Search Results (1,564)

Background: Intraductal papillary mucinous neoplasm (IPMN) is a mucin-producing pancreatic tumor with variable malignant potential. While most are asymptomatic and indolent, a subset progress to invasive carcinoma or cause local complications such as pancreatitis. Spontaneous fistulation into adjacent organs is an increasingly recognized phenomenon with impact on prognosis and management. The incidence of fistulation in IPMN in the reported literature is 1.9–6.6%. The most common sites are the stomach, duodenum and bile duct. Reported outcomes are poor, with a median survival of approximately 16 months. Methods: We describe four patients with IPMN complicated by fistula, confirmed by endoscopic or histopathological evaluation with CT and MRI images and discuss the available literature of fistulating IPMN. Results: Fistulation occurred at the common bile duct, stomach, duodenum and duodeno-jejunal junction. Two of four patients passed away at 4.8 and 24.8 months from detection of fistula. Histology revealed high-grade dysplasia or invasive carcinoma in most patients, highlighting the aggressive nature of IPMNs complicated by fistulae. Conclusions: Our findings reinforce the importance of recognizing fistula formation as a marker of aggressive disease in IPMN. Although surgical resection remains the treatment of choice in suitable candidates, the rarity of this entity means that standardized management guidelines are lacking. Full article

Background/Objectives: Claudin-18.2 (CLDN18.2) has recently emerged as a therapeutic target in gastric cancer; however, its prognostic relevance in the neoadjuvant setting remains insufficiently defined. We evaluated the clinical significance of CLDN18.2 and fibroblast growth factor receptor 2b (FGFR2b) expression in patients with locally advanced gastric cancer treated with neoadjuvant therapy. Methods: This retrospective single-center study included 64 patients with locally advanced gastric cancer who received neoadjuvant chemotherapy followed by curative surgery. Pretreatment endoscopic biopsy specimens were analyzed using immunohistochemistry to assess CLDN18.2 and FGFR2b expression. Survival outcomes were evaluated using Kaplan–Meier analysis and Cox proportional hazards regression models. Results: CLDN18.2 positivity was detected in 29.7% of patients and was not associated with baseline clinicopathological characteristics or pathological treatment response. However, CLDN18.2-positive tumors demonstrated significantly shorter relapse-free survival (median 19.0 vs. 36.6 months, p = 0.038) and overall survival (median 28.9 vs. 53.4 months, p = 0.005). In multivariable analysis, CLDN18.2 positivity remained an independent predictor of relapse-free survival. FGFR2b positivity was observed in 14.1% of patients and was evaluated descriptively due to limited case numbers. Conclusions: CLDN18.2 expression may represent a clinically relevant prognostic biomarker reflecting aggressive tumor biology in locally advanced gastric cancer treated with neoadjuvant therapy. Full article

Background/Objectives: Helicobacter pylori (HP) antibiotic eradication treatment in Germany is, at present, empirical according to the national guidelines. The aim of our prospective multicentre study was to implement routine susceptibility testing in daily clinical practice to facilitate resistance-oriented first-line antibiotic therapy and to collect local resistance data. Methods: From 1 January 2024 to 30 April 2025, in two German hospitals (in Bielefeld and Datteln), the patients who underwent gastroscopy and those who had biopsies for histopathology also underwent biopsies for the Helicobacter urease test (HUT). Positive HUT samples were sent for susceptibility testing: they were checked for phenotypic/cultural resistance to amoxicillin, clarithromycin, metronidazole, levofloxacin, rifampicin and tetracycline and genotypic/molecular resistance to clarithromycin and fluoroquinolones. Results: In total, in 1503 cases, both HUT and histology were performed, in which 256 (17.0%) histologies were HP-positive. We sent 311/1503 (20.7%) positive HUTs for susceptibility testing. In 120 (38.6%) of them, it was possible to culture HP, and for 118 cases, phenotypic resistance testing was performed. In 200/311 cases, PCR was also executed, with 111/200 cases being subjected to subsequent molecular resistance testing. Resistance patterns varied regionally, with metronidazole resistance observed in 3–33%, clarithromycin resistance in 16–20% and levofloxacin resistance in 13–16% cases. Conclusions: it is technically and logically feasible to perform HP antibiotic susceptibility testing via the same biopsy used for the HUT. The proposed procedures might be applied both in hospital and outpatient settings in endoscopic offices. Routine susceptibility testing is useful not only for the individual patient but also for monitoring the development of regional resistance patterns as a basis for better-targeted empiric therapy. Additionally, this approach might help to reduce the resistance dynamics at large in terms of antimicrobial stewardship. Full article

