BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from c...BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from centers or analysis of large databases.Although a meta-analysis has shown fewer adverse events as a composite(bleeding,pancreatitis,Perf)during ERCP performed at high-volume centers,there is very little real-world data on endoscopist and center procedural volumes,ERCP duration and complexity on the occurrence of Perf.AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume,ERCP time,and complexity from a national endoscopic repository.Patients from clinical outcomes research initiative-national endoscopic database(2000-2012)who underwent ERCP were stratified based on the endoscopist and center volume(quartiles),and total procedure duration and complexity grade of the ERCP based on procedure details.The effects of these variables on the Perf that occurred were studied.Continuous variables were compared between Perf and no perforations(NoPerf)using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.RESULTS A total of 14153 ERCPs were performed by 258 endoscopists,with 20 reported Perf(0.14%)among 16 endoscopists.Mean patient age in years 61.6±14.8 vs 58.1±18.8(Perf vs.NoPerf,P=NS).The cannulation rate was 100%and 91.5%for Perf and NoPerf groups,respectively.13/20(65%)of endoscopists were high-volume performers in the 4th quartile,and 11/20(55%)of Perf occurred in centers with the highest volumes(4th quartile).Total procedure duration in minutes was 60.1±29.9 vs 40.33±23.5(Perf vs NoPerf,P<0.001).Fluoroscopy duration in minutes was 3.3±2.3 vs 3.3±2.6(Perf vs NoPerf P=NS).50%of the procedures were complex and greater than grade 1 difficulty.3/20(15%)patients had prior biliary surgery.13/20(65%)had sphincterotomies performed with stent insertion.Peritonitis occurred in only 1/20(0.5%).CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers.However,Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.展开更多
AIM:To conduct a systemic review and meta-analysis to investigate the role of early precut technique.Multiple randomized controlled trails(RCTs)have reported conflicting results of the early precut sphincterotomy.METH...AIM:To conduct a systemic review and meta-analysis to investigate the role of early precut technique.Multiple randomized controlled trails(RCTs)have reported conflicting results of the early precut sphincterotomy.METHODS:MEDLINE/PubMed,EMBASE,Cochrane Central Register of Controlled Trials and Database of Systematic Reviews,and recent abstracts from major conference proceedings were searched(June 2013).Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included.Pooled estimates of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP),cannulation and adverse events were analyzed by using odds ratio(OR).Random and fixed effects models were used as appropriate.Publication bias was assessed by funnel plots.Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.RESULTS:Seven randomized and seven non-randomized trials met inclusion criteria.Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant(OR=0.58;95%CI:0.32-1.05;P=0.07).No heterogeneity was noted among the studies with I2 of 0%.CONCLUSION:Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.展开更多
Hepatocellular carcinoma(HCC) is the most common primary liver malignancy. The incidence of hepatocellular carcinoma has increased dramatically by 80% over the past two decades in the United States. Numerous basic sci...Hepatocellular carcinoma(HCC) is the most common primary liver malignancy. The incidence of hepatocellular carcinoma has increased dramatically by 80% over the past two decades in the United States. Numerous basic science and clinical studies have documented a strong association between hepatocellular carcinoma and the metabolic syndrome. These studies have documented that, in most patients, non-alcoholic fatty liver disease is the hepatic manifestation of the metabolic syndrome, which may progress to hepatocellular carcinoma through the cirrhotic process. However, minority of patients with non-alcoholic fatty liver disease may progress to hepatocellular carcinoma without cirrhosis.This review summarizes the current literature of the link between hepatocellular carcinoma and metabolic syndrome with special emphasis on various components of the metabolic syndrome including risk of association with obesity, diabetes mellitus, hyperlipidemia,and hypertension. Current understanding of pathophysiology, clinical features, treatments, outcomes,and surveillance of hepatocellular carcinoma in the background of metabolic syndrome and non-alcoholic fatty liver disease is reviewed. With the current epidemic of metabolic syndrome, the number of patients with non-alcoholic fatty liver disease is increasing.Subsequently, it is expected that the incidence and prevalence of HCC will also increase. It is very important for the scientific community to shed more light on the pathogenesis of HCC with metabolic syndrome,both with and without cirrhosis. At the same time it is also important to quantify the risk of hepatocellular carcinoma associated with the metabolic syndrome in a prospective setting and develop surveillance recommendations for detection of hepatocellular carcinoma in patients with metabolic syndrome.展开更多
