Gastrointestinal Endoscopic Examination Research Articles

Appendiceal intussusception caused by endometriosis

In September, 2011, a 44-year-old woman presented to our surgical outpatient department with lower abdominal pain of a few weeks’ duration, nausea, and vomiting. There was no change in her bowel habits and no rectal bleeding. Her medical history included hiatus hernia, iron and folate defi ciency anaemia, and chronic fatigue syndrome. On physical examination she had lower abdominal tenderness, without signs of peritoneal irritation. Routine blood investigations showed low haemoglobin and high C-reactive protein concentrations. A gastrointestinal endoscopic examination was done because of her chronic symptoms and iron defi ciency anaemia, Gastroscopy did not show any upper gastrointestinal changes other than the hiatus hernia. However, colonoscopy showed a 3 cm luminal invagination of the caecum at the site of the appendiceal orifi ce, suggestive of an appendiceal intussusception (fi gure A). Appendiceal intussusception was confi rmed by a CT scan, which showed an intraluminal lesion corres ponding to an inverted appendix. Our patient was off ered open surgical resection. During surgery, caecal thickening with a complete appendiceal intussception was seen. The caecum and terminal ileum were well perfused. A partial caecectomy that included the intussuscepted appendix was done. Histological examination of the specimen confi rmed complete intussusception of the appendix, consistent with a Type-V McSwain classi fi cation, and previously unsuspected foci of endomet riosis scattered in the submucosa and muscularis propria, with involvement of the serosal surface (fi gure B). Our patient recovered and at 2-month follow-up in January, 2012, was pain free and on hor monal suppression of endometriosis. The reported incidence of endometriosis of the appendix is less than 1%. Endometriosis causing intussusception of the appendix is rare with only 37 published cases. Most reports have highlighted the diagnostic and management challenges. Young adults presenting with lower abdominal pain are commonly diagnosed with infl ammatory

Magnetic resonance imaging features of multiple duodenal lipomas: a rare cause of intestinal obstruction

A 65-year-old man was evaluated because of vomiting and epigastric pain. The patient underwent upper gastrointestinal endoscopy and endoscopic ultrasound examination and was found to have multiple polypoid lesions in the D1 and D2 portions of the duodenum, causing almost complete obstruction of the duodenal lumen. The lesions were hyperintense on T1-weighted and intermediately intense on T2-weighted images, with a drop in signal on T1- and T2-weighted fat-suppressed images, consistent with a diagnosis of duodenal lipomas. Pathohistological examination confirmed the diagnosis of duodenal lipomas.

Factors Associated With Diagnosis of Obscure Gastrointestinal Bleeding by Video Capsule Enteroscopy

Capsule enteroscopy (CE) is the best noninvasive tool to explore the entire small bowel of patients with obscure gastrointestinal bleeding (OGIB); it has a diagnostic yield of 40%-80%. However, little is known about the factors associated with a diagnosis of OGIB by CE. We analyzed data from 911 consecutive patients who underwent CE for OGIB from January 2004 to January 2010. Results from upper and lower gastrointestinal endoscopy examinations were negative in all patients. CE findings were recorded. Features of patients that were associated with diagnosis of OGIB by CE were identified by using logistic regression. Based on CE, 509 patients (56%) had a confirmed lesion responsible for the OGIB: 203 had disease of the small bowel (22%), 88 had ulcerations (10%), 70 had tumors (8%), 24 had varices (2%), 6 had diverticula (0.5%), and 118 had what appeared to be bleeding lesions of the esophagus or stomach (10.6%) or colon (2%). Factors independently associated with a diagnosis of OGIB by CE were age >60 years (odds ratio [OR], 1.2), male sex, history of overt bleeding (OR, 3.8), and current hospitalization (OR, 1.4). Women were less likely to be diagnosed with OGIB by CE (OR, 0.7). A history of overt bleeding is the factor most strongly associated with a diagnosis of OGIB by CE. Male sex, age >60 years, and inpatient status were also independent predictors of positive diagnosis by CE.

Prevalence of upper digestive endoscopy and gastric histopathology findings in morbidly obese patients

The prevalence of obesity has been increasing in modern society. Roux-en-y gastric bypass is a bariatric surgery that involves the exclusion of significant part of the stomach. Atrophy, intestinal metaplasia and gastric cancer have been associated with infection by Helicobacter pylori. To evaluate the presence of endoscopy findings and histological changes in morbid obese patients for the presence of inflammatory cells, inflammatory activity, lymphoid hyperplasia, H. pylori infection, atrophy and intestinal metaplasia in the gastric mucosa. Upper digestive endoscopy and gastric histopathological were studied in 126 obese patients in the preoperative evaluation for bariatric surgery. Upper digestive endoscopy abnormalities were diagnosed in 73/126 (57.9%) patients. In three patients (2.4%) the upper gastrointestinal endoscopy diagnosed gastric ulcer and one patient (0.8%) had duodenal ulcer. The histopathological from gastric biopsies of these obese patients showed 65.1% of mucosa inflammation, inflammatory activity in 50.0%, infection by H. pylori in 53.2%, lymphoid hyperplasia in 50.0% and atrophy and/or intestinal metaplasia in 16.7%. In present study, with routine preoperative upper gastrointestinal endoscopy and histopathological examination, were detected 57.9% patients with endoscopy abnormalities, high prevalence of infection by H. pylori (53%) and 16.7% of gastric atrophy and/or intestinal metaplasia.

