Early Endoscopy Research Articles

How Can We Maximize Skills for Non-Variceal Upper Gastrointestinal Bleeding: Injection, Clipping, Burning, or Others?

Endoscopy has its role in the primary diagnosis and management of acute non-variceal upper gastrointestinal bleeding. Main roles of endoscopy are identifying high risk stigmata lesion, and performing endoscopic hemostasis to lower the rebleeding and mortality risks. Early endoscopy within the first 24 hours enables risk classification according to clinical and endoscopic criteria, which guide safe and prompt discharge of low risk patients, and improve outcomes of high risk patients. Techniques including injection therapy, ablative therapy and mechanical therapy have been studied over the recent decades. Combined treatment is more effective than injection treatment, and single treatment with mechanical or thermal method is safe and effective in peptic ulcer bleeding. Specific treatment and correct decisions are needed in various situations depending on the site, location, specific characteristics of lesion and patient's clinical conditions.

Update on risk scoring systems for patients with upper gastrointestinal haemorrhage

Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.

Identifying Gaps in After-Hours Endoscopic Practices

Identifying Gaps in After-Hours Endoscopic Practices

Weekend and nighttime effect on the prognosis of peptic ulcer bleeding

To evaluate whether weekend or nighttime admission affects prognosis of peptic ulcer bleeding despite early endoscopy. Retrospective data collection from four referral centers, all of which had a formal out-of-hours emergency endoscopy service, even at weekends. A total of 388 patients with bleeding peptic ulcers who were admitted via the emergency room between January 2007 and December 2009 were enrolled. Analyzed parameters included time from patients' arrival until endoscopy, mortality, rebleeding, need for surgery and length of hospital stay. The weekday and weekend admission groups comprised 326 and 62 patients, respectively. There were no significant differences in baseline characteristics between the two groups, except for younger age in the weekend group. Most patients (97%) had undergone early endoscopy, which resulted in a low mortality rate regardless of point of presentation (1.8% overall vs 1.6% on the weekend). The only outcome that was worse in the weekend group was a higher rate of rebleeding (12% vs 21%, P = 0.030). However, multivariate analysis revealed nighttime admission and a high Rockall score (≥ 6) as significant independent risk factors for rebleeding, rather than weekend admission. Early endoscopy for peptic ulcer bleeding can prevent the weekend effect, and nighttime admission was identified as a novel risk factor for rebleeding, namely the nighttime effect.

Gastroesophageal Reflux after Vertical Banded Gastroplasty is Alleviated by Conversion to Gastric Bypass

Conversion operations after vertical banded gastroplasty (VBG) are sometimes performed because of vomiting and/or acid regurgitation. Primary operation with gastric bypass (GBP) is known to reduce gastroesophageal reflux (GERD). Previous studies have not been designed to differentiate between the effects of the altered anatomy and of the ensuing weight loss. No series has reported data on acid reflux before and after conversion from VBG to GBP. We invited eight VBG patients with current symptoms of GERD. All had intact staple lines as assessed by barium meal and gastroscopy. Acid reflux was quantified using 48-h Bravo capsule measurements. Conversion operations were performed creating an isolated 15-20-ml pouch; the previously banded part of gastric wall was excised. Gastrojejunostomy was made end to end with a 28-mm circular stapler. The study is based on five patients consenting to early postoperative endoscopy and pH measurement. All patients were women with a mean age of 49.5 years and BMI of 36.3. Time since VBG was 132.1 months. Time from conversion to second measurement was 46.6 days and BMI at that time 32.7. There was no mortality and no serious morbidity. All patients improved clinically and no patient had to go back on proton pump inhibition or antacids. Total time with pH < 4.0 was reduced from 18.4% to 3.3% (p < 0.05). DeMeester score was reduced from 58.1 to 15.9 (p < 0.05). The effect of converting VBG-operated patients to GBP results in a near-normalisation of acid reflux parameters and a discontinuation of proton pump inhibitor medication.

