Anupam Kumar Singh

The optimal timing and frequency of direct endoscopic necrosectomy (DEN) following endoscopic ultrasound (EUS)-guided drainage of infected walled-off necrosis (WON) remain unclear. This was a single-center, open-label randomized trial. Patients with proven or clinically suspected infected WON (>10 cm) with >30% solid debris were included. In the top-down group, DEN was performed during the index EUS-guided drainage session and repeated after 24 hours until complete clearance was achieved. In the step-up group, DEN was performed only in the presence of predefined clinical criteria after initial drainage. The primary end point was the number of reinterventions required to achieve clinical success. Secondary end points included new-onset organ failure, procedure-related adverse events, readmission, length of stay, and all-cause mortality. Out of 208 patients screened during the study period, 54 patients were enrolled (27 per group). The median (IQR) number of reinterventions was lower in the top-down group (1 [2] vs. 2 [2]; P = 0.02), while the number of DENs (2 [1] vs. 1 [2]; P = 0.31) and overall procedure burden (4 [2] vs. 4 [2]; P = 0.95) were similar across both groups. Patients in the step-up group had higher readmission rates (44.4% vs. 18.5%; P = 0.04) and longer length of stay (12 [17] vs. 4 [8.5] days; P0.99), and mortality (11.1% vs. 18.5%; P = 0.70) were similar across both groups. In patients with infected WON and substantial solid debris, a top-down strategy was associated with shorter hospitalization and fewer readmissions with a similar overall procedural burden; however, readmission events may have been influenced by adjunctive strategy-related factors.

Current guidelines do not recommend routine proton pump inhibitor (PPI) use after endoscopic variceal ligation (EVL) because of limited evidence. In this randomised controlled trial of 170 patients (66.5% with alcohol-related liver disease), PPI therapy (40 mg daily for 3 months) was compared with no PPI treatment. Recurrent bleeding at 2 weeks and 3 months was significantly more frequent in the no-PPI group in both intention-to-treat (ITT) and per-protocol (PP) analyses, with absolute differences of 10%–15%. All deaths in the no-PPI group were related to rebleeding. Post-EVL ulcer extent and pain were also significantly reduced with PPI therapy. These findings indicate that post-EVL PPI use reduces rebleeding risk and may also lower associated mortality.

Background: Appropriate tapering strategy for corticosteroids in ulcerative colitis (UC) is uncertain. Aim: To compare the efficacy and safety of two steroid tapering regimens in patients with active UC. Methods: We randomised patients with active UC with initial steroid response after 2 weeks to short (total 6 weeks) or long taper (total 10 weeks). Randomization was stratified for acute severe UC. The primary outcome was steroid‐free clinical remission at 6 months. Secondary outcomes included assessment of symptomatic remission, relapse rate, endoscopic and histological scores, and safety. Results: Of 94 patients (48 in long, 46 in short taper) randomised, short taper was inferior to long taper in inducing clinical remission at 6 months (RR = 2.19; CI 1.08–4.46; p = 0.02). The relapse rates were similar in the long (37%) and short taper (46%) arms (HR: 0.34; CI: 0.10–1.11; p = 0.42). The median UCEIS scores (3 vs. 2; p = 0.23) and Nancy scores [2 (IQR 0–3) vs. 1.5 (0.75–3); p = 0.4] were not different between arms. Adverse events in the long and short taper arms, such as acne (14.58% vs. 2.16%), myopathy (8.33% vs. 6.52%), skin changes (2.08% vs. 2.17%), mood changes (0% vs. 4.34%), cytopenia (0% vs. 2.17%), and headache (6.25% vs. 6.52%) were similar. Conclusion: A shorter taper duration of 6 weeks was inferior to a longer taper of 10 weeks in achieving clinical remission of UC at 6 months. Trial Registration: CTRI Number: CTRI/2021/06/034129

Background: Immunogenic response to hepatitis B virus (HBV) vaccine in patients with inflammatory bowel disease (IBD) is variable and often suboptimal. Aim: To compare the immunogenicity of standard‐dose (20 μg) vs. double‐dose (40 μg) HBV vaccination in patients with IBD. Methods: We randomised patients with IBD 1:1 to receive standard‐ or double‐dose HBV vaccine at 0, 1 and 6 months. Anti‐HBs titres were measured 1 month after the third dose. The primary outcome was an adequate immune response (AIR; anti‐HBs titre > 10 IU/L). Secondary outcomes included an effective immune response (EIR; anti‐HBs titre > 100 IU/L) and seroconversion stratified by disease activity. Results: We randomised 45 patients to the standard‐dose and 43 to the double‐dose. Overall, 63 patients (71.6%) achieved AIR, and 51 (57.9%) achieved EIR. Both AIR (88.4% vs. 55.6%, p = 0.001) and EIR (69.8% vs. 46.7%, p = 0.028) rates were significantly higher with the double‐dose. Among patients receiving immunosuppressive therapy, double‐dose vaccination demonstrated significantly higher AIR (87.5% vs. 45.2%, p < 0.001) and EIR (65.6% vs. 35.5%, p = 0.017), while differences were not significant in those without immunosuppression. On multivariable analysis, predictors of AIR included double‐dose vaccination (odds ratio [OR] 11.63; 95% confidence interval [CI] 2.63–51.46) and anti‐TNFs (OR 0.03; 95% CI 0.002–0.6). Double‐dose vaccination was also associated with higher odds of achieving EIR (OR 3.52; 95% CI 1.04–11.92). Conclusions: Double‐dose HBV vaccination significantly improved AIR and EIR over standard‐dose. These findings support a double‐dose strategy to optimize seroconversion in patients with IBD, especially those receiving immunosuppressive therapy.

