The American College of Gastroenterology Guidelines:Management of Acute Pancreatitis(referred to as the"2024 guidelines"),released in March 2024,presents 11 recommendations and 23 key concepts for the management of acute pancreatitis(AP)based on different levels of evidence quality.The 2024 guidelines provide detailed explanations regarding the diagnostic criteria,etiology,initial assessment,severity stratification,initial management,endoscopic retrograde cholangiopancreatography,antibiotic use,nutritional support,and surgical interventions for AP.Compared to the 2023 edition of the American College of Gastroenterology Guidelines,the 2024 edition offers more detailed recommendations and comprehensive evidence-based medical data,which is of great significance in optimizing the diagnosis and treatment process for AP patients and improving patient outcomes.

Objective:To explore the regulation effect and possible mechanism of transcutaneous electrical acustimulation (TEA) on the improvement of gastrointestinal motility and inflammation in patients with acute pancreatitis (AP).Methods:A randomized, single-blinded, sham-controlled study was performed. A total of 62 AP patients were randomly divided into the TEA group ( n=31) and sham-TEA group ( n=31), on the basis of regular treatment, who received TEA treatment at Neiguan (PC6) and Zusanli (ST36) or sham-TEA treatment at corresponding pseudo stimulation acupoints for 2 days. Abdominal distension score, time to first defecation, gastric slow wave, heart rate variability (low frequency and high frequency, reflecting sympathetic and vagal activity, respectively), serum level of tumor tecrosis factor (TNF)-α, plasma levels of motilin, ghrelin and vasoactive intestinal peptide(VIP) tested by enzyme linked immunosorbent assay were compared before and after the treatment. Wilcoxon rank test, Mann-Whitney U test, t-test and two factor repeated measurement analysis of variance were used for statistical analysis. Results:After the treatment, abdominal distension score of TEA group was lower than that of sham-TEA group(1 (0 to 2) vs.5(3 to 6)) and time to first defecation was earlier than that of sham-TEA group((55.00±24.27) h vs.(67.95±23.84) h), the percentage of normal gastric slow wave was higher than that of sham-TEA group((57.42±11.16)% vs. (40.92±8.52)%), and the differences were statistically significant ( Z=-4.95、 t=-2.12、 F=61.53, all P<0.05). After the treatment, the serum level of TNF-α of TEA group was significantly lower than that of sham-TEA group((4.27±1.28) ng/L vs.(6.19±2.03) ng/L), and the difference was statistically significant ( F=28.65, P<0.05). The ratio of post/pre-treatment of low frequency heart rate variability of the TEA group was significantly lower than that of sham-TEA group, however, the result of high frequency was opposite (0.87±0.18 vs.1.14±0.16, 1.19±0.18 vs.0.96±0.13), and the differences were statistically significant ( t=-6.22 and 5.74, both P<0.05). After the treatment, the plasma level of ghrelin of TEA group was higher than that of sham-TEA group ((2.02±0.62) μg/L vs. (0.93±0.49) μg/L), the VIP level was lower than of sham-TEA group ((30.58±12.20) μg/L vs.(44.35±29.52) μg/L), and the differences were statistically significant ( F=59.22 and 5.50, both P<0.05). However, there was no significant difference in motilin levels between two groups ((24.57±9.58) ng/L vs. (22.75±9.58) ng/L, P>0.05). Conclusion:TEA treatment can improve gastrointestinal motility and inhibit the inflammation in early AP, which may be related with the regulation of autonomic function, gastrointestinal hormone ghrelin and VIP.

