Background and Objectives: Functional gastric stenosis, a consequence of sleeve gastrectomy, is defined as a rotation of the gastric tube along its longitudinal axis. It is brought on by gastric twisting without the anatomical constriction of the gastric lumen. During endoscopic examination, the staple line is deviated with a clockwise rotation, and the stenosis requires additional endoscopic manipulations for its transposition. Upper gastrointestinal series show the gastric twist with an upstream dilatation of the gastric tube in some patients. Data on its management have remained scarce. The objective was to assess the efficacy and safety of endoscopic balloon dilatation in the management of functional post-sleeve gastrectomy stenosis. Patients and Methods: Twenty-two patients with functional post-primary-sleeve-gastrectomy stenosis who had an endoscopic balloon dilatation between 2017 and 2023 were included in this retrospective study. Patients with alternative treatment plans and those undergoing endoscopic dilatation for other forms of gastric stenosis were excluded. The clinical outcomes were used to evaluate the efficacy and safety of balloon dilatation in the management of functional gastric stenosis. Results: A total of 45 dilatations were performed with a 30 mm balloon in 22 patients (100%), a 35 mm balloon in 18 patients (81.82%), and a 40 mm balloon in 5 patients (22.73%). The patients’ clinical responses after the first balloon dilatation were a complete clinical response (4 patients, 18.18%), a partial clinical response (12 patients, 54.55%), and a non-response (6 patients, 27.27%). Nineteen patients (86.36%) had achieved clinical success at six months. Three patients (13.64%) who remained symptomatic even after achieving the maximal balloon dilation of 40 mm were considered failure of endoscopic dilatation, and they were referred for surgical intervention. No significant adverse events were found during or following the balloon dilatation. Conclusions: Endoscopic balloon dilatation is an effective and safe minimally invasive procedure in the management of functional post-sleeve-gastrectomy stenosis.

Objective. The intend of the present study was to assess the diagnostic performance of strain elastography in investigating the thyroid nodule malignancy taking the surgical biopsy as a gold standard reference test. Methods. The study included 120 patients with 123 thyroid nodules, of which 67 had total thyroidectomy. The American College of Radiology Thyroid Imaging Reporting and Data Systems (ACR-TIRADS) were evaluated for all nodules. All suspicious nodules were referred for a fine needle aspiration cytology (FNAC) if they fulfilled the required size. Strain elastography was performed for each suspicious nodule. Ultrasound-guided FNAC was performed for all suspicious nodules. Total thyroidectomy was performed in those whom the suspicious nodules were proven by FNAC. Results. Strain ratio had a sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of 84%, 81%, 95%, 85%, and 84%, respectively, with a cut point 1.96. Elasticity score had a sensitivity, specificity, PPV, NPV, and diagnostic accuracy of 100%, 80%, 95%, 85% and 87%, respectively, with a cut point 0.96. The elasticity score had a statistically significantly odds ratio for detecting the benignity 3.9 C. I (1.6-9.3). Conclusion. Strain elastography has a high diagnostic performance in detecting the malignant as well as benign nodules, thus it can limit the rate of unneeded FNAC or surgery especially among B3 and B4 groups with indeterminate cytology.