Mechanisms of Bleeding and Approach to Patients With Axial-Flow Left Ventricular Assist Devices

Axial-flow LVADs have become an integral tool in the management of end-stage heart failure. Consequently, nonsurgical bleeding has emerged as a major source of morbidity and mortality in this fragile population. The mechanisms responsible for these adverse events include acquired von Willebrand disease, GI tract angiodysplasia formation, impaired platelet aggregation, and overuse of anticoagulation therapy. Because of ongoing concerns for pump thrombosis and thromboembolic events, the thrombotic/bleeding paradigm has led to a difficult clinical dilemma for those managing patients treated with axial flow LVADs. As the field progresses, advances in the understanding of the pathological mechanisms underlying bleeding/thrombosis risk, careful risk stratification, and potential use of novel anticoagulants will all play a role in the management of the LVAD patient.

Endoscopic manifestation of purpura abdominalis and the pathogen of purpura abdominalis

Objective To evaluate the endoscopic manifestation of purpura abdominalis in child patients for early diagnosis and discuss the pathogen of purpura abdominalis.Methods The endoscopic and clinical manifestation of 91 patients with purura abdominalis were studied.Ten kinds of food allergenspecific IgG were detected by ELISA method in 91 patients with purpura abdominalis.13C-UBT was detected in 91 patients with purpura abdominalis.Results Endoscopy revealed congestion,edema,splotch hemorrhage and erosion,mostly in duodenum descendent and bulb.IgG positive rate of various foods was detected in 82 patients.13C-UBT positive rate was 70.3％.Conclusions Early endoscopy was an important treatment in the differential diagnosis of purura abdominalis.Both Helicobacterpylori infection and food intolerance could be the reason of purpura abdominalis. Key words: Purpura, schoenlein-henoch/DI/PA/ET; Endoscopy

Mortality from nonulcer bleeding is similar to that of ulcer bleeding in high-risk patients with nonvariceal hemorrhage: a prospective database study in Italy

Nonulcer causes of bleeding are often regarded as minor, ie, associated with a lower risk of mortality. To assess the risk of death from nonulcer causes of upper GI bleeding (UGIB). Secondary analysis of prospectively collected data from 3 national databases. Community and teaching hospitals. Consecutive patients admitted for acute nonvariceal UGIB. Early endoscopy, medical and endoscopic treatment as appropriate. Thirty-day mortality, recurrent bleeding, and need for surgery. A total of 3207 patients (65.8% male), mean (standard deviation) age 68.3 (16.4) years, were analyzed. Overall mortality was 4.45% (143 patients). According to the source of bleeding, mortality was 9.8% for neoplasia, 4.8% for Mallory-Weiss tears, 4.8% for vascular lesions, 4.4% for gastroduodenal erosions, 4.4% for duodenal ulcer, and 3.1% for gastric ulcer. Frequency of death was not different among benign endoscopic diagnoses (overall P = .567). Risk of death was significantly higher in patients with neoplasia compared with benign conditions (odds ratio 2.50; 95% CI, 1.32-4.46; P < .0001). Gastric or duodenal ulcer significantly increased the risk of death, but this was not related to the presence of high-risk stigmata (P = .368). The strongest predictor of mortality for all causes of nonvariceal UGIB was the overall physical status of the patient measured with the American Society of Anesthesiologists score (1-2 vs 3-4, P < .001). No data on the American Society of Anesthesiologists class score in the Prometeo study. Nonulcer causes of nonvariceal UGIB have a risk of death, similar to bleeding peptic ulcers in the clinical context of a high-risk patient.

Reply to Corbett &amp; Cameron

We would like to thank Corbett & Cameron for their letter. Our study [1] was an observational study with prospectively collected data. It showed that urgent endoscopy was associated with lower mortality in high-risk but not low-risk nonvariceal upper gastrointestinal bleeding. Our findings are consistent with the recommendations of an international consensus [2] which states that there is no additional benefit conferred by urgent endoscopy (< 12 hours) compared with early endoscopy (> 12 hours) in unselected nonvariceal upper gastrointestinal bleeding. In the majority of our cohort, urgent endoscopy was not associated with decreased mortality. Endoscopy within 13 hours was associated with lower mortality only in a very small subset of patients with severe nonvariceal upper gastrointestinal bleeding, as triaged using the Glasgow-Blatchford score.

Timing of endoscopy in high-risk patients with nonvariceal upper gastrointestinal bleeding

We read with interest the study by Lim et al. [1], which suggests that earlier endoscopy is associated with better outcomes for high-risk patients with nonvariceal upper gastrointestinal bleeding (NVUGIB). NVUGIB has a significant mortality. Whilst endoscopic therapy has been shown to significantly improve this, there is also good evidence that most of the mortality in patients presenting with NVUGIB is not directly related to bleeding [2] and little evidence to suggest that very early endoscopy affects outcomes although consensus suggests that it should be performed within 24 hours [3].

