Antiplatelet therapy is a well-established risk factor for gastrointestinal bleeding, yet hemobilia induced by these agents remains rarely reported. Acute cholangitis secondary to choledocholithiasis in patients on antiplatelet therapy presents significant clinical challenges, as the medication can precipitate hemobilia, subsequently exacerbating the cholangitis. Here, we report a 73-year-old female with a history of multiple biliary interventions and long-term aspirin use, exemplifying this clinical challenge. Although elective endoscopic retrograde cholangiopancreatography (ERCP) was scheduled following a 1-week aspirin discontinuation, the sudden onset of severe abdominal pain necessitated emergency intervention. ERCP revealed hemobilia with clots obstructing the major duodenal papilla. Therapeutic ERCP successfully evacuated the clots, extracted the stones, and placed a nasobiliary drain. The patient stabilized without requiring angiography or surgery. This case highlights that abrupt changes in abdominal pain patterns in calculous cholangitis patients receiving antiplatelet therapy should raise suspicion for hemobilia, underscoring the need for timely and effective clinical intervention.

Bile leaks (BLs) following T-tube removal, while typically not life-threatening, can result in serious complications if diagnosis or treatment is delayed. Endoscopic retrograde cholangiopancreatography (ERCP) is currently the preferred modality for managing such leaks in liver transplantation (LT) recipients. We present a retrospective case series of six LT patients who developed BLs after T-tube removal and were successfully managed using fully covered self-expandable metal stents (FCSEMSs). This report details our clinical experience alongside a review of the existing literature regarding this specific clinical entity.

Perihilar cholangiocarcinoma (pCCA), originating from the second-order bile ducts and extending to the cystic duct insertion, is the most common cholangiocarcinoma subtype and carries a dismal prognosis. It is typically characterized by obstructive jaundice and elevated serum carbohydrate antigen 19-9 (CA19-9); however, these features significantly overlap with those of benign biliary diseases. While endoscopic retrograde cholangiopancreatography-guided tissue sampling is crucial for diagnosis, its sensitivity remains suboptimal. Consequently, up to 15% of preoperatively suspected pCCA cases are confirmed as benign strictures postoperatively. Given the close association between choledocholithiasis and pCCA, distinguishing malignancy from stone-induced inflammatory disease remains a significant diagnostic challenge. Herein, we report a rare case of chronic cholangitis mimicking pCCA, ultimately attributed to calculi containing a retained foreign body.

OBJECTIVE:To evaluate the efficacy of endoscopic retrograde cholangiography (ERC)-guided biliary drainage as a preliminary method for reducing jaundice in patients with unresectable malignant hilar biliary obstruction (UMHBO), and to identify risk factors associated with sub-optimal jaundice reduction. METHODS:A cohort of 33 patients with UMHBO, spanning from March 2016 to July 2024, was included in the study. A 30% reduction in total bilirubin (TB) was considered indicative of a favorable jaundice-reducing effect (TB before discharge/TB before ERC). RESULTS:The rate of good jaundice-reducing effect was 78.8% (26/33) with the use of biliary plastic stents during the initial ERC. Notably, pre-ERC levels of gamma glutamyltranspeptidase (GGT) and alanine aminotransferase (ALT) were lower in the poor effect group compared to the good effect group (260.0 vs. 479.5 U/L, 55.0 vs. 84.5 U/L, respectively, P < 0.05). Carbohydrate antigen 19-9 (CA19-9) was higher in the poor effect group than in the good effect group (7948.6 vs. 542.1 U/ml, P < 0.05). However, binary logistic regression analysis did not reveal that pre-ERC levels of GGT, ALT, and CA19-9 were independent risk factors for poor jaundice reduction. CONCLUSION:ERC with the placement of biliary plastic stents as the initial jaundice reducing method was available in UMHBO patients. Independent risk factors that lead to poor jaundice reduction were still elusive.

