Publications by authors named "James L Buxbaum"

38 Publications

ASGE guideline on the role of endoscopy in the management of malignant hilar obstruction.

Gastrointest Endosc 2021 Aug 20;94(2):222-234.e22. Epub 2021 May 20.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

This clinical guideline from the American Society for Gastrointestinal Endoscopy (ASGE) provides an evidence-based approach for the management of patients with malignant hilar obstruction (MHO). This document was developed using the Grading of Recommendations Assessment, Development and Evaluation framework and addresses primary drainage modality (percutaneous transhepatic biliary drainage [PTBD] vs endoscopic biliary drainage [EBD]), drainage strategy (unilateral vs bilateral), and stent selection (plastic stent [PS] vs self-expandable metal stent [SEMS]). Regarding drainage modality, in patients with MHO undergoing drainage before potential resection or transplantation, the panel suggests against routine use of PTBD as first-line therapy compared with EBD. In patients with unresectable MHO undergoing palliative drainage, the panel suggests PTBD or EBD. The final decision should be based on patient preferences, disease characteristics, and local expertise. Regarding drainage strategy, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placement of bilateral stents compared with a unilateral stent in the absence of liver atrophy. Finally, regarding type of stent, in patients with unresectable MHO undergoing palliative stent placement, the panel suggests placing SEMSs or PSs. However, in patients who have a short life expectancy and who place high value on avoiding repeated interventions, the panel suggests using SEMSs compared with PSs. If optimal drainage strategy has not been established, the panel suggests placing PSs. This document clearly outlines the process, analyses, and decision processes used to reach the final recommendations and represents the official ASGE recommendations on the above topics.
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http://dx.doi.org/10.1016/j.gie.2020.12.035DOI Listing
August 2021

ASGE guideline on the management of cholangitis.

Gastrointest Endosc 2021 Aug 20;94(2):207-221.e14. Epub 2021 May 20.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Cholangitis is a GI emergency requiring prompt recognition and treatment. The purpose of this document from the American Society for Gastrointestinal Endoscopy's (ASGE) Standards of Practice Committee is to provide an evidence-based approach for management of cholangitis. This document addresses the modality of drainage (endoscopic vs percutaneous), timing of intervention (<48 hours vs >48 hours), and extent of initial intervention (comprehensive therapy vs decompression alone). Grading of Recommendations, Assessment, Development, and Evaluation methodology was used to formulate recommendations on these topics. The ASGE suggests endoscopic rather than percutaneous drainage and biliary decompression within 48 hours. Additionally, the panel suggests that sphincterotomy and stone removal be combined with drainage rather than decompression alone, unless patients are too unstable to tolerate more extensive endoscopic treatment.
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http://dx.doi.org/10.1016/j.gie.2020.12.032DOI Listing
August 2021

Dynamic changes in the pancreatitis activity scoring system during hospital course in a multicenter, prospective cohort.

J Gastroenterol Hepatol 2021 Feb 18. Epub 2021 Feb 18.

Division of Gastroenterology, Hepatology, and Nutrition, Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.

Background And Aim: The primary aim was to validate the Pancreatitis Activity Scoring System (PASS) in a multicenter prospectively ascertained acute pancreatitis (AP) cohort. Second, we investigated the association of early PASS trajectories with disease severity and length of hospital stay (LOS).

Methods: Data were prospectively collected through the APPRENTICE consortium (2015-2018). AP severity was categorized based on revised Atlanta classification. Delta PASS (ΔPASS) was calculated by subtracting activity score from baseline value. PASS trajectories were compared between severity subsets. Subsequently, the cohort was subdivided into three LOS subgroups as short (S-LOS): 2-3 days; intermediate (I-LOS): 3-7 days; and long (L-LOS): ≥7 days. The generalized estimating equations model was implemented to compare PASS trajectories.

Results: There were 434 subjects analyzed including 322 (74%) mild, 86 (20%) moderately severe, and 26 (6%) severe AP. Severe AP subjects had the highest activity levels and the slowest rate of decline in activity (P = 0.039). Focusing on mild AP, L-LOS subjects (34%) had 28 points per day slower decline; whereas, S-LOS group (13%) showed 34 points per day sharper decrease compared with I-LOS (53%; P < 0.001). We noticed an outlier subset with a median admission-PASS of 466 compared with 140 in the rest. Morphine equivalent dose constituted 80% of the total PASS in the outliers (median morphine equivalent dose score = 392), compared with only 25% in normal-range subjects (score = 33, P value < 0.001).

Conclusions: This study highlighted that PASS can quantify AP activity. Significant differences in PASS trajectories were found both in revised Atlanta classification severity and LOS groups, which can be harnessed in AP monitoring/management (ClincialTrials.gov number, NCT03075618).
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http://dx.doi.org/10.1111/jgh.15430DOI Listing
February 2021

ASGE guideline on the role of endoscopy in the management of benign and malignant gastroduodenal obstruction.

