EGD Examination Research Articles

Two-dimensional shear wave elastography for screening varices in Asian patients with primary biliary cholangitis

ABSTRACT Objectives: The presence of varices affects the survival of patients with primary biliary cholangitis (PBC). The aim of this study is to assess the criteria based on liver stiffness (LS) measured by two-dimensional shear wave elastography (2D-SWE) and platelet count (PLT), and recently published noninvasive models for triaging PBC patients. Methods: 231 patients with PBC who underwent EGD and 2D-SWE examination were enrolled. Areas under the receiver-operating characteristic curve (AUROC) were used to assess the performance of 2D-SWE for predicting all-size varices and high-risk varices. All-size varices and high-risk varices miss rate < 10% and <5%, respectively, were acceptable for screening varices. Results: The AUROCs of LS for predicting all-size varices and high-risk varices were 0.87 (95%CI: 0.82–0.91) and 0.84 (95%CI: 0.74–0.86), respectively. LS <25 kPa and PLT >110 × 109/L spared 46.3% EGD screening, with 3.7% high-risk varices miss rate and 8.4% all-size varices miss rate. One hundred and sixteen (50.2%) patients met the Newcastle varices in PBC score (cutoff, 0.5), with 4.3% high-risk varices miss rate and 11.2% all-size varices miss rate. Conclusion: The criteria based on LS and PLT are useful for triaging PBC patients. LS <25 kPa and PLT >110 × 109/L could be the optimal criteria for screening varices.

Implementation effect of institutional policy of EGD observation time on neoplasm detection

The observation time in EGD is associated with detection rate of premalignant or neoplastic lesions in the upper GI (UGI) tract. The aim of this study was to evaluate an institutional policy of EGD observation time on the detection rate of UGI neoplasms. From July 2017 to March 2019, all endoscopists were requested to comply with our institutional policy of spending more than 3 minutes of observation time in every screening EGD. Observation time was defined as the time from when the endoscope reached the duodenum to when it was withdrawn. We obtained a neoplasm detection rate (NDR) during this period and compared it with that of a baseline period from 2009 to2015. During the study period, 30,506 EGDs were performed. Mean subject age was 49.9 ± 10.5 years, and 56.5% were men. All endoscopists achieved an average EGD observation time of more than 3 minutes during this period. Mean observation time was 3:35 ± 0:50, which was significantly longer than the baseline (2:38 ± 0:21, P< .001). NDR was .33%, which was higher than the baseline (.23%, P< .001). Even after adjusting for subjects' age and gender, smoking history, and endoscopists' biopsy sampling rate, prolonged EGD observation time of more than 3 minutes increased the NDR of UGI neoplasms (odds ratio, 1.51; 95% confidence interval, 1.21-1.75). This study provides evidence that implementing a protocol of a prolonged observation time could increase NDR. Observation time should be an important quality indicator of the EGD examination.

2563 When Considering a Broad Differential to Diarrhea and Joint Pain: Don't Forget About Whipple's Disease

INTRODUCTION: Whipple's disease (WD) is a rare systemic disease caused by bacteria Tropheryma whipplei and commonly overlooked as a diagnosis. CASE DESCRIPTION/METHODS: A 42-year-old man presented to the ED for intolerance chronic of diarrhea, lower extremity swelling, paresthesia, migratory monoarticular arthralgia, and weakness. Over 2 years he lost 60-pounds and had early satiety, intermittent dysphagia, and decreased concentration. Physical exam was remarkable for a scaphoid abdomen with mild diffuse tenderness, knee joint tenderness, lower extremity strength 4/5. Labs abnormalities: hemoglobin 6.5 g/dL, albumin 1.9, 25-OH vitamin D 5 ng/mL (nml &gt; 30 ng/mL), CRP 25.4 mg/L. Bilateral lower extremity ultrasound showed a blood clot in the right deep femoral vein and bilateral baker's cysts. Colonoscopy and EGD examinations were unrevealing. Histologic exam of duodenum biopsies showed dilated fat vacuoles and a positive periodic acid-Schiff (PAS) stain confirming Whipple's Disease. Cerebrospinal fluid was negative and cognitive changes improved with electrolyte replacement. He was treated with a 14-day course of intravenous ceftriaxone followed by Bactrim doubled-strength twice a day. After intravenous antibiotics, the diarrhea resolved and he regained weight. DISCUSSION: WD most commonly affects men (86%), farmers (35%), and those with occupational exposure to soil or animals (66%). Transmission is thought to be fecal-oral since sewage workers are more prevalent carriers. Common symptoms are weight loss, arthralgia, diarrhea, and abdominal pain. Arthralgia is the sentinel symptom preceding others by ∼6 years. Less common include skin hyperpigmentation, endocarditis, and CNS symptoms (severe disease). Three diagnostic tests exist: PAS-staining, PCR of the 16S ribosomal RNA of T. whipplei, and immunohistochemistry (IHC) via rabbit anti-T. whippleiantibodies. Diagnostic criteria include: 1) small intestine biopsies positive on PAS stain for bacillus material in the lamina or 2 positive tests from other origins. Initial testing is done with EGD and duodenal biopsies submitted for PAS staining and PCR testing ± IHC. If extraintestinal symptoms, PAS staining and PCR testing ± IHC on tissue or fluid samples. CSF should be tested by PCR in all cases. After diagnosis, treatment starts with a 2-week course of IV of antibiotics (4 weeks if CNS infection or endocarditis) followed by one year of Bactrim. Relapse occurs in 17-35%, years later.

