Goals: To estimate the frequency and cause of nonresponsive celiac disease (CD). Background: Treatment of CD is based on life-long adherence to a gluten-free diet (GFD). Some celiac patients experience persistence of symptoms despite a GFD. This condition is defined as nonresponsive CD. Study: Celiac patients on a GFD for at least 12 months underwent diet compliance assessment, laboratory tests, breath tests, endoscopic, and histologic evaluations according to the symptoms/signs reported. Results: Seventy of 321 (21.8%) patients had persistent or recurrent symptoms/signs. The cause of symptom persistence was evaluated in 56 of 70 patients. Thirteen of 56 (23%) patients were antiendomysial antibody positive. Among the patients with negative serology, 1 had fibromyalgia, and 3 had evidence that disproved the diagnosis of CD. The remaining 39 patients with negative serology underwent duodenal biopsy sampling, which evidenced histologic alterations in 24 patients. Among the 15 patients with normal histology 3 were lactose intolerant, 9 had irritable bowel syndrome, 2 had gastroesophageal reflux disease, and in 1 patient a cause for the persistent symptom was not identified. In patients with confirmed diagnosis of CD, exposure to dietary gluten was the main cause of persistence of symptoms/signs, and consistently after dietary modification, symptoms resolved in 63% of the patients at later time points during follow-up. Conclusion: Nonresponsive CD occurs in nearly one fifth of celiac patients on GFD and its occurrence suggests further investigations to optimize the management of celiac patients.

Pancreatic pseudocysts (PPs) and walled-off necrosis (WON) are two distinct sequelae of acute and chronic pancreatitis, requiring accurate differentiation to guide appropriate management. Computed tomography (CT) and magnetic resonance imaging (MRI) remain essential for distinguishing PPs from WON, assessing their content, and identifying potential complications. Endoscopic ultrasound (EUS) has emerged as a key modality for both diagnosis and drainage planning, offering high-resolution imaging and the possibility of real-time aspiration. Management strategies have evolved significantly, shifting from surgical to minimally invasive approaches. Endoscopic drainage, including EUS-guided transmural drainage with double-pigtail or lumen-apposing metal stents (LAMS), has become the preferred strategy for symptomatic or infected collections. Endoscopic necrosectomy is increasingly performed for WON, providing a less invasive alternative to surgical debridement. However, patient selection and procedural techniques remain topics of ongoing debate. The aim of this review is to provide a comprehensive synthesis of current evidence regarding the diagnosis and management of pancreatic pseudocyst and walled-off necrosis. We will synthesize current evidence on diagnostic criteria, imaging modalities, and therapeutic algorithms for PPs and WON. We will discuss technical aspects, success rates, and complications associated with drainage modalities, comparing endoscopic, percutaneous, and surgical approaches. Special attention will be given to recent advancements in interventional endoscopy and their impact on patient outcomes. By integrating clinical insights with the latest literature, this review aims to provide an up-to-date reference for clinicians managing pancreatic fluid collections. A literature search was performed using PubMed, Scopus, Web of Science, and MEDLINE databases to identify relevant studies on diagnostic criteria, imaging techniques, and management strategies.

Background: Despite weak evidence, antibiotic prophylaxis prior to endoscopic ultrasound-guided through-the-needle biopsy (EUS-TTNB) of pancreatic cystic lesions (PCLs) is routinely used in clinical practice. We aim to compare a group of patients treated with antibiotics before EUS-TTNB of PCLs and a group who did not undergo antimicrobial prophylaxis. Methods: Out of 236 patients with pancreatic cystic lesions referred to two high-volume centers between 2016 and 2021, after propensity score matching, two groups were compared: 98 subjects who underwent EUS-TTNB under antibiotic prophylaxis and 49 subjects without prophylaxis. Results: There was no difference in terms of baseline parameters between groups. Final diagnosis was serous cystadenoma in 36.7% of patients in the group not treated with prophylaxis and in 37.7% of patients in the control group, whereas IPMN and mucinous cystadenoma were diagnosed in 3 (6.1%) and 16 (32.6%) versus 6 (6.1%) and 32 (32.6%) patients in the two groups, respectively (p = 0.23). Overall, the adverse event rate was 6.1% in the group not treated with antibiotic prophylaxis and 5.1% in the control group (p = 0.49). Only a single infectious adverse event occurred in each group (p = 0.48). The diagnostic yields were 89.7% and 90.8% in the two groups (p = 0.7), and the diagnostic accuracy rate was 81.6% in both groups (p = 1.0). Conclusions: Prophylactic antibiotics do not seem to influence the risk of infection, and their routine use should be discouraged.

Introduction: Development of gastric neuroendocrine neoplasms in subjects infected with Helicobacter pylori is rare and it occurs through pathogenetic mechanisms related to gastrin. Presentation of case: We report a case of gastric neuroendocrine tumor in a patient infected with Helicobacter pylori and normal gastrin levels. He was treated by endoscopic mucosal dissection after eradication of Helicobacter pylori infection. Histologically the tumor was consistent with a grade 2 well differentiated neuroendocrine tumor. It was characterized by the presence of lymphoid aggregates around and inside the neoplasia. Discussion: Helicobacter pylori -associated chronic gastritis can rarely cause the development of gastric neuroendocrine tumors through mechanisms unrelated to gastrin. Conclusion: The one related to a chronic Helicobacter pylori infection may be considered a distinct type of gastric neuroendocrine tumor. Highlights:

Acinar cystic transformation (ACT), also known as ‘acinar cell cystadenoma’, is an uncommon cystic neoplasm of pancreas with unknown malignant potential. This case regards a woman with symptomatic pancreatic head ACT, revealed with pathological exam of specimen after pancreaticoduodenectomy. A 57-years-old patient presented mild hyperbilirubinemia and recurrent cholangitis; she underwent to ERCP, EUS and MRI, and these exams revealed a large cyst of the pancreatic head that caused biliary compression. The discussion of the case by the multidisciplinary group indicated surgical resection. Pancreatic ACT is so rare, and its preoperative diagnosis is difficult. The symptoms of the patients and the features of the cyst are the criteria to choose a surgical resection.