Conventional duodenoscopy is challenging to perform in patients with a surgically altered anatomy (SAA). Short single-balloon enteroscopy (SBE) is an innovative alternative. We investigated the performance of short SBE in patients with SAA and explored risk factors for unsuccessful intubation. Patients who underwent short SBE from October 2019 to October 2023 were retrospectively analyzed. Successful enteroscopic intubation was defined as endoscope reaching the target site of the afferent limb and identification of the papilla of Vater or pancreaticobiliary-enteric anastomosis. In total, 99 short SBE procedures were performed in 64 patients (40 men, 24 women) with a mean age of 61 years (range, 36–86 years). The patients had a history of choledochoduodenostomy (n = 1), Billroth II gastrojejunostomy (n = 11), pancreaticoduodenectomy (n = 17), Roux-en-Y reconstruction with hepaticojejunostomy (n = 31), and Roux-en-Y reconstruction with total gastrectomy (n = 4). Successful enteroscopic intubation occurred in 57 of 99 (57.6%) procedures. No perforation or severe pancreatitis occurred. Multivariable analysis showed that Roux-en-Y reconstruction was a risk factor for intubation failure (hazard ratio, 4.2; 95% confidence interval, 1.1–15.8; p = 0.033). Short SBE is efficacious and safe in patients with postsurgical anatomy. Roux-en-Y reconstruction adversely affects the success of short SBE intubation.

BACKGROUND:Although overnight fasting is recommended prior to endoscopic retrograde cholangiopancreatography (ERCP), the benefits and safety of high-carbohydrate fluid diet (CFD) intake 2 h before ERCP remain unclear. This study aimed to analyze whether high-CFD intake 2 h before ERCP can be safe and accelerate patients' recovery. METHODS:This prospective, multicenter, randomized controlled trial involved 15 tertiary ERCP centers. A total of 1330 patients were randomized into CFD group ( n = 665) and fasting group ( n = 665). The CFD group received 400 mL of maltodextrin orally 2 h before ERCP, while the control group abstained from food/water overnight (>6 h) before ERCP. All ERCP procedures were performed using deep sedation with intravenous propofol. The investigators were blinded but not the patients. The primary outcomes included postoperative fatigue and abdominal pain score, and the secondary outcomes included complications and changes in metabolic indicators. The outcomes were analyzed according to a modified intention-to-treat principle. RESULTS:The post-ERCP fatigue scores were significantly lower at 4 h (4.1 ± 2.6 vs. 4.8 ± 2.8, t = 4.23, P <0.001) and 20 h (2.4 ± 2.1 vs. 3.4 ± 2.4, t = 7.94, P <0.001) in the CFD group, with least-squares mean differences of 0.48 (95% confidence interval [CI]: 0.26-0.71, P <0.001) and 0.76 (95% CI: 0.57-0.95, P <0.001), respectively. The 4-h pain scores (2.1 ± 1.7 vs. 2.2 ± 1.7, t = 2.60, P = 0.009, with a least-squares mean difference of 0.21 [95% CI: 0.05-0.37]) and positive urine ketone levels (7.7% [39/509] vs. 15.4% [82/533], χ2 = 15.13, P <0.001) were lower in the CFD group. The CFD group had significantly less cholangitis (2.1% [13/634] vs. 4.0% [26/658], χ2 = 3.99, P = 0.046) but not pancreatitis (5.5% [35/634] vs. 6.5% [43/658], χ2 = 0.59, P = 0.444). Subgroup analysis revealed that CFD reduced the incidence of complications in patients with native papilla (odds ratio [OR]: 0.61, 95% CI: 0.39-0.95, P = 0.028) in the multivariable models. CONCLUSION:Ingesting 400 mL of CFD 2 h before ERCP is safe, with a reduction in post-ERCP fatigue, abdominal pain, and cholangitis during recovery. TRAIL REGISTRATION:ClinicalTrials.gov , No. NCT03075280.

Endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for duct-to-duct anastomotic bile leakage (D-D aBL) after liver transplantation (LT). This study aimed to compare the time required for ERCP and D-D aBL recovery in post-LT patients with and without T-tube drainage. A total of 40 patients (11 with T-tube drainage and 29 without T-tube drainage) with confirmed D-D aBLs treated successfully with ERCP from July 2016 to September 2021 were reviewed. The mean interval from LT to initial ERCP was significantly longer in patients with T-tube drainage than in those without T-tube drainage (41.9 vs 25.1 days, P < .05). However, there was no significant difference in the time required for ERCP to result in D-D aBL healing between patients with T-tube drainage and those without T-tubes (33.4 vs 23.0 days). T-tube indwelling did not significantly prolong the course required for ERCP to resolve D-D aBL in post-LT patients.

PDF file - 266K, Gene Ontology analysis of differentially expressed genes after RNF43 Knockdown. Gene Ontology analysis was performed using EASE software, the bar indicates if the gene is up- (white) or down- (black) regulated after RNF43 knockdown.