Necessity of transnasal gastroscopy in routine diagnostics: a patient-centred requirement analysis

IntroductionNumerous indications require regular upper gastrointestinal endoscopy (oesophagogastroduodenoscopy; EGD) in outpatients. In most cases, peroral gastroscopy is performed. The aim of this study was to evaluate the need of transnasal...

Colonic Marginal Zone B-Cell Lymphoma (MALT Lymphoma) in a Patient Negative for H. pylori: Case Report

Introduction: 80-year-old female found to have 30-mm uT4 uN3 sigmoid Marginal Zone B-cell lymphoma during colonoscopy and subsequent EUS with negative H. pylori antigen testing and EGD tissue biopsy. Case Description:During routine colonoscopy a patient was found to have a large non-obstructing sigmoid mass 30-cm proximal to the anus (figure 1). Four days later, EUS examination revealed a 30-mm mass evading through the muscularis propria into the serosa (figure 2). The mass was suspicious for adenocarcinoma and staged via EUS as uT4 uN3 tumor. However, the pathology was positive for Marginal B-Cell Lymphoma. The patient was sent for H. pylori stool antigen testing, EGD examination and referred to colorectal surgery. EGD showed a non-bleeding gastric ulcer along with chronic gastritis. Multiple biopsies including that of duodenal bulb, antrum and gastro-esophageal junction showed normal mucosa negative for H. pylori. After 12 weeks of PPI therapy, repeat EGD showed resolution of the gastric ulcer. As the patient remained asymptomatic, no further treatment modalities were initially pursued. However, given the association between MALT lymphoma and H. pylori infection, the patient was empirically started on triple therapy and will have a repeat colonoscopy for further assessment of the mass at the completion of therapy. Discussion: MALT lymphomas are usually defined as low grade B-Cell lymphoma that can occur in variety of extranodal organs though the most common site is the stomach with the colon and rectum accounting for <10% of the cases. Colonic MALT lymphomas are usually an incidental finding on colonoscopic examination or coinciding with a GI bleed. Currently, a treatment consensus is lacking. There have been case reports in which patient negative for H. pylori have improved after eradication antibiotic therapy due to the elimination of an unknown luminal organism. Radiation, surgical resection, chemo and immunotherapy, and endoscopic removal of the colonic lesions have also been described as fairly successful treatment modalities without any evidence of recurrence. At present, prognosis of non-gastric MALT is usually poor with a 5-10-year survival rate with disseminated lymphoma being implicated as the cause of death 20-50% of the time. It is prudent that clinicians and researcher alike remain aware of non-gastric MALT lymphoma and their associated outcomes in pursuit of improving treatment algorithms for these tumors in the future.1630_A Figure 1. Non-obstructing sigmoid mass 30 cm proximal to the anus.1630_B Figure 2. The 30-mm sigmoid mass breaking through the muscularis propria into the serosa examined via EUS (Endoscopic Ultrasound)

Upper GI involvement in children with familial adenomatous polyposis syndrome: single-center experience and meta-analysis of the literature

Familial adenomatous polyposis (FAP) is a hereditary syndrome that can affect the entire GI tract. Current screening recommendations include EGD starting at age 25 to 30 years or earlier in symptomatic patients. However, few reports describe upper GI tract involvement in children with FAP that support the notion of early screening. The aim of our study is to understand the prevalence and severity of upper GI involvement in children with FAP. We performed a retrospective review of the Mayo Clinic records, between 1992 and 2016, to identify children with the diagnosis of FAP who underwent EGD examinations. A systematic review of the literature was performed to include published studies reporting children with FAP and upper GI findings. The retrospective study included 69 children with a mean age of 13.5 years (range, 3-18). Thirty-six children (52%) had duodenal adenoma with low-grade dysplasia. Five children required an ampullectomy secondary to enlarged and polypoid ampullas. Combined with published studies, a total of 206 children with upper GI findings were identified, of which 87 (42%) had duodenal adenoma (1 had high-grade dysplasia). Meta-analysis of 5 series demonstrated duodenal adenoma detection rate of 39% (95% confidence interval, 21%-57%; I2= 85%). The available data to date show that children with FAP can have clinically relevant lesions in the upper GI tract earlier than previously foreseen, suggesting that earlier screening may be indicated. Larger multicenter prospective studies are needed to determine the best approach and optimal age for EGD screening in children with FAP.

