Endoscopic transsection of the sphincter of the papilla of Vater during endoscopic retrograde cholangiopancreatography (ERCP) is a common procedure usually in connection with biliary stone removal or before stent insertion. Papillotomy results in irreversible loss of the regulating and barrier func­tions of the papilla of Vater. Besides the well-known early complications the long-term disadvantageous consequences should be taken into consideration. These are the high rate of relapsing common bile duct stones and frequent occurrence of cholecystitis in patients who did not undergo early cholecystectomy after papillotomy. The only risk factor for these long-term complications is pneumobilia. This concerns only small part of patients, as after biliary stone removal the early cholecystectomy is the standard of care, nowadays. In cases when endoscopic sphincterotomy can be avoided (removal of biliary stones less than 8 mm), it would be worthwhile to preserve the function of the sphincter of papilla of Vater to decrease the risk of long-term negative consequences (cholecystitis in case of remaining gallbladder, relapsing biliary duct stones, overall adverse events). Current guideline suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially cov­ered biliary self-expandable metal stents. In case of biliary plastic stenting for the indication of biliary leak the endoscopic papillotomy results in less post-ERCP pancreatitis compared to stenting without sphincterotomy.

Histamine intolerance (HIT) is an ill-defined clinical entity that has not yet been included in the official medical nomenclature. Symptoms are mediated by histamine, but its origin is largely disputed: increased release, reduced elimination and the role of exogenous histamine sources have all been suggested. The role of the alimentary tract in the etiopathogenesis is underlined by the fact that certain foods and nutrients typically trigger the symptoms. At the same time, what separates this syndrome from simple food allergy is that the allergens typically cause variable severity of symptoms at different time points. In the last 20 years, a serum ELISA biomarker has become available: diamine oxidase (DAO) shows a reproducibly correlates with the severity of the symptoms, and dietary recommendations have been introduced for symptomatic relief from histamine release and exogenous sources of histamine. At the same time, randomized controlled clinical trials are not available to prove their effectiveness, subjective clinical experience is that they improve the patient's symptoms in many cases, yet do not eliminate them completely and have massive negative impact on the quality of life. However, research on the microbiome and on the intestinal barrier has opened new insights to this field as well. According to our current knowledge, the decrease in the serum DAO level is an indicator of the consumption of the "DAO-pool" stored in leukocytes, which most often develops in connection with chronic histamine release due to the barrier damage. That is why intestinal histaminosis seems more appropriate for the name of the disease. We suggest that the main clinical focus should be targeted at identification of the cause of histamine release: changes of the gut microbiome and intestinal barrier damage, which in turn directs targeted nutritional therapy at the forefront of the treatment of the disease.

Acute pancreatitis begins as a sterile inflammation, which can become superinfected if necrosis develops in the pancreas. It affects a small part (5%) of patients with acute pancreatitis, but it is severe and has high a mortality rate. This probably explains why most doctors start antibiotic treatment even without proof of infection, that does not improve the outcome of pancreatitis, and unnecessary antibiotic treatment has many negative effects. The decision is usually based on high inflammatory parameters (C-reactive protein, white blood cell count) and the occurrence of fever, even though any of these can be caused by sterile inflammation of the pancreas. Before starting antibiotics, it is necessary to clarify the localization of the infection and, if possible, to perform a culture. Pancreatic necrosis superinfection develops mainly from the second week, at which time the patient usually has multi-organ failure. As a first step, it is necessary to prove the fact of pancreatic necrosis with imaging techniques. Determination of the procalcitonin level helps in the decision. In case of proven or probable superinfection, a broad-spectrum antibiotic that penetrates the necrotic tissue should be chosen.

Inflammatory bowel disease (IBD) poses complex issues in pregnancy, but with adequate, high-quality care excellent pregnancy outcomes are achievable. In this article, we review the current evidence and recommendations for fertility, pregnancy, delivery, and lactation in IBD patients and aim to provide guidance for clinicians involved in their care. Seventeen per cent of women with IBD are voluntarily childless compared with 6% of women in the general population. It is associated with disease burden, poor knowledge, or incorrect information about pregnancy and IBD. Active IBD is associated with an increased risk of preterm birth, low for gestation weight and fetal loss. Except for methotrexate and tofacitinib the risk of a flare outweighs the risk of IBD medication and maintenance of remission from IBD should be the main of care. Most women with IBD will experience a normal pregnancy and can have a vaginal delivery. Active perianal Crohn’s dis­ease is an absolute and ileal pouch surgery a relative indication for a caesarean section. Breast feeding is beneficial to the infant and the risk from most IBD medications is negligible.