Introduction Biliary brushings are often the only way to confirm a diagnosis of malignancy in patients presenting with biliary strictures. There is a paucity of data regarding the parameters that may affect the diagnostic yield of this technique. The aim of this study was to identify key factors that may improve diagnostic sensitivity in hepatobiliary malignancies. Methods Brushing outcomes were identified over a 2-year period and analysed by demographic factors (age, sex), indication of the procedure, site and length of stenosis on ERCP, CBD dilatation on CT/MRCP/ERCP, site and size of mass, laboratory values (ALP, ALT, bilirubin) prior to the procedure, and final outcome (histologically or radiologically confirmed). We calculated the ratio of at least suspicious for malignancy results out of the total cases of malignancies. Final outcome was defined by histology or radiological evidence of cancer in the follow-up period. Data was retrospectively retrieved and processed using the EPR (electronic patient record) hospital database and the radiology InSight PACS system. Data was analysed using the statistical package SPSS v.25. Results A total of 59 brushing results were identified over the period 01/2017–01/2019. 52 (88.1%) were malignant and 7 (11.9%) were benign. The mean age was 71.4 yrs and the majority of malignancies were pancreatic cancer (33/52; 63.5%), with the remainder including cholangiocarcinoma (7), ampullary cancer (6) and other malignancies. Forty of 52 cases were true positives, indicating a sensitivity of 76.9%, while the specificity was 100% (no false negative and 7/7 true negative). Among the factors examined, sensitivity was significantly associated with the site of stenosis (89.2% for distal vs. 50% for mid and mid-distal stenoses, p=0.023), and with the mass being in the pancreatic head versus in the uncinate process (84.6 vs 40%, p=0.029). Sensitivity was higher for longer strictures (63.6% vs 46% for strictures >1.9 cm (i.e. the median value), and for larger masses (mean size of mass 4 cm in true positive vs 2.6 cm in false negatives) but these results did not reach statistical significance. The age, CBD dilatation on imaging, type of cancer and the laboratory markers before the procedure were not associated with differences in the diagnostic yield. Conclusions Distal CBD stenoses and pancreatic head lesions are associated with statistically significant increase in brushing sensitivity for malignancy. This study suggests that in the absence of a distal CBD stricture or a pancreatic head lesion, further investigation modalities (additional brushings, EUS, percutaneous biopsy, cholangioscopy) will be more likely required to achieve diagnostic certainty.

Introduction Brushings at ERCP play a crucial role in establishing a diagnosis in cases of biliary strictures. In this study, we examined if brushing practice can make a difference to the diagnostic yield resulting in less interventions. We analysed ERCP data over the last two and a half years at the Royal Berkshire Hospital, where inclusion of the brush head for cytology and performing three or more passages across the stricture has been standard practice. Methods We looked at results of brushings taken by 2 ERCPists in a single centre between September 2016 to February 2018. The initial brushing result from each individual patient was included. Brushing results were classified as non-diagnostic, negative, atypical, suspicious or positive for malignancy. Brushings classified as suspicious and identified as malignant were categorised into the positive group; those classified as non-diagnositc, non-malignant and atypical were categorised as negative. For comparison purposes we considered the corresponding histology and/or radiological findings and/or positive immunohistochemistry in the follow-up period. Data was analysed using the statistical package SPSS v.25. Results In total, 71 individual brushing outcomes were identified over a 2.5-year period. In 61 of 71 cases (85.9%) the final diagnosis was cancer, with the majority being pancreatic cancer (36/61; 59%). The sensitivity was estimated at 77% (47/61 true positive), the specificity and the positive predictive value (PPV) were both 100% (0 false negative, 10 true negative), while the negative predictive value (NPV) was 38%. When we looked at only ‘positive for malignancy’ results, the sensitivity stood at 60%. In 15/61 cases (24.6%) a supplementary report was needed to confirm the result and it changed the outcome in only 3 cases (20%). Conclusions Biliary brushings are a very useful means of providing a diagnosis during ERCP and are characterised by a high PPV and low NPV. Negative results should not be interpreted as absence of malignancy but if the yield is at least suspicious, the specificity approaches 100%. This study suggests that sending the brush head for cytology and performing three or more passages across the stricture increases diagnostic sensitivity when compared to published data reporting on sensitivities up to 64% (Burnett AS, Calvert TJ, Chokshi RJ. Sensitivity of endoscopic retrograde cholangiopancreatography standard cytology: 10-y review of the literature. J Surg Res. 2013;184:304– 11.)

Acute pancreatitis may rarely be caused by papillary mass lesions such as adenocarcinomas and neuroendocrine tumours. Occasionally these papillary lesions may cause recurrent episodes of acute pancreatitis and patients presenting in this way require further pancreatic investigation. We believe this to be the first reported case of a duodenal papillary somatostatinoma causing recurrent acute pancreatitis. The patient was investigated with multiple imaging modalities, both at endoscopy and with more traditional radiology, and treated with resection by Whipple's pancreaticoduodenectomy. If diagnosed early in the absence of distant metastases the prognosis of papillary somatostatinoma with tumour resection is excellent.