To study the clinical effect of non-ampullary duodenal mucosal lesions treated by endoscopic resection. A retrospective analysis was performed on the data of 58 cases of duodenal non-ampullary mucosal lesions treated by endoscopic resection from January 2016 to June 2019 from 3 hospitals. Among 58 cases, 27 lesions (46.6%) were located in the duodenal bulb and 31 (53.4%) in the duodenal descending part (including the ball-drop boundary). Forty-six patients (79.3%) received endoscopic mucosal resection, 7 (12.1%) received endoscopic submucosal dissection and 5 (8.6%) received pre-cut endoscopic mucosal resection. Few postoperative complications were found except for 1 case of intraoperative bleeding, 1 case of delayed bleeding 2 days after surgery, 1 case of lesion residual and 2 cases of postoperative abdominal pain. No perforation occurred. Endoscopic treatment of non-ampullary duodenal mucosal lesions is safe and effective.

Objective:To analyze the clinical, genetic characteristics and follow-up data of Chinese patients with hypophosphatasia (HPP).Methods:A retrospective analysis was conducted on six children with HPP admitted to the Department of Endocrinology, Genetics and Metabolism in Beijing Children′s Hospital from October 2010 to January 2019. Summarized the clinical and follow-up data of all six patients, as well as the pathogenic variants of five children.Results:The serum alkaline phosphatase levels of all six children (five males and one female) were significantly reduced (2-49 U/L). The 6 patients aged from 2 months to 6 years and 4 months, 4 infantile HPP, 1 childhood HIP and 1 odonto HPP. The four patients with infantile HPP presented with anorexia, slow weight gain and hypercalcemia, whereas the one patient with childhood HPP and the other patient with odonto HPP had tooth loss. The patient with childhood HPP also manifested with motor dysfunction. Genetic testing was conducted for five patients and 4 unrelated Chinese families and revealed 10 variations in ALPL gene, including 7 missense variation, 1 insertion variation, 1 frameshift variation, 1 deletion variation.Of which 3 were novel (p.Y28C, p.268, F>L, p.A176V).One of the infantile patients lost follow-up and the other three deceased. The clinical conditions were much improved with medical intervention for patients with childhood, orodonto HPP.Conclusions:While HPP patients with different ages of onset present with common features, the prognosis differ significantly. The prognosis is good for patients with childhood, orodonto HPP and poor for patients with infantile HPP. Genetic testing is the main method for definitive diagnosis.

Objective:To investigate the clinical and genetic features, and treatment of X-linked hypophosphatemic rickets (XLH).Methods:In this retrospective study, we reviewed the medical records of 25 pediatric patients with XLH who were admitted to Department of Endocrinology Genetics and Metabolism,Beijing Children′s Hospital from January 2010 to January 2020. The clinical characteristics, PHEX gene variants, as well as clinical outcome of the patients were summarized. To analyze the correlation between genotype and phenotype, the patients were divided into different subgroups according to the location of the variants, including N-terminal-located vs. C-terminal-located variant, and Zn-binding domain exon 17 or 19 variant vs. non-exon 17 or 19 variant. The age at onset, height standard deviation score (HtSDS), intercondylar or intermalleolar distance, fasting serum phosphorus, and HtSDS and intercondylar or intermalleolar distance at the final follow-up were compared by rank sum test or t text. Results:Among the 25 children with XLH, 8 were boys and 17 were girls. The median age of onset was 1.2 (1.0, 1.8) years, and the median age of diagnosis was 2.5 (1.5, 4.3) years. The main clinical manifestations were abnormal gait and lower limb deformity. The HtSDS was -2.0(-3.2, -0.8), and the intercondylar or intermalleolar distance was 4.5 (3.0, 6.0) cm. The fasting serum phosphorus level was 0.8 (0.7, 0.9) mmol/L, while the serum alkaline phosphatase level was (721±41) U/L and the serum calcium level was (2.5±0.1) mmol/L. Three patients (12%) had parathyroid hormone levels above the upper limit of the normal range. Twenty-five patients (100%) showed radiographic changes of active rickets. Nephrocalcinosis was found in 2 cases (9%). Twenty-four different PHEX variations were detected in 25 patients, among whom 11 (44%) had not been reported previously. No hot spot variation was found. No statistical differences (all P>0.05) were identified in clinical features and outcomes either in comparing patients with N-terminal (21 cases) and C-terminal (4 cases) variants, or in comparing patients with variant located in exon 17 or 19 (4 cases) or not (21 cases). Twenty-four cases (96%) were treated regularly with phosphate supplements and active vitamin D. After 2.7 (1.6, 5.0) years of follow-up, clinical symptoms were relieved in 96% (24/25) of the patients. The HtSDS after treatment had no significant difference compared to that before treatment (-2.0(-3.2, -0.8) vs.-2.0(-2.8, -1.1), Z =-0.156, P>0.05), while the intercondylar or intermalleolar distance after treatment was significantly reduced compared to that before treatment (4.5(3.0, 6.0) vs. 1.5(0, 3.3) cm, Z =-3.043, P<0.05). Bone X-rays were reexamined in 17 cases after treatment, and radiographic signs of rickets were improved. Eighteen cases had secondary hyperparathyroidism and 7 cases had nephrocalcinosis. Conclusions:The main clinical manifestations of XLH are abnormal gait, lower limb deformity and short stature. A high proportion of novel variations of PHEX gene but no hot spot variation neither genotype-phenotype correlation are found. Regular treatment with phosphate supplements and active vitamin D can significantly improve the symptoms except for the height. However, the rate of adverse events including secondary hyperparathyroidism and nephrocalcinosis seems to be high.