Metastatic Renal Cell Cancer to Thyroid Diagnosed by Endoscopic Ultrasound (EUS)-Guided Fine Needle Aspiration (FNA) Technique

Medical literature about the role of Endoscopic ultrasound (EUS) in identifying thyroid lesions is limited. We present a case of secondary thyroid cancer from renal cell carcinoma (RCC) metastasis, diagnosed by thyroid EUS-fine needle aspiration (FNA) approach that was done for staging of esophageal adenocarcinoma, in a patient with 11 years history of complete right nephrectomy for RCC. An 81 year old female patient presented to our facility with dysphagea to both solids and liquids. Initial EGD examination of the esophagus revealed a distal esophageal mass of 5 cm in length, that was biopsied, and the histopathologic results revealed esophageal adenocarcinoma. For staging, the patient underwent computed tomography (CT) of the chest, which showed the lower esophageal mass with mediastinal lymphadenopathy. Next, the patient underwent upper gastrointestinal (GI) EUS for assessment of the esophageal adenocarcinoma and the mediastinal lymph nodes. The EUS-FNA examination of the mediastinal lymph nodes revealed no lymphatic spread. A diagnosis of esophageal adenocarcinoma with stage of T3N0M0 was made. Upon withdrawing the EUS scope, examination of the thyroid revealed a hypoechoic, round, and well-demarcated mass that measured 26.9 mm x 21.9 mm in the right lobe (Image1A). The radial echoendoscope was then withdrawn and the Olympus video curvilinear array echoendoscope was advanced through the mouth into the proximal esophagus. Under echoendosonographic guidance, FNA with a 25-gauge needle (Expect EUS-FNA 25 G needle; Boston Scientific, Menomonie, WI, USA) was performed successfully without adverse events (Image 1B). Cytopathologist was present in the room and confirmed the adequacy of the sample. The thyroid FNA results showed renal cell carcinoma with positive Immunohistochemical stains for PAX8 and CAIX while negative for thyroid transcription factor-1 (TTF1), thyroglobulin and chromogranin (Image 2A-C). A diagnosis of metastatic RCC was made. The patient had a history of right renal cell carcinoma (RCC) status post right nephrectomy 11 years ago (Image 2D). The patient was referred for further oncology work up and management. In conclusion, diagnosis of metastatic RCC to thyroid by EUS-FNA approach during local staging of esophageal malignancy is feasible and safe.Figure: (A) EUS examination of the thyroid revealed a hypoechoic, round, and well-demarcated mass that measured 26.9 mm x 21.9 mm in the right lobe. (B) Under EUS guidance, FNA with a 25-gauge needle (Expect EUS-FNA 25 G needle; Boston Scientific, Menomonie, WI, USA) was performed successfully.Figure: (A) Cell block of thyroid nodule FNA is displaying multiple nests of clear cells, which have clear to eosinophilic cytoplasm. These nests are separated by delicate vascular network and surrounded by lymphocytic infiltrate (H&E stain, original magnification X 400). (B) Staining of Cell block with PAX-8 shows strong nuclear positivity (PAX-8 immunohistochemistry stain, original magnification X 200). (C) Staining the cell block with thyroid transcription factor-1 (TTF-1) shows negative staining (TTF-1 immunohistochemistry stain, original magnification X 200). (D) Kidney section is showing multiple nests of clear cells, which have clear to eosinophilic cytoplasm. These nests are separated by delicate vascular network (H&E stain, original magnification X 400).

Su1982 Favorable Prognostic Factors in Advanced Gastric Cancer Patients Ineligible for Criteria of the Clinical Trial

Background/Aims: According to Correa's hypothesis, adenoma at stomach plays a role in gastric carcinogenesis as a precursor. Since endoscopic resection including endoscopic submucosal dissection for premaligant or cancerous lesion has been generally accepted as one of treatment options, endoscopist may have a chance to get the pathologic results showing early gastric cancer arising from adenoma (EGC-AFA). However there have been few reports about clinicopathologic characteristics of EGC-AFA. The aim of this study was to evaluate characteristics of EGC-AFA compared to de novo EGC treated by endoscopic resection. Methods: Between January 2008 and December 2011, 1005 EGCs form 981 S-524 AGA Abstracts patients by endoscopic resectionwere enrolled.We retrospectively reviewed clinicopathologic data of 1005 EGC lesions. Among them 161 lesions (16%) were EGC-AFA and 844 (84%) were de novo EGC. Results: There was no significant difference of age, sex, location of tumor, and gross morphology on EGD between two groups. Synchronous cancer was significantly more frequent in EGC-AFA than in de novo EGC (19.3% vs 10.3%, p=0.001). The tumor size of EGC-AFA measured on EGD was significantly larger than that of de novo EGC (16.6±9.9mm vs 14.5±7.3mm, p=0.004). However, there was no significant difference of actual tumor size on pathologic specimen. The frequency of pathologic discrepancy between biopsy specimen and resected one was higher in EGC-AFA than in de novo EGC (36.6% vs 24.2%, p=0.01). In pathologic characteristics, the differentiated type adenocarcinoma has been shown more frequent in EGC-AFA than de novo EGC (95% vs 88%, p= 0.009), and the submucosal invasion according to T stage (T1b) was significantly less frequent in EGC-AFA than in de novo EGC (12.4% vs 18.0%, p=0.001). Conclusion: The observation of co-existence of adenoma and carcinoma in one specimen is not uncommon. Due to association of adenomatous changes around cancerous lesion, misdiagnosis rate at biopy specimen higher in EGC-AFA and the size measurement of EGC-AFA might be exaggerated on EGD examination. The features of more differentiation and less invasiveness would give more favorable prognosis to EGC-AFA. The endoscopist should pay attention on synchronous ormetachronous lesions on follow up endoscopic examinationwhen encountered EGC-AFA.

