Acute cholangitis requires both timely source control and appropriate empiric antimicrobial therapy. Although unnecessarily broad antimicrobial coverage should be avoided from an antimicrobial stewardship perspective, the choice of empiric therapy should not be reduced to a simple comparison between broad- and narrow-spectrum regimens. Patients with biliary stents, repeated biliary interventions, recurrent cholangitis, healthcare exposure, proton pump inhibitor use, prior resistant-organism isolation, or prior antimicrobial exposure may have an increased risk of antimicrobial-resistant pathogens. In such patients, broad-spectrum empiric therapy may be selected not as routine overtreatment, but as risk-adapted treatment to avoid inadequate initial coverage. Observational studies evaluating empiric antimicrobial spectrum should therefore account for patient-level resistant-pathogen risk, microbiological findings, source-control details, and de-escalation practices. A risk-adapted approach may better balance antimicrobial stewardship with patient safety in acute cholangitis.

Intracholecystic papillary-tubular neoplasm (ICPN) is a preinvasive neoplasm arising from the gallbladder mucosa, with a better prognosis than conventional gallbladder carcinoma; however, accurate preoperative differentiation based solely on imaging remains challenging. When complicated by infection, inflammatory changes often mimic tumor invasion, making it difficult to accurately evaluate the tumor extent. We report the case of an 83-year-old male with a liver abscess and suspected advanced gallbladder carcinoma. Initial imaging suggested invasion of the liver and right hepatic artery, and the tumor was initially considered unresectable given the advanced age of the patient and reduced activities of daily living. However, imaging after infection control suggested limited invasion. During endoscopic management of cholangitis, we successfully advanced the cholangioscope into the gallbladder. Direct observation revealed that the interior of the gallbladder was filled with a papillary tumor. Biopsy findings supported the diagnosis of ICPN. Surgery was performed subsequently, achieving complete resection. Pathological examination revealed that the invasion was confined to the mucosa (pT1a). This case suggests that infection control may be essential for evaluating the tumor extent. The case also suggests that peroral cholangioscopy is valuable in the diagnosis of ICPN.

Evidence regarding the efficacy and tolerability of chemotherapy in older patients with pancreatic cancer remains insufficient. This study aimed to determine the optimal chemotherapy regimen and relative dose intensity (RDI) in older patients with pancreatic cancer. This retrospective analysis included patients aged ≥ 75 years with metastatic pancreatic cancer treated with gemcitabine plus nab-paclitaxel (GnP) or gemcitabine (Gem) monotherapy, using data from the Tokushukai Real-World Data project. Patients were categorized by RDI into high (≥ 85

Anaplastic pancreatic carcinoma (APC) is an extremely rare and aggressive histological subtype of pancreatic cancer with a poor prognosis. The therapeutic significance of BRCA1/2 mutations, which are established targets in pancreatic ductal adenocarcinoma (PDAC), remains unclear in APC. We report the case of a man in his 70s diagnosed with metastatic pleomorphic APC. Germline testing revealed a pathogenic BRCA2 variant. After achieving stable disease with 5 months of platinum-based chemotherapy (mFOLFIRINOX), he was transitioned to maintenance therapy with the poly(ADP-ribose) polymerase (PARP) inhibitor olaparib. Olaparib maintained stable disease for 18 months. Although his clinical course was complicated by a concurrent sigmoid colon cancer, the patient remains alive at 47 months post-diagnosis. To the best of our knowledge, this case is the first to report long-term disease control with a PARP inhibitor in a patient with BRCA2-mutated APC of the pleomorphic (non-osteoclast-like giant cell) subtype. Our findings suggest the potential efficacy of a “platinum-based therapy followed by PARP maintenance” strategy in BRCA-mutated APC and highlight the importance of early germline BRCA testing.