PDF file - 16459K, RNF43 expression in human Hepatocellular carcinoma tissues. Representative images (magnification 100) of RNF43 stained tumors with (A) more than 75% positive tumor cells (+2), (B) 5-75% positive tumor cells (+1), and (C) less than 5% RNF43-positive tumor cells (0). (D) Adjacent noncancerous liver tissues.

PDF file - 392K, Knockdown of RNF43 induces apoptosis in HCC cells. (A) At 72 hours after transfection with indicated siRNAs, the effect of RNF43 knockdown on cell apoptosis was assessed by flow cytometry using Annexin V/PI Apoptosis Kit (n=3, **p < 0.01, ***p < 0.001). (B) Protein expression of activated Caspase-3 was evaluated by Western blotting.

Background: ABO-incompatible liver transplantation (ABOi LT) under the desensitization protocol with rituximab had excellent survival outcomes comparable to those of ABO-compatible liver transplantation (ABOc LT). In this work, we explored the effect of ABOi LT on recipients from the perspective of biliary microbiota and metabonomics. Methods: Liver transplant (LT) recipients treated at our center were enrolled in the study. In total, 6 ABOi LT recipients and 12 ABOc LT recipients were enrolled, and we collected their bile five times (during LT and at 2 days, 1 week, 2 weeks and 1 month after LT). The collected samples were used for 16S ribosomal RNA sequencing and liquid chromatography mass spectrometry analysis. Results: We obtained 90 bile samples. Whether in group ABOi LT or ABOc LT, the most common phyla in all of the samples were Firmicutes, Proteobacteria, Bacteroidetes and Actinobacteria. The most common genera were Lactobacillus, Weissella, Klebsiella, Pantoea and Lactococcus. There was no significant difference in the diversity between the two groups at 1 week, 2 weeks and 1 month after LT. However, the biggest disparities between the ABOi LT recipients and ABOc LT recipients were observed 2 days after LT, including increased biodiversity with a higher ACE, Chao1, OBS and Shannon index (p < 0.05), and more Staphylococcus in ABOi LT and binary–Jaccard dissimilarity, which indicated varying β-diversity (p = 0.046). These differences were not observed at 1 week, 2 weeks and 1 month after LT. The principal coordinate analysis (PCoA) revealed that the composition of the bile microbiota did not change significantly within 1 month after LT by longitudinal comparison. In an analysis of the bile components, the metabolites were not significantly different every time. However, four enrichment KEGG pathways were observed among the groups. Conclusion: These findings suggest that ABOi LT under the desensitization protocol with rituximab did not significantly affect the biliary microbiota and metabolites of recipients.

PDF file - 6281K, Knockdown of RNF43 inhibits invasion, migration and ECM adhesion of HCC Cells. Cells were transfected with indicated siRNAs. Seventy-two hours after transfection, the impact of RNF43 knockdown on invasion, migration and ECM adhesion was evaluated. (A) Representative images showing decreased migration in RNF43 siRNA-transfected HCC cells. (B) Representative images of wound-healing experiments. (C) The impact of RNF43 knockdown on adhesion of SMMC-7721 cells to different extracellular matrix proteins (n=3, **p < 0.01). (D) Knockdown of RNF43 inhibited the expression of Integrin β4. (E) Knockdown of RNF43 showed no effect on E-cadherin expression.

PDF file - 204K, Effects of siRNAs on RNF43 mRNA expression. HepG2 and SMMC-7721 cells were transfected with RNF43 siRNAs (RNF43-si1, -si2, and -si3), negative control siRNAs (siNC), or Mock-transfected (Mock). RNF43 mRNA expression was measured by qRT-PCR 48 hours after transfection.

PDF file - 7954K, Histology and IHC analysis of HCC xenografts. (a, b) Hematoxylin-eosin-stained sections of xenograft tumors (magnification 400). Mitotic cells (arrows) were quantified in five randomly chosen high-power fields (n=5, *p = 0.04). (c, d) CD31 stained sections of xenograft tumors (Original magnification 200). Microvessels (arrows) were quantified in five randomly chosen high-power fields (n=5, *p = 0.01). (e, f) Tumor sections measured by TUNEL staining (Original magnification 200). TUNEL-positive cells (arrows) were quantified in 5 randomly chosen high-power fields (n=5, *p = 0.03). (g, h) RNF43 stained sections of xenograft tumors.