in the setting of multiple PD strictures, calcifications and dilatations. We hypothesized that S-PJ and L-PJ ensure comparable clinical outcomes. The primary outcomes were pain relief and quality of life (QOL); the secondary outcomes were perioperative characteristics, body weight, patients’ satisfaction with treatment, and readmission rate due to CP.RESULTSOverall, 91 patients underwent side-to-side PJ for CP, including S-PJ in 46 patients and L-PJ in 45 patients. S-PJ resulted in better perioperative outcomes: Significantly shorter operative time (107.5 min vs 134 min), lower need for intraoperative (0% vs 15.6%) and total (2.2% vs 31.1%) blood transfusions, and lower rate of perioperative complications (6.5% vs 17.8%). We noted no significant difference in pain relief, improvement in QOL, body weight gain, patients’ satisfaction with surgical treatment, or readmission rate due to CP.CONCLUSIONBased on our data, in the setting of a uniformly dilated PD, S-PJ provides adequate decompression of the PD. As the clinical outcomes following S-PJ are not inferior to those of L-PJ, S-PJ should be preferred as a surgical option in the case of a uniformly dilated PD.