Ulcerative colitis is usually localised to the colon, leading to a uniform mucosal inflammation. Rarely, endoscopic findings or even an abdominal radiograph may reveal mucosal islands, which are defined as patches of residual normal mucosa within inflamed areas. They usually portend a poor prognosis. We report such a case where cytomegalovirus colitis, confirmed via immuno-histochemistry, was found. This case highlights the potential prognostic value of these findings, which, though subtle, can guide early, aggressive, but effective management.

Acute pancreatitis (AP) is one of the most common gastrointestinal emergencies, with pancreatic fluid collection (PFC) representing a frequent complication requiring precise evaluation for optimal management. While computed tomography (CT) remains the most widely utilized radiological investigation, it has limitations in correctly identifying and quantifying solid debris within PFCs and evaluating main pancreatic duct (MPD) integrity. Endoscopic ultrasound (EUS) offers improved visualization but is invasive and operator-dependent. Magnetic resonance imaging (MRI) provides superior characterization of PFCs, allowing excellent visualization of necrotic debris, liquid components, degree of encapsulation, and MPD anatomy without ionizing radiation—making it suitable for repeated evaluations. Abbreviated MRI (AMRI) protocols, involving acquisition of a few selected sequences while maintaining comprehensive evaluation capability, have emerged as promising tools for efficient assessment of AP patients. This review evaluates the utility of MRI and AMRI in characterizing PFCs and its implications for management decisions.

Background: Clostridioides difficile infection (CDI) and acute severe ulcerative colitis (ASUC) are both independently associated with poor outcome. The impact of CDI on the outcome of severe flare of ulcerative colitis is not studied. In the current study, we assess the impact of CDI on the outcome of ASUC. Methods: Data of ASUC patients were collected from January 2022 to July 2024. Parameters included were demographic profile, disease characteristics, biochemical investigations, and stool C. difficile toxin A/B (CDTA). Patients were categorized into ASUC-CDI and ASUC groups. Primary outcomes were need of rescue therapy, colectomy, and mortality during index admission. Six-month outcomes were flare of disease, colectomy, and mortality. Results: Of the 117 patients included, 91 (77.8%) patients were in the ASUC group and 26 (22.2%) in the ASUC-CDI group. Baseline parameters were similar between the 2 groups. Overall, 86 (73.5%) patients responded to corticosteroid therapy. Need of rescue therapy (24.2% vs. 33.6%, P=0.287), colectomy (3.3% vs. 11.5%, P=0.093), and mortality (1.1% vs. 3.8%, P=0.345) rates were comparable between the ASUC and ASUC-CDI groups. Six-month colectomy (4.4% vs. 15.4%) and mortality (1.1% vs. 7.7%) rates were numerically higher in the ASUC-CDI group, though statistically nonsignificant. Conclusion: The immediate and short-term outcome of patients with acute severe ulcerative colitis in the presence of C. difficile infection is determined by the severity of ulcerative colitis flare.

Endoscopic ultrasound (EUS)-guided gastroenterostomy (EUS-GE) is a commonly used modality in patients with gastric outlet obstruction, with results equivalent to surgical gastrojejunostomy [1] [2]. Inadvertent gastrocolostomy is a rare but major complication of EUS-GE [3]. As the transverse colon is a mobile structure, it can overlap the jejunal loop, and failure to identify this can lead to inadvertent gastrocolostomy [3]. A 76-year-old man with metastatic pancreatic carcinoma presented with symptoms of gastric outlet obstruction. After multidisciplinary team discussion, the patient was scheduled for EUS-GE using a device-assisted method (nasojejunal catheter). On EUS examination, after liberal instillation of methylene blue stained normal saline within the small bowel, distended jejunal loops could be visualized. However, on careful examination, a different bowel loop could be seen between the gastric wall and the jejunal loop. The overlapping bowel loop had three features that differed from the jejunal loops: absence of valvulae conniventes, presence of solid/semisolid floating material within the lumen (brown arrow in [Fig. 1] b,c), and absence of the intraluminal nasojejunal catheter. In contrast, jejunal loops had valvulae conniventes (blue arrow in [Fig. 1] a,c), clean fluid within the lumen (white arrow in [Fig. 1] a), and the intraluminal nasojejunal tube could be seen. Based on these features, we diagnosed a colonic overlapping loop between the gastric wall and jejunal loops. In view of this overlapping colonic loop, safe access to the jejunal loop could not be secured ([Fig. 1], [Video 1]). The procedure was abandoned and the patient continued nasojejunal tube feeding for the next 48 hours. After 48 hours, successful EUS-GE was performed. In this case, we believe that due to liberal instillation of normal saline, the transverse colonic loop became distended with fluid and mobilised between the gastric wall and jejunum. We did not puncture the colonic loop as might have been expected to be filled with methylene blue-stained normal saline [3]. This case highlights important characteristics of colonic loops on EUS examination and the steps needed to identify these features to prevent inadvertent gastrocolostomy. Endoscopy_UCTN_Code_TTT_1AS_2AB Article published online: 29 May 2024 © 2024. The Author(s). This article was originally published by Thieme in Endoscopy 2024; 56: E100–E101 as an open access article under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/). Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany