Acute pancreatitis (AP) is one of the leading causes of emergency department visits and hospital admissions in Western countries. Although numerous aetiologies have been described, up to 90% of cases are attributable to gallstones and chronic alcohol abuse. The clinical presentation of AP is highly variable, ranging from mild, self-limiting disease to severe forms characterised by infected necrotising pancreatitis, systemic complications, and organ failure. Severe cases frequently require prolonged hospitalisation and are associated with increased mortality. Early identification of disease severity and accurate determination of the underlying aetiology are therefore essential to guide appropriate treatment, reduce the risk of complications, and improve patient outcomes. This review discusses the pivotal role of diagnostic radiology in the evaluation and staging of AP, with the aim of optimising patient management, treatment planning, and follow-up. Particular emphasis is placed on transabdominal ultrasound (TA-US), computed tomography (CT), and magnetic resonance imaging (MRI), as well as recent advances in artificial intelligence (AI) and its emerging applications in pancreatic imaging.

Background and Objective:EUS-guided gallbladder drainage (EUS-GBD) has emerged as a viable alternative for patients with acute cholecystitis who are unfit for surgery. However, standardized guidelines for its indications, techniques, and management remain limited. The objective of this study is to develop evidence-based consensus recommendations for EUS-GBD in benign and malignant conditions, aimed at guiding clinical decision-making and improving patient outcomes. Methods:A 3-step modified Delphi process was used by the Interventional Endoscopy and Ultrasound Group, involving multidisciplinary experts in gastroenterology, surgery, and radiology. Four task forces conducted systematic literature reviews and generated PICO (Patients, Interventions, Comparator, and Outcomes)-formatted clinical questions. Evidence was graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, and consensus was defined as ≥80% agreement among panelists. Results:Twenty-two clinical questions were addressed, covering indications, timing, techniques, device selection, procedural aspects, and postprocedural care for EUS-GBD. Recommendations include the preferential use of EUS-GBD over percutaneous and transpapillary approaches in high-risk patients, early intervention in select cases, the use of lumen-apposing metal stents, and tailored postprocedural strategies. All recommendations were conditional, except for one strong recommendation in favor of EUS-GBD over other modalities, supported by moderate-quality evidence. Conclusions:This consensus offers a comprehensive, multidisciplinary guideline for the safe and effective use of EUS-GBD in clinical practice. These recommendations aim to standardize care and support future research in this rapidly evolving field.

Background: Although endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using lumen-apposing metal stents (LAMS) has become one of the treatments of choice for acute cholecystitis (AC) in fragile patients, scant data are available on real-life settings and long-term outcomes. Methods: We performed a multicenter retrospective study including EUS-guided GBD using LAMS for AC in 19 Italian centers from June 2014 to July 2020. The primary outcomes were technical and clinical success, and the secondary outcomes were the rate of adverse events (AE) and long-term follow-up. Results: In total, 116 patients (48.3% female) were included, with a mean age of 82.7 ± 11 years. LAMS were placed, transgastric in 44.8% of cases, transduodenal in 53.3% and transjejunal in 1.7%, in patients with altered anatomy. Technical success was achieved in 94% and clinical success in 87.1% of cases. The mean follow-up was 309 days. AEs occurred in 12/116 pts (10.3%); 8/12 were intraprocedural, while 1 was classified as early (<15 days) and 3 as delayed (>15 days). According to the ASGE lexicon, two (16.7%) were mild, three (25%) were moderate, and seven (58.3%) were severe. No fatal AEs occurred. In subgroup analysis of 40 patients with a follow-up longer than one year, no recurrence of AC was observed. Conclusions: EUS-GBD had high technical and clinical success rates, despite the non-negligible rate of AEs, thus representing an effective treatment option for fragile patients.