Duodenal varices, though rare, are potentially life-threatening complications of portal hypertension. Management is challenging when balloon-occluded retrograde transvenous obliteration (BRTO) fails to achieve complete obliteration. Endoscopic ultrasonography-guided variceal therapy (EUS-VT) is effective for gastric varices, but reports of duodenal varices remain limited. We present a case of a 71-year-old woman with alcoholic liver cirrhosis and duodenal variceal bleeding. Initial hemostasis was achieved with endoscopic variceal ligation, followed by BRTO. However, rebleeding occurred due to incomplete obliteration caused by dual afferent veins. EUS-VT comprising n-butyl cyanoacrylate was performed as salvage therapy because of ascites and vascular complexity. Despite technical challenges, EUS-VT successfully obliterated the varices. Post-procedural computed tomography showed lipiodol migration into the portal system. No rebleeding or liver dysfunction occurred. Ascites worsened-likely because of BRTO and/or EUS-VT-but was manageable with low-dose diuretics. This case highlights EUS-VT as a feasible option after failed BRTO for duodenal varices. A meticulous technique is essential to preventing glue migration.

Duodenal stenting is a widely used palliative treatment for gastric outlet obstruction (GOO) caused by unresectable malignancies. Compared to surgical gastrojejunostomy, duodenal stenting allows for earlier oral intake, shorter hospitalization, and earlier chemotherapy initiation. However, its long-term efficacy is limited by stent occlusion, which typically occurs 2-4 months post-procedure, due to tumor ingrowth, overgrowth, or food impaction. Covered stents can reduce tumor ingrowth but increase the migration risk, particularly in patients receiving chemotherapy. This review provides a comprehensive comparison of duodenal stenting, surgical gastrojejunostomy, and endoscopic ultrasound-guided gastroenterostomy, by discussing their clinical outcomes, advantages, and limitations. We further explore stent selection based on stricture characteristics, optimal placement techniques, post-procedural management, and for handling complications including occlusion, migration, bleeding, and perforation. Additionally, we address technical challenges and troubleshooting strategies, including management of guidewire-induced perforation, incomplete stent expansion, and bile duct obstruction for overlapping biliary and duodenal stricture cases. Despite its widespread clinical use, no prior review has comprehensively covered both the technical and clinical aspects of duodenal stenting so extensively. By providing a clinically oriented, practical guide, this review serves as a valuable resource for endoscopists and gastroenterologists, facilitating optimized decision-making and improved outcomes for patients with GOO in real-world practice.

BACKGROUND:Pancreatic fluid leakage is a rare complication of pancreatic cancer and often requires drainage when conservative therapy fails. Endoscopic, percutaneous, and surgical drainage are options. Minimally invasive endoscopic procedures are generally considered the first-line treatment, with either a transpapillary approach or an endoscopic ultrasound-guided transmural approach selected depending on the case. Various dilators are used to dilate tracts to the leakage site. However, reports of dilation through a rigid trans-tumoral tract using a drill dilator remain extremely rare. CASE SUMMARY:A 74-year-old woman with pancreatic body and tail cancer developed fever and left-sided chest pain after multiple courses of chemotherapy. Computed tomography revealed fluid accumulation around the pancreatic tail and spleen along with a left pleural effusion. The effusion was diagnosed as reactive secondary to pancreatic fluid leakage. Endoscopic retrograde cholangiopancreatography identified irregular stenosis of the main pancreatic duct in the pancreatic body. Distal to the stenosis, the main ductal structure was nearly obliterated by the tumor. The contrast medium had leaked into the pancreatic fluid leakage area through several fine, disrupted ductal structures. The guidewire was successfully advanced through an extremely fine tract that was not the main contrast-filling route. Standard dilators failed to expand the rigid trans-tumoral tract. A second endoscopic retrograde cholangiopancreatography using a drill dilator successfully expanded the trans-tumoral tract, enabling endoscopic nasopancreatic drainage tube placement. Subsequently, the pancreatic fluid leakage and pleural effusion resolved. CONCLUSION:Even in rigid trans-tumoral tracts, the use of a drill dilator can facilitate successful tract expansion, enabling effective drainage.