Background and Objectives: Endoscopic biliary plastic stenting is a safe and effective temporary therapeutic modality used in various benign biliary disorders. Long-term indwelling stents for more than one year without retrieval are termed “forgotten biliary stents”. In clinical practice, the forgotten stents are underestimated and the majority of data were obtained from case reports. The aim of this study was to determine the forgotten-biliary-plastic-stent-related complications, their management, and the patients’ clinical outcomes. Materials and Methods: This retrospective study was performed at three hospitals during the period from January 2021 to December 2023. In total, 577 patients with biliary plastic stents—inserted for a variety of benign biliary conditions—were included. They were divided into two groups, as follows: group 1 included 527 patients who had biliary stents removed within 3 months, and group 2 included 50 patients with biliary stents retrieved after one year of their deployment. The stent-related complications (e.g., acute cholangitis, stent clogging, distal stent migration, new common bile duct (CBD) stone formation, and proximal stent migration) and the endoscopic management success rate were evaluated. Results: Irretrievable CBD stones were the main indication for biliary plastic stenting in both groups. The stent-related complications, number of endoscopic sessions, and hospital admissions were significantly higher in the patients with forgotten biliary stents than those with stent removal within 3 months. All the study patients were successfully managed endoscopically with uneventful outcomes. Conclusions: Based on this retrospective study, non-adherence to the endoscopists’ instructions is the main reason for retained biliary stents for more than one year. The patients with forgotten stents had significantly higher complication rates, a higher number of endoscopic sessions, and a higher number of hospital admissions than those with stents that were retrieved in the scheduled time. All patients were managed endoscopically with a technical success rate of 100%, and with no complication-related mortality.

Background: NAFLD is the commonest liver pathology globally which is distinguished by hepatic steatosis without evidence of secondary injurious hepatic agents.The spectrum of liver affection in NAFLD is variable starting from mild steatosis to evident fibrosis and may extend to extra hepatic morbidities.CVD is one of the highly serious systemic comorbidities of NAFLD including various degrees of cardiovascular dysfunction especially at the level of left ventricle.Whole blood viscosity (WBV) is an important rheological parameter that affects blood flow in the circulation with subsequent affection of tissue perfusion, so investigators try to elucidate the role of WBV as a crucial player in the etiopathogenesis of LVD in NAFLD cases and hence its use as an early preditictor marker.Patients and Methods: This is a cross sectional study that was carried out on 50 NAFLD cases grouped into 2 groups based on the existence presence of LVD: Group 1 included 26 patients with LVD, group 2 included 24 patients without LVD. The patients’ demographic, clinical, laboratory and radiological data were recorded on a special observation sheet. Whole blood viscosity and ECHO cardiography assessment of the left ventricular function of patients were also recorded. Statistical analysis was done for all collected data using the IBM, SPSS version 23. Significance of obtained results was considered at p-value of less than 0.05.Results: WBV was significantly increased in group 1 compared to group 2. WBV had appeared to be an excellent predictor of LVD in patients with NAFLD; it was positively correlated with hemoglobin, hematocrit, fatty liver status and fibrosis and all LVD parameters except for ejection fraction and relative wall thickness. By logistic regression analysis hemoglobin, whole blood viscosity, and left ventricular end-diastolic diameter are the only predictors in NAFLD patients with LVD. WBV at a cut-off value of 4.38; the AUC was 0.756, the sensitivity was 96.15%, the specificity was 83.33%, the PPV was 86.20%, and the NPV was 95.23%.Conclusion: WBV is a good, easily obtained and affordable marker for the determination of LVD in cases with NAFLD.

Aims: Endoscopic evaluation of symptomless IDA patients and related lesions. Study Design: A Cross-sectional epidemiological study. Place and Duration of Study: The hematology unit of the Internal medicine department in Tanta university hospital, the duration of the study was 6 months from 1 January to 31 June 2019. Methodology: 100 consecutive patients with laboratory base diagnosis of IDA without GI symptoms were involved in the study and their clinical and biochemical variables were recorded. All patients underwent esophagogastroduodenoscopy (EGD) and colonoscopy. Endoscopic findings were documented as the presence/absence of bleeding-related lesions or other causes of IDA. Results: Possible cause of anemia was found in 95% and bleeding related lesions were found in 70% of patients. Upper GIT lesions were found in 70% of patients with 42% bleeding related lesions. Lower GIT lesions were found in 33% of patients with 21% bleeding related lesions. On multivariable logistic regression: old age, low hemoglobin (HB), low serum ferritin, and positive fecal occult blood test (FOBT) were predictive factors for GIT lesions and cause of IDA. Conclusion: Clinical and biochemical markers can predict GI lesions on endoscopy in IDA patients without GI symptoms. A high proportion of upper GI involvement makes EGD an initial endoscopic procedure however, a colonoscopy should be done in old age, and when upper GI lesions don't correlate with the severity of IDA.

