Background and Objectives: Needle-based confocal laser endomicroscopy (nCLE) is a procedure in which an AQ-Flex nCLE mini-probe is passed through an EUS-FNA needle into a pancreatic lesion to enable ...subsurface in vivo tissue analysis. In this study, we conducted a systematic review and meta-analysis of nCLE for the diagnosis of pancreatic lesions. Materials and Methods: We conducted a comprehensive search of several databases and conference proceedings, including PubMed, EMBASE, Google-Scholar, MEDLINE, SCOPUS, and Web of Science databases (earliest inception to March 2020). The primary outcomes assessed the pooled rate of diagnostic accuracy for nCLE and the secondary outcomes assessed the pooled rate of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and adverse events (AE) of nCLE to diagnose premalignant/malignant pancreatic lesions. Results: Eleven studies on 443 patients were included in our analysis. The pooled rate of diagnostic accuracy of EUS nCLE was 83% (95 confidence interval CI = 79-87; I 2 = 0). The pooled rate of sensitivity, specificity, PPV and NPV of EUS nCLE was 85.29% (95% CI = 76.9-93.68; I 2 = 85%), 90.49% (95% CI = 82.24-98.74; I 2 = 64%), 94.15% (95% CI = 88.55-99.76; I 2 = 68%), and 73.44% (95% CI = 60.16-86.72; I 2 = 93%), respectively. The total AE rate was 5.41% (±5.92) with postprocedure pancreatitis being the most common AE at 2.28% (±3.73). Conclusion: In summary, this study highlights the rate of diagnostic accuracy, sensitivity, specificity, and PPV for distinguishing premalignant/malignant lesions. Pancreatic lesions need to be further defined with more validation studies to characterize CLE diagnosis criteria and to evaluate its use as an adjunct to EUS-FNA.
Approximately 10-62% of patients with primary sclerosing cholangitis (PSC) will develop dominant strictures at some point during their disease. Because of the paucity of available data, optimal ...endoscopic therapeutic strategies remain unclear. We performed a systematic review and meta-analysis of endoscopic balloon dilation vs. balloon dilation plus stenting of dominant strictures in PSC.
A comprehensive literature search from inception to November 2020 was performed. Primary outcomes were clinical and technical success. Secondary outcomes reported were adverse events (AE). Clinical success was defined in most studies as improvement in symptoms such as fever, abdominal pain, pruritus, fatigue and/or liver enzymes. The statistical analysis was done using comprehensive meta-analysis (CMA Version 3).
The technical success rates for balloon and balloon plus stent were 96.8% and 91.9%, respectively. The clinical success rates for balloon and balloon plus stent were 86.5% and 70.8%, respectively. The overall AE rates for balloon and balloon plus stent were 11.2% and 26.9%, respectively. Other AE rates in balloon and balloon plus stent were cholangitis (4.8% vs. 11.4%), bile duct perforation (1.3% vs. 1.6%), post-procedural pancreatitis (2.2% vs. 9.8%), and bleeding (1.5% vs. 1.2%), respectively. Low to considerable heterogeneity was noted in our meta-analysis.
Balloon dilation appears to be superior in terms of clinical and technical successes, with overall lower rates of AE compared to balloon dilation plus stenting for the management of PSC dominant strictures. Further trials are needed to validate our findings.
Background and Objectives: EUS-guided ethanol ablation has emerged as an alternative method for pancreatic lesions. Recently, paclitaxel was added to ethanol to assess ablative effects in pancreatic ...lesions. We performed a systematic review and meta-analysis on EUS-guided ethanol ablation (EUS E) versus EUS-guided ethanol with paclitaxel (EUS EP) ablation for the management of pancreatic lesions. Methods: Comprehensive search of multiple electronic databases and conference proceedings including PubMed, EMBASE, Google Scholar, and Web of Science databases (from inception to May 2020). The primary outcome evaluated complete ablation of the lesions radiologically and the secondary outcome evaluated adverse events (AEs). Results: Fifteen studies on 524 patients were included in our analysis. The pooled complete ablation rate was 58.89% (95% confidence interval (CI) = 38.72-77.80, I2 = 91.76%) and 55.99% (95% CI = 44.66-67.05, I2 = 0) in the EUS E and EUS EP groups (P = 0.796), respectively. The pooled AE rates were 13.92% (95% CI = 4.71-26.01, I2 = 83.43%) and 31.62% (95% CI = 3.36-68.95, I2 = 87.9%) in the EUS E and EUS EP groups (P = 0.299), respectively. The most common AE was abdominal pain at 7.27% (95% CI = 1.97-14.6, I2 = 68.2%) and 12.44% (95% CI = 0.00-39.24, I2 = 81.1%) in the EUS E and EUS EP groups (P = 0.583), respectively. Correlation coefficient (r) was ‒0.719 (P = 0.008) between complete ablation and lesion size. Conclusion: Complete ablation rates were comparable among both groups. AE rates were higher in the EUS EP group. Further randomized controlled trials are needed to validate our findings.
INTRODUCTION:
Microscopic colitis comprises two histologic subtypes; Collagenous colitis (more severe) and Lymphocytic colitis (LC). The pathogenesis is unclear but likely multifactorial with some ...associations to smoking and diseases with autoimmune background. Potential causative drugs have also been implicated with the most common being NSAIDS, PPI and Selective serotonin-reuptake inhibitors (SSRI). We are reporting a case of Duloxetine, a selective serotonin and norepinephrine-reuptake inhibitor (SNRI), causing LC.
CASE DESCRIPTION/METHODS:
A 49 yo F, caucasian with PMH of GERD and recent diagnosis of fibromyalgia was referred to gastroenterology clinic for diarrhea of unexplained origin for 1 month. Patient claimed diarrhea began 6 weeks after starting Duloxetine. She reported around 5 episodes of explosive watery, brown bowel movements daily with bloating. She also endorsed fatigue, dizziness and joint pains. She denied fevers, chills, blood in the stools, abdominal pain, nausea, vomiting. She denied any recent travel, new food trial, sick contact, new medications other than Duloxetine. She didn't use NSAIDs or PPI. Her other home medications were Levothyroxine and Lisinopril. Her symptoms of upper body pain, loss of energy and mood swing had improved considerably, and her rheumatologist doubled the dose of Duloxetine and the patient noted that the number of daily bowel movements increased. Physical exam showed hyperactive bowel sounds and colonoscopy revealed a completely normal colon. The pathology of the biopsy taken reported diffuse mixed colonic inflammation, marked intraepithelial lymphocytosis and focal acute cryptitis favoring lymphocytic colitis with no evidence of collagenous colitis. Infectious etiologies were ruled out. Decision was made to taper the Duloxetine, and patient was started on Loperamide. Upon follow-up visit two months later, pt reported complete resolution of the diarrhea, but recurrence of her fibromyalgia symptoms for which she was given cyclobenzaprine, which seemed to be have helped.
DISCUSSION:
Lymphocytic colitis is often insidious but sudden onset was reported in forty percent of patients. There were two other published case reports of duloxetine-associated LC, and just like this case, discontinuation of the medication resulted in prompt resolution of the diarrhea. Microscopic colitis has been associated with excessive fluid loss and malabsorption caused by the inflammation and can easily result in dehydration, dizziness and weight loss affecting quality of life.
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