Gastrointest Endosc 2021 02 7;93(2):309-322.e4. Epub 2020 Nov 7.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

This American Society for Gastrointestinal Endoscopy guideline provides evidence-based recommendations for the endoscopic management of gastric outlet obstruction (GOO). We applied the Grading of Recommendations, Assessment, Development and Evaluation methodology to address key clinical questions. These include the comparison of (1) surgical gastrojejunostomy to the placement of self-expandable metallic stents (SEMS) for malignant GOO, (2) covered versus uncovered SEMS for malignant GOO, and (3) endoscopic and surgical interventions for the management of benign GOO. Recommendations provided in this document were founded on the certainty of the evidence, balance of benefits and harms, considerations of patient and caregiver preferences, resource utilization, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.gie.2020.07.063DOI Listing
February 2021

Early Weight-Based Aggressive vs. Non-Aggressive Goal-Directed Fluid Resuscitation in the Early Phase of Acute Pancreatitis: An Open-Label Multicenter Randomized Controlled Trial (The WATERFALL Trial), Design, and Rationale.

Front Med (Lausanne) 2020 2;7:440. Epub 2020 Sep 2.

Gastroenterology Department, Alicante University General Hospital, Alicante Institute for Health and Biomedical Research (ISABIAL), Alicante, Spain.

Treatment options are limited for acute pancreatitis (AP). Early aggressive fluid resuscitation (AFR) has been widely considered beneficial because of theoretical improvement in end-organ perfusion, including the pancreas and gut, with pancreatic necrosis and bacterial translocation as consequences of ischemia. There is scarce direct evidence for its association to improved outcomes. Furthermore, it has been described that AFR may be associated with poor outcomes in severe AP. WATERFALL is an investigator-initiated international multicenter open-label randomized controlled trial comparing AFR vs. moderate fluid resuscitation (MFR) in AP. The main outcome variable will be the incidence of moderate to severe AP (a clinically relevant outcome that has been validated). Aggressive fluid resuscitation will consist in lactated Ringer solution (LR) 20-mL/kg bolus (administered over 2 h) followed by LR 3 mL/kg per hour. Patients randomized to MFR will receive an LR bolus 10 mL/kg in case of hypovolemia or no bolus in patients with normal volemia, followed by LR 1.5 mL/kg per hour. The patients will be assessed at 3 (±1), 12 (±4), 24 (±4), 48 (±4), and 72 (±4) h from recruitment, and fluid resuscitation will be adjusted to the patient's clinical and analytical status according to a protocol. Based on a prospective multicenter study, the incidence of moderate to severe AP is 35%. Sample sizes of 372 patients per group (overall 744) achieve 80% power to detect a difference in the incidence of moderate to severe AP of 10%, at a significance level (α) of 0.05 using a two-sided -test, assuming a 10% dropout rate. These results assume that three sequential tests are made using the O'Brien-Fleming spending function to determine the test boundaries.
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http://dx.doi.org/10.3389/fmed.2020.00440DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7492535PMC
September 2020

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in familial adenomatous polyposis syndromes.

Gastrointest Endosc 2020 05 10;91(5):963-982.e2. Epub 2020 Mar 10.

Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, Arizona, USA.

Familial adenomatous polyposis (FAP) syndrome is a complex entity, which includes FAP, attenuated FAP, and MUTYH-associated polyposis. These patients are at significant risk for colorectal cancer and carry additional risks for extracolonic malignancies. In this guideline, we reviewed the most recent literature to formulate recommendations on the role of endoscopy in this patient population. Relevant clinical questions were how to identify high-risk individuals warranting genetic testing, when to start screening examinations, what are appropriate surveillance intervals, how to identify endoscopically high-risk features, and what is the role of chemoprevention. A systematic literature search from 2005 to 2018 was performed, in addition to the inclusion of seminal historical studies. Most studies were from worldwide registries, which have compiled years of data regarding the natural history and cancer risks in this cohort. Given that most studies were retrospective, recommendations were based on epidemiologic data and expert opinion. Management of colorectal polyps in FAP has not changed much in recent years, as colectomy in FAP is the standard of care. What is new, however, is the developing body of literature on the role of endoscopy in managing upper GI and small-bowel polyposis, as patients are living longer and improved endoscopic technologies have emerged.
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http://dx.doi.org/10.1016/j.gie.2020.01.028DOI Listing
May 2020

ASGE guideline on minimum staffing requirements for the performance of GI endoscopy.