Acute cholangitis (AC) frequently presents as a community-acquired infection and is associated with a high prevalence of antibiotic use among infectious diseases. The Tokyo Guidelines 2018 (TG18) recommend 4–7 days of antibiotic administration after biliary drainage. However, this recommendation lacks strong evidence of its effectiveness and is primarily based on heterogeneous clinical findings and expert opinions. Recent retrospective studies have advocated a shorter 1- to 3-day antibiotic course as effective for AC treatment, prompting the need to reassess the treatment duration to achieve therapeutic efficacy while minimizing resistance and adverse effects. We designed a multicenter, non-blinded, randomized trial to evaluate the efficacy of short-course therapy compared to standard-course therapy for AC management. The short-course therapy group will receive 1–3 days of intravenous (IV) antibiotic treatment after successful biliary drainage compared to 4–7 days of IV antibiotics after successful biliary drainage for the standard-course therapy group. The primary outcome is the clinical cure rate within 14 days from the endoscopic retrograde cholangiopancreatography (ERCP) procedure. Participants will be allocated to either treatment course using a minimization method in a non-blinded, randomized manner, with stratification factors including condition severity and facility. We determined that 210 participants would be required to achieve a statistical power of 90 https://jrct.niph.go.jp/re/reports/detail/73862 This study was registered at the Japan Registry of Clinical Trials under registry number jRCT1031230709. Registered on 14 March 2024, https://jrct.niph.go.jp/re/reports/detail/73862

Amyloidosis is a rare cause of common bile duct (CBD) stricture that often presents with nonspecific symptoms. We herein report the case of a 61-year-old woman with CBD stricture caused by amyloidosis diagnosed through cholangioscopy and confirmed by a biopsy, with subsequent findings identifying it as AA-type amyloidosis. This condition poses diagnostic challenges owing to its rarity and non-specific manifestations. When common causes are excluded, amyloidosis should be considered in the differential diagnosis of CBD stricture. Advanced imaging and cholangioscopy with targeted biopsies are essential for making an accurate diagnosis. Documenting such cases and further research are vital to improve the understanding and management of amyloidosis-related biliary stricture.

A 78-year-old woman presented with epigastric pain and underwent contrast-enhanced abdominal computed tomography (CT), which revealed a mass in the ampullary region. Endoscopic ultrasonography (EUS) and retrograde cholangiopancreatography (ERCP) confirmed a papillary lesion with a contrast defect in the bile duct. An initial biopsy suggested an adenoma. Owing to the extent of the lesion, surgery was recommended; however, the patient opted for follow-up. After five months, CT and EUS revealed significant tumor growth, raising the suspicion of malignancy. Consequently, subtotal stomach-preserving pancreatoduodenectomy was performed, and postoperative pathology confirmed an intra-ampullary papillary tubular neoplasm (IAPN) with low-grade dysplasia. IAPN is noninvasive and consists of the growth of the ductal epithelium, which is equivalent to adenoma or low-grade adenocarcinoma. Although it is generally characterized by slow growth owing to its noninvasive nature, this case was unique in that it showed rapid progression. Despite being a low-grade IAPN, this case represents a rare instance of rapid enlargement within five months. This case underscores the importance of vigilant monitoring of low-grade IAPN, given its potential for accelerated growth.