Background Common bile duct (CBD) stones are seen in ∼7–12%. They vary in size ranging from rather small (∼1–2 mm) to very large (>3 cm). Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy and basket or balloon extraction are well-established therapeutic procedures for the management of CBD stones.Aim The aim of the present study was to assess the role of biliary stenting in management of large or multiple CBD stones by comparison between stone size, number, and index between both sessions of ERCP, with average duration of 2 months.Patients and methods A total of 25 patients referred to our center with radiological evidence of large CBD stones (≥2 cm) and/or multiple stones (≥3) were included. Initial ERCP with biliary stenting was performed. After 2 months or more, second-look ERCP was performed with stone extraction, with comparison of stone number, size, and index between both sessions.Results Our study showed statistical significant reduction in stone size, index, and number, with availability of stones removal in the second session. Moreover, reduction in bilirubin level was observed.Conclusion In conclusion, temporary biliary stenting within an average of 2 months has a role in the management of large and multiple CBD stones and will facilitate stone extraction.

Background Hepatitis C arthropathy is one of the most important extra-hepatic manifestations of HCV. Its clinical presentation is rheumatoid like in about 30% of the cases and the differentiation between both is very important and difficult at the same time as the treatment is completely different. Anti-cyclic citrullinated peptide (Anti- CCP) antibodies can be used as serological markers in differentiation between them but many studies have variable and non-conclusive results concerning its importance. Objectives The aim of this study is to determine whether anti- CCP antibody is helpful alone in discriminating patients with HCV-associated arthropathy from patients with rheumatoid arthritis. Methods In this cross sectional comparative study we included 70 subjects, from Tanta University Hospital, Egypt and divided them into four groups: 30 Rheumatoid arthritis patients not infected with HCV,15 HCV patients with typical polyarthritis like RA without erosions or rheumatoid nodules, 15 HCV patients without arthropathy and 10 Normal subjects as a control group. We measured the level of Anti-CCP and RF in all groups. Results By the end of the study we found that anti-CCP was positive in 83.3% of RA group, 66.7% of HCV with arthropathy group, 40% of HCV without arthropathy group and in 30% of normal control group and there was a significant difference between RA group and HCV without arthropathy and control group, but there was no significant difference between RA and HCV arthropathy However during the comparison between the four groups as regard the degree of positivity of anti-CCP level there was a big difference in the degree of positivity in RA group and HCV arthropathy where 19 (63.3%) were strong positive in RA groups while only (20%)were strong positive in HCV related arthropathy. Conclusions Anti CCP can be a used as an early step in differentiating RA from HCV related arthropathy. If its level is strong positive this can highly suggest early rheumatoid arthritis but if the level is moderately positive or weak positive or even negative it is not enough alone as a marker differentiating RA from HCV related arthropathy. References Michele Bombardieri, Cristiano Alessandri, Giancarlo Labbadia ea. Role of anti-cyclic citrullinated peptide antibodies in discriminating patients with rheumatoid arthritis from patients with chronic hepatitis C infection-associated polyarticular involvement. Arthritis Res Ther 2004;6(2):R137–41. E Or, A C, Ayten Y, N Gr-P, Hulagu S. The positivity of rheumatoid factor and anti-cyclic citrullinated peptide antibody in nonarthritic patients with chronic hepatitis c infection. Rheumatol International 2010;30(4):485–8. M.Elnadry, Abdel-Rashed M, M.A.Abdel-Monem, S.El-Eter, Fathy W. Anti-Cyclic Citrullinated Peptide Frequency in Egyptian Patients with Chronic Hepatitis C Virus Infection with and without Articular Manifestation Journal of American Science 2013;9(11). Disclosure of Interest None declared