Gastrointest Endosc 2020 04 6;91(4):723-729.e17. Epub 2020 Feb 6.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Efforts to increase patient safety and satisfaction, a critical concern for health providers, require periodic evaluation of all factors involved in the provision of GI endoscopy services. We aimed to develop guidelines on minimum staffing requirements and scope of practice of available staff for the safe and efficient performance of GI endoscopy. The recommendations in this guideline were based on a systematic review of published literature, results from a nationwide survey of endoscopy directors, along with the expert guidance of the American Society for Gastrointestinal Endoscopy (ASGE) Standards of Practice Committee members, ASGE Practice Operation Committee members, and the ASGE Governing Board.
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http://dx.doi.org/10.1016/j.gie.2019.12.002DOI Listing
April 2020

ASGE guideline on the management of achalasia.

Gastrointest Endosc 2020 02 13;91(2):213-227.e6. Epub 2019 Dec 13.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA.

Achalasia is a primary esophageal motor disorder of unknown etiology characterized by degeneration of the myenteric plexus, which results in impaired relaxation of the esophagogastric junction (EGJ), along with the loss of organized peristalsis in the esophageal body. The criterion standard for diagnosing achalasia is high-resolution esophageal manometry showing incomplete relaxation of the EGJ coupled with the absence of organized peristalsis. Three achalasia subtypes have been defined based on high-resolution manometry findings in the esophageal body. Treatment of patients with achalasia has evolved in recent years with the introduction of peroral endoscopic myotomy. Other treatment options include botulinum toxin injection, pneumatic dilation, and Heller myotomy. This American Society for Gastrointestinal Endoscopy Standards of Practice Guideline provides evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of the 4 aforementioned achalasia therapies.
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http://dx.doi.org/10.1016/j.gie.2019.04.231DOI Listing
February 2020

American Society for Gastrointestinal Endoscopy guideline on the role of endoscopy in the management of acute colonic pseudo-obstruction and colonic volvulus.

Gastrointest Endosc 2020 02 30;91(2):228-235. Epub 2019 Nov 30.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.

Colonic volvulus and acute colonic pseudo-obstruction (ACPO) are 2 causes of benign large-bowel obstruction. Colonic volvulus occurs most commonly in the sigmoid colon as a result of bowel twisting along its mesenteric axis. In contrast, the exact pathophysiology of ACPO is poorly understood, with the prevailing hypothesis being altered regulation of colonic function by the autonomic nervous system resulting in colonic distention in the absence of mechanical blockage. Prompt diagnosis and intervention leads to improved outcomes for both diagnoses. Endoscopy may play a role in the evaluation and management of both entities. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on the evaluation and endoscopic management of sigmoid volvulus and ACPO.
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http://dx.doi.org/10.1016/j.gie.2019.09.007DOI Listing
February 2020

Liver Fluke.

N Engl J Med 2019 Nov;381(19):e34

University of Southern California, Los Angeles, CA

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http://dx.doi.org/10.1056/NEJMicm1903220DOI Listing
November 2019

ASGE review of adverse events in colonoscopy.

Gastrointest Endosc 2019 12 25;90(6):863-876.e33. Epub 2019 Sep 25.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.

Colonoscopy is the most commonly performed endoscopic procedure and overall is considered a low-risk procedure. However, adverse events (AEs) related to this routinely performed procedure for screening, diagnostic, or therapeutic purposes are an important clinical consideration. The purpose of this document from the American Society for Gastrointestinal Endoscopy's Standards of Practice Committee is to provide an update on estimates of AEs related to colonoscopy in an evidence-based fashion. A systematic review and meta-analysis of population-based studies was conducted for the 3 most common and important serious AEs (bleeding, perforation, and mortality). In addition, this document includes an updated systematic review and meta-analysis of serious AEs (bleeding and perforation) related to EMR and endoscopic submucosal dissection for large colon polyps. Finally, a narrative review of other colonoscopy-related serious AEs and those related to specific colonic interventions is included.
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http://dx.doi.org/10.1016/j.gie.2019.07.033DOI Listing
December 2019

SpHincterotomy for Acute Recurrent Pancreatitis Randomized Trial: Rationale, Methodology, and Potential Implications.

Pancreas 2019 09;48(8):1061-1067

Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA.

Objectives: In patients with acute recurrent pancreatitis (ARP), pancreas divisum, and no other etiologic factors, endoscopic retrograde cholangiopancreatography (ERCP) with minor papilla endoscopic sphincterotomy (miES) is often performed to enlarge the minor papillary orifice, based on limited data. The aims of this study are to describe the rationale and methodology of a sham-controlled clinical trial designed to test the hypothesis that miES reduces the risk of acute pancreatitis.