Esophageal carcinoma affects more than 450000people worldwide and the incidence is rapidly increasing.In the United States and Europe,esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its ...Esophageal carcinoma affects more than 450000people worldwide and the incidence is rapidly increasing.In the United States and Europe,esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence.Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages.Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett’s esophagus.These risk factors include chronic gastroesophageal reflux disease,hiatal hernia,advanced age,male sex,white race,cigarette smoking,and obesity.The annual risk of esophageal cancer is approximately 0.25%for patients without dysplasia and 6%for patients with high-grade dysplasia.Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa.The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option.The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia.Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation,photodynamic therapy and cryoablation.Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion.Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor,positive lymph node and submucosal invasion.Surgical resection should be offered to patients with deep submucosal invasion.展开更多
Gangliocytic paraganglioma is a rare neuroendocrine tumor predominantly arising in the second part of the duodenum with rare local recurrence or metastasis to regional lymph nodes.A 92-year-old female presented with o...Gangliocytic paraganglioma is a rare neuroendocrine tumor predominantly arising in the second part of the duodenum with rare local recurrence or metastasis to regional lymph nodes.A 92-year-old female presented with obstructive jaundice.On exam she had pale conjunctiva and icteric sclera.Abdominal examination revealed tenderness in the upper abdomen.Laboratory data was consistent with obstructive jaundice.Computed tomography of the abdomen revealed a dilated gall bladder and a common bile duct(CBD)with no evidence of liver lesions or pancreatic head mass.Endoscopic ultrasonography revealed a 1 cm isoechoic submucosal nodule at the periampullary area,dilated CBD(9 mm),a prominent pancreatic duct(4.1 mm)and a hydropic gall bladder with no stones.Endoscopic retrograde cholangiopancreaticography was performed to relieve obstruction and showed a 1 cm periampullary mass which underwent an en-bloc snare resection.Histopathology analyses with immunohistochemical stains were positive for cytokeratin,synaptophysin,S-100 protein,neuron specific enolase and negative for actin and desmin consistent with periampullary gangliocytic paraganglioma.Periampullary gangliocytic paraganglioma is a rare benign tumor of the small bowel.Common presentation includes abdominal pain and obstructive jaundice which should be included in differential diagnosis of obstructive jaundice.Endoscopic resection is a curative therapy in the absence of local invasion or distant metastasis.展开更多
Originating from Wuhan in China,coronavirus disease 2019(COVID-19)spread globally within months and was declared a pandemic by World Health Organization in March 2020,making it one of the biggest healthcare calamities...Originating from Wuhan in China,coronavirus disease 2019(COVID-19)spread globally within months and was declared a pandemic by World Health Organization in March 2020,making it one of the biggest healthcare calamities of our time.As more data on COVID-19 infection became available,what was initially thought to be a simple respiratory illness was found to be more complex.Many extra-pulmonary manifestations are now frequently reported for COVID-19 in available literature,most commonly gastrointestinal and hepatopancreatobiliary manifestations.Due to early scarcity of data,extra pulmonary manifestations were initially overlooked and may have contributed to nosocomial spread of the infection.Practitioners,especially gastroenterologists,who frequently encounter patients with these symptoms,need to be aware of them.This can not only help minimize the nosocomial spread,ensure safety of provider but also help conserve already stretched-thin healthcare resources.A tremendous amount of COVID-19 related literature is getting added to the growing pool every day,making it difficult for providers to follow.The aim of our review is to summarize the available evidence for gastrointestinal and hepatopancreatobiliary manifestations of COVID-19.We here briefly discussed the possible pathophysiologic mechanism for these manifestations and summarized the recommendations put forward by multiple gastrointestinal societies regarding safe and effective clinical practice during the ongoing pandemic.展开更多
Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and the...Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and their infants.Few challenges arise in reaching an accurate diagnosis in light of such physiological changes.Laboratory test results should be carefully interpreted and the knowledge of what normal changes to expect is prudent to avoid clinical misjudgment.Other challenges entail the methods of treatment and their safety for both the mother and the baby.This review summarizes liver diseases that are not unique to pregnancy.We focus on viral hepatitis and its mode of transmission,diagnosis,effect on the pregnancy,the mother,the infant,treatment,and breast-feeding.Autoimmune hepatitis,primary biliary cirrhosis,primary sclerosing cholangitis,Wilson’s disease,Budd Chiari and portal vein thrombosis in pregnancy are also discussed.Pregnancy is rare in patients with cirrhosis because of the metabolic and hormonal changes associated with cirrhosis.Variceal bleeding can happen in up to 38%of cirrhotic pregnant women.Management of portal hypertension during pregnancy is discussed.Pregnancy increases the pathogenicity leading to an increase in the rate of gallstones.We discuss some of the interventions for gallstones in pregnancy if symptoms arise.Finally,we provide an overview of some of the options in managing hepatic adenomas and hepatocellular carcinoma during pregnancy.展开更多
Endoscopic ultrasound(EUS) has revolutionized the diagnostic and therapeutic approach to patients with gastrointestinal disorders. Its application in patients with liver disease and portal hypertension is increasing. ...Endoscopic ultrasound(EUS) has revolutionized the diagnostic and therapeutic approach to patients with gastrointestinal disorders. Its application in patients with liver disease and portal hypertension is increasing. Patients with chronic liver disease are at risk for development of portal hypertension sequale such as ascites, spontaneous bacterial peritonitis and gastroesophageal varices. Bleeding esophageal and gastric varices are among the most common causes of mortality in patients with cirrhosis. Thus, early detection and treatment improve the outcome in this population. EUS can improve the detection and diagnosis of gastroesophageal varices and collateral veins and can provide endoscopic therapy of gastroesophageal varices such as EUS-guided sclerotherapy of esophageal collateral vessels and EUS-guided cynoacrylate(Glue) injection of gastric varices. EUS can also provide knowledge on the efficacy of pharmacotherapy of portal hypertension. Furthermore, EUS can provide assessment and prediction of variceal recurrence after endoscopic therapy and assessment of portal hemodynamics such as E-Flow and Doppler study of the azygous and portal veins. Moreover, EUS-guided fine needle aspiration may provide cytologic diagnosis of focal hepatic tumors andanalysis of free abdominal fluid.Using specialized EUSguided needle biopsy,a sample of liver tissue can be obtained to diagnose and evaluate for chronic liver disease.EUS-guided fine needle injection can be used to study portal vein pressure and hemodynamics,and potentially could be used to assist in exact measurement of portal vein pressure and placement of intrahepatic portosystemic shunt.展开更多
Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and the...Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and their infants.This review summarizes liver diseases that are unique to pregnancy.We discuss clinical conditions that are seen only in pregnant women and involve the liver;from Hyperemesis Gravidarum that happens in 1out of 200 pregnancies and Intrahepatic Cholestasis of Pregnancy(0.5%-1.5%prevalence),to the more frequent condition of preeclampsia(10%prevalence)and its severe form;hemolysis,elevated liver enzymes,and a low platelet count syndrome(12%of pregnancies with preeclampsia),to the rare entity of Acute Fatty Liver of Pregnancy(incidence of 1 per 7270 to 13000deliveries).Although pathogeneses behind the development of these aliments are not fully understood,theories have been proposed.Some propose the special physiological changes that accompany pregnancy as a precipitant.Others suggest a constellation of factors including both the mother and her fetus that come together to trigger those unique conditions.Reaching a timely and accurate diagnosis of such conditions can be challenging.The timing of the condition in relation toward which trimester it starts at is a key.Accurate diagnosis can be made using specific clinical findings and blood tests.Some entities have well-defined criteria that help not only in making the diagnosis,but also in classifying the disease according to its severity.Management of these conditions range from simple medical remedies to measures such as immediate termination of the pregnancy.In specific conditions,it is prudent to have expert obstetric and medical specialists teaming up to help improve the outcomes.展开更多
Endoscopic ultrasound(EUS)-guided fine needle aspira-tion(FNA) of the liver is a safe procedure in the diag-nosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for...Endoscopic ultrasound(EUS)-guided fine needle aspira-tion(FNA) of the liver is a safe procedure in the diag-nosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modali-ties of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the con-ventional endoscopic brushing and biopsy.展开更多