Background Gastric antral vascular ectasia (GAVE) is characterized by mucosal and submucosal vascular ectasia causing recurrent hemorrhage and thus, chronic anemia, in patients with cirrhosis. Treatment with argon plasma coagulation (APC) is an effective and safe method, but requires multiple sessions of endoscopic therapy. Endoscopic band ligation (EBL) was found to be a good alternative for APC as a treatment for GAVE, especially in refractory cases. The aim of this prospective randomized controlled study was to evaluate the safety and efficacy of EBL, as compared to APC, in the treatment of GAVE and gastric fundal vascular ectasia (GFVE). Patients and methods A total of 88 cirrhotic patients with GAVE were prospectively randomized to endoscopic treatment with either EBL or APC, every 2 weeks until complete obliteration was accomplished; then they were followed up endoscopically after 6 months, plus they had monthly measurement of hemoglobin levels during that period. Results We describe the presence of mucosal and submucosal lesions in the gastric fundal area that were similar to those found in GAVE in 13 patients (29.5%) of the EBL group and 9 patients (20.5%) of the APC group; we named this GFVE. In these cases, we treated the fundal lesions with the same techniques we had used for treating GAVE, according to the randomization. We found that EBL significantly decreased the number of sessions required for complete obliteration of the lesions (2.98 sessions compared to 3.48 sessions in the APC group (p < 0.05)). Hemoglobin levels increased significantly after obliteration of the lesions in both groups, compared to pretreatment values (p < 0.05), but with no significant difference between the two groups (p > 0.05); however, the EBL group of patients required a significantly smaller number of units of blood transfusion than the APC group of patients (p < 0.05). There were no significant differences in adverse events nor complications between the two groups (p > 0.05). Conclusions This study described and histologically proved the presence of GFVE occurring comcomitantly with GAVE in cirrhotic patients. We showed that GFVE can be successfully managed by EBL or APC. Our study revealed that EBL is more effective and is comparable in safety to APC, in the treatment of GAVE and GFVE in cirrhotic patients.

DH Ziada, S El Saadany, M Enaba, M Ghazy, A Hasan. The interaction among insulin resistance, liver fibrosis and early virological response in Egyptian patients with chronic hepatitis C. Can J Gastroenterol 2012;26(6):325-329BACKGROUND: Hepatitis C virus (HCV) infection may induce insulin resistance (IR) irrespective of the severity of liver disease, and there is evidence of a central role for IR in failure to achieve sustained virological response (SVR) in HCV patients.OBJECTIVE: To assess IR as a predictor of the severity of hepatic fibrosis in Egyptian HCV patients, and its effect on early viral kinetics and virological response to HCV therapy.METHODS: A total of 140 chronic HCV patients were divided into two groups according to the homeostasis model assessment-IR (HOMA-IR). Group 1 consisted of 48 chronic HCV patients with HOMA-IR >= 2, and group 2 consisted of 92 chronic HVC patients without IR (HOMA IR <2). All patients were treated with combination therapy (pegylated interferon-alpha 2a plus ribavirin) for 48 weeks and studied for viral kinetics throughout the period of therapy.RESULTS: The study revealed that older age, higher body mass index and HOMA-IR >= 2 were significantly associated with advanced fibrosis. Rapid virological response, complete early virological response and SVR were significantly lower in the IR-HCV group compared with the non-IR-HCV group. Univariate and multivariate analyses revealed that older age, fibrosis (F >= 3), high viral load (>600,000 IU/mL) and HOMA-IR >= 2 were significantly associated with a lack of viral kinetics as well as SVR. However, HOMA-IR >= 2 was the main independent variable associated with lack of SVR. On the other hand, body mass index, plasma insulin level and HOMA-IR decreased significantly compared with starting levels in patients who achieved SVR. This suggests a cause and effect relationship between HCV infection and IR.CONCLUSION: IR in chronic HCV patients is associated with progressive fibrosis and slow viral kinetics, and could be a predictor for lack of rapid and early virological response. Therefore, HOMA-IR levels should be measured and improved before starting antiviral treatment.

PURPOSE The purpose of this study was to present the safety and effectiveness of an expectant protocol employing Savary-Gilliard dilatation in benign oesophageal stricture in infants and toddlers along a decade of experience. PATIENTS AND METHODS Thirty eight infants and toddlers with benign oesophageal stricture with age ranged between 5 and 22 months were treated by modified dilatation protocol. Complications and outcomes of the dilatation protocol were reported during a follow-up period of 12 to 100 months. RESULTS We have 25 cases of corrosive stricture, 4 congenital, 4 post-reflux and 5 post-anastomotic strictures. A total of 654 dilatations in 265 sessions were done. The corrosive subgroup has a mean dysphagia score of 2.6 pre-dilatation that improved at 6 months after end of dilatation to a mean of 0.3. In the non-corrosive subgroup, significant lower number of dilatation and sessions were reported. We have three failures that need surgery. Thirty five cases reach acceptable oesophageal caliber. Mucosal tear and small perforation each reported once. Small diverticulum reported twice. CONCLUSIONS The expectant dilatation protocol is feasible in managing benign oesophageal stricture in infants and toddlers without increasing the morbidity. It is effective even in long segment or multiple corrosive strictures.

BACKGROUND:In Egypt, few data are available on the outcome of colonoscopy. Epidemiologic studies have shown that inflammatory bowel disease (IBD) tends to increase. Endoscopists have reported an increasing incidence of IBD and colorectal cancer (CRC). This may be explained by an increasing index of suspicion and the availability of endoscopy. Population-based studies are lacking.AIM:The aim of our study was to retrospectively evaluate the patient characteristics and final diagnosis in patients subjected to colonoscopy in Tanta University Hospital and affiliated hospitals at the middle of Nile delta of Egypt, which is one of the most densely populated regions in the country.METHODS:This study was done at the endoscopy units of Tanta University Hospital and affiliated hospitals (all units of colonoscopy at Gharbia governorate) from June 2008 to June 2009. A total of 864 patients presented with different indications for colonoscopy. All findings were recorded, analyzed, and discussed.RESULTS:Colonoscopy revealed a diagnosis of ulcerative colitis (UC) in 22%, hemorrhoids in 18%, CRC in 15%, benign colorectal polyps in 9%, Crohn's disease (CD) in 3%, diverticulosis in 2%, and anal fissures in 2% of patients. No organic colonic disease was found in 28% of patients. Complications occurred in less than 1% of the cases.CONCLUSION:In Egyptian patients subjected to colonoscopy, the most frequent diagnoses were UC, followed by hemorrhoids, CRC, benign polyps, and CD. This may represent an increasing incidence of UC and CRC. Colonoscopy was safe and few complications were recorded. Prospective population-based studies are needed in order to measure the incidence, prevalence, and risk factors of various diseases of the colon in Egypt.

BACKGROUND:Despite several attempts to make the conventional tubular stents with a central lumen for flow less susceptible to a biofilm buildup and thereby prevent clogging, this goal has remained elusive. We hypothesized that the creation of pathways for fluid flow around the stent instead of through it would avoid this problem. The aim of our study was to report the development and the evaluation of a novel lumen-less stent.METHODS:By using a software computer modeling, a 10F "winged" stent was designed. A pilot feasibility study was performed by using a prototype of this stent for endoscopic biliary drainage in 5 patients with malignant biliary obstruction.OBSERVATIONS:Modeling data revealed that the winged stent offers a larger surface area for flow, higher velocity of flow, and increased flow rates compared with the conventional tubular stent. In the clinical trial, there was a significant decrease of serum bilirubin after the placement of this stent (serum bilirubin before and 2 weeks after stent placement, 14.94 +/- 5.7 mg/dL vs. 2.86 +/- 1.4 [p < 0.004]), accompanied by radiologic evidence of decompression of the biliary system.CONCLUSIONS:We have shown that it is possible to provide adequate biliary drainage by using a stent without a lumen. Such a design may have potential clinical advantages over existing designs.