Su1983 Pepsinogen I/II Ratio Is Superior to Pepsinogen I and II and Gastrin 17 in the Diagnosis of Atrophic Gastritis

Background/Aims: According to Correa's hypothesis, adenoma at stomach plays a role in gastric carcinogenesis as a precursor. Since endoscopic resection including endoscopic submucosal dissection for premaligant or cancerous lesion has been generally accepted as one of treatment options, endoscopist may have a chance to get the pathologic results showing early gastric cancer arising from adenoma (EGC-AFA). However there have been few reports about clinicopathologic characteristics of EGC-AFA. The aim of this study was to evaluate characteristics of EGC-AFA compared to de novo EGC treated by endoscopic resection. Methods: Between January 2008 and December 2011, 1005 EGCs form 981 S-524 AGA Abstracts patients by endoscopic resectionwere enrolled.We retrospectively reviewed clinicopathologic data of 1005 EGC lesions. Among them 161 lesions (16%) were EGC-AFA and 844 (84%) were de novo EGC. Results: There was no significant difference of age, sex, location of tumor, and gross morphology on EGD between two groups. Synchronous cancer was significantly more frequent in EGC-AFA than in de novo EGC (19.3% vs 10.3%, p=0.001). The tumor size of EGC-AFA measured on EGD was significantly larger than that of de novo EGC (16.6±9.9mm vs 14.5±7.3mm, p=0.004). However, there was no significant difference of actual tumor size on pathologic specimen. The frequency of pathologic discrepancy between biopsy specimen and resected one was higher in EGC-AFA than in de novo EGC (36.6% vs 24.2%, p=0.01). In pathologic characteristics, the differentiated type adenocarcinoma has been shown more frequent in EGC-AFA than de novo EGC (95% vs 88%, p= 0.009), and the submucosal invasion according to T stage (T1b) was significantly less frequent in EGC-AFA than in de novo EGC (12.4% vs 18.0%, p=0.001). Conclusion: The observation of co-existence of adenoma and carcinoma in one specimen is not uncommon. Due to association of adenomatous changes around cancerous lesion, misdiagnosis rate at biopy specimen higher in EGC-AFA and the size measurement of EGC-AFA might be exaggerated on EGD examination. The features of more differentiation and less invasiveness would give more favorable prognosis to EGC-AFA. The endoscopist should pay attention on synchronous ormetachronous lesions on follow up endoscopic examinationwhen encountered EGC-AFA.

Su1986 Epithelial Proliferation/Apoptosis Balance in Atrophic Gastritis in Presence and Absence of Gastric Cancer: A Molecular/ Immunohistochemical Evaluation

Background/Aims: According to Correa's hypothesis, adenoma at stomach plays a role in gastric carcinogenesis as a precursor. Since endoscopic resection including endoscopic submucosal dissection for premaligant or cancerous lesion has been generally accepted as one of treatment options, endoscopist may have a chance to get the pathologic results showing early gastric cancer arising from adenoma (EGC-AFA). However there have been few reports about clinicopathologic characteristics of EGC-AFA. The aim of this study was to evaluate characteristics of EGC-AFA compared to de novo EGC treated by endoscopic resection. Methods: Between January 2008 and December 2011, 1005 EGCs form 981 S-524 AGA Abstracts patients by endoscopic resectionwere enrolled.We retrospectively reviewed clinicopathologic data of 1005 EGC lesions. Among them 161 lesions (16%) were EGC-AFA and 844 (84%) were de novo EGC. Results: There was no significant difference of age, sex, location of tumor, and gross morphology on EGD between two groups. Synchronous cancer was significantly more frequent in EGC-AFA than in de novo EGC (19.3% vs 10.3%, p=0.001). The tumor size of EGC-AFA measured on EGD was significantly larger than that of de novo EGC (16.6±9.9mm vs 14.5±7.3mm, p=0.004). However, there was no significant difference of actual tumor size on pathologic specimen. The frequency of pathologic discrepancy between biopsy specimen and resected one was higher in EGC-AFA than in de novo EGC (36.6% vs 24.2%, p=0.01). In pathologic characteristics, the differentiated type adenocarcinoma has been shown more frequent in EGC-AFA than de novo EGC (95% vs 88%, p= 0.009), and the submucosal invasion according to T stage (T1b) was significantly less frequent in EGC-AFA than in de novo EGC (12.4% vs 18.0%, p=0.001). Conclusion: The observation of co-existence of adenoma and carcinoma in one specimen is not uncommon. Due to association of adenomatous changes around cancerous lesion, misdiagnosis rate at biopy specimen higher in EGC-AFA and the size measurement of EGC-AFA might be exaggerated on EGD examination. The features of more differentiation and less invasiveness would give more favorable prognosis to EGC-AFA. The endoscopist should pay attention on synchronous ormetachronous lesions on follow up endoscopic examinationwhen encountered EGC-AFA.