Autoimmune pancreatitis (AIP) is a unique form of chronic pancreatitis with a multifactorial pathogenesis. Historically, it has been classified as type 1 and type 2, according to its clinical and histological features. The diagnosis of AIP is challenging and relies on a combination of clinical, histopathologic, serologic, and imaging characteristics. In the available guidelines, the imaging hallmarks of AIP are based on cross-sectional imaging and cholangiopancreatography retrograde endoscopic findings. Endoscopic ultrasound (EUS) is generally used for pancreatic tissue acquisition to rule out pancreatic cancer and diagnose AIP with limited accuracy. Several papers reported the reliability of EUS for providing informative morphologic features of AIP. Nowadays, the improvement in the resolution of EUS conventional images and the development of new ancillary technologies have further increased the diagnostic yield of EUS: contrast-enhanced EUS and EUS elastography are non-invasive and real-time techniques that strongly support the diagnosis and management of pancreatic diseases. In this review article, we will present the role of conventional EUS and ancillary diagnostic techniques in the diagnosis of AIP to support clinicians and endosonographers in managing this condition.

We present the case of a 58-years-old caucasian male who was hospitalized in our hospital with an early diagnosis of a jejunal tumor. However, all the instrumental and laboratory testing conducted were inconclusive and a preoperative diagnosis was not established. Patient was scheduled for surgery and en-bloc resection of the jejunal mass was performed. Microscopic analysis of the specimen reported the presence of intense mixed lympho-granulocytic inflammatory infiltrate of the mucosa associated with entamoeba parasites and a diagnosis of intestinal ameboma was ruled out. Ameboma is a rare complication of chronic amoebic colitis. usually found in the cecum and ascending colon. To our knowledge, this is the first case of an intestinal ameboma involving the jejunum to be reported in medical literature.

Introduction: The development of dedicated endoscopes and the technical evolution of endoscopic ultrasound (EUS) have allowed a direct approach to pancreatic neoplastic lesions both for diagnosis and treatment. Among the more promising targets are pancreatic neuroendocrine tumors (Pan-NETs). Aim: to describe the evolution of endoscopic ultrasound-guided radiofrequency ablation (EUS-RFA) with particular attention to the treatment of PanNETs, focusing on safety and clinical efficacy of the technique. Methods: MEDLINE, Scopus, and Cochrane Library databases were searched for studies reporting about EUS-RFA for the treatment of PanNETs. Studies with outcomes of interest were selected and results were reported to describe clinical success, complications, fol-low-ups, and electrodes used. Clinical success was defined as the disappearance of clinical symp-toms for functional (F-) PanNETs and as complete ablation per nonfunctional (NF)-PanNETs. The pooled data were analyzed by a random-effects model. Results: Nineteen studies were selected, including 183 patients (82 males, 44.8%) with 196 lesions (101 F-PanNETs and 95 NF-PanNETs). Pooled estimates for the overall AE rates for the clinical efficacy were 17.8% (95% CI 9.1–26.4%) and 95.1% (95% CI 91.2–98.9%) for F-PanNETs and 24.6% (95% CI 7.4–41.8%) and 93.4% (95% CI 88.4–98.4%) for NF-PanNETs. Conclusions: EUS-RFA appears to be a mini-invasive technique with a good safety and efficacy profile for the treatment of F- and NF-PanNETs. EUS-RFA could be of-fered as possible alternative to surgery for the treatment of low-grade NF- or F-PanNETs, especially for those patients that are not eligible or are at high-risk for surgery.

