Gastrointestinal Tract

Prevention of severe post-ERCP pancreatitis? It is possible.

Alexey G. Korotkevich — 2024-06-28

Background and Objectives: The main issue of post-endoscopy pancreatitis (PEP) prevention remains an urgent and still an un-solved problem. Despite the relatively low incidence of severe pancreatitis development, treatment costs and mortality rates remain unreasonably high. The purpose of this article is to evaluate the author’s technique for preventing severe PEP progression based on their personal experience. Methods: The study was conducted in a double-centered randomized setting in 836 patients with pancreatobiliary pathology who underwent endoscopic retrograde cholangiopancreatography (ERCP) and/or endoscopic papillosphincterotomy (EPST) from 2016 to 2023. All patients were divided into 4 groups. Group 1 (341 patients) received conventional therapy consisting of medications and the use of a guidewire. Group 2 (100 patients) received a submucosal 10 ml saline injection postbulbar blockade (PBB) (“fake”) in addition to standard premedication. Standard premedication and one “true” PBB with lidocaine or procaine were given to Group 3 (252 patients) upon the completion of the interventions. Group 4 consisted of 143 patients who were given standard premedication and a “true” double PBB (DPBB)—before and after the manipulation itself. Results: The evaluation of PBB’s effectiveness was improved through the development of the DPBB technique. DPBB’s effectiveness in PEP prophylaxis was demonstrated through the absence of severe PEP cases. The benefits of PBB and DPBB were not only rapid pain relief, but also prevention of post-papillotomy bleeding. Regardless of the method used for PEP prophylaxis, hyperamylasemia regression was longer with the use of plastic stents. The average admission period for patients after DPBB was 11.3 ± 1.2 days, which was significantly shorter than in other groups. Conclusion: DPBB was proven to be the most straightforward, simple, and effective technique for severe PEP prophylaxis in comparison with PBB and conventional methods.

Multi-modal conservative management of intra-abdominal collections in fistulising Crohn’s disease

Mohammad Shir Ali — 2024-02-22

Background and Objectives: The management of intra-abdominal collections in fistulising Crohn’s disease (CD) has traditionally involved surgery. However, conservative management is a potential alternative. In this study, we report our experience with multi-modal conservative management of intra-abdominal collections secondary to perforating CD. Methods: Medical records of CD patients with a history of intra-abdominal collections or fistulas over the past five years were reviewed retrospectively. Patients were included if they were initially managed conservatively using any combination of antibiotics, exclusive enteral nutrition (EEN), percutaneous drainage of collections, endoscopic dilatation of associated strictures and medical therapy for IBD with steroids, immunomodulators and/or biologics. Results: Eleven participants were included. All participants had penetrating CD affecting the terminal ileum. Nine participants had intra-abdominal collection on cross-sectional imaging whilst the remaining two participants had fistulising disease and sepsis without a discrete collection. Eight participants completed a 6–8 weeks course of EEN. All participants were treated with antibiotics and a thiopurine. Steroids were used in eight participants and biological agents in six. Six participants underwent endoscopic dilatation of small bowel strictures. After a median follow up of 20 months [range: 3–210] nine participants had evidence of adequate clinical, biochemical, radiological and endoscopic improvement. Complete resolution of abscess was seen in 4/7 participants and a significant reduction in abscess size was seen in 2/7. Two participants had complete endoscopic and histological remission and complete resolution of abscess. Both participants with fistulising disease (without a collection) had evidence of healed fistula tract on progress imaging and endoscopy. Two participants underwent surgery after failure of initial conservative management. Conclusion: Intra-abdominal collections in fistulising CD can be managed successfully in appropriately selected patients using a multi-modal approach incorporating antibiotics, EEN, endoscopic dilatations of culprit strictures and optimised medical management using steroids (for induction of remission), immunomodulators and biologics.