Pregnancy in patients with advanced liver disease is uncommon as most women with decompensated cirrhosis are infertile and have high rate of anovulation.However,if gestation ensued;it is very challenging and carries h...Pregnancy in patients with advanced liver disease is uncommon as most women with decompensated cirrhosis are infertile and have high rate of anovulation.However,if gestation ensued;it is very challenging and carries high risks for both the mother and the baby such as higher rates of spontaneous abortion,prematurity,pulmonary hypertension,splenic artery aneurysm rupture,postpartum hemorrhage,and a potential for life-threatening variceal hemorrhage and hepatic decompensation.In contrary,with orthotopic liver transplantation,menstruation resumes and most women of childbearing age are able to conceive,give birth and lead a better quality of life.Women with orthotopic liver transplantation seeking pregnancy should be managed carefully by a team consultation with transplant hepatologist,maternal-fetal medicine specialist and other specialists.Pregnant liver transplant recipients need to stay on immunosuppression medication to prevent allograft rejection.Furthermore,these medications need to be monitored carefully and continued throughout pregnancy to avoid potential adverse effects to mother and baby.Thus delaying pregnancy 1 to 2 years after transplantation minimizes fetal exposure to high doses of immunosuppressants.Pregnant female liver transplant patients have a high rate of cesarean delivery likely due to the high rate of prematurity in this population.Recent reports suggest that with close monitoring and multidisciplinary team approach,most female liver transplant recipient of childbearing age will lead a successful pregnancy.展开更多
The application of artificial intelligence(AI)using deep learning and machine learning approaches in modern medicine is rapidly expanding.Within the field of Gastroenterology,AI is being evaluated across a breadth of ...The application of artificial intelligence(AI)using deep learning and machine learning approaches in modern medicine is rapidly expanding.Within the field of Gastroenterology,AI is being evaluated across a breadth of clinical and diagnostic applications including identification of pathology,differentiation of disease processes,and even automated procedure report generation.Many pancreatic pathologies can have overlapping features creating a diagnostic dilemma that provides a window for AI-assisted improvement in current evaluation and diagnosis,particularly using endoscopic ultrasound.This topic highlight will review the basics of AI,history of AI in gastrointestinal endoscopy,and prospects for AI in the evaluation of autoimmune pancreatitis,pancreatic ductal adenocarcinoma,chronic pancreatitis and intraductal papillary mucinous neoplasm.展开更多
文摘BACKGROUND Perforations(Perf)during endoscopic retrograde cholangiopancreatography(ERCP)are rare(<1%)but potentially fatal events(up to 20%mortality).Given its rarity,most data is through case series studies from centers or analysis of large databases.Although a meta-analysis has shown fewer adverse events as a composite(bleeding,pancreatitis,Perf)during ERCP performed at high-volume centers,there is very little real-world data on endoscopist and center procedural volumes,ERCP duration and complexity on the occurrence of Perf.AIM To study the profile of Perf related to ERCP by center and endoscopist procedure volume,ERCP time,and complexity from a national endoscopic repository.Patients from clinical outcomes research initiative-national endoscopic database(2000-2012)who underwent ERCP were stratified based on the endoscopist and center volume(quartiles),and total procedure duration and complexity grade of the ERCP based on procedure details.The effects of these variables on the Perf that occurred were studied.Continuous variables were compared between Perf and no perforations(NoPerf)using the Mann-Whitney U test as the data demonstrated significant skewness and kurtosis.RESULTS A total of 14153 ERCPs were performed by 258 endoscopists,with 20 reported Perf(0.14%)among 16 endoscopists.Mean patient age in years 61.6±14.8 vs 58.1±18.8(Perf vs.NoPerf,P=NS).The cannulation rate was 100%and 91.5%for Perf and NoPerf groups,respectively.13/20(65%)of endoscopists were high-volume performers in the 4th quartile,and 11/20(55%)of Perf occurred in centers with the highest volumes(4th quartile).Total procedure duration in minutes was 60.1±29.9 vs 40.33±23.5(Perf vs NoPerf,P<0.001).Fluoroscopy duration in minutes was 3.3±2.3 vs 3.3±2.6(Perf vs NoPerf P=NS).50%of the procedures were complex and greater than grade 1 difficulty.3/20(15%)patients had prior biliary surgery.13/20(65%)had sphincterotomies performed with stent insertion.Peritonitis occurred in only 1/20(0.5%).CONCLUSION Overall adverse events as a composite during ERCP are known to occur at a lower rate with higher volume endoscopists and centers.However,Perf studied from the national database show prolonged and more complex procedures performed by high-volume endoscopists at high-volume centers contribute to Perf.