Endoscopic ultrasound (EUS) has become an essential tool in vascular interventions due to its imaging potential in the proximity of various vascular structures in the mediastinum and abdominal cavity. EUS-guided variceal therapy (EUS-VT) has emerged as a promising approach for treating gastric varices (GV). Although still underused, EUS-VT offers such advantages as precise targeting and real-time variceal puncture visualization, making it a valuable alternative when conventional therapies fail. We report the case of a 63-year-old man with GVs secondary to fatty liver cirrhosis, who experienced repeated variceal ruptures despite multiple prior interventions (e.g., balloon-occluded retrograde transvenous obliteration, percutaneous transhepatic obliteration, partial splenic embolization, and several endoscopic injection sclerotherapy (EIS) sessions). During his most recent variceal rupture episode, EUS-VT was performed. A 23-gauge sclerotherapy needle failed to reach the target varix under EUS guidance. However, successful puncture and obliteration could be achieved using a 22-gauge fine-needle aspiration needle and cyanoacrylate glue. Doppler imaging confirmed lipiodol distribution and the absence of blood flow, indicating successful embolization. No adverse events occurred or rebleeding was observed during the one-month follow-up. This case demonstrates the clinical utility of EUS-VT as a rescue therapy for gastric variceal bleeding in patients with anatomically complex lesions refractory to standard treatments. EUS-VT should be considered a viable option in selected cases when conventional EIS is unsuccessful due to anatomical limitations.

Globally, antibiotic resistance is linked to increased morbidity, mortality, and healthcare costs, which necessitates further research on optimal antibiotic usage. Acute cholangitis (AC), a common cause of community-acquired bacteremia, often requires antimicrobial therapy. Therefore, studying the appropriate use of antibiotics for AC is considered crucial for suppressing the emergence of resistant bacteria and reducing adverse antibiotic-associated events. The Tokyo Guidelines 2018 (TG18) recommend 4-7 days of antibiotics post-biliary drainage. However, this lacks strong evidence and is based primarily on various evidence and expert opinions. Recent retrospective studies advocate for a shorter 1-3-day antibiotic course for AC, thereby prompting a need to reassess the treatment duration to balance therapeutic efficacy and minimize resistance and adverse effects. Choosing the appropriate duration and antibiotics based on susceptibility to pathogens causing cholangitis is important. Awareness of local resistance patterns and understanding patients' risks of resistant pathogens are prerequisite for effective treatment. We must explore the applicability of these guidelines in specific scenarios such as severe AC, positive blood cultures, fever, or hilar biliary obstructions due to malignancy. This comprehensive review considers both the duration and type of antibiotics and aims to enhance treatment outcomes while reducing the risk of resistant bacterial infections.

The standard treatment duration for acute cholangitis (AC) involves a 4-7-day antimicrobial treatment post-biliary drainage; however, recent studies have suggested that a <= 2-3 days is sufficient. However, clinical practice frequently depends on body temperature as a criterion for discontinuing antimicrobial treatment. Therefore, in this study, we assessed whether patients with AC can achieve successful outcomes with a <= 7-day antimicrobial treatment, even with a fever, assuming the infection source is effectively controlled. We conducted a single-center retrospective study involving patients with AC, defined following the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a <= 7-day antimicrobial treatment. Patients were categorized into the febrile and afebrile groups based on their body temperature within 24 h before completing antimicrobial treatment. The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 post-biliary drainage without recurrence or death by day 30. The secondary outcome was a 3-month recurrence rate. Logistic regression with inverse probability of treatment weighting was used. Overall, 408 patients were selected, among whom 40 (9.8%) were febrile. The two groups showed no significant differences in the clinical cure and 3-month recurrence rates. Notably, the subgroups limited to patients with a <= 3-day antibiotic treatment duration also showed no differences in these outcomes. Therefore, our results suggest that discontinuing antibiotics within the initially planned treatment period was sufficient for successful drainage cases of AC, regardless of the patient's fever status during the 24 h leading up to termination.