Methods: The SpHincterotomy for Acute Recurrent Pancreatitis (SHARP) trial is a multicenter, international, sham-controlled, randomized trial comparing endoscopic ultrasound + ERCP with miES versus endoscopic ultrasound + sham for the management of ARP. A total of 234 consented patients having 2 or more discrete episodes of acute pancreatitis, pancreas divisum confirmed by magnetic resonance cholangiopancreatography, and no other clear etiology for acute pancreatitis will be randomized. Both cohorts will be followed for a minimum of 6 months and a maximum of 48 months.

Results: The trial is powered to detect a 33% risk reduction of acute pancreatitis frequency.

Conclusions: The SHARP trial will determine whether ERCP with miES benefits patients with idiopathic ARP and pancreas divisum. Trial planning has informed the importance of blinded outcome assessors and long-term follow-up.
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http://dx.doi.org/10.1097/MPA.0000000000001370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6699897PMC
September 2019

ASGE guideline on the role of endoscopy for bleeding from chronic radiation proctopathy.

Gastrointest Endosc 2019 08 22;90(2):171-182.e1. Epub 2019 Jun 22.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA.

Chronic radiation proctopathy is a common sequela of radiation therapy for malignancies in the pelvic region. A variety of medical and endoscopic therapies have been used for the management of bleeding from chronic radiation proctopathy. In this guideline, we reviewed the results of a systematic search of the literature from 1946 to 2017 to formulate clinical questions and recommendations on the role of endoscopy for bleeding from chronic radiation proctopathy. The following endoscopic modalities are discussed in our document: argon plasma coagulation, bipolar electrocoagulation, heater probe, radiofrequency ablation, and cryoablation. Most studies were small observational studies, and the evidence for effectiveness of endoscopic therapy for chronic radiation proctopathy was limited because of a lack of controlled trials and comparative studies. Despite this limitation, our systematic review found that argon plasma coagulation, bipolar electrocoagulation, heater probe, and radiofrequency ablation were effective in the treatment of rectal bleeding from chronic radiation proctopathy.
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http://dx.doi.org/10.1016/j.gie.2019.04.234DOI Listing
August 2019

ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis.

Gastrointest Endosc 2019 06 9;89(6):1075-1105.e15. Epub 2019 Apr 9.

Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA. Electronic address:

Each year choledocholithiasis results in biliary obstruction, cholangitis, and pancreatitis in a significant number of patients. The primary treatment, ERCP, is minimally invasive but associated with adverse events in 6% to 15%. This American Society for Gastrointestinal Endoscopy (ASGE) Standard of Practice (SOP) Guideline provides evidence-based recommendations for the endoscopic evaluation and treatment of choledocholithiasis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to rigorously review and synthesize the contemporary literature regarding the following topics: EUS versus MRCP for diagnosis, the role of early ERCP in gallstone pancreatitis, endoscopic papillary dilation after sphincterotomy versus sphincterotomy alone for large bile duct stones, and impact of ERCP-guided intraductal therapy for large and difficult choledocholithiasis. Comprehensive systematic reviews were also performed to assess the following: same-admission cholecystectomy for gallstone pancreatitis, clinical predictors of choledocholithiasis, optimal timing of ERCP vis-à-vis cholecystectomy, management of Mirizzi syndrome and hepatolithiasis, and biliary stent therapy for choledocholithiasis. Core clinical questions were derived using an iterative process by the ASGE SOP Committee. This body developed all recommendations founded on the certainty of the evidence, balance of risks and harms, consideration of stakeholder preferences, resource utilization, and cost-effectiveness.
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http://dx.doi.org/10.1016/j.gie.2018.10.001DOI Listing
June 2019

Efficacy and Safety of Digital Single-Operator Cholangioscopy for Difficult Biliary Stones.

Clin Gastroenterol Hepatol 2018 06 24;16(6):918-926.e1. Epub 2017 Oct 24.

Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan.

Background & Aims: It is not clear whether digital single-operator cholangioscopy (D-SOC) with electrohydraulic and laser lithotripsy is effective in removal of difficult biliary stones. We investigated the safety and efficacy of D-SOC with electrohydraulic and laser lithotripsy in an international, multicenter study of patients with difficult biliary stones.

Methods: We performed a retrospective analysis of 407 patients (60.4% female; mean age, 64.2 years) who underwent D-SOC for difficult biliary stones at 22 tertiary centers in the United States, United Kingdom, or Korea from February 2015 through December 2016; 306 patients underwent electrohydraulic lithotripsy and 101 (24.8%) underwent laser lithotripsy. Univariate and multivariable analyses were performed to identify factors associated with technical failure and the need for more than 1 D-SOC electrohydraulic or laser lithotripsy session to clear the bile duct.