Extrahepatic cholangiocarcinoma (eCCA) is a highly aggressive malignancy arising from the biliary epithelium, with surgical resection representing the only potentially curative treatment. The predominant periductal infiltrating growth pattern, characterized by subepithelial tumor spread and desmoplastic stromal reaction, severely limits the diagnostic sensitivity of conventional endoscopic sampling techniques, which primarily assess the luminal mucosal surface. This review provides a histomorphology-oriented diagnostic framework for indeterminate extrahepatic biliary strictures, integrating advanced endoscopic technologies with emerging optical diagnostic approaches. ERCP combined with cholangioscopy demonstrates superior sensitivity for perihilar strictures, while EUS-guided tissue acquisition shows higher diagnostic yield in distal cholangiocarcinoma, also providing locoregional staging. Advanced EUS technologies—including elastography, contrast harmonic EUS, and Detective Flow Imaging—further improve characterization of indeterminate strictures by evaluating tissue stiffness, microvascular architecture, and periductal infiltration. Ex vivo fluorescence confocal laser microscopy (FCM) enables real-time microscopic evaluation of biopsy specimens, reducing diagnostic turnaround time and minimizing inadequate sampling. A location-adapted diagnostic algorithm integrating cross-sectional imaging, ERCP, cholangioscopy, and EUS is proposed. An integrated, biology-informed endoscopic approach tailored to tumor location and ductal wall involvement may significantly improve early eCCA detection and guide patient selection for curative treatment. Full article

The prevalence of Crohn’s disease has increased over the last few decades, even in developing countries, whereas that of intestinal tuberculosis has decreased, which places both diseases at an epidemiological crossroads. Crohn’s disease and intestinal tuberculosis share many clinical, endoscopic, imaging, and pathological features, which sometimes make differential diagnosis very difficult; an accurate diagnosis is, however, very important since an erroneous treatment can worsen the evolution or delay proper therapy. The association between past TB infection and Crohn’s disease can make the diagnosis especially hard. This review summarizes current data on specific features that allow differentiation between Crohn’s disease and intestinal tuberculosis, paying particular attention to the microbiome, clinical signs, endoscopy, cross-sectional imaging, bacteriological, and immunological findings detailed. The importance of computerized models and scores for the differentiation is also detailed, because common features may make the differentiation based on a single criterion difficult. Full article

Background/Objectives: Malignant distal biliary obstruction (MDBO) is a frequent complication of pancreatic cancer and often leads to obstructive jaundice, impaired liver function, and delayed oncologic treatment. Endoscopic biliary drainage using endoscopic retrograde cholangiopancreatography (ERCP) with stent placement is the standard minimally invasive approach for restoring biliary flow. However, clinical outcomes and complication rates vary across studies depending on stent design, placement technique, and patient characteristics. The aim of this systematic review was to evaluate the clinical outcomes and complications associated with endoscopic biliary stenting in pancreatic cancer-related MDBO. Methods: A systematic literature search was performed in PubMed/MEDLINE, ScienceDirect, Web of Science, and the Cochrane Library for studies published between January 2016 and January 2026. Studies evaluating ERCP-guided biliary stenting in adult patients with pancreatic cancer-related malignant distal biliary obstruction were included. Study selection followed PRISMA 2020 guidelines, and methodological quality was assessed using the Newcastle–Ottawa Scale. Clinical outcomes including technical success, clinical success, stent patency, recurrent biliary obstruction, and procedure-related complications were analyzed. Results: Eighteen studies involving a total of 3291 patients were included in the qualitative synthesis. Technical success rates were consistently high, reaching up to 100% in several studies, while clinical success rates generally exceeded 90%. Median time to recurrent biliary obstruction ranged from approximately 102 to 541 days depending on stent type and placement technique. Recurrent biliary obstruction was the most frequently reported complication, occurring in 30.7% of patients. Stent migration occurred in 14.9% of cases, while post-ERCP pancreatitis was reported in approximately 4.2% of patients. Several studies demonstrated longer patency with self-expandable metal stents compared with plastic stents. Conclusions: Endoscopic biliary stenting performed during ERCP is an effective and safe strategy for the management of malignant distal biliary obstruction in pancreatic cancer. Self-expandable metal stents provide more durable biliary drainage and reduce the need for repeat interventions. Nevertheless, recurrent biliary obstruction remains a common limitation, highlighting the need for further improvements in stent technology and optimized placement strategies. Full article