Sa1492 Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD)

Diagnostic Yield of Single Versus Double Endoscopic Examinations in Chronic Graft-Versus-Host-Disease (GVHD) Daena Watcha, Anne Liu, Laura Johnston, Lauren B. Gerson* Epidemiology, Stanford University, Stanford, CA; Medicine, Stanford University, Stanford, CA; Bone and Marrow Transplantation, Stanford University, Stanford, CA; Gastroenterology, Stanford University, Redwood City, CA Background: GI manifestations of chronic graft-versus-host disease (GVHD) cause significant morbidity and mortality. There has been debate regarding the utility of double versus single endoscopic examinations, optimal sites of biopsy, and whether symptoms should dictate the type of endoscopic examination performed. Methods: We performed a case-control study of 23 chronic GI-GVHD cases and 48 controls who underwent single (upper endoscopy (EGD), sigmoidoscopy (SIG), or colonoscopy (COLO)) or double (EGD plus either SIG or COLO) endoscopic procedures at least 100 days post-bone marrow transplantation between 1/2000-9/2011. We selected patients who did not have a prior diagnosis of acute GVHD, as determined by the Glucksburg criteria. Chronic GI-GVHD status was determined by the Seattle criteria. The NIH criteria were used as of 2008. Chart verification was performed to document that the patient underwent treatment with high dose steroids (corticosteroids 1 mg/kg). We collected data regarding symptoms at presentation, type of endoscopic examination performed, endoscopic findings (Cruz-Correa, Endoscopy 2002), sites of biopsy, and results of pathology examinations. Results: The GI-GVHD cases underwent 23 total endoscopic examinations including 13 (57%) double and 10 (43%) single procedures. The controls underwent 67 endoscopies including 14 (21%) double and 53 (79%) single procedures. Performance of bidirectional endoscopic examination demonstrated a positive association with diagnostic yield for chronic GVHD (p 0.001, Table 1). Symptoms leading to endoscopic examinations included diarrhea, abdominal pain, nausea, anorexia, vomiting, dysphagia, melena, failure to thrive, and GERD. The presence of diarrhea was associated with the finding of GVHD (p 0.001, Table 2). The diagnostic yield of double endoscopy alone (based on endoscopic findings without pathology) was 85% compared to 78% for lower endoscopy and 61% for EGD (p 0.3). The diagnostic yield of double endoscopy with biopsy was 92%, compared to 72% for EGD only and 83% for lower endoscopy alone (p 0.4). For the EGD examinations, biopsy at the duodenum gave the highest diagnostic yield at 92% (p 0.008 compared to gastric biopsies). In lower endoscopic examination, there was no significant difference between biopsies obtained from the right colon (terminal ileum, cecum and ascending colon, yield of 61%) and the left colon (descending colon, sigmoid and rectum, yield of 77%, p NS). Overall, 99% of patients with chronic GVHD had similar pathologic findings to those found in acute GVHD. Conclusion: The presence of diarrhea, but not nausea or abdominal pain, was positively associated with a diagnosis of chronic GVHD. The diagnostic yield was highest in patients undergoing both upper and full colonoscopic examinations with biopsies.

Sensitivity and Accuracy of Endoscopic Ultrasound in Diagnosing the Layer of Origin for Gastric Subepithelial Lesions