BACKGROUNDThe introduction of lumen-apposing metal stents (LAMS) for endoscopic ultrasound (EUS)-guided drainages has marked a turning point in the field of interventional ultrasound and it is gathering worldwide diffusion in different clinical settings. Nevertheless, the procedure may conceal unexpected pitfalls. LAMS misdeployment is the most frequent cause of technical failure and it can be considered a procedure-related adverse event when it hampers the conclusion of the planned procedure or results in significant clinical consequences. Stent misdeployment can be managed successfully by endoscopic rescue maneuvers to allow the completion of the procedure. To date, no standardized indication is available to guide an appropriate rescue strategy depending on the type of procedure or of misdeployment.AIMTo evaluate the incidence of LAMS misdeployment during EUS-guided choledochoduodenostomy (EUS-CDS), gallbladder drainage (EUS-GBD) and pancreatic fluid collections drainage (EUS-PFC) and to describe the endoscopic rescue strategies adopted under the circumstance.METHODSWe conducted a systematic review of the literature on PubMed by searching for studies published up to October 2022. The search was carried out using the exploded medical subject heading terms "lumen apposing metal stent", "LAMS", "endoscopic ultrasound" and "choledochoduodenostomy" or "gallbladder" or "pancreatic fluid collections". We included in the review on-label EUS-guided procedures namely EUS-CDS, EUS-GBD and EUS-PFC. Only those publications reporting EUS-guided LAMS positioning were considered. The studies reporting a technical success rate of 100% and other procedure-related adverse events were considered to calculate the overall rate of LAMS misdeployment, while studies not reporting the causes of technical failure were excluded. Case reports were considered only for the extraction of data regarding the issues of misdeployment and rescue techniques. The following data were collected from each study: Author, year of publication, study design, study population, clinical indication, technical success, reported number of misdeployment, stent type and size, flange misdeployed and type of rescue strategy.RESULTSThe overall technical success rate of EUS-CDS, EUS-GBD and EUS-PFC was 93.7%, 96.1%, and 98.1% respectively. Significant rates of LAMS misdeployment have been reported for EUS-CDS, EUS-GBD and EUS-PFC drainage, respectively 5.8%, 3.4%, and 2.0%. Endoscopic rescue treatment was feasible in 86.8%, 80%, and 96.8% of cases. Non endoscopic rescue strategies were required only in 10.3%, 16% and 3.2% for EUS-CDS, EUS-GBD, and EUS-PFC. The endoscopic rescue techniques described were over-the-wire deployment of a new stent through the created fistula tract in 44.1%, 8% and 64.5% and stent-in-stent in 23.5%, 60%, and 12.9%, respectively for EUS-CDS, EUS-GBD, and EUS-PFC. Further therapeutic option were endoscopic rendezvous in 11.8% of EUS-CDS and repeated procedure of EUS-guided drainage in 16.1% of EUS-PFC.CONCLUSIONLAMS misdeployment is a relatively common adverse event in EUS-guided drainages. There is no consensus on the best rescue approach in these cases and the choice is often made by the endoscopist relying upon the clinical scenario, anatomical characteristics, and local expertise.

A 48-year-old patient was referred for anemia, jaundice, and right upper-quadrant pain, 5 months after a thorough evaluation for anemia resulting from obscure gastrointestinal bleeding. Abdominal imaging at admission showed a mass in the gallbladder, and endoscopic ultrasound confirmed the presence of a polyp-like lesion with a vascular stalk and clots within the gallbladder. During endoscopic ultrasound, hemobilia was visible (Figures A, B, and C, and Video 1). Laparoscopic cholecystectomy was performed with resolution of symptoms and the final diagnosis was gallbladder melanoma (Figure D). The patient had no history of melanoma and a search for an alternative primary site was unrevealing. Adjuvant treatment with nivolumab was initiated. Primary gallbladder and biliary tract melanoma is extremely rare, with only 37 and 14 cases reported in the literature, respectively. Most cases are caused by metastatic disease. No record of melanoma, the presence of a solitary lesion with a polypoid shape, and histologic examination showing junctional activity all indicate a primary tumor. Gallbladder melanoma most commonly is asymptomatic, but symptoms may occur including abdominal pain, nausea and vomiting, anemia, hemobilia, obstructive jaundice, and acute cholecystitis. Hemobilia associated with jaundice and right upper-quadrant pain, known as Quincke's triad, is an uncommon clinical manifestation, with only a handful of reported cases. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmMTA0YmQ4ZDFmZTA1MjcyZDMwYmU2MDliZmEyMTg1NyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNzAzMjY4NDA1fQ.bbrGxCioHz6UNzPkj229dcAXqLsQIkFRxyvqdVFR2jJDTI6QL0WHBuvlzkfM_WRaOcSUk9poyg7uT-Z91i9uFnCAxl5jqW13-1_5YWJhRcixAW3kiGVtsAf4DMZi-DHBqD1NH6dP6f1GP6CT7FV2hPGLkyDDsn5Js8GoZSQ_7ddjyBcLmSShcC2xIeFdn1wwPdL7SRGIDNObG6gosCWm2o12Dbos0eMJYjZtXL9voAQGrDytya-D4EwD4UsyP4h3QNUc6U7uP4rGR_k0Vdc9QlRVxgrTk0r8tQYuirs4o8lDNkUB0DNbJEAtdfU7TbZ1651TzDoes72uI6GZMV-H1A Download .mp4 (19.58 MB) Help with .mp4 files Video