文摘AIM:To conduct a systemic review and meta-analysis to investigate the role of early precut technique.Multiple randomized controlled trails(RCTs)have reported conflicting results of the early precut sphincterotomy.METHODS:MEDLINE/PubMed,EMBASE,Cochrane Central Register of Controlled Trials and Database of Systematic Reviews,and recent abstracts from major conference proceedings were searched(June 2013).Randomized and non-randomized studies comparing early precut technique with prolonged standard methods were included.Pooled estimates of post-endoscopic retrograde cholangiopancreatography(ERCP)pancreatitis(PEP),cannulation and adverse events were analyzed by using odds ratio(OR).Random and fixed effects models were used as appropriate.Publication bias was assessed by funnel plots.Heterogeneity among studies was assessed by calculating I2 measure of inconsistency.RESULTS:Seven randomized and seven non-randomized trials met inclusion criteria.Meta-analysis of RCTs showed a decrease trend for PEP with early precut sphincterotomy but was not statistically significant(OR=0.58;95%CI:0.32-1.05;P=0.07).No heterogeneity was noted among the studies with I2 of 0%.CONCLUSION:Early precut technique for common bile duct cannulation decreases the trend of post-ERCP pancreatitis.
基金Supported by Raymond E and Vaona H Peck Chair in Cancer Research
文摘Hepatocellular carcinoma(HCC) is the most common primary liver malignancy. The incidence of hepatocellular carcinoma has increased dramatically by 80% over the past two decades in the United States. Numerous basic science and clinical studies have documented a strong association between hepatocellular carcinoma and the metabolic syndrome. These studies have documented that, in most patients, non-alcoholic fatty liver disease is the hepatic manifestation of the metabolic syndrome, which may progress to hepatocellular carcinoma through the cirrhotic process. However, minority of patients with non-alcoholic fatty liver disease may progress to hepatocellular carcinoma without cirrhosis.This review summarizes the current literature of the link between hepatocellular carcinoma and metabolic syndrome with special emphasis on various components of the metabolic syndrome including risk of association with obesity, diabetes mellitus, hyperlipidemia,and hypertension. Current understanding of pathophysiology, clinical features, treatments, outcomes,and surveillance of hepatocellular carcinoma in the background of metabolic syndrome and non-alcoholic fatty liver disease is reviewed. With the current epidemic of metabolic syndrome, the number of patients with non-alcoholic fatty liver disease is increasing.Subsequently, it is expected that the incidence and prevalence of HCC will also increase. It is very important for the scientific community to shed more light on the pathogenesis of HCC with metabolic syndrome,both with and without cirrhosis. At the same time it is also important to quantify the risk of hepatocellular carcinoma associated with the metabolic syndrome in a prospective setting and develop surveillance recommendations for detection of hepatocellular carcinoma in patients with metabolic syndrome.
文摘Esophageal carcinoma affects more than 450000people worldwide and the incidence is rapidly increasing.In the United States and Europe,esophageal adenocarcinoma has superseded esophageal squamous cell carcinoma in its incidence.Esophageal cancer has a high mortality rates secondary to the late presentation of most patients at advanced stages.Endoscopic screening is recommended for patients with multiple risk factors for cancer in Barrett’s esophagus.These risk factors include chronic gastroesophageal reflux disease,hiatal hernia,advanced age,male sex,white race,cigarette smoking,and obesity.The annual risk of esophageal cancer is approximately 0.25%for patients without dysplasia and 6%for patients with high-grade dysplasia.Twenty percent of all esophageal adenocarcinoma in the United States is early stage with disease confined to the mucosa or submucosa.The significant morbidity and mortality of esophagectomy make endoscopic treatment an attractive option.The American Gastroenterological Association recommends endoscopic eradication therapy for patients with high-grade dysplasia.Endoscopic modalities for treatment of early esophageal adenocarcinoma include endoscopic resection techniques and endoscopic ablative techniques such as radiofrequency ablation,photodynamic therapy and cryoablation.Endoscopic therapy should be precluded to patients with no evidence of lymphovascular invasion.Local tumor recurrence is low after endoscopic therapy and is predicted by poor differentiation of tumor,positive lymph node and submucosal invasion.Surgical resection should be offered to patients with deep submucosal invasion.