A 70-year-old retired gentleman presented with a 3-week history of right-sided jaw pain, numbness, difficulty swallowing and an enlarging mass along his lower jaw. He noted some bleeding from the mass just prior to admission. He had recently experienced a reduced appetite, difficulty swallowing and approximately one stone in weight loss. Three weeks prior to admission, he noticed increasing shortness of breath and a reduced exercise tolerance. There were no symptoms affecting his vocal cords, nose or ears. His past medical history included a triple heart bypass, pacemaker insertion, hypertension and insulin-dependent diabetes mellitus. He was a non-smoker and non-drinker. His medication included aspirin, bisoprolol, doxasozin, furosemide, metformin, insulin, ramipril and simvastatin. On initial examination, there was a lesion on his right mandible measuring 5 × 6 cm with protrusion into the gingivae (Figures 1 and 2). His abdomen was soft and non-tender and there was mild epigastric pain on palpation but no obvious masses. There was no obvious organomegaly. The oral mass was non-tender with bloody …

Collagenous gastritis is a rare disorder first described in 1989. After encountering two cases, we decided to review the literature and evaluate the collagen band. A systematic review of PubMed and EMBASE databases was performed. Twenty-eight cases have been previously described and two patterns of presentations are identifiable: children or young adults (median age 12 years, range 2-22 years) presenting with symptoms attributable to the gastritis (anaemia and pain); and older adults (median age 52 years, range 35-77 years) presenting with loose stools, often associated with collagenous colitis or coeliac disease. Our two cases (one child and one adult) matched this pattern. Immunostaining of the collagen band for collagens II, III, IV and VI, and tenascin showed that the band in our cases was predominantly tenascin. In conclusion, collagenous gastritis is a rare entity whose presentation depends on the age of the patient. An autoimmune aetiology seems possible given its associations. Treatment is empirical. The 30 cases now reported show that the disorder can relapse or persist for years. Eur J Gastroenterol Hepatol 21:1419-1424 (C) 2009 Wolters Kluwer Health | Lippincott Williams & Wilkins.

Eradication rate was comparable between those patients with MTZ-resistance and MTZsensitive strains (85.7% vs 86.4%).Bismuth-based quadruple regimen containing MTZ is highly effective in Hp eradication, can overcome MTZ-resistance, well tolerated and canbe considered as a primary therapy for Hp infection in an are with high metronidazole and clarithromycin resistance.

Background: Metallic stents are used to palliate dysphagia in patients with oesophageal malignancy. The British Society of Interventional Radiology published a Registry of Oesophageal Stenting (ROST) in 2004 with data from 17 centres in the UK. Aim: The aim of this audit was to assess the efficacy of oesophageal stents in malignancy in a large UK district general hospital and compare our results to the published ROST data. Methods: Patients who had an oesophageal stent at The Royal Berkshire hospital from 2001-05 were identified, and case-notes reviewed. Results: TUMOUR/ PATIENT DEMOGRAPHICS: 74 patients (58% male) had stents (compared with 458 patients in the ROST data (62% male)). 68% (62% ROST) had adenocarcinoma (8 had confirmed Barret's oesophagus - all long segment), 25% (27% ROST) squamous carcinoma, 7% (4% ROST) extrinsic compression. 2% were in the upper 1/3 oesophagus, 23% mid 1/3 oesophagus, 67% in the lower 1/3, 5% arose at the GOJ and 3% extended from the stomach proximally (compared to 8% ,25%,65% and 2% in ROST respectively). 9 had previous carcinoma of other organs. 91% patients presented with dysphagia (97% ROST), 27% with weight loss, 10% nausea/ vomiting and 3% with reflux symptoms. Pre-Stenting: 12% had a barium meal pre-endoscopy. 28% had chemotherapy and 35% had radiotherapy and combined therapy (45% ROST received pre-stent palliation). 2 patients had an oesophagectomy (8% ROST), but had recurrent disease. The median time from diagnostic endoscopy to stent was 28 days (range 0-64 days). Stenting was carried out by 5 consultants (3 physicians/2 surgeons). 37% had concurrent dilatation & stenting (10% ROST). 45% patients had covered Ultraflex stents and 41% Flamingo Wallstents, 11% covered wallstents, 3% Choo stent. Post-Stenting: There were no immediate complications, however 3 stents migrated distally after 2 weeks (all lower 1/3 stents) (4% ROST). 1 patient died during the in-patient stay due to disease progression (> 2 weeks post-procedure). 88% had symptomatic benefit, and of these patients 47% had weight gain. The median duration of symptom palliation was 2.5 months (range 1 week - 10 months), and the median time from stent to death was 2 months (range 7 days-12 months) (50% ROST patients dead at 92 days). Conclusion: With experienced operators and a low complication rate in our hospital, oesophageal stenting remains an effective palliative procedure with good symptomatic benefit for patients with a terminal illness. However the life expectancy of this patient cohort makes long term assessment of stent function/ effectiveness difficult. Our patient cohort and results are comparable to the published UK ROST data.