Proton pump inhibitors in cirrhosis: Tradition or evidence based practice?

Gallstone ileus is a rare cause of mechanical bowel obstruction due to the passage of a solitary large gallstone into the gastrointestinal tract through a cholecystoenteric fistula [1]. Early surgical intervention is the treatment of choice; however, the surgical mortality rate is high as most patients are elderly and many suffer from concomitant diseases [2]. Ultrasound-guided extracorporeal shock wave lithotripsy (ESWL) has been suggested as an effective, noninvasive therapeutic alternative to surgery. Cases of jejunal and gastric gallstone ileus treated with ESWL have already been described [3] [4] [5]. However, the use of ultrasound-guided ESWL is limited in the colon because the stones are often not radiopaque or only partially calcified, and are frequently covered by intestinal gas, which prevents clear localization of the gallstone. We describe a case of gallstone ileus of the colon that was successfully treated with radiologically guided ESWL that visualized the obstruction by focusing on a metallic clip that had been inserted during a previous rectosigmoidoscopy. An 80-year-old woman was admitted to hospital with fever, constipation, and abdominal pain. A computed tomography (CT)-scan showed colonic distension, air–fluid levels, and a 5-cm, partially calcified stone that was obstructing the colon at the rectosigmoid junction ([Fig. 1]). In addition, there was evidence of pneumobilia in the common bile duct and intrahepatic biliary ducts, and of a fistula from the gallbladder into the colon at the hepatic flexure. Ultrasonography failed to visualize the gallstone because of interference from abundant colonic gas, while rectosigmoidoscopy confirmed the presence of a large, nonremovable biliary stone ([Fig. 2]). During the endoscopy, a metallic clip was inserted into the colonic mucosa close to the obstruction so that the area to be treated could be visualized radiologically. The patient subsequently underwent three sessions of ESWL focusing radiologically on the metallic clip inserted adjacent to the obstruction. The treatments were well tolerated, with no analgesia or sedation required, and allowed the gallstone to be successfully fragmented and removed during a further rectosigmoidoscopy ([Fig. 3]). A subsequent Gastrografin enema confirmed the presence of a cholecystocolic fistula and resolution of the colonic obstruction after removal of the gallstone ([Fig. 4]). Endoscopy_UCTN_Code_CCL_1AD_2AJ

Zenker’s Diverticulum (ZD) is the most common hypopharyngeal diverticulum; however, it is often underdiagnosed. It results from the herniation of the mucosa and submucosa through Killian’s Triangle. Dysphagia is the primary symptom, occurring in 80–90% of cases. The primary goal of treatment is to transect the cricopharyngeal muscle (CM) and connect the ZD cavity to the esophageal lumen. Traditional treatments include surgical open transcervical diverticulectomy and CM septomyotomy, using rigid or flexible endoscopes. However, surgery is burdened by technical difficulties and not negligible rates of adverse events (AEs). For this reason, endoscopic techniques for ZD treatment have gained traction in recent years. Flexible endoscopic septum division (FESD), introduced nearly 20 years ago, involves a full-thickness incision of the diverticular septum. The advent of third-space endoscopy has led to the application of these techniques to ZD treatment as well. Zenker-POEM (Z-POEM) and, subsequently, Per Oral Endoscopic Septomyotomy (POES) have been developed. Hybrid techniques, such as Peroral Endoscopic Diverticulotomy (POED) and tunneling-free methods, represent additional ZD treatment options. This review outlines the armamentarium of ZD endoscopic management, summarizing the characteristics of these techniques, their benefits and limitations, and highlighting future research directions.