A 70-year-old woman with acute cholangitis was referred to our unit for treatment. Complex choledocholithiasis with impacted stones prevented endoscopic retrograde cholangiopancreatography (ERCP) and the patient underwent biliary drainage by endoscopic ultrasound (EUS)-guided choledochoduodenostomy (CDS) using a cautery-enhanced 8 × 8-mm lumen-apposing metal stent (LAMS) over a guidewire.

Endoscopic ultrasound-guided biliary drainage (EUS-BD) has become the procedure of choice for relieving biliary obstruction in patients for which traditional endoscopic retrograde cholangiopancreatography (ERCP) is unsuccessful. Certain patients may require hepatobiliary surgery after EUS-BD. The outcomes of patients undergoing surgery after EUS-BD is unknown. We compare feasibility and outcomes of curative surgery after EUS-guided BD to standard published data on interval surgery after conventional ERCP.

During the recent outbreak of COV-SARS 2 infection, most hospitals in Italy as well as in almost every country of the world have been forced to reallocate their resources to cope with the huge flow of patients in need of hospitalization and even intensive care for respiratory symptoms. In this context, gastroenterology departments and endoscopy centers have significantly reduced their activity. In a recent survey Repici et al. [1Repici A, Pace F, Gabbiadini R. et al. Endoscopy units and the COVID-19 outbreak: a multi-center experience from Italy. Gastroenterology 2020 PMID: 32283102(e-pub).Google Scholar] documented that, following the COVID-19 epidemic, 39 out of 41 endoscopy units (EUs) in northern Italy (95.1%) continued to perform urgent procedures, while the same proportion warranted examinations to hospitalized patients, 28 EUs (68.3%) kept scheduling colorectal cancer screening colonoscopies (FIT+), 9 EUs (22.0%) ensured endoscopic therapeutic procedures, and 7 (17.1%) maintained all kind of endoscopic activities. In quantitative terms, this corresponded to a 75–99% reduction in activity in 28% of endoscopic units, and to a 50–75% reduction in 9% of units, with only a single unit maintaining its workload unchanged. Finally, most EUs limited their activity to urgent cases, including patients at high-risk of cancer, such as FIT+. As a result, a formerly planned endoscopic procedure has been postponed or canceled for a large number of patients; the burden of this unmet demand will affect the booking lists as soon as hospitals resume their usual activities. Elective endoscopy activity must be restored for many reasons: first of all, with the mitigation measures that many countries have adopted, the duration of the pandemic is expected to increase by at least six months, leveling the incidence curve and making the prolonged deferral of elective procedures unsustainable [2Gupta S. Shahidi N. Gilroy N. Rex D.K. Burgess N.G. Bourke M.J. A proposal for the return to routine endoscopy during the COVID-19 pandemic.Gastrointest Endosc. 2020; https://doi.org/10.1016/j.gie.2020.04.050Abstract Full Text Full Text PDF Scopus (32) Google Scholar]; in addition, routine endoscopy has a huge economic and health impact. In the United States alone, a hypothetical suspension of elective endoscopy for 6 months is expected to lead to the delayed diagnosis of over 2800 colorectal cancers and 22,000 high-grade adenomatous polyps with malignant potential [3Peery A.F. Crockett S.D. Murphy C.C. et al.Burden and cost of gastrointestinal, liver, and pancreatic diseases in the United States: update 2018.Gastroenterology. 2019; 156 (e11): 254-272Abstract Full Text Full Text PDF PubMed Scopus (944) Google Scholar]. The 6-month mortality rate for those who would eventually be diagnosed with colorectal cancer would increase by 6.5% [4Pita-Fernández S. González-Sáez L. López-Calviño B. et al.Effect of diagnostic delay on survival in patients with colorectal cancer: a retrospective cohort study.BMC Cancer. 2016; 16: 664Crossref PubMed Scopus (48) Google Scholar]. The problem is how to restart elective endoscopy and how to reschedule the examinations that have been postponed. Inherently, as the COVID-19 epidemic is likely to persist, we should possibly reconsider the current indications for endoscopy, as only a revision of the indications could allow for a workload that must necessarily be significantly reduced, due to social distancing and other restrictive measures to be continued in the near future. We would like to report a survey among 10 endoscopy centers in Northern Italy that had already participated in another study [5Armellini E. Repici A. Alvisi C. et al.Analysis of patients attitude to undergo urgent endoscopic procedures during COVID_19 outbreak in Italy.Digest Liver Disease. 