Background/Objectives: Chronic and recurrent sialadenitis are inflammatory disorders of the major salivary glands often managed with repeated courses of systemic antibiotics, despite limited long-term efficacy and growing concerns regarding antimicrobial resistance. Minimally invasive intraductal therapies, including sialoendoscopy with irrigation, have emerged as effective alternatives aimed at addressing ductal obstruction and chronic inflammation while reducing antibiotic exposure. This study aimed to systematically review the available evidence on the effectiveness and safety of sialoendoscopy with intraductal irrigation in the management of chronic and recurrent sialadenitis, with particular attention to its potential antibiotic-sparing role. Methods: A literature review was conducted in accordance with PRISMA guidelines. Major scientific databases were searched to identify studies evaluating sialoendoscopy with intraductal irrigation in patients with chronic or recurrent sialadenitis. Study characteristics, patient populations, irrigation protocols, and clinical outcomes were extracted and qualitatively analyzed. Results: Sialoendoscopy with intraductal irrigation was associated with significant clinical improvement in more than two-thirds of patients, with complete or partial symptom resolution. The procedure demonstrated high technical feasibility and a favorable safety profile. Symptom control was maintained across most etiological subgroups. The need for prolonged or repeated systemic antibiotic treatment decreased following endoscopic intervention. Conclusions: Sialoendoscopy with intraductal irrigation may represent a promising and minimally invasive therapeutic option for chronic and recurrent sialadenitis and may contribute to improved antibiotic stewardship by reducing unnecessary systemic antibiotic use. These findings suggest that intraductal therapeutic strategies could be considered within evolving care pathways for chronic salivary gland disorders, aligning clinical management with broader public health efforts to combat antimicrobial resistance. Full article

Background/Objectives: Ustekinumab has been approved for the treatment of moderate to severe ulcerative colitis. Real-world data regarding its efficacy and the discovery of predictive factors of response need to be studied further. We aimed to evaluate the efficacy and identify predictors of response to induction treatment with ustekinumab in patients with ulcerative colitis. Methods: This is a multicenter, prospective cohort study. Clinical response (CR) at week 16 was the primary endpoint, and steroid-free clinical remission (SFCRem) and endoscopic response were the secondary endpoints. Baseline histology, mucosal gene expression, and pharmacokinetics were studied for their effect on response to treatment. Results: We included 123 patients (mean age = 50.3 years). CR was recorded in 70.8% (75/106), SFCRem in 48% (59/123), endoscopic improvement in 71.4% (40/56), and mucosal healing in 28.6% (16/56). Higher PRO-stool frequency (OR = 0.49, p = 0.027), concomitant use of 5-ASA (OR = 3.69, p = 0.021), platelet number of ≥284 × 10⁹/L (OR = 6.52, p = 0.001) at baseline, and a drop in the total count of platelets by 10⁸/L (OR = 1.23, p = 0.022) at week 8 were independently associated with CR. Elevated trough levels of ustekinumab at week 16 were associated with a higher probability of endoscopic improvement (median difference = 3784 ng/mL, p = 0.013), with an optimal cut-off value of 3500 ng/mL (AUC = 0.82, 95% CI: 0.66–0.96). Increased mucosal mRNA expression for IL-23 (p = 0.007) and IL-23R (p = 0.031) at baseline was associated with increased probability of CR. Higher continuous Geboes scores at baseline were associated with a lower probability of CR (OR = 0.80, p = 0.045), with an optimal cut-off value of 14 (AUC = 0.75, 95% CI: 0.57–0.93). Conclusions: Clinical, laboratory, and molecular markers may identify patients with ulcerative colitis who are more likely to respond to ustekinumab. Full article