文摘Gangliocytic paraganglioma is a rare neuroendocrine tumor predominantly arising in the second part of the duodenum with rare local recurrence or metastasis to regional lymph nodes.A 92-year-old female presented with obstructive jaundice.On exam she had pale conjunctiva and icteric sclera.Abdominal examination revealed tenderness in the upper abdomen.Laboratory data was consistent with obstructive jaundice.Computed tomography of the abdomen revealed a dilated gall bladder and a common bile duct(CBD)with no evidence of liver lesions or pancreatic head mass.Endoscopic ultrasonography revealed a 1 cm isoechoic submucosal nodule at the periampullary area,dilated CBD(9 mm),a prominent pancreatic duct(4.1 mm)and a hydropic gall bladder with no stones.Endoscopic retrograde cholangiopancreaticography was performed to relieve obstruction and showed a 1 cm periampullary mass which underwent an en-bloc snare resection.Histopathology analyses with immunohistochemical stains were positive for cytokeratin,synaptophysin,S-100 protein,neuron specific enolase and negative for actin and desmin consistent with periampullary gangliocytic paraganglioma.Periampullary gangliocytic paraganglioma is a rare benign tumor of the small bowel.Common presentation includes abdominal pain and obstructive jaundice which should be included in differential diagnosis of obstructive jaundice.Endoscopic resection is a curative therapy in the absence of local invasion or distant metastasis.
文摘Originating from Wuhan in China,coronavirus disease 2019(COVID-19)spread globally within months and was declared a pandemic by World Health Organization in March 2020,making it one of the biggest healthcare calamities of our time.As more data on COVID-19 infection became available,what was initially thought to be a simple respiratory illness was found to be more complex.Many extra-pulmonary manifestations are now frequently reported for COVID-19 in available literature,most commonly gastrointestinal and hepatopancreatobiliary manifestations.Due to early scarcity of data,extra pulmonary manifestations were initially overlooked and may have contributed to nosocomial spread of the infection.Practitioners,especially gastroenterologists,who frequently encounter patients with these symptoms,need to be aware of them.This can not only help minimize the nosocomial spread,ensure safety of provider but also help conserve already stretched-thin healthcare resources.A tremendous amount of COVID-19 related literature is getting added to the growing pool every day,making it difficult for providers to follow.The aim of our review is to summarize the available evidence for gastrointestinal and hepatopancreatobiliary manifestations of COVID-19.We here briefly discussed the possible pathophysiologic mechanism for these manifestations and summarized the recommendations put forward by multiple gastrointestinal societies regarding safe and effective clinical practice during the ongoing pandemic.
文摘Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and their infants.Few challenges arise in reaching an accurate diagnosis in light of such physiological changes.Laboratory test results should be carefully interpreted and the knowledge of what normal changes to expect is prudent to avoid clinical misjudgment.Other challenges entail the methods of treatment and their safety for both the mother and the baby.This review summarizes liver diseases that are not unique to pregnancy.We focus on viral hepatitis and its mode of transmission,diagnosis,effect on the pregnancy,the mother,the infant,treatment,and breast-feeding.Autoimmune hepatitis,primary biliary cirrhosis,primary sclerosing cholangitis,Wilson’s disease,Budd Chiari and portal vein thrombosis in pregnancy are also discussed.Pregnancy is rare in patients with cirrhosis because of the metabolic and hormonal changes associated with cirrhosis.Variceal bleeding can happen in up to 38%of cirrhotic pregnant women.Management of portal hypertension during pregnancy is discussed.Pregnancy increases the pathogenicity leading to an increase in the rate of gallstones.We discuss some of the interventions for gallstones in pregnancy if symptoms arise.Finally,we provide an overview of some of the options in managing hepatic adenomas and hepatocellular carcinoma during pregnancy.
文摘Endoscopic ultrasound(EUS) has revolutionized the diagnostic and therapeutic approach to patients with gastrointestinal disorders. Its application in patients with liver disease and portal hypertension is increasing. Patients with chronic liver disease are at risk for development of portal hypertension sequale such as ascites, spontaneous bacterial peritonitis and gastroesophageal varices. Bleeding esophageal and gastric varices are among the most common causes of mortality in patients with cirrhosis. Thus, early detection and treatment improve the outcome in this population. EUS can improve the detection and diagnosis of gastroesophageal varices and collateral veins and can provide endoscopic therapy of gastroesophageal varices such as EUS-guided sclerotherapy of esophageal collateral vessels and EUS-guided cynoacrylate(Glue) injection of gastric varices. EUS can also provide knowledge on the efficacy of pharmacotherapy of portal hypertension. Furthermore, EUS can provide assessment and prediction of variceal recurrence after endoscopic therapy and assessment of portal hemodynamics such as E-Flow and Doppler study of the azygous and portal veins. Moreover, EUS-guided fine needle aspiration may provide cytologic diagnosis of focal hepatic tumors andanalysis of free abdominal fluid.Using specialized EUSguided needle biopsy,a sample of liver tissue can be obtained to diagnose and evaluate for chronic liver disease.EUS-guided fine needle injection can be used to study portal vein pressure and hemodynamics,and potentially could be used to assist in exact measurement of portal vein pressure and placement of intrahepatic portosystemic shunt.