Objective:To investigate the indication of pre-cut-endoscopic mucosal resection (pre-cut-EMR) on the treatment of colorectal laterally spreading tumors (LSTs).Methods:A retrospective study was performed on data of colorectal LSTs patients, who underwent pre-cut-EMR in Wuxi Second People’s Hospital and Zhongshan Hospital from January 2014 to June 2019. The relationships between the clinical characteristics of the lesions and the success rate and complications of pre-cut-EMR were analyzed.Results:Data of 132 colorectal LSTs cases were included in the study. Morphology of 29 (22.0%) LSTs were homogeneous granular type, 43 (32.6%) LSTs were mixed non-granular type, 58 (43.9%) LSTs were flat elevated type, and 2 (1.5%) LSTs were pseudo-depressed type. The diameter of lesions was 2.3±1.5 cm (ranged from 2.0 cm to 5.0 cm). Among the 132 LSTs, 36 (27.3%) tumors were located in rectum, 15 (11.4%) in sigmoid colon, 10 (7.6%) in descending colon, 17 (12.9%) in splenic flexure of colon, 21 (15.9%) in transverse colon, 24 (18.2%) in hepatic flexure of colon, 6 (4.5%) in ascending colon, and 3 (2.3%) in cecum. The histopathological diagnoses of the 132 LSTs included low grade intraepithelial neoplasia in 58 cases (43.9%), high grade intraepithelial neoplasia in 69 cases (52.3%), intramucosal carcinoma in 2 cases (1.5%), and canceration in 3 cases (2.3%). Pre-cut-EMR was achieved in all 132 patients, and the operation time was 25.3±13.6 min (ranged 20-65 min). The rate of en bloc resection and complete resection were 95.5% (126/132) and 100.0% (132/132), respectively. Two cases (1.5%) had intraoperative perforation, and were both located in the sigmoid colon with the diameter of 4.0 cm and 4.5 cm, respectively. Twelve cases (9.0%) had immediate bleeding during operation, and 2 cases (1.5%) had delayed bleeding after operation. Patients had been followed up for 6-24 months, the wound healed well after operation, and no local recurrence was found.Conclusion:Pre-cut-EMR is an effective and safe therapy for colorectal LSTs with diameter less than 4.0 cm.