Results: The mean procedure time was longer in the electrohydraulic lithotripsy group (73.9 minutes) than in the laser lithotripsy group (49.9 minutes; P < .001). Ducts were completely cleared (technical success) in 97.3% of patients (96.7% of patients with electrohydraulic lithotripsy vs 99% patients with laser lithotripsy; P = .31). Ducts were cleared in a single session in 77.4% of patients (74.5% by electrohydraulic lithotripsy and 86.1% by laser lithotripsy; P = .20). Electrohydraulic or laser lithotripsy failed in 11 patients (2.7%); 8 patients were treated by surgery. Adverse events occurred in 3.7% patients and the stone was incompletely removed from 6.6% of patients. On multivariable analysis, difficult anatomy or cannulation (duodenal diverticula or altered anatomy) correlated with technical failure (odds ratio, 5.18; 95% confidence interval, 1.26-21.2; P = .02). Procedure time increased odds of more than 1 session of D-SOC electrohydraulic or laser lithotripsy (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P < .001).

Conclusions: In a multicenter, international, retrospective analysis, we found D-SOC with electrohydraulic or laser lithotripsy to be effective and safe in more than 95% of patients with difficult biliary stones. Fewer than 5% of patients require additional treatment with surgery and/or extracorporeal shockwave lithotripsy to clear the duct.
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http://dx.doi.org/10.1016/j.cgh.2017.10.017DOI Listing
June 2018

Metallic coil and N-butyl-2-cyanoacrylate for closure of pancreatic duct leak (with video).

Gastrointest Endosc 2018 Apr 24;87(4):1122-1125. Epub 2017 Aug 24.

Division of Gastrointestinal and Liver Diseases, University of Southern California Keck School of Medicine, Los Angeles, California, USA.

Background And Aims: Pancreatic fistula is a challenging yet common adverse event of partial pancreatectomy. Our objective is to determine the feasibility of endoscopic closure of a pancreatic fistula using a combination of a metallic coil and N-butyl-2-cyanoacrylate (NBCA) glue.

Methods: A patient with a postoperative pancreatic stump leak recalcitrant to conservative management and pancreatic duct stent placement underwent endoscopic/fluoroscopic placement of a metallic coil in the pancreatic duct followed by injection of .5 mL NBCA and lipiodol mixture directed at the coil. The patient's clinical condition, Jackson-Pratt (JP) drain output, and pancreatic enzyme content were monitored daily after the procedure.

Results: The patient's clinical condition improved. JP drain output and amylase/lipase levels progressively decreased to resolution within 7 days of the procedure. No adverse events occurred as a result of the procedure.

Conclusions: Endoscopic closure of pancreatic fistula with a metallic coil and NBCA glue is feasible and may be a useful modality for treatment of refractory postpancreatectomy-related fistula.
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http://dx.doi.org/10.1016/j.gie.2017.08.015DOI Listing
April 2018

Narrow-band imaging versus white light versus mapping biopsy for gastric intestinal metaplasia: a prospective blinded trial.

Gastrointest Endosc 2017 Nov 30;86(5):857-865. Epub 2017 Mar 30.

Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut and Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.

Background And Aims: Gastric intestinal metaplasia (GIM) is a gastric cancer precursor. Narrow-band imaging (NBI) may improve detection of GIM. We compared detection of GIM with high-definition white-light (HD-WL) endoscopy, NBI, and mapping biopsies in a population with increased gastric cancer risk.

Methods: Patients undergoing upper endoscopy had HD-WL examination by 1 endoscopist, followed by an NBI examination by a second endoscopist blinded to HD-WL findings. The location of abnormalities detected by HD-WL and NBI were recorded by a research coordinator, and targeted biopsies of abnormal areas were performed after NBI. Subsequently, 5 mapping biopsies were performed per patient. Biopsy specimens were read by a pathologist blinded to mode of acquisition. The primary outcome was the proportion of patients with GIM.

Results: We enrolled 112 patients: 107 (96%) were Hispanic or Asian, and 34 (30%) had GIM. Higher proportions of patients with GIM were detected by NBI (22/34 [65%]) and mapping (26/34 [76%]) versus HD-WL (10/34 [29%]) (P < .005 for both comparisons). GIM was detected by NBI in only 6 patients and only by mapping biopsy in 10 patients; no patient had GIM detected solely by HD-WL. Higher proportions of sites with GIM also were detected with NBI (30/57 [53%]) and mapping biopsies (38/57 [67%]) than HD-WL (16/57 [28%]) (P < .005 for both comparisons). The median number of biopsies per patient with mapping biopsies (5) was significantly higher than with NBI (2) or HD-WL (1).

Conclusions: HD-WL endoscopy is insufficient for detection of GIM in patients at increased risk for gastric cancer. NBI-targeted biopsies plus mapping biopsies should be used. (Clinical trial registration number: NCT02197351.).
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http://dx.doi.org/10.1016/j.gie.2017.03.1528DOI Listing
November 2017

Early Aggressive Hydration Hastens Clinical Improvement in Mild Acute Pancreatitis.

