Non-alcoholic fatty liver disease (NAFLD) is now recognized as the most common chronic liver disease worldwide, along with the concurrent epidemics of metabolic syndrome and obesity. Patients with NAFLD have increased risks of end-stage liver disease, hepatocellular carcinoma, and liver-related mortality. However, the largest cause of death among patients with NAFLD is cardiovascular disease followed by extrahepatic malignancies, whereas liver-related mortality is only the third cause of death. Extrahepatic complications of NAFLD include chronic kidney disease, extrahepatic malignancies (such as colorectal cancer), psychological dysfunction, gastroesophageal reflux disease, obstructive sleep apnea syndrome, periodontitis, hypothyroidism, growth hormone deficiency, and polycystic ovarian syndrome. The objective of this narrative review was to summarize recent evidences about extrahepatic complications of NAFLD, with focus on the prevalent/incident risk of such diseases in patients with NAFLD. To date, an appropriate screening method for extrahepatic complications has not yet been determined. Collaborative care with respective experts seems to be necessary for patient management because extrahepatic complications can occur across multiple organs. Further studies are needed to reveal risk profiles at baseline and to determine an appropriate screening method for extrahepatic diseases.

The presence of main pancreatic duct (MPD) dilatation is important for diagnosing pancreatic ductal adenocarcinomas (PDACs). However, we occasionally encounter PDAC cases without MPD dilatation. The objectives of this study were to compare the clinical findings and prognosis of pathologically diagnosed PDAC cases with and without MPD dilatation and to extract factors related to the prognosis of PDAC. The 281 patients pathologically diagnosed with PDAC were divided into two groups: the dilatation group (n = 215), consisting of patients with MPD dilatation of 3 mm or more, and the non-dilatation group (n = 66), consisting of patients with MPD dilatation less than 3 mm. We found that the non-dilatation group had more cancers in the pancreatic tail, more advanced disease stage, lower resectability, and worse prognoses than the dilatation group. Clinical stage and history of surgery or chemotherapy were identified as significant prognostic factors for PDAC, while tumor location was not. Endoscopic ultrasonography (EUS), diffusion-weighted magnetic resonance imaging (DW-MRI), and contrast-enhanced computed tomography had a high tumor detection rate for PDAC even in the non-dilatation group. Construction of a diagnostic system centered on EUS and DW-MRI is necessary for the early diagnosis of PDAC without MPD dilatation, which can improve its prognosis.

Endoscopic ultrasonography-guided biliary drainage (EUS-BD) is increasingly being used as a drainage technique in cases where endoscopic retrograde cholangiopancreatography (ERCP) cannot be performed. However, in patients with a massive esophageal hiatal hernia, this poses a risk of mediastinitis due to thoracic puncture. Upside-down stomach, first described in 1926 as type IV diaphragmatic hiatal hernia, is a rare condition in which a large portion of the stomach migrates into the thoracic cavity due to organoaxial rotation [1]. There have been reports of ERCP in patients with upside-down stomach [2] [3] but none of EUS-BD. This is the first report of EUS-BD for distal bile duct obstruction in a patient with pancreatic head cancer and upside-down stomach. An 84-year-old woman presented to our hospital with the chief complaint of weight loss. Computed tomography revealed a 35-mm tumor in the pancreatic head, and obstruction of the distal bile duct and duodenum by the tumor was suspected ([Fig. 1]). The patient also had an esophageal hiatal hernia of the upside-down stomach type, and almost all of her stomach had prolapsed into the thoracic cavity ([Fig. 2], [Fig. 3]). We decided to attempt endoscopic ultrasonography-guided choledochoduodenostomy (EUS-CDS) along with duodenal stent placement in the papillary region. A forward-viewing scope was advanced to the duodenum, and a stiff-type guidewire was advanced to the jejunum ([Fig. 4]). The guidewire was left in place, and the endoscope was removed while the loop for the upside-down stomach was released. A convex endoscope (UCT-260; Olympus, Tokyo, Japan) was then advanced over the wire to the esophagogastric junction. The contrast catheter was advanced, and the endoscope was successfully maneuvered around it to the duodenum. Thereafter, EUS-CDS was performed, and a covered self-expanding metal stent (ZEO STENT, 8 × 60 mm; Zeon Medical Inc., Tokyo, Japan) was placed successfully ([Video 1], [Fig. 5]). This case demonstrates that EUS-BD can be safely performed for malignant distal bile duct obstruction with upside-down stomach if EUS-CDS is used. Endoscopy_UCTN_Code_TTT_1AS_2AH Article published online: 17 May 2024 © 2024. The Author(s). This is an open access article published by Thieme 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

Background: This study aimed to evaluate the safety and efficacy of using a combination of dexmedetomidine (DEX) and midazolam (MDZ) for sedation in patients over 80 years of age during endoscopic retrograde cholangiopancreatography (ERCP).Methods: Thirty-two patients over 80 years of age who were scheduled to undergo ERCP from June 2020 to February 2021 at the International University of Health and Welfare Atami Hospital were included. Seventeen patients who received DEX + MDZ for sedation during ERCP were compared with a historical control group (patients who received MDZ alone). In addition, the safety and efficacy of sedation were evaluated using between-group comparisons.Results: The MDZ dose required in the DEX + MDZ group was significantly lower than in the historical control group (8.5 mg vs. 18 mg, p<0.001). There was no significant difference in respiratory depression between the two groups (0% vs. 6.9%, p=0.585). During and after the examination, the minimum systolic blood pressure and minimum heart rate were significantly lower in the DEX + MDZ group than in the historical control group. However, serious complications were not observed.Conclusions: The results indicate that the DEX + MDZ combination is potentially safe and effective in sedating the elderly and does not cause serious complications.