Simultaneous Cytomegalovirus and Clostridium difficile Colitis in a Patient with Inflammatory Bowel Disease

Purpose: A 65-year-old male with a history of ulcerative colitis presented with four months of diarrhea with rectal bleeding. The patient was taking 10 mg of prednisone daily. He reported diffuse abdominal pain, fevers, chills, and fatigue. Stool studies were positive for Clostridium difficile (C. difficile) by polymerase chain reaction (PCR) testing. Although therapy with oral vancomycin and intravenous metronidazole was initiated, there was no clinical respone. A flexible sigmoidoscopy revealed severely congested, hemorrhagic, inflamed, nodular, ulcerated, pseudomembrane-covered mucosa in the rectosigmoid colon. Biopsies revealed chronic active inflammation, ulceration and granulation tissue response. Immunohistochemical staining was positive for Cytomegalovirus (CMV) infection. The patient was treated with gancyclovir in addition to oral vancomycin. A repeat colonoscopy two weeks later showed clearance of cytomegalovirus infection. Repeat stool studies tested negative for C. difficile by PCR. The patient's diarrhea and abdominal pain improved. Previous studies have demonstrated that patients with inflammatory bowel disease (IBD) are at increased risk for the development of C. difficile infection compared to non-IBD patients. Corticosteroids, immunomodulators and biologic agents are utilized in the treatment of ulcerative colitis and their use is a well documented risk for CMV infection. However, concomitant infection with C. difficile and CMV colitis in IBD is infrequently reported. We present a case of simultaneous CMV and C. difficile colitis in a patient with IBD who was not receiving an immunomodulator or biologic agent and was on low dose prednisone. Patients with IBD on any of the aforementioned therapies who present with hemorrhagic diarrhea should be considered for early endoscopy with tissue biopsies for CMV, even if fecal testing for C. difficile is positive, in order to obtain a reliable diagnosis and start proper treatment as soon as possible. The differential diagnosis should include CMV colitis, even if pseudomembranes are visualized on endoscopy, in IBD patients receiving any type of immunosuppressive therapy.

Update on the Endoscopic Management of Peptic Ulcer Bleeding

Upper gastrointestinal bleeding is the most common gastrointestinal emergency, with peptic ulcer as the most common cause. Appropriate resuscitation followed by early endoscopy for diagnosis and treatment are of major importance in these patients. Endoscopy is recommended within 24 h of presentation. Endoscopic therapy is indicated for patients with high-risk stigmata, in particular those with active bleeding and visible vessels. The role of endoscopic therapy for ulcers with adherent clots remains to be elucidated. Ablative or mechanical therapies are superior to epinephrine injection alone in terms of prevention of rebleeding. The application of an ulcer-covering hemospray is a new promising tool. High dose proton pump inhibitors should be administered intravenously for 72 h after endoscopy in high-risk patients. Helicobacter pylori should be tested for in all patients with peptic ulcer bleeding and eradicated if positive. These recommendations have been captured in a recent international guideline.

Synchronous gastric and colonic metastases of invasive lobular breast carcinoma: case report and review of the literature

Breast cancer is the most common malignancy in women and the main cause of cancer death in the UK. Gastrointestinal (GI) tract metastasis and carcinomatosis from primary breast cancer are rare but breast cancer is the second most common primary malignancy to metastasise to the GI tract after malignant melanoma. The metastatic patterns of invasive lobular carcinoma (ILC) and invasive ductal carcinoma (IDC) have been shown to differ considerably. Liver, lung and brain metastases are more common in IDC. Most series report a greater prediliction for lobular carcinoma to metastasise to the GI tract, gynaecological organs or peritoneum. The presentation of GI metastasis due to breast cancer is typically vague and the clinical, radiological, endoscopic and histopathologic findings are often difficult to distinguish from primary gastric carcinoma. Such a patient is more likely to present to a luminal surgeon or gastroenterologist than a breast surgeon. Therefore a high index of clinical suspicion with early endoscopy in those with non-specific symptoms and a past history of breast cancer, particularly ILC, are recommended. It is imperative to differentiate between metastatic breast cancer and primary gastric carcinoma as treatment strategies differ hugely. Therefore, correlation of endoscopic biopsy histology with the primary breast cancer histology is essential. Treatment modalities are limited to appropriate systemic therapy, which may have a palliative effect in up to 50%. Surgical intervention is nearly always limited to palliative bypass only. Prognosis is consistent with the median survival of all women with metastatic disease secondary to breast cancer.