Objective:To investigate the pathogenic spectrum of enteroviruses associated with hand, foot and mouth disease (HFMD) in the Yantai region of Shandong province in 2016, and analyze the evolution of epidemic strains of coxsackie virus group A type 6 (CV-A6) in the pathogenic spectrum of HFMD enteroviruses and the variations of important amino acid sites in the VP1 region.Methods:A total of 738 samples were collected from the patients with HFMD in Yantai region in 2016 to conduct DNA and serotype tests of enterovirus (EV) by real-time RT-PCR and further count the number and proportion of each type of enterovirus positive specimens. Based on the predominant serotype of enteroviruses, eight serotypes of the CV-A6 strains were selected to carry out VP1 regions amplification for the determination and analysis of nucleotide sequencing and phylogenetic analysis.Results:A total of 460 enteroviruses strains were isolated from 738 samples, including pathogens strains: 258 CV-A16 (56.09%), 62 EV-A71 (13.48%), 49 CV-A10 (10.65%), 44 CV-A6 (9.57%) and 9 CV-A4 (1.96%). Eight CV-A6 positive specimens were isolated from the viruses and the nucleotide-sequence analysis of the whole VP1 region was conducted. The sequence analysis of eight CV-A6 strains demonstrated that the homologies of nucleotide and amino acid were 96.12% - 100% and 97.78% - 100% respectively. The phylogenetic analysis indicated that the eight CV-A6 strains were subdivided into the genotype D subtype D3. Compared with the reference strain, CVA6-Gdula-AY421764, amino acids of CV-A6 strains in Yantai city observed at sites 10, 14, 174, 194, 279, 283 and 305 in VP1 region appeared mutant.Conclusions:CV-A16, EV-A71, CV-A10 and CV-A6 were the main common pathogens of HFMD in Yantai region in 2016. All the CV-A6 strains isolated in this study belonged to subtype D3 in genotype D.

Objective To evaluate the efficacy and safety of Willis covered stent in the treatment of traumatic carotid cavernous fistulae (tCCF).Methods The imaging and clinical data of 7 patients with tCCF treated with Willis covered stent in Shanghai Punan Hospital from November 2015 to June 2018 were analyzed retrospectively.Results Seven Willis covered stent were used in 7 patients.Immediately after stent release,angiography showed that the fistulae completely disappeared in 6 cases.One patient had a small amount of endoleak,and there was still a small amount of endoleaks after balloon dilatation.It was not further treated.There were no operative complications.During 3-12 months follow-up,no new neurological deficits were found in all patients.Angiographic follow-up of 2 patients showed that the fistulae completely disappeared without recurrence.The internal carotid arteries were patent,no in-stent stenosis and stent displacement.Conclusions Wills covered stent can be used as a treatment for tCCF.Its efficacy is satisfactory and the safety is good.

OBJECTIVETo analyze the risk factors of carcinogenesis of large colorectal polyps (diameter ≥ 10 mm) found by colonoscopy.

METHODSClinicopathological and follow-up data of 418 consecutive patients who were diagnosed as colorectal polyps with diameter≥10 mm by colonoscopy at two endoscopy centers of the Affiliated Wuxi Second People's Hospital, Nanjing Medical University (n=207) and Zhongshan Hospital, Fudan University (n=211) from January 2015 to December 2016 were retrospectively collected. High-grade intraepithelial neoplasia and cancer were defined as malignancy in this study. Chi square test was used for univariate analysis, and logistic regression was used for multivariate analysis (in patients with multiple polyps, if the pathological findings were all low grade intraepithelial neoplasia, one polyp with the largest diameter was selected to enter the model; in patients with high grade intraepithelial neoplasia, one polyp of high grade intraepithelial neoplasia with the largest diameter was selected to enter the model). Associated risk factors of malignancy were analyzed.