Background/Objectives: Rising antimicrobial resistance threatens Helicobacter pylori eradication worldwide, yet real-world data on microbiologically confirmed treatment outcomes from the Middle East remain scarce. This study aimed to determine the confirmed eradication failure rate among treatment-naïve patients, identify independent predictors of failure, and characterize gaps in post-treatment testing practices. Methods: This retrospective cohort study included treatment-naïve adults diagnosed with H. pylori infection at King Abdulaziz Medical City in Riyadh between January 2015 and August 2023. The primary outcome was microbiologically confirmed eradication failure, defined exclusively as a positive post-treatment test of cure (urea breath test, stool antigen, or endoscopic biopsy). Exploratory logistic regression was used to identify factors associated with treatment failure. Results: Of 850 patients, 196 (23.1%) had a documented post-treatment eradication test. The confirmed failure rate was 33.7% (66/196). In multivariate analysis, atrophic gastritis (aOR 3.22, 95% CI: 1.29–8.02; p = 0.012) and pregnancy (aOR 12.76, 95% CI: 1.79–91.06; p = 0.011) were independently associated with failure. No treatment regimen was significantly associated with eradication outcome. Conclusions: One in three tested patients failed first-line eradication, and over three-quarters of treated patients never received a confirmatory test of cure. These findings support transitioning to bismuth-based quadruple therapy in line with current guidelines and local resistance data, mandating routine post-treatment eradication testing, and establishing antimicrobial susceptibility surveillance. Full article

Gastric neuroendocrine tumors (NETs) are increasingly diagnosed as incidental findings during upper gastrointestinal endoscopy. For the gastroenterologist, the crucial challenge is not only at the time of endoscopic recognition but also when the pathology report states “well-differentiated gastric NET”. At that moment, the key clinical question is how to manage it correctly. Gastric NETs are biologically heterogeneous, and their management depends primarily on the pathophysiological setting in which they arise. Type 1 tumors develop in chronic atrophic gastritis and are usually indolent; type 2 tumors arise in the context of gastrinoma and MEN1; type 3 tumors are sporadic and carry a substantially higher metastatic risk. Consequently, the same histological label may correspond to profoundly different clinical scenarios. This review addresses what the gastroenterologist should do after receiving an incidental histological diagnosis of gastric NET, how to reconstruct the gastric background, when to suspect a sporadic type 3 lesion, how to select patients for endoscopic treatment versus staging or surgery, and how to interpret incomplete endoscopic resection. Particular attention is devoted to the emerging concept of proton pump inhibitor-associated gastric NETs, which may represent a distinct gastrin-driven subgroup with lower malignant potential than truly sporadic type 3 tumors. A practical algorithm and a clinicopathological comparison of the classic three gastric NET types are provided to support decision-making in daily practice. Full article

Background and Clinical Significance: Endoscopic third ventriculostomy (ETV) is a well-established cerebrospinal fluid (CSF) diversion technique for treating obstructive hydrocephalus. Here, the complication of post-ETV hyponatremia is rare. Separately, aqueductal web as a cause of obstructive hydrocephalus is also an uncommon occurrence. We present an unusual case of an adolescent who presented with late symptoms of obstructive hydrocephalus secondary to an aqueductal web and developed a delayed onset of post-operative hyponatremia after a successful ETV procedure. Pertinent aspects of the case are discussed in corroboration with the recent literature. Case Presentation: A previously well 14 year old presented with symptoms of raised intracranial pressure. Neuroimaging demonstrated progressively enlarging ventricles associated with an aqueductal web. She underwent an uneventful ETV and was discharged home. However, she was readmitted for symptomatic hyponatremia that was investigated and most likely attributed to Syndrome of Inappropriate Antidiuretic Hormone Secretion (SIADH). She was managed with fluid restriction with good clinical improvement. Conclusions: We herein report a case of delayed onset of obstructive hydrocephalus secondary to an aqueductal web, treatment challenges faced and the patient’s unexpected occurrence of hyponatremia after a technically successful ETV. This emphasizes that clinicians need to be mindful of this potential post-operative complication and the ability to discern subtle symptoms in a patient whose clinical signs may not be straightforward. Full article

A 47-year-old woman with metastatic pancreatic adenocarcinoma, diagnosed five months earlier and treated with palliative chemotherapy, was admitted with fever, jaundice, and right upper quadrant pain consistent with ascending cholangitis. Treatment with antibiotics was initiated and an endoscopic retrograde cholangiography was performed, whereby a biliary stent was placed to relieve malignant biliary obstruction. Physical examination revealed moderate ascites. Careful inspection of the umbilicus revealed a small nodular lesion located within the umbilical fold that became visible only after eversion of the umbilicus. The lesion had developed gradually over several weeks. Computed tomography confirmed the known pancreatic malignancy with metastatic disease and ascites. On re-review of the images, a small soft tissue nodule replacing the umbilicus was also visible. The lesion was clinically consistent with a Sister Mary Joseph nodule, an umbilical metastasis most commonly associated with advanced gastrointestinal or gynecologic malignancies. These lesions may arise through lymphatic or hematogenous spread or through direct extension into the umbilicus. This case highlights that umbilical metastases may be subtle and located within the umbilical fold, requiring careful physical examination to be detected. Full article

