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Acute pancreatitis is an inflammatory disease characterized by interstitial edema, inflammatory cell infiltration, and acinar cell necrosis, depending on its severity. Regardless of the extent of tissue injury, acute pancreatitis is a completely reversible process with evident normal tissue architecture after recovery. Its pathogenic mechanism has been known to be closely related to intracellular digestive enzyme activation. In contrast to acute pancreatitis, chronic pancreatitis is characterized by irreversible tissue damage such as acinar cell atrophy and pancreatic fibrosis that results in exocrine and endocrine insufficiency. Recently, many studies of chronic pancreatitis have been prompted by the discovery of the pancreatic stellate cell, which has been identified and distinguished as the key effector cell of pancreatic fibrosis. However, investigations into the pathogenesis and treatment of pancreatitis face many obstacles because of its anatomical location and disparate clinical course. Due to these difficulties, most of our knowledge on pancreatitis is based on research conducted using experimental models of pancreatitis. In this review, several experimental models of pancreatitis will be discussed in terms of technique, advantages, and limitations.

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Pancreatitis is the most frequent and distressing complication of endoscopic retrograde cholangiopancreatography (ERCP). Many recent studies have reported the use of pharmacological agents to reduce post-ERCP pancreatitis (PEP); however, the most effective agents have not been established. Reduction in the incidence of PEP in high-risk patients has been reported through specific cannulation techniques such as guide wire-assisted cannulation and the use of pancreatic stents. The present review focuses on ERCP techniques for the prevention of PEP.

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During the last decade, great progress has been made in minimally invasive endoscopic techniques. For pancreatic pseudocysts (PPCs), endoscopic drainage has become the first-line therapeutic option. Recent advances in therapeutic endoscopic ultrasound (EUS)-related techniques have focused on EUS-guided transmural drainage, which is now replacing the conventional endoscopy-guided transmural drainage. While transmural drainage is usually performed using multiple plastic stents with or without a nasocystic drain, fully covered self-expandable metal stents are now being used with increasing frequency. In this review, we discuss some of the controversies related to the endoscopic drainage of PPCs.

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Chronic pancreatitis is a progressive inflammatory disease that destroys pancreatic parenchyma and alters ductal stricture, leading to ductal destruction and abdominal pain. Pancreatic duct stones (PDSs) are a common complication of chronic pancreatitis that requires treatment to relieve abdominal pain and improve pancreas function. Endoscopic therapy, extracorporeal shock wave lithotripsy (ESWL), and surgery are treatment modalities of PDSs, although lingering controversies have hindered a consensus recommendation. Many comparative studies have reported that surgery is the superior treatment because of reduced duration and frequency of hospitalization, cost, pain relief, and reintervention, while endoscopic therapy is effective and less invasive but cannot be used in all patients. Surgery is the treatment of choice when endoscopic therapy has failed, malignancy is suspected, or duodenal stricture is present. However, in patients with the appropriate indications or at high-risk for surgery, endoscopic therapy in combination with ESWL can be considered a first-line treatment. We expect that the development of advanced endoscopic techniques and equipment will expand the role of endoscopic treatment in PDS removal.

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In the present report, we describe an unusual case of an intramural gastric abscess caused by a foreign body, detected in the form of a subepithelial tumor. A 64-year-old woman was referred to our gastroenterology clinic for further evaluation of a gastric subepithelial tumor. The patient presented with a 1-month history of sustained dull epigastric pain. Esophagogastroduodenoscopy revealed an ill-demarcated, round, smooth, protruding lesion with a small central erosion on the great curvature of the proximal antrum. Endoscopic ultrasonography indicated the presence of an ovoid, heterogeneous, hypoechoic lesion with small echogenic foci located in the submucosa and muscularis propria layers. An abdominal computed tomography scan showed focal gastric wall thickening and regional lymph node enlargement. Endoscopic submucosal dissection was performed for definite diagnosis and management. Thus, we detected a toothpick and removed it using grasping forceps. The final diagnosis was an intramural gastric abscess caused by a toothpick.

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Although acupuncture is known as a safe procedure that is widely used in many countries, complications including infection, hemorrhage, hematoma, pneumothorax, nerve damage, and cardiac tamponade have been reported. A needle penetrating the stomach after acupuncture, however, is very rare. Here, we report the case of 47-year-old woman who experienced abdominal pain 2 days after receiving acupuncture. Upper gastrointestinal endoscopy identified an approximately 2.5-cm long needle in the posterior wall of the antrum. The needle was removed endoscopically using rat tooth forceps with no complications.

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Midazolam is a type of anesthetic agent frequently used for conscious sedation during a variety of medical procedures. Anaphylactic reactions to midazolam are rarely reported. However, we observed a case of midazolam hypersensitivity in which emergency measures were required to ensure patient recovery after administration of midazolam as a sedative. The occurrence of the anaphylactic reaction to midazolam was confirmed by elevated serum tryptase levels. The current case report presents a discussion of our findings.

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A patient with acute obscure gastrointestinal bleeding was found to have a large amount of food retention in the stomach after fasting for >12 hours. We tried to adjust the patient's body position to facilitate capsule endoscopic examination. The patient laid on the bed on his right side, which is the position required for a normal procedure, and then his hip was raised while his upper body was lowered gradually until the pylorus appeared at the center of the screen of the real-time monitor. It took 15 minutes of body position adjustment to make the pylorus appear at the center of the monitor and another 5 minutes for the capsule endoscope to enter the duodenum. The lesion was ultimately found at the terminal small intestine.

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Acute duodenal ischemia and periampullary intramural hematoma are rare complications after endoscopic retrograde cholangiopancreatography (ERCP). A 77-year-old man with splenomegaly complained of abdominal pain caused by common bile duct (CBD) stone. After successful removal of the CBD stone without immediate complications, the patient developed intramural hematoma around the ampulla of Vater along with diffuse duodenal edema. The findings were compatible with acute intestinal ischemia, and further evaluation revealed that he had underlying primary myelofibrosis. Myeloproliferative diseases are known to be significantly associated with an increased risk of thrombohemorrhagic complications. Therefore, particular attention should be given to this group of patients when a high-risk procedure such as ERCP is performed.

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Fatal air embolism to the cerebrum during an endoscopic retrograde cholangiopancreatography (ERCP) has not been reported in a patient with a biliodigestive anastomosis and multiresistant extended-spectrum β-lactamase Escherichia coli (ESBL) bacteremia. A 59-year-old woman with a history of laparoscopic cholecystectomy and iatrogenic injury of the right choledochal duct, choledochojejunostomy (biliodigestive anastomosis), recurrent cholangitis, revision of the biliodigestive anastomosis, recurrent liver abscesses, and recurrent stenting of stenotic bile ducts, was admitted because of fever and tenderness of the right upper quadrant. On ERCP, a previously deployed covered Wallstent was replaced. Blood cultures grew ESBL. After stent removal 8 days later, the patient did not wake up and developed arterial hypotension and respiratory insufficiency, requiring mechanical ventilation. Computed tomography scans showed extensive air embolism to the liver, heart, and cerebrum. She died 1 day later. Although the exact pathogenesis of the fatal cerebral air embolism remains speculative, the nonphysiological anatomy and chronic infection with ESBL may have been contributory factors.

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