Am J Gastroenterol 2017 05 7;112(5):797-803. Epub 2017 Mar 7.

Section of Digestive Diseases, Yale School of Medicine, New Haven, Connecticut, USA.

Objectives: Early aggressive intravenous hydration is recommended for acute pancreatitis treatment although randomized trials have not documented benefit. We performed a randomized trial of aggressive vs. standard hydration in the initial management of mild acute pancreatitis.

Methods: Sixty patients with acute pancreatitis without systemic inflammatory response syndrome (SIRS) or organ failure were randomized within 4 h of diagnosis to aggressive (20 ml/kg bolus followed by 3 ml/kg/h) vs. standard (10 ml/kg bolus followed by 1.5 mg/kg/h) hydration with Lactated Ringer's solution. Patients were assessed at 12-h intervals. At each interval, in both groups, if hematocrit, blood urea nitrogen (BUN), or creatinine was increased, a bolus of 20 ml/kg followed by 3 ml/kg/h was given; if labs were decreased and epigastric pain was decreased (measured on 0-10 visual analog scale), hydration was then given at 1.5 ml/kg/h and clear liquid diet was started. The primary endpoint, clinical improvement within 36 h, was defined as the combination of decreased hematocrit, BUN, and creatinine; improved pain; and tolerance of oral diet.

Results: The mean age of the patients was 45 years and only 14 (23%) had comorbidities. A higher proportion of patients treated with aggressive vs. standard hydration showed clinical improvement at 36 h: 70 vs. 42% (P=0.03). The rate of clinical improvement was greater with aggressive vs. standard hydration by Cox regression analysis: adjusted hazard ratio=2.32, 95% confidence interval 1.21-4.45. Persistent SIRS occurred less commonly with aggressive hydration (7.4 vs. 21.1%; adjusted odds ratio (OR)=0.12, 0.02-0.94) as did hemoconcentration (11.1 vs. 36.4%, adjusted OR=0.08, 0.01-0.49). No patients developed signs of volume overload.

Conclusions: Early aggressive intravenous hydration with Lactated Ringer's solution hastens clinical improvement in patients with mild acute pancreatitis.
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http://dx.doi.org/10.1038/ajg.2017.40DOI Listing
May 2017

Prevention and management of post-ERCP pancreatitis.

JOP 2014 Nov 28;15(6):544-51. Epub 2014 Nov 28.

Advanced Digestive Health Center, Keck/USC Medical Center. Los Angeles, CA, USA.

Pancreatitis remains as one of the most frequent and serious complications of ERCP. Research has identified several patient-related and procedural risk factors, which help guide the endoscopist in prophylaxis and management of pancreatitis. Recent studies have had a major impact on both procedural techniques and pharmacological methods for prophylaxis of post-ERCP pancreatitis. The purpose of this article is to review the relevant literature and describe the most recent and effective approaches in prevention and management of post-ERCP pancreatitis.
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http://dx.doi.org/10.6092/1590-8577/2853DOI Listing
November 2014

Strongyloidiasis hyperinfection in a patient with a history of systemic lupus erythematosus.

Am J Trop Med Hyg 2014 Oct 4;91(4):806-9. Epub 2014 Aug 4.

Department of Pathology, Department of Surgery, and Department of Gastroenterology, Los Angeles County-University of Southern California Medical Center, Los Angeles, California.

Strongyloidiasis is a parasitic disease caused by Strongyloides stercoralis, a nematode predominately endemic to tropical and subtropical regions, such as Southeast Asia. Autoinfection enables the organism to infect the host for extended periods. Symptoms, when present, are non-specific and may initially lead to misdiagnosis, particularly if the patient has additional co-morbid conditions. Immunosuppressive states place patients at risk for the Strongyloides hyperinfection syndrome (SHS), whereby the organism rapidly proliferates and disseminates within the host. Left untreated, SHS is commonly fatal. Unfortunately, the non-specific presentation of strongyloidiasis and the hyperinfection syndrome may lead to delays in diagnosis and treatment. We describe an unusual case of SHS in a 30-year-old man with a long-standing history of systemic lupus erythematosus who underwent a partial colectomy. The diagnosis was rendered on identification of numerous organisms during histologic examination of the colectomy specimen.
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http://dx.doi.org/10.4269/ajtmh.14-0228DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4183409PMC
October 2014

Endoscopic ultrasound, the one-stop shop for abdominal pain?

United European Gastroenterol J 2013 Oct;1(5):326-8

Division of Gastroenterology and Hepatology, American University of Beirut School of Medicine, Lebanon.

The Endosonography for Right Sided and Acute Upper Intestinal Misery (EFRAIM) study indicates that the yield of endoscopic ultrasound (EUS) is equivalent if not superior to upper endoscopy combined with transabdominal ultrasound in patients presenting with acute discomfort. Furthermore, this strategy may be more cost effective as EUS simultaneously enables assessment of intraluminal disease as well as extra intestinal pathology. These results are in sync with prior studies demonstrating the hegemony of EUS in the assessment of pancreaticobiliary disease and its role in the assessment of enigmatic chronic abdominal pain. Nevertheless, EUS does not permit assessment for appendicitis or genitourinary catastrophe. Thus a careful history and physical examination to localize pain to the right upper quadrant and epigastrium is essential.
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http://dx.doi.org/10.1177/2050640613502964DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4040775PMC
October 2013

Magnetic resonance imaging of the gut: a primer for the luminal gastroenterologist.

Am J Gastroenterol 2014 Apr 7;109(4):497-509; quiz 510. Epub 2014 Jan 7.

Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Magnetic resonance imaging (MRI) is well established for imaging the solid organs of the abdomen and pelvis. In recent years it has been having an increasingly important role in the evaluation of the gastrointestinal (GI) tract. Fluoroscopy and abdominal computed tomography, the traditional mainstays of bowel imaging, remain valuable; however, the contemporary emphasis on decreasing patient radiation exposure is driving practice toward non-ionizing modalities such as MRI. The inherent dynamic properties of MRI, its superior tissue contrast, and cross-sectional capabilities offer additional advantages. Here we review, from esophagus to anus, techniques and indications for MRI of the GI lumen with an emphasis on the normal MRI appearance of the GI tract and commonly encountered pathology.
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http://dx.doi.org/10.1038/ajg.2013.452DOI Listing
April 2014

Ratio of pancreatic duct caliber to width of pancreatic gland by endosonography is predictive of pancreatic cancer.

Pancreas 2013 May;42(4):670-9

Department of Gastroenterology and Hepatology, University of Alabama in Birmingham, Birmingham, AL, USA.

Objectives: This study aimed to determine whether (1) a pancreatic duct (PD) diameter to pancreatic gland width (G) ratio (PDG) by endoscopic ultrasonography (EUS) predicts pancreatic cancer (PC) and (2) whether this ratio better indicates PC compared to PD dilation alone.

Methods: Patients presenting for EUS were classified into the following 4 categories: (1) normal, (2) noncalcific chronic pancreatitis (NCCP), (3) calcific CP (CCP), and (4) PC.

Results: There were 198 patients enrolled. Final diagnoses were PC (n = 34), CCP (n = 16), and normal/NCCP (n = 148). The median PD diameter (8, 5, and 2 mm, respectively; P = <0.001), G (16, 20, and 17 mm, respectively; P = 0.002), and PDG ratio were significantly different among groups (0.54, 0.25, and 0.12, respectively; P < 0.001). Patients with PC were more likely to have a PDG ratio of greater than or equal to 0.34 compared to CCP, and normal/NCCP groups (94%, 19%, 1.3%, respectively; P < 0.001). The positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of PDG greater than or equal to 0.34 for detecting cancer were 87%, 99%, 94%, 97%, and 97%, respectively. The accuracy and positive predictive value of PD dilation alone for diagnosing PC were 83% and 50%, respectively.

Conclusions: A PDG ratio is a good predictor of PC and is better than PD dilation. This sign should be routinely used by endosonographers to improve EUS diagnostic capability of PC.
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http://dx.doi.org/10.1097/MPA.0b013e31827305b8DOI Listing
May 2013

How good is endoscopic ultrasound-guided fine-needle aspiration in diagnosing the correct etiology for a solid pancreatic mass?: A meta-analysis and systematic review.

Pancreas 2013 Jan;42(1):20-6

Division of Gastroenterology and Hepatology, Massachusetts General Hospital and Brigham Women's Hospital, Harvard School of Medicine, Boston, MA, USA.

Objectives: The objective of this study was to evaluate the accuracy of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in diagnosing the correct etiology for a solid pancreatic mass.

Method: Data extracted from EUS-FNA studies with a criterion standard (either confirmed by surgery or appropriate follow-up) were selected. Articles were searched in MEDLINE, CINAHL, and Cochrane Central Register of Controlled Trials & Database of Systematic Reviews. Pooling was conducted by both fixed- and random-effects models.

Results: Initial search identified 3610 reference articles, of these 360 relevant articles were selected and reviewed. Data were extracted from 41 studies (N = 4766) which met the inclusion criteria. Pooled sensitivity of EUS-FNA in diagnosing the correct etiology for solid pancreatic mass was 86.8% (95% confidence interval [CI], 85.5-87.9). Endoscopic ultrasound-guided FNA had a pooled specificity of 95.8% (95% CI, 94.6-96.7). Positive likelihood ratio of EUS was 15.2 (95% CI, 8.5-27.3), and the negative likelihood ratio was 0.17 (95% CI, 0.13-0.21).