Background: Isolated gallbladder injuries are rare, especially when initial imaging is normal. Advanced imaging is required to detect delayed complications. Moreover, it is necessary to make an appropriate diagnosis while selecting the most suitable treatment option. Case Presentation: A 49-year-old man fell while cycling and developed worsening abdominal pain. Initial contrast-enhanced computed tomography (CT) scans showed no abnormalities. However, the patient later developed cholangitis and cholecystitis caused by biliary obstruction from a delayed gallbladder hematoma. Magnetic resonance imaging (MRI) and magnetic resonance cholangiopancreatography (MRCP) were used to diagnose this condition. The patient was initially managed conservatively with antibiotics, which led to temporary symptomatic improvement. Notably, the patient developed a delayed recurrence of suspected acute cholangitis (Grade I) on Day 12 due to hematoma migration. After recurrence, endoscopic nasobiliary drainage was performed as a step-up approach, in accordance with the Tokyo Guidelines 2018 management bundle, to achieve biliary decompression, followed by elective laparoscopic cholecystectomy. Pathological examination revealed chronic cholecystitis with hematoma. Conclusions: Isolated gallbladder injuries should be considered in patients with blunt abdominal trauma. Delayed hematoma formation can lead to biliary obstruction, even without initial CT findings. In such cases, early implementation of MRI and MRCP, along with close clinical monitoring for delayed recurrence, is essential. A strategic “step-up approach” incorporating endoscopic drainage is a safe and effective management option prior to definitive surgery. Full article

Background/Objectives: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a type 2 inflammatory disease frequently associated with recurrence after endoscopic sinus surgery (ESS). Although biologic therapies such as dupilumab have demonstrated efficacy in severe CRSwNP, the optimal timing of treatment initiation in relation to surgery remains unclear. This study aimed to evaluate the clinical outcomes of early postoperative initiation of dupilumab after revision ESS using a multidimensional assessment of disease control. Methods: This retrospective observational study included adult patients with severe CRSwNP treated with dupilumab at a tertiary referral centre. All patients had undergone at least two previous ESS procedures and initiated dupilumab within 30 days following revision surgery. Clinical outcomes were assessed at baseline and after 12 months, including Nasal Polyp Score (NPS), Sinonasal Outcome Test-22 (SNOT-22), nasal congestion and olfactory visual analogue scale (VAS) scores, and asthma control in patients with comorbid asthma. Treatment response was evaluated using a multidomain assessment. Results: Ten patients were included. After 12 months, significant improvements were observed in NPS (from 4.7 ± 2.3 to 0.4 ± 1.0; p = 0.0019) and SNOT-22 (from 61.9 ± 17.3 to 26.5 ± 14.7; p = 0.0019). Nasal congestion and olfactory VAS scores also improved significantly. Most patients (70%) achieved an excellent multidimensional response, while 30% showed a moderate response. No patients required systemic corticosteroids or revision surgery during follow-up. Conclusions: Early postoperative initiation of dupilumab after revision ESS was associated with improvements in endoscopic findings, symptom severity, and quality of life. These findings suggest that the early postoperative period may represent a therapeutic window in selected patients with severe recurrent CRSwNP. However, results should be interpreted with caution and considered hypothesis-generating. Full article

Pediatric subglottic stenosis (SGS) remains a significant cause of upper airway obstruction in infants and children, most commonly resulting from prolonged endotracheal intubation. Although open airway reconstruction procedures such as laryngotracheal reconstruction (LTR) and partial cricotracheal resection (PCTR) provide definitive treatment for severe disease, their invasiveness and the burden of postoperative management have prompted increasing interest in less invasive approaches. Endoscopic balloon dilation has emerged as an effective therapeutic option, particularly for early-stage, short-segment, and soft acquired stenosis. This review summarizes the pathophysiology, clinical presentation, and severity assessment of pediatric SGS, and discusses the evolution of surgical management with particular emphasis on the role of balloon dilation. Technical aspects—including balloon sizing, adjunctive radial incision, dilation protocols, and local pharmacologic therapies—are outlined. Endoscopic balloon dilation is most effective in carefully selected patients, particularly those with early-stage and less severe stenosis. While it can significantly reduce the need for open airway reconstruction, recurrence remains a key limitation, necessitating careful patient selection and long-term follow-up. This article represents a narrative review of the current literature combined with the authors’ clinical experience. Full article