Can Quality of Care for Patients with Cirrhosis Be Measured?

The ultimate purpose of measuring quality of care is to discriminate between healthcare providers in order to motivate improvement. Recently, a set of evidence-based indicators has been proposed for measurement of processes of care for patients with cirrhosis, for example early endoscopy for variceal bleeding. The objective of this study was to determine whether these indicators can be measured in a reliable and automated fashion in routine practice. We applied the top five indicators, based on agreement of a panel of experts, to hospitalized adults at our institution over a 3-year period. Only two of the indicators could be reliably measured on the basis of the published wording, and these two still required physician chart review. After applying some assumptions, the indicators were met in 46-100% of cases. None of the indicators was linked to a single physician or institution in all cases, and none occurred with sufficient frequency to discriminate quality between providers. Measuring quality of care in cirrhosis is a laudable objective, but current indicators are not yet ready for administrative use.

Can Quality of Care for Patients With Cirrhosis Be Measured?

Introduction The ultimate purpose of measuring quality of care is to discriminate between healthcare providers in order to motivate improvement. Recently, a set of evidence-based indicators has been proposed for measurement of processes of care for patients with cirrhosis, for example early endoscopy for variceal bleeding. The objective of this study was to determine whether these indicators can be measured in a reliable and automated fashion in routine practice. Materials and methods We applied the top five indicators, based on agreement of a panel of experts, to hospitalized adults at our institution over a 3-year period. Results Only two of the indicators could be reliably measured on the basis of the published wording, and these two still required physician chart review. After applying some assumptions, the indicators were met in 46‐100% of cases. None of the indicators was linked to a single physician or institution in all cases, and none occurred with sufficient frequency to discriminate quality between

Tu1450 Is Polyp Detection Rate a Valid Proxy for Adenoma Detection Rate for Measuring the Technical Quality of Colonoscopy?

endoscopy significantly reduced the odds of observing stigmata of bleeding to 0.53, 0.44, and 0.37 at 12, 24, and 48 hours, respectively (p 0.001). Patients with higher Rockall scores (for nonvariceal lesions) had a significantly higher odds of stigmata of bleeding (p 0.001). Stigmata of bleeding was identified less often in females than males (p 0.001). Time to endoscopy did not significantly affect other clinical outcomes including rebleeding events, transfusion requirements, length of hospital stay, surgery, or mortality. Conclusion: In patients with UGIB, the likelihood of identifying stigmata of bleeding (and hence performing endoscopic therapy) is significantly associated with time. However, other outcomes did not vary significantly with time to endoscopy. The data suggest that the earlier endoscopy is performed, the more likely treatment can be employed.

Helicobacter pyloriinfection in bleeding peptic ulcer patients after non-steroidal antiinflammatory drug consumption

To establish the prevalence of Helicobacter pylori (H. pylori) infection in patients with a bleeding peptic ulcer after consumption of non-steroidal antiinflammatory drugs (NSAIDs). A very early upper endoscopy was performed to find the source of upper gastrointestinal bleeding and to take biopsy specimens for analysis of H. pylori infection by the rapid urease (CLO) test, histological examination, and bacterial culture. IgG anti-CagA were also sought. The gold standard for identifying H. pylori infection was positive culture of biopsy specimens or contemporary positivity of the CLO test and the presence of H. pylori on tissue sections. Eighty patients, 61 males (76.3%), mean age 61.2 ± 15.9 years, were consecutively enrolled. Forty-seven (58.8%) patients occasionally consumed NSAIDs, while 33 (41.3%) were on chronic treatment with low-dose aspirin (LD ASA). Forty-four (55.0%) patients were considered infected by H. pylori. The infection rate was not different between patients who occasionally or chronically consumed NSAIDs. The culture of biopsy specimens had a sensitivity of 86.4% and a specificity of 100%; corresponding figures for histological analysis were 65.9% and 77.8%, for the CLO test were 68.2% and 75%, for the combined use of histology and the CLO test were 56.8% and 100%, and for IgG anti-CagA were 90% and 98%. The highest accuracy (92.5%) was obtained with the culture of biopsy specimens. Patients with a bleeding peptic ulcer after NSAID/LD ASA consumption frequently have H. pylori infection. Biopsy specimen culture after an early upper gastrointestinal tract endoscopy seems the most efficient test to detect this infection.