Conclusions: Endoscopic ultrasound-guided FNA is an excellent diagnostic tool to detect the correct etiology for solid pancreatic masses. When available, EUS-FNA should be strongly considered as the first diagnostic tool for sampling these lesions to optimize patient management.
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http://dx.doi.org/10.1097/MPA.0b013e3182546e79DOI Listing
January 2013

Recent advances in diagnostic and therapeutic endoscopic ultrasound.

Expert Rev Gastroenterol Hepatol 2012 Sep;6(5):525-7

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http://dx.doi.org/10.1586/egh.12.44DOI Listing
September 2012

Dynamic telecytology compares favorably to rapid onsite evaluation of endoscopic ultrasound fine needle aspirates.

Dig Dis Sci 2012 Dec 24;57(12):3092-7. Epub 2012 Jun 24.

Division of Gastroenterology, The University of Southern California, Los Angeles, CA, USA.

Background And Aims: Rapid onsite evaluation (ROSE) has been demonstrated to correlate with final cytologic interpretations and improves the diagnostic yield of endoscopic ultrasound (EUS)-fine needle aspiration (FNA); however, its availability is variable across centers. The aim of this prospective study was to evaluate whether remote telecytology can substitute for ROSE.

Methods: Consecutive patients who underwent EUS-FNA for diverse indications at a high volume referral center were enrolled and all samples were prospectively evaluated by three methods. ROSE was performed by a cytopathologist in the procedure room; simultaneously dynamic telecytology was done by a different cytopathologist in a remote location at our institution. The third method, final cytologic interpretation in the laboratory, was the gold standard. Telecytology was performed using an Olympus microscope system (BX) which broadcasts live images over the Internet. Accuracy of telecytology and agreement with other methods were the principle outcome measurements.

Results: Twenty-five consecutive samples were obtained from participants 40-87 years old (median age 63, 48 % male). There was 88 % agreement between telecytology and final cytology (p < 0.001) and 92 % agreement between ROSE and final cytology (p < 0.001). There was consistency between telecytology and ROSE (p value for McNemar's χ(2) = 1.0). Cohen's kappa for agreement for telecytology and ROSE was 0.80 (SE = 0.11), confirming favorable correlation.

Conclusion: Dynamic telecytology compares favorably to ROSE in the assessment of EUS acquired fine needle aspirates. If confirmed by larger trials, this system might obviate the need for onsite interpretation of EUS-FNA specimens.
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http://dx.doi.org/10.1007/s10620-012-2275-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3640867PMC
December 2012

Oncocytic intraductal papillary mucinous neoplasm with carcinomatous degeneration.

Gastrointest Endosc 2012 Apr;75(4):898-9; discussion 898-9

Department of Gastroenterology, the University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1016/j.gie.2012.01.026DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4144676PMC
April 2012

Unusual, metastatic, or neuroendocrine tumor of the pancreas: a diagnosis with endoscopic ultrasound-guided fine-needle aspiration and immunohistochemistry.

Saudi J Gastroenterol 2012 Mar-Apr;18(2):99-105

Department of Gastroenterology and Hepatology, University of Alabama in Birmingham, Birmingham Alabama, USA.

Background/aim: To determine the yield of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) in combination with immunostains in diagnosing unusual solid pancreatic masses (USPM) in comparison with pancreatic adenocarcinoma (ACP).

Patients And Methods: All EUS-FNA of solid pancreatic masses performed with a 22-gauge needle were included. Data on clinical presentations, mass characteristics, presence of pancreatitis, yield of tissue, and final diagnosis were compared between the two groups. On site cytopathology was provided and additional passes were requested to perform immunostains.

Results: Two hundred and twenty-nine cases with either adenocarcinoma or USPM were included. The median age of the cohort was 65 years. ACP (210/229, 92%) accounted for the majority of the cases. The USPM included neuroendocrine (NET) masses (n=13), metastatic renal carcinoma (n=3), metastatic melanoma (n=1), lymphoma (n=1), and malignant fibrous histiocytoma (n=1). Subjects with ACP were significantly more likely to present with loss of weight (P=0.02) or obstructive jaundice (P<0.001). Subjects with ACP were more likely to have suspicious/atypical FNA biopsy results as compared with USPM (10% vs 0%). The sensitivity of EUS-FNA with immunostains was 93% in ACP as compared with 100% in USPM. Diagnostic accuracy was higher in USPM as compared with ACP (100% vs 93%).

Conclusions: EUS-FNA using a 22-gauge needle with immunostains has excellent diagnostic yield in patients with USPMs, which is comparable if not superior to the yield in pancreatic adenocarcinoma.
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http://dx.doi.org/10.4103/1319-3767.93810DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3326984PMC
July 2012