Safety outcomes of low versus high dose imatinib mesylate in patients with advanced, metastatic, or nonresectable gastrointestinal stromal tumors: A systematic review

Marena A. Marucci — 2024-03-12

Background and Objectives: Gastrointestinal stromal tumors (GIST) are a rare cancer where tumors grow along the gastrointestinal tract. While treatment options aim towards surgical resection, some patients present with advanced metastatic and/or nonresectable diseases. The tyrosine kinase inhibitor imatinib mesylate is approved for this indication. However, dose escalation from 400 to 600 mg/d or 800 mg/d is allowed. The present study systematically evaluates the safety outcomes, particularly the incidence of grade ≥ 3 adverse events (AEs) with low dose compared with high dose imatinib in these patients. Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines were utilized to identify relevant studies through the PubMed, Cochrane Library, and Ovid databases and included randomized and non-randomized clinical trials comparing a low dose intervention of imatinib 400 mg/d with a high dose comparator of 600 or 800 mg/d in patients with histologically confirmed advanced metastatic and/or nonresectable GIST. Four studies were reviewed regarding study summaries and patient characteristics, patient demographics, and risk of bias, with a main emphasis on the evaluation of both efficacy outcomes and safety outcomes. Results: Three of the four studies did not provide significant differences in response outcomes; however, all four studies reported a higher incidence of grade ≥ 3 AEs in the high dose imatinib groups. Individual study reports of more high dose patients experiencing a grade ≥ 3 event ranged from 0.6% to 19.8%, while combined low and high dose patient arms revealed a 17.1% difference favoring a high dose patient event. A sub-analysis of the three most frequently occurring categories, blood and lymphatic system disorders, gastrointestinal disorders, and general disorders and administration site conditions each revealed more high dose patients experiencing said category events compared to those low dose counterparts. Conclusion: Low dose imatinib provides clinically meaningful response and demonstrated better tolerability with less frequently reported reactions. This evidence supports further research into the maintenance of 400 mg/d for this patient population compared to a dose
escalation.

Liver Transplantation in a Stage IV Malignancy; A new norm

Rehmat U. Awan — 2024-05-14

Adult intussusception secondary to intestinal tuberculosis: A case report

Saima Shabir — 2024-06-28

Adult intussusception is a rare disorder that accounts for only 1% of intestinal obstruction and 3%–5% of all intussusceptions. The classical triad of intussusception includes abdominal pain, bleeding per rectum, and palpable mass. The underlying causes of gut telescoping include gallstone ileus, acute leukemia after consolidation chemotherapy, immunocompromised status, and intestinal tuberculosis. Management involves laparotomy or laparoscopic reduction, along with treatment of the underlying cause. We present the case of a 35-year-old-female who presented with a complaint of absolute constipation for three days. Physical examination revealed tender abdomen with sluggish bowel sounds. Abdominal ultrasound showed ileocolic intussusception as the cause. Consequently, the patient underwent right hemicolectomy with ileostomy. Further workup confirmed intestinal tuberculosis as the causative factor, and antituberculosis therapy (ATT) was initiated. Intestinal tuberculosis can lead to intussusception and should be considered in adult patients presenting with abdominal pain, palpable masses, and bloody stool. Such patients require postoperative anti-tuberculosis therapy to cure the underlying tuberculosis.

Right-side shift of colorectal cancer in Trinidad and Tobago: A change in distribution

Shamir O. Cawich — 2024-05-10

Background and Objectives: Previously published epidemiologic data from Trinidad and Tobago suggested that left-sided colorectal cancer (CRC) was more common, but accepted, standardized definitions for CRC laterality were not used. This study aims to collect data from patients with CRC in Trinidad & Tobago in order to determine anatomic site using standardized definitions. Methods: A retrospective audit of hospital records was carried out for all patients with CRC over a 10-year period from January 1, 2011 to January 30, 2021. Standardized definitions were used to classify CRC laterality: Right-sided CRC was defined as those that arose in the cecum, ascending colon, hepatic flexure and/or transverse colon. Left-sided primaries were defined as those that originated from the splenic flexure, descending colon and/or sigmoid colon. The following data were extracted: laterality, gender, age and ethnicity. Descriptive statistical analyses were generated with SPSS version 21. Results: The records of 326 patients with CRC were examined in this study. There was a predominance of right-sided (43%) over left sided primaries. There was a statistically significant relationship between right sided CRC and female (58.2% vs. 41.8%; P = 0.00168), black ethnicity (60.2% vs. 38.6%; P = 0.0076) and younger age (60.9 vs. 65.9 years; P = 0.00028). Conclusion: There is a predominance of right-sided CRC in this eastern Caribbean nation, significantly associated with younger, female and black population.