RESULTSAmong the 418 patients, 278(66.5%) were male and 140(33.5%) were female, with mean age of (58.7±10.2) (range 15-87) years old. Of 398 patients undergoing endoscopic treatment with resected 456 polyps, 142 cases with 150 polyps were malignant, including 134 polyps of high-grade intraepithelial neoplasia and 16 polyps of intra-mucosal cancer. The other 20 patients showed negative elevation signs after endoscopic submucosal injection and were transferred to surgery, of whom 20 polyps were resected. Histological examination of these 20 polyps indicated invasive cancer. Univariate analysis showed that age ≥ 50 years [40.5% (150/370) vs. 25.0% (12/48), χ² =4.323, P=0.041], multiple polyps [77.5%(31/40) vs. 34.7%(131/378), χ² =12.900, P=0.001], polyp locating at rectum [59.0%(36/61) vs. 32.3%(134/415), χ² =22.736, P=0.000], polyp diameter ≥31 mm [74.1%(20/27) vs. 33.4%(150/449), χ² =36.493, P=0.000] and tubular villous adenoma [67.4%(120/178) vs. 16.8%(50/298), χ² =71.810, P=0.000] were associated with malignancy. Multivariate analysis showed that age ≥ 50 years(OR=2.473, 95%CI:1.209-5.058, P=0.013), multiple polyps (OR=2.472, 95%CI: 1.300-4.702, P=0.006), polyp locating at rectum (OR=1.253, 95%CI: 1.091-1.439, P=0.001) and the polyp diameter ≥31 mm (OR=1.500, 95%CI:1.196-1.881, P=0.000) were independent risk factors for malignancy of large colorectal polyps. The mean follow-up time was (9.6±4.2) months. During the follow-up period, 86 patients (20.5%) who received endoscopic resection developed recurrent adenoma which all were successfully removed by colonoscopic polypectomy. Two patients(0.5%) developed colon cancer 6 months after endoscopic resection and both underwent radical surgery and chemotherapy. Their previous pathology from endoscopic resection was tubular villous adenoma and high grade intraepithelial neoplasia. All the patients were alive during the follow-up period.

CONCLUSIONSAge ≥50 years old, multiple polyps, polyps locating at rectum and polyps with diameter ≥ 31 mm are the risk factors of malignancy. Emphasized examination should be recommended for those with the above mentioned risk factors to avoid missed diagnosis and misdiagnosis. The choice of endoscopic treatment must be reasonable for curative resection.