Purpose: Gastric subepithelial lesions (GSL) are usually found incidentally by imaging or upper endoscopy. The most common etiology is gastrointestinal stromal tumors (GIST), which are pre-malignant lesions. Other etiologies include leiomyoma, leiomysarcoma, lipoma, and schwannoma. Endoscopic ultrasound (EUS) has become an important diagnostic tool by helping to assess size, tissue characteristics, and layer of origination. These factors, especially layer of origin, can implicate GIST over other diagnoses and significantly impact further management strategy by appropriately referring pre-malignant or malignant lesions to resection. The aim of this study was to evaluate the sensitivity and accuracy of EUS in discerning the layer of origin (LO) of GSL. Methods: A retrospective chart review of EUS reports, images, cytology, and surgical pathology for all patients with subepithelial lesions presenting between April 2006 and February 2010 was done at our tertiary medical center. A total of 30 patients were identified who underwent EUS followed by laparoscopic wedge resection of a GSL. EUS were performed by a single experienced endosonographer. All patients underwent standard EGD and complete examination with a linear echoendoscope. FNA was performed by making 1 to 5 passes with a 22-gauge needle, at the discretion of the endosonographer. Immunohistochemical specimens were prepared as direct smears with routine hematoxylin and eosin-stained sections. Surgical specimens from laparoscopic resection were reviewed by staff pathologists. Results: 30 patients were identified who underwent EUS followed by wedge resection of a GSL. 27 of these patients had an EUS diagnosis of a GSL arising from either the submucosa (SM) or muscularis propria (MP), which was confirmed with surgical pathology. One patient had a false positive EUS finding of a GSL arising from the MP. Two patients had EUS findings of a GSL in the deep mucosa and SM, respectively, which on pathology involved the MP. The sensitivity and accuracy of EUS for determining the layer of origin of GSL in this study was 93% and 90%, respectively. Of the 25 GSLs arising from the MP by EUS, 15 (60%) were found to be GIST, 4 (16%) leiomyomas, 3 (12%) schwannomas, 1 glomus tumor, 1 nodular sclerosed submucosal pseudotumor, and one false positive that was a leiomyoma, but did not involve the MP. The lesions ranged from 0.6 cm - 3.5 cm in size. Conclusion: Based on our findings, EUS is highly sensitive and accurate for diagnosing the layer of origin for GSL. Of the GSLs arising from the MP diagnosed by EUS, the majority were GISTs. EUS remains an important tool in the appropriate evaluation and referral of patients for possible surgical resection of GSLs.

Effect of Acid Pump Antagonist (Revaprazan, Revanex®) on Result of13C Urea Breath Test in Patients withHelicobacter pyloriAssociated Peptic Ulcer Disease

Revaprazan (Revanex(R)) is a novel proton pump inhibitor (PPI) that has a somewhat different effect on proton pump compared with the other PPI's, also (called as 'acid pump antagonist'). We aimed to examine the false negative rate of 13C-urea breath test (UBT) in the patients with Helicobacter pylori (H. pylori) associated peptic ulcer disease who were treated with revaprazan and evaluate the anti-urease activity of revaprazan. Total 55 patients were enrolled in this study. They received EGD examination between January 2009 and December 2009 and diagnosed histologically as H. pylori associated peptic ulcer disease. All patients took revaprazan only. Three patients were excluded because of underlying chronic disease and inappropriate breath sampling. The remaining 52 patients had UBT at 0, 2 and 4 weeks of revaprazan use. After 2 weeks of the cessation of revaprazan, they had the fourth UBT. At 2 and 4 weeks, the false negative rates of UBT were 5.8% and 23.1%, respectively (p=0.05). After 2 weeks of the cessation, the cases of the false negative result were five. Four out of five patients had prolonged negative results on two or three successive tests, and baseline 13C difference value did not predict the false negative results. False negative results of UBT were common and increased with prolonged use of acid pump antagonist. As PPI, it had also anti-urease activity and most patients (47/52, 90.4%) reverted to positive results by 2 weeks after the cessation of taking the medication.

Recurrent Esophageal Candidiasis

Purpose: Introduction: We report a newly diagnosed thymoma in a patient with recurrent candidal esophagitis. Methods: Case Presentation: A 60 year-old white woman presented to her gastroenterologist for evaluation of dysphagia to solid foods. There was no personal history of diabetes mellitus, HIV, scleroderma, achalasia, recent use of glucocorticoids or antibiotic use. Physical exam was unremarkable. EGD examination revealed Candidal esophagitis. A CBC was noted for lymphopenia prompting a detailed immune evaluation. This evaluation revealed normal numbers and percentages of CD4 and CD8 T cells, serum chemistries, thyroid function, quantitative immunoglublins, CRP and ESR. ANA was weakly positive. TTG and Gliadin antibody were normal. HIV testing was negative. Delayed hypersensitivity testing showed anergy to Candida species. Chest CT showed an anterior mediastinal mass suspicious for thymoma. A stage II thymoma was subsequently removed. Her post-operative course has been complicated with recurrent candidal esophagitis and new onset myasthenia gravis. Results: Discussion: Esophageal candidiasis may present with substernal pain, dysphagia, odynaphagia or often, without any symptoms at all. The finding of esophageal candidiasis should warrant an investigation for an underlying etiology (Table). A thorough history and physical should be sought. Routine laboratory tests should be ordered to rule out common predisposing diseases for candidal esophagitis, such as diabetes and HIV. In our patient the history did not reveal any past infections. A review of her medication list was noted only for a previous course of acid suppression therapy for her peptic ulcer disease. Her physical exam did not reveal any stigmata of mucocutaneous candidiasis. EGD revealed normal structure. Routine laboratories ruled out HIV, diabetes, and endocrinopathies; however, CBC showed lymphopenia. The immunologic evaluation suggests an underlying T cell defect, as the patient had normal numbers of T cells and quantitative immunoglobulins, yet an anergic response to delayed hypersensitivity testing to Candida. Part of the work up in evaluating a patient with obvious thymocyte defect is a chest CT to rule out thymoma, as confirmed in this case.Table: Risk Factors for Candidal Esophagitis.Conclusion: In summary esophageal candidiasis is normally related to a predisposing condition. The clinician generally should identify first whether one is immunocompetent or immunodeficient. In the immunocompetent individual, medications should be considered and structural abnormalities of the esophagus should be ruled out. Classifying a patient as immunodeficient may not be as obvious as expected, as such in this case, one can have a seemingly normal immunologic evaluation.