2020; https://doi.org/10.1016/j.dld.2020.05.015Abstract Full Text Full Text PDF PubMed Scopus (29) Google Scholar], related to patients' decision to undergo or cancel endoscopic procedures planned during the coronavirus epidemic, even if prescribed as relatively urgent by their General Practitioners. The purpose of the present survey was to ascertain whether endoscopic examinations, previously booked for the period of interruption of endoscopic activity, would simply be canceled or postponed and, if so, on what policy (i.e. based on a clinical decision, with a medical review of indications and priorities, or simply on an administrative one). To gather information, we prepared a simple questionnaire which asked three simple questions relating to the interval between March 9 and April 30:1)number of upper and lower endoscopies planned but not performed, due to the interruption of the activity connected to the global reorganizations of COVID-19 hospitals, precluding the performance of routine endoscopy;2)policy adopted to "recover" these patients, if any;3)percentage of rescheduled patients who agreed to undergo the procedure. We collected data from 3079 patients regarding 1417 upper endoscopies and 1662 colonoscopies. In most centers, no reprogramming policy was adopted, and endoscopy units were given indications that all previously booked procedures should simply be re-booked by patients. In 6 EUs only, patients were contacted directly by the medical staff and asked if they wanted to reschedule the procedure or, conversely, if they wanted it canceled. Rescheduling was chosen by 27.5% to 85% of patients, cancelation by 10% to 57.5% of cases, the figures highlighting impressive differences among the participating EUs. Patients who agreed to reassign the procedure were informed that the date could be adjusted according to a priority based on the indications and severity of the potential condition. In the remaining 5 EUs, patients were contacted by administrative staff and informed that the procedure would be automatically rescheduled, without any triage. We do not know what corresponding percentage of patients contacted by administrative staff accepted or refused to undergo the endoscopic examination. Globally, the burden of searching for a new appointment has been left to the citizen despite the fact that the choice not to provide endoscopic examinations during the COVID-19 peak was made by hospitals and health authorities in the two Italian regions, and not by the citizens. The ongoing COVID-19 epidemic has been the cause not only of deaths, serious illnesses of previously healthy people and severe stress for hospitals and doctors, but it will likely have long-lasting negative consequences for people's health. In order to safe reopening of EU, the AGA therefore suggested implementing a triage system, and all procedures to be reallocated should be reviewed by qualified medical personnel and classified as time sensitive or non-time sensitive by adopting a suggested framework [6Sultan S. Lim J.K. Altayar O. Davitkov P. Feuerstein J.D. Siddique S.M. FalckYtter Y. El-Serag H.B. on behalf of the AGA, AGA institute rapid recommendations for gastrointestinal procedures during the COVID-19 pandemic.Gastroenterology. 2020; https://doi.org/10.1053/j.gastro.2020.03.072Abstract Full Text Full Text PDF Scopus (237) Google Scholar]. However, we should understand that the COVID-19 epidemic is not close to extinguish but will remain with us for the foreseeable future (at least six months). We must therefore resume routine (i.e. elective) outpatient endoscopy and we must recognize that the volume of endoscopic outpatient procedures will decrease compared to the past, due to persistent limitations (social distance and other practical measures that limit contact between people, to prevent spread of SARS-CoV2 infection). It means that we must actually make a significant selection of deferrable or non-deferrable endoscopic procedures, and this can only be done by experienced gastroenterologists. Here we appeal to our health authorities to understand that COVID-19 does represent a great challenge, but it also offers an opportunity to try to reduce inadequacy in endoscopy, which has so far been a major global concern: for example, it is estimated that 56% of upper gastrointestinal endoscopy diagnostic procedures are considered inappropriate, i.e. not according to guidelines [7Hassan C. Bersani G. Buri L. et al.Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian society of digestive endoscopy.Gastrointest Endosc. 2007; 65: 767-774Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar, 8Manes G. Balzano A. Marone P. et al.Appropriateness and diagnostic yield of upper gastrointestinal endoscopy in an open-access endoscopy system: a prospective observational study based on the Maastricht guidelines.Aliment Pharmacol Ther. 2002; 16: 105-110Crossref PubMed Scopus (35) Google Scholar, 9O'Sullivan J.W. Albasri A. Nicholson B.D. Perera R. Aronson J.K. Roberts N. Heneghan C Overtesting and undertesting in primary care: a systematic review and meta-analysis.BMJ Open. 2018; 8e018557PubMed Google Scholar, 10de Jong J.J. Lantinga M.A. Drenth J.P.H Prevention of overuse: a view on upper gastrointestinal endoscopy.World J Gastroenterol. 2019; 25: 178-189Crossref PubMed Scopus (34) Google Scholar]. None.