Role of diaphragm in pancreaticopleural fistula

A pancreatic pleural effusion may result from a pancreatopleural fistula. We herein discuss two interesting issues in a similar case report of a pleural effusion caused after splenectomy, which was recently published in the World Journal of Gastroenterology. Pancreatic exudate passes directly through a natural hiatus in the diaphragm or by direct penetration through the dome of the diaphragm from a neighboring subdiaphragmatic collection. The diaphragmatic lymphatic "stomata" does not contribute to the formation of such a pleural effusion, as it is inaccurately mentioned in that report. A strictly conservative approach is recommended in that article as the management of choice. Although this may be an option in selected frail patients, there has been enough accumulative evidence that a pancreaticopleural fistula may be best managed by early endoscopy in order to avoid complications causing prolonged hospitalization.

Should Prophylactic Low-dose Aspirin Therapy be Continued in Peptic Ulcer Bleeding?

Patients taking low-dose aspirin for cardiovascular prevention who develop an acute peptic ulcer bleeding event represent a serious challenge in clinical practice. Aspirin discontinuation is associated with increased risk of developing a new cardiovascular event, but there is little evidence on the outcomes and best management strategy in the setting of an acute ulcer bleeding event. In this clinical scenario, it is common clinical practice to interrupt aspirin treatment for various, sometimes long, periods of time. A recent study suggests that patients with bleeding ulcers who keep taking aspirin after successful endoscopic therapy followed by high-dose intravenous pantoprazole, bolus of 80 mg followed by 8 mg/h for 3 days, have a small increase in the risk of rebleeding but a lower overall and cardiovascular 30-day mortality rate than those who stop taking aspirin treatment. Based on current, although limited, data, we propose that these patients should undergo early endoscopic therapy to control bleeding followed by a high-dose intravenous PPI, with early reintroduction of aspirin treatment within a 5-day window after the last dose. However, in patients taking aspirin for the primary prevention of cardiovascular events, it seems reasonable to stop aspirin treatment, re-evaluate the indication and, if needed, reintroduce aspirin after the risk of ulcer rebleeding decreases, usually after hospital discharge. In the presence of an acute ulcer bleeding event soon after the placement of coronary stents, the risk of stent thrombosis with removal of antiplatelet therapy is very high. We believe that early therapeutic endoscopy and a high-dose intravenous PPI is advisable in order to maintain patients on dual antiplatelet therapy. Until more evidence becomes available, clinicians will have to rely on actual data and the use of common sense to select the best option for the patient.

Postoperative Cephazolin Usage is Sufficient for Preventing Infection after Septoplasty Procedure

The use of antibiotics in septoplasty is a common practice among most ear, nose, and throat doctors; however, there are few studies proving the efficacy, which is considered as unnecessary by some authors. The aim of this pilot study was to evaluate the effect of two different kinds of antimicrobial agent on efficacy and safety after septoplasty surgery and to show that use of cephazolin, 1.0 g, postoperatively, might be sufficient for preventing infection after septoplasty procedure. Patients were randomly divided into two groups with a simple randomization method. The first group of 80 patients received cephazolin, 1.0 g i.v., once postoperatively and the second group of 80 patients received amoxicillin–clavulanate orally for 7 days postoperatively (1000 mg). An early and late postoperative questionnaire and nasal endoscopy evaluation was performed and patients were followed up in the outpatient service to investigate the presence of complications. There was no significant difference in postoperative pain between groups A and B, using visual analog scale scores at the 1st postoperative day. There were no differences related to the amount of purulent discharge found at the lower margin of the inferior turbinate through nasal endoscopy performed on the 14th day postoperatively. There were no statistical significances among groups for complications rates and postoperative endoscopic evaluation. Septoplasties are considered potentially contaminated surgeries, and cephazolin, 1.0 g i.v., given once postoperatively is enough to prevent potential complications with its easy and effective use.