Celiac Disease in Older Adults

Purpose: Celiac disease (CD) occurs in about 1% of US population (NIH Consensus Conference on CD 2004). It may be asymptomatic for many years or may present with diarrhea, abdominal pain, bloating, fatigue and weight loss. Common non-GI symptoms include anemia (iron deficiency and/or folate deficiency), arthritis and infertility. CD may remain latent for years and upto 20% of patients are older than 60 when CD is first diagnosed (Hankey GL. CD in elderly. Gut 1994; 35:65–67). CD is diagnosed by SB mucosal biopsy and serological testing of antibodies (IgA anti-tTG, IgA antiendomysial). WCE has provided us an opportunity to identify classical features of celiac disease and also to evaluate the nature, location and extent of mucosal abnormalities. Aim: The aim of this study is to identify various abnormalities in patients with CD with regard to their nature, location and extent of mucosal involvement in older adults.Table: Cases of Celiac disease in older adultsMethods: In this prospective study, patients presented for evaluation of CD underwent WCE according to standard protocols. Results: Total number of CD cases: 13, Older adults (Age above 60): 7 cases. (Males 2, Females 5) Common indications: Anemia, chronic diarrhea, abdominal pain and unexplained weight loss (More than one indication coexisted in some patients). Common findings: Scalloping, mucosal atrophy, layering or stacking of mucosal folds, mosaic pattern and nodularity (Multiple findings coexisted). Conclusions: 1) Anemia in the older adults (age > 60) may be the sole manifestation of CD and needs further evaluation to confirm the diagnosis. 2) WCE provides as valuable tool to visualize the entire small bowel mucosa and to identify the nature, location and extent of mucosal abnormalities seen in CD. 3) In CD the duodenum may be entirely normal by the EGD examination while the proximal and distal small intestine may show classic features of CD.

Primary non-Hodgkin''s lymphoma in esophagus-a case report

A 57-year old man with gradually appeared dysphagia during one year period. Barium meal imaging of upper digestive tract and chest CT indicated esophageal stricture and incrassation of total esophageal wall, but there was no clinical evidence suggesting swelling of lymph nodes appearing in cervix, lung and mediastinum. 1 year later, incrassation of esophageal mocosa still existed in middle and distal part of esophagus by EGD examination. Then esophageal motility investigation and intra-luminal miniature probe sonography (MPS) were performed, it revealed that disorder of esophageal movement and 1.5˜2.0cm thickened mucosal layer of the esophagus with homogeneous hypoechoic structure. Followed by large piecemeal biopsy, the histo-pathological examination suggested: squamous epithelia was partially disappeared and replaced by same size, round or ovoid with clear nuclei proliferated lymphoid cells. Immunohistochemical and special staining indicated: I1415: AE1/AE3-, EMA-, LCA+, L26+, CD3-, CHG-, CD138-, κ+, λ-, Bcl2+, Bcl6-. Final result was primary Non-Hodgkin's lymphoma (NHL) microcyte type-B.

Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: A randomized controlled study

Background: The diagnostic and therapeutic value of EGD in patients with upper GI bleeding is often limited by the presence of residual blood or clots. When infused before EGD, erythromycin, a potent gastrokinetic drug, might improve the quality of EGD in patients with upper GI bleeding. The aim of this study was to assess the effect of erythromycin on the quality of the EGD in patients with acute upper GI bleeding. Methods: Forty-one patients admitted to the intensive care unit because of acute upper GI bleeding were included in a randomized, endoscopist-blinded, controlled trial, comparing erythromycin (3 mg/kg intravenously over 30 minutes) to no treatment (control patients). EGD was performed 30 to 90 minutes after the end of the infusion. The primary study outcome was quality of EGD examination, as evaluated on a scale of 0 to 3, and the need to perform a second diagnostic EGD within the next 8 days. Secondary outcomes were efficiency of the endoscopic hemostatic therapy and intensity of esophagogastroduodenal contractions, as evaluated on a scale of 0-3. Results: The characteristics of the patients and lesions found by EGD were similar in both groups. Quality of the EGD examination was significantly better in the erythromycin group (n = 19) compared with the control group (n = 22) (2.5 [0.8] vs. 1.5 [1.3]; p = 0.02). Three patients receiving erythromycin required a second EGD compared with 10 control patients ( p = 0.089). Erythromycin did not interfere with the performance of EGD or the efficiency of hemostatic procedures. The intensity of gastroduodenal contractions was similar in both groups. No adverse event was observed. Conclusions: In patients with acute upper GI bleeding, infusion of erythromycin before endoscopy significantly improved the quality of EGD and tended to reduce the need for second-look endoscopy. (Gastrointest Endosc 2002;56:174-9.)