文摘Pregnancy is a special clinical state with several normal physiological changes that influence body organs including the liver.Liver disease can cause significant morbidity and mortality in both pregnant women and their infants.This review summarizes liver diseases that are unique to pregnancy.We discuss clinical conditions that are seen only in pregnant women and involve the liver;from Hyperemesis Gravidarum that happens in 1out of 200 pregnancies and Intrahepatic Cholestasis of Pregnancy(0.5%-1.5%prevalence),to the more frequent condition of preeclampsia(10%prevalence)and its severe form;hemolysis,elevated liver enzymes,and a low platelet count syndrome(12%of pregnancies with preeclampsia),to the rare entity of Acute Fatty Liver of Pregnancy(incidence of 1 per 7270 to 13000deliveries).Although pathogeneses behind the development of these aliments are not fully understood,theories have been proposed.Some propose the special physiological changes that accompany pregnancy as a precipitant.Others suggest a constellation of factors including both the mother and her fetus that come together to trigger those unique conditions.Reaching a timely and accurate diagnosis of such conditions can be challenging.The timing of the condition in relation toward which trimester it starts at is a key.Accurate diagnosis can be made using specific clinical findings and blood tests.Some entities have well-defined criteria that help not only in making the diagnosis,but also in classifying the disease according to its severity.Management of these conditions range from simple medical remedies to measures such as immediate termination of the pregnancy.In specific conditions,it is prudent to have expert obstetric and medical specialists teaming up to help improve the outcomes.
文摘Endoscopic ultrasound(EUS)-guided fine needle aspira-tion(FNA) of the liver is a safe procedure in the diag-nosis and staging of hepatobiliary malignancies with a minimal major complication rate. EUS-FNA is useful for liver lesions poorly accessible to other imaging modali-ties of the liver. EUS-guided FNA of biliary neoplasia and malignant biliary stricture is superior to the con-ventional endoscopic brushing and biopsy.
文摘Pregnancy in patients with advanced liver disease is uncommon as most women with decompensated cirrhosis are infertile and have high rate of anovulation.However,if gestation ensued;it is very challenging and carries high risks for both the mother and the baby such as higher rates of spontaneous abortion,prematurity,pulmonary hypertension,splenic artery aneurysm rupture,postpartum hemorrhage,and a potential for life-threatening variceal hemorrhage and hepatic decompensation.In contrary,with orthotopic liver transplantation,menstruation resumes and most women of childbearing age are able to conceive,give birth and lead a better quality of life.Women with orthotopic liver transplantation seeking pregnancy should be managed carefully by a team consultation with transplant hepatologist,maternal-fetal medicine specialist and other specialists.Pregnant liver transplant recipients need to stay on immunosuppression medication to prevent allograft rejection.Furthermore,these medications need to be monitored carefully and continued throughout pregnancy to avoid potential adverse effects to mother and baby.Thus delaying pregnancy 1 to 2 years after transplantation minimizes fetal exposure to high doses of immunosuppressants.Pregnant female liver transplant patients have a high rate of cesarean delivery likely due to the high rate of prematurity in this population.Recent reports suggest that with close monitoring and multidisciplinary team approach,most female liver transplant recipient of childbearing age will lead a successful pregnancy.
文摘The application of artificial intelligence(AI)using deep learning and machine learning approaches in modern medicine is rapidly expanding.Within the field of Gastroenterology,AI is being evaluated across a breadth of clinical and diagnostic applications including identification of pathology,differentiation of disease processes,and even automated procedure report generation.Many pancreatic pathologies can have overlapping features creating a diagnostic dilemma that provides a window for AI-assisted improvement in current evaluation and diagnosis,particularly using endoscopic ultrasound.This topic highlight will review the basics of AI,history of AI in gastrointestinal endoscopy,and prospects for AI in the evaluation of autoimmune pancreatitis,pancreatic ductal adenocarcinoma,chronic pancreatitis and intraductal papillary mucinous neoplasm.