Background and study aims COVID-19 has dramatically impacted endoscopy practice because upper endoscopy procedures can be aerosol-generating. Most elective procedures have been rescheduled. Endoscopic retrograde cholangiopancreatography (ERCP) is frequently performed in emergency or urgent settings in which rescheduling is not possible. We evaluated the impact of the COVID-19 pandemic on ERCP in Italy during the SARS-CoV-2 lockdown, in areas with high incidence of COVID-19. Patients and methods We performed a retrospective survey of centers performing ERCP in high COVID-19 prevalence areas in Italy to collect information regarding clinical data from patients undergoing ERCP, staff, case-volume and organization of endoscopy units from March 8, 2020 to April 30, 2020. Results We collected data from 31 centers and 804 patients. All centers adopted a triage and/or screening protocol for SARS-CoV-2 and performed follow-up of patients 2 weeks after the procedure. ERCP case-volume was reduced by 44.1 % compared to the respective 2019 timeframe. Of the 804 patients undergoing ERCP, 22 (2.7 %) were positive for COVID-19. Adverse events occurred at a similar rate to previously published data. Of the patients, endoscopists, and nurses, 1.6 %, 11.7 %, and 4.9 %, respectively, tested positive for SARS-CoV-2 at follow up. Only 38.7 % of centers had access to a negative-pressure room for ERCP. Conclusion The case-volume reduction for ERCP during lockdown was lower than for other gastrointestinal endoscopy procedures. No definitive conclusions can be drawn about the percentage of SARS-CoV-2-positive patients and healthcare workers observed after ERCP. Appropriate triage and screening of patients and adherence to society recommendations are paramount.

The COVID-19 pandemic has rapidly affected every country and overwhelmed many healthcare systems. Intensive care treatment may be needed for extended durations. Patients experience consequences of respiratory illness and post-intensive care illness (1,2).

Disease 53S3 (2021) S87-S219 S207 stenting was achieved in 54/56 (96.4%).Clinical success of biliary drainage was obtained in 51/56 (91.1%) and clinical success of duodenal stenting in 49/56 (87.5%).We observed 12/56 (21.4%) complications: 7 intra-procedural (4 self-limiting bleedings, 2 LAMS maldeployments, 1 iatrogenic duodenal perforation), 5 early (pancreatitis) and 13 late "stent-related" (10 cholangitis due to biliary stent ingrowth/plugs, 2 stent migration and 1 outlet obstruction due to duodenal stent ingrowth). Conclusions:In a referral center for bilio-pancreatic diseases, the impact of concomitant malignant GOO and MBO is significant.Combined stenting of bilio-duodenal malignant strictures is an effective, minimally invasive and alternative to surgery procedure, with low complication rate, thus becoming the standard of palliative care in this setting.AF.

Endoscopic ultrasound-guided choledochoduodenostomy (EUS-CDS) with lumen apposing metal stent (LAMS) has emerged as a procedure with encouraging results in terms of safety and effectiveness in patients with malignant distal biliary obstruction and failed endoscopic retrograde cholangiopancreatography (ERCP).