7032 Gastrointestinal endoscopy in a large urban medical center iii- esophagogastroduodenoscopy (egd) in patients with upper gi bleeding.

During the period of 1/97- 4/99 767 EGD examinations were performed at Kings County Medical Center. 307 (40%) of these were done for the indication of upper GI bleeding. Of these, 25.1% were emergency procedures performed in the emergency area (15.8%), intensive care units (10.1%), or the GI endoscopy unit (74.1%). Successful completion of EGD examination was accomplished in 83.1% of the cases for emergencies and 93.7% for routine cases. In 46 cases (15%) a therapeutic technique was applied consisting of heater probe application (5.2%), injection therapy (12.1%), or sclerotherapy (0.7%). There were no endoscopic complications. The endoscopic diagnoses made were as follows: esophagitis 63 (20.2%), M-W tear 20 (6.5%), esophageal ulcer 8 (2.6%), esophageal ulcer w/ active bleeding 4 (1.3 %), esophageal varices 24 (7.8%), Barrett s esophagus 3 (1 %), esophageal candidiasis 11 (3.6%), esophageal cancer 3 (1%), hiatus hernia 49 (16%), gastritis 106 (34.5 %), gastric ulcer (GU) 81 (26.4%), GU w/ active bleeding 8 (2.6%), GU w/ visible vessel 13 (4.2%), gastric polyp 9 (2.9%), gastric cancer 8 (2.6%), duodenitis, 60 (19.5%), duodenal ulcer (DU) 78 (25.4%), DU w/ active bleed 9 (2.9%), DU w/ visible vessel 7 (2.3%), duodenal polyp 4 (1.3%), and abnormal papilla 2 (.7%). Conclusions: In this population: 1) Upper GI bleeding is the most common indication for EGD. 2) Gastritis, gastric ulcer, and duodenal ulcer were the most frequent diagnoses. 3) Approximately 10% of patients were actively bleeding during EGD. 4) Therapeutic intervention was performed in 15% of cases.

7214 Gastrointestinal endoscopy at a large urban medical center v - use of conscious sedation for esophagogastroduodenoscopy (egd).

During the period of 1/97-4/99 767 EGD examinations were performed at Kings County Medical Center. All employed standard size video endoscopic equipment. 2 cases (0.2%) were done under general anesthesia. 227 (29.6%) of these examinations were performed without the use of any sedation. In 538 (70.1 %) conscious sedation was employed. Versed alone (mean dose=1.14mg) was used in 59.6 % of cases; 61.6% routine cases (mean=1.09 mg), and 55.3% emergency cases (mean=1.23mg). Versed and Demerol were given in 5.0 % of routine (mean=1.16 and 27.63mg, respectively) and 10.7 % of emergency cases (2.56 and 38.89 mg). Demerol alone was given in 0.7% of routine(mean 32.5 mg), and 1% of emergency cases (25 mg). Successful completion of examinations was achieved in 90.3% of those receiving no sedation and 87.9% of sedated patients. The mean age of unsedated patients was 57.1 years, while sedated patients were 53.5 years. 12.8% percent of unsedated patients were examined emergently. Choice of sedation could not be related to the indication for procedures. There were 2 complications (0.3%), both micro-perforations of the esophagus requiring no invasive treatment. Conclusions: 1. A major fraction of EGD were performed with no sedation. 2. In sedated patients, the dose of medications was minimal. 3. Completion rates were relatively low, but did not vary as a function of sedation at the doses given. 4. No patient experienced cardiopulmonary complications. 5. 90% of patients tolerated EGD using standard equipment in the absence of sedation. During the period of 1/97-4/99 767 EGD examinations were performed at Kings County Medical Center. All employed standard size video endoscopic equipment. 2 cases (0.2%) were done under general anesthesia. 227 (29.6%) of these examinations were performed without the use of any sedation. In 538 (70.1 %) conscious sedation was employed. Versed alone (mean dose=1.14mg) was used in 59.6 % of cases; 61.6% routine cases (mean=1.09 mg), and 55.3% emergency cases (mean=1.23mg). Versed and Demerol were given in 5.0 % of routine (mean=1.16 and 27.63mg, respectively) and 10.7 % of emergency cases (2.56 and 38.89 mg). Demerol alone was given in 0.7% of routine(mean 32.5 mg), and 1% of emergency cases (25 mg). Successful completion of examinations was achieved in 90.3% of those receiving no sedation and 87.9% of sedated patients. The mean age of unsedated patients was 57.1 years, while sedated patients were 53.5 years. 12.8% percent of unsedated patients were examined emergently. Choice of sedation could not be related to the indication for procedures. There were 2 complications (0.3%), both micro-perforations of the esophagus requiring no invasive treatment. Conclusions: 1. A major fraction of EGD were performed with no sedation. 2. In sedated patients, the dose of medications was minimal. 3. Completion rates were relatively low, but did not vary as a function of sedation at the doses given. 4. No patient experienced cardiopulmonary complications. 5. 90% of patients tolerated EGD using standard equipment in the absence of sedation.