Objective To investigate clinical efficacy and prognostic factors of hilar cholangiocarcinoma.Methods The retrospective case-control study was conducted.The clinicopathological data of 322 patients with hilar cholangiocarcinoma who were admitted to the Xiangya Hospital of Central South University between December 2005 and November 2015 were collected.Preoperative staging and classification of tumor and treatment planning were carried out according to the results of laboratory and imaging examinations.Observation indexes:(1) clinical features and results of assisted examinations;(2) treatments and results of pathological examination;(3) followup and survival;(4) prognostic factors analysis:gender,age,preoperative highest total bilirubin (TBil),preoperative carcinoembryonic antigen (CEA),preoperative CA19-9,preoperative CA242,preoperative CA125,treatment methods and TNM staging.The follow-up of outpatient examination and telephone interview was perfornmed to detect patients' survival up to November 2016.Survival curve was drawn using the Kaplan-Meier method.Survival and univariate analyses were done using the Log-rank test,and multivariate analysis was done using the Cox proportional hazard model.Results (1) Clinical features and results of assisted examinations:among the 322 patients,there were 301 patients with a chief complaint of jaundice.Of the 322 patients,the preoperative highest levels of TBil,DBil,ALT and AST in 322 patients were 3.9-785.2 μmol/L,1.6-410.2 μ mol/L,14.8-484.5 U/L and 21.4-539.8 U/L,respectively.Levels of ALP and GGT in 272 patients were 93.8-1 890.0 U/L and 2.0-1 832.8 U/L,respectively.Seventy-seven of 292 patients had an elevated CEA level,272 of 298 patients had an elevated CA19-9 level,153 of 260 patients had an elevated CA242 level and 86 of 260 patients had an elevated CA125 level.According to Bismuth-Corlette type,24 patients were detected in type Ⅰ,115 in type Ⅱ,55 in type Ⅲa,63 in type Ⅲb and 65 in type Ⅳ.(2) Treatments and results of pathological examination:Of the 322 patients,104 patients underwent radical resection,including 79 with hilar bile duct resection (9 combined with vascular resection and reconstruction) and 25 with extended hepatic lobectomy (16 combined with caudate lobectomy),and 218 patients underwent palliative treatments,including 134 with external biliary drainage and 84 with internal biliary drainage.Five patients were dead in the perioperative period,of which 2 died of acute liver failure,1 died of systemic infection and multiple organ failure,1 died of acute renal failure and 1 died of acute suppurative cholangitis,septic shock and disseminated intravascular coagulation.Of 263 patients receiving pathological examination,adenocarcinoma was detected in 253 patients (12 with high-differentiated adenocarcinoma,85 with moderate-differentiated adenocarcinoma,33 with low-differentiated adenocarcinoma and 123 with indefinite differentiation),mucinous adenocarcinoma in 5 patients,cholangiocarcinoma in 3 patients and neuroendocrine carcinoma in 2 patients.TNM staging of 322 patients:stage Ⅰ was detected in 8 patients,stage Ⅱ in 53 patients,stage Ⅲ in 132 patients,stage Ⅳ in 96 patients and indefinite stage in 33 patients.(3) Follow up and survival:among the 322 patients,296 were followed up for 12-132 months,with a median follow-up time of 65 months,including 94 with radical resection and 202 with palliative treatments.Among the 296 patients,the median survival time and 1-,3-,5-year survival rates were 10 months,47.1％,20.2％ and 9.5％,respectively.0f296 patients with follow-up,median survival time and 1-,3-,5-year survival rates were 31 months,84.0％,46.2％,25.0％ in 94 patients receiving radical resection and 7 months,29.9％,8.1％ and 2.3％ in 202 patients receiving palliative treatment,respectively,with a statistically significant difference between the 2 groups (x2=78.777,P＜ 0.05).Among the 94 patients receiving follow-up and radical resection,the median survival time and 1-,3-,5-year survival rates were 31 months,82.1％,45.1％,25.7％ in 73 patients undergoing hilar bile duct resection and 35 months,90.5％,49.8％,22.1％ in 21 patients undergoing hepatic lobectomy,respectively,with no statistically significant difference (x2=0.186,P＞0.05).Among the 73 patients undergoing hilar bile duct resection,median survival time and 1-,3-,5-year survival rates were 16 months,57.1％,0,0 in 7 patients combined with vascular resection and reconstruction and 34 months,84.6％,49.5％,27.5％ in 66 patients undergoing simplex hilar bile duct resection,respectively,showing a statistically significant difference (x2 =11.977,P＜ 0.05).(4) Prognostic factors analysis:results of univariate analysis showed that preoperative highest TBil,preoperative CEA,preoperative CA242,preoperative CA125,treatment methods and TNM staging were related factors affecting prognosis of patients with hilar cholangiocarcinoma (x2=25.009,18.671,9.359,33.628,94.729,77.136,P＜0.05).Multivariate analysis showed that preoperative highest TBil ≥ 342.0 μmol/L,preoperative CEA ≥ 5.00 μg/L,palliative treatments,TNM stage Ⅲ and Ⅳ were the independent risk factors affecting the poor prognosis of patients with hilar cholangiocarcinoma (HR =2.270,2.147,3.166,2.351,95％ confidence interval:1.587-3.247,1.446-3.188,2.117-4.734,1.489-3.712,P＜0.05).Conclusions Prognosis of hilar cholangiocarcinoma is still unsatisfactory.The R0 resection is the key in radical surgery.Preoperative highest TBil≥342.0 μmol/L,preoperative CEA ≥ 5.00 μg/L,palliative treatments,TNM stage Ⅲ-Ⅳ are independent risk factors affecting the poor prognosis of patients with hilar cholangiocarcinoma.