BACKGROUND:Short-term treatment of acute cholangitis is sufficient for cure compared with the standard treatment duration. Whether this short-course antimicrobial therapy is effective in patients with acute cholangitis with positive blood cultures has not been fully investigated. This study assessed whether patients with acute cholangitis could achieve successful outcomes with a three-day or shorter antimicrobial treatment period, even with a positive blood culture.METHODS:This single-center retrospective study involved patients with acute cholangitis, defined according to the Tokyo Guidelines 2018 for any cause, who underwent successful biliary drainage and completed a seven-day or shorter antimicrobial treatment. Patients were categorized into six groups based on the duration of antibiotic use (short or standard) after endoscopic retrograde cholangiopancreatography and blood culture findings (positive, negative, or no collection). The primary outcome was the clinical cure rate, defined as no initial presenting symptoms by day 14 after biliary drainage and no recurrence or death by day 30. Secondary outcomes included a three-month recurrence rate and length of hospital stay.RESULTS:In total, 389 cases were selected, and 27 patients (6.9%) undergoing short-course therapy tested positive for blood culture. The clinical cure rate (n=25, 92.6%) in this group was comparable to that in the other groups. For the three-month recurrence rate (n=1, 3.7%) and median hospital stay (six days), this group's outcomes were either better or similar to those of the other groups.CONCLUSIONS:For cases of successful drainage in acute cholangitis, even with positive blood cultures, short-term antibiotic therapy may be appropriate.

INTRODUCTION:The objective of this study was to evaluate esophageal varices (EVs) as predictors of poor prognosis with low tolerability after balloon-occluded retrograde transvenous obliteration (BRTO) in patients with overt hepatic encephalopathy (HE). METHODS:This study retrospectively enrolled 107 patients who underwent BRTO for uncontrollable overt HE. The enrolled patients were divided into two groups based on the presence of EVs using propensity matching. The present study assessed the technical success rate and safety of BRTO in both the groups. Further, the event-free survival, HE-free survival, and the overall survival (OS) were compared between the two groups. Event-free survival was defined as the time period during which the patients did not developed complications related to portal hypertension, including EVs, hepatic ascites, and portal vein thrombosis. RESULTS:After propensity matching, the EV and non-EV groups had 37 and 36 patients, respectively. Only 1 patient experienced an unsuccessful procedure in the EV group. Procedure-related adverse events in the EV group and non-EV group occurred in 11 and 7 patients, respectively (p = 0.417). The event-free survival after BRTO in the EV and non-EV group were 1,283 (95% CI: 798-1,767) days and 2,257 (1,722-2,792) days, respectively. Event-free survival was significantly worse in the EV group than in the non-EV group (p = 0.014). Furthermore, the EV group experienced worse OS than the non-EV group (p = 0.001 and p < 0.001, respectively). CONCLUSIONS:The presence of EVs could potentially be associated with a higher risk of adverse outcomes or mortality after BRTO treatment in individuals with HE.

A 50-year-old woman was referred to our hospital with elevated serum amylase levels. Physical examination revealed no jaundice or abdominal tenderness. Serum IgG4 was negative. Computed tomography revealed a localized pancreatic duct narrowing in the pancreatic head, with caudal pancreatic duct dilation and an intraductal papillary mucinous neoplasm. Pancreatic enlargement was not observed. Endoscopic ultrasonography (EUS) showed a small hypoechoic mass. Although EUS-guided, fine-needle aspiration was performed, no diagnosis was established. Endoscopic retrograde pancreatography showed a localized narrowing in the main pancreatic duct of the pancreatic head. A biopsy of the narrowing was performed through the minor papilla because of difficult access from the major papilla. The specimen showed the infiltration of numerous IgG4-positive plasma cells, suggesting type 1 autoimmune pancreatitis (AIP). Six months later, magnetic resonance cholangiopancreatography revealed improvement in the narrowing without specific treatment. The patient presented with localized narrowing of the pancreatic duct and caudal duct dilation, which was distinct from pancreatic cancer. Diagnostic difficulties arose from negative serum IgG4 results, the lack of typical imaging characteristics of AIP, and failure to meet the AIP criteria according to the relevant Japanese and international guidelines. However, AIP was suspected and surgery was successfully avoided through a biopsy.