Upper gastrointestinal endoscopy detection of synchronous multiple primary cancers in esophagus and stomach: single center experience from china.

The present study was undertaken to clarify the prevalence and clinicopathological features of synchronous multiple primary cancers (SMPCs) under upper gastrointestinal endoscopic examination. We enrolled 45,032 consecutive patients who underwent upper gastrointestinal endoscopic examination for digestive disease from January 2006 to December 2007 in our hospital and analyzed the clinicopathological features of SMPCs in esophagus and stomach. SMPCs are defined as two or over two different cancerous lesions developing in the same or other organs within 6 months. SMPCs were identified in 46 patients (0.1%). The gender ratio was 5.6 : 1 (male/female) and the mean age was 59.4 years. Synchronous esophageal and gastric cancers were the most frequent, being seen in 32 patients (0.07%). The most common histological types of SMPCs were squamous cell carcinoma in esophagus and adenocarcinoma in stomach, respectively. There were 27 (59%) SMPCs patients who had the history of simultaneous exposure to tobacco smoking and alcohol drinking. Additionally, 32 (78%) esophageal squamous cell cancers were associated with tobacco use. And 23 adenocarcinomas of the stomach were associated with Helicobacter pylori infection.

Incidence of Propofol Injection Pain and Effect of Lidocaine Pretreatment During Upper Gastrointestinal Endoscopy

Propofol has been used in the past for sedation in upper gastrointestinal (GI) endoscopic procedures. This study aimed to measure the incidence of propofol injection pain and evaluate the effect of lidocaine on pain caused during sedative upper GI endoscopic examinations. Subjects scheduled to undergo sedative diagnostic upper GI endoscopy were randomly assigned to lidocaine and placebo groups. Pretreatment with a bolus of 1% lidocaine 2ml or normal saline 2ml into the largest dorsal vein of the non-dominant hand was followed by propofol administration. Pain intensity was estimated by an examiner blinded to the group assignment using a four-point verbal rating scale. A score of 1-3 was regarded as pain. A total of 121 patients (males, 69; age, 58.6±12.1years) completed the study; 61 and 60 subjects were randomly assigned to the lidocaine and placebo groups, respectively. The incidence of pain during upper GI endoscopy was 60%. The lidocaine group showed a lower incidence of pain than the placebo group (37.7% vs. 60.0%, P=0.018). The lidocaine group perceived significantly less pain than the placebo group (median pain score, 0 vs. 1, P=0.008). Only lidocaine pretreatment was an independently associated factor against pain perception (OR, 0.380; 95% CI, 0.177-0.815; P=0.013). Pretreatment using lidocaine was found to be effective in reducing propofol injection-induced pain. However, its usefulness for GI endoscopic procedures in daily clinical practice needs further evaluation because of the low intensity of pain.

On the Association Between Soft Drink Consumption and Helicobacter pylori Infection

The association between soft drink (SD) consumption and Helicobacter pylori infection remains unclear. To examine the relationship between SD consumption and H. pylori infection. A prospective study included individuals who were referred for an upper gastrointestinal endoscopic examination because chronic dyspepsia within a period of 1 year. In addition to determining daily SD consumption and the risk factors for H. pylori infection by asking all study participants to complete a standard questionnaire about their diet, daily eating and drinking habits, and their lifestyle before undergoing the endoscopic examination. H. pylori infection was established by a positive result of the rapid urease test and histology. Of the 312 individuals who were referred for the endoscopic examination because chronic dyspepsia, 269 met the inclusion criteria. H. pylori infection was found in 164 (61%) of the 269 study participants, and, of these, 104/164 individuals were SD consumers with H. pylori infection versus 24/105 individuals without H. pylori infection (63 vs. 23%, respectively, P < 0.001). The results of the multiple logistic regression analysis showed that SD consumption (odds ratio = 4.0; 95 % confidence interval = 3.19–5.82,P < 0.001), was associated with H. pylori infection. SD consumption is associated with H. pylori infection in individuals with chronic dyspepsia.

Endoscopist’s thumb and other injuries

The demand for gastrointestinal endoscopic examinations has increased as a result of various factors including the advent of bowel screening and advances in endoscopic therapeutic treatment. The risks to patients are now well known. Less, however, is known about the risks to the staff carrying out these procedures. In this article, Sheila Mair discusses repetitive stress injury as a risk to endoscopists.

An Interesting Case of Chronic Idiopathic Non-cirrhotic Portal Vein Thrombosis

Purpose: Introduction: Portal vein thrombosis was first reported in 1868 by Balfour and Stewart. It is a rare condition that typically presents in non-cirrhotic patients. Inherited (Factor V Leiden and Prothrombin gene mutation G201210A, Protein C, S, Anti thrombin III deficiency) and acquired thrombophilias (Lupus Anticoagulant, myeloproliferative diseases, malignancy, surgery and trauma) account for majority of the cases of portal vein thrombosis. Doppler ultrasound studies are usually the initial test of choice. Case Report: 63 year old Hispanic Female with history of hypertension, Diabetes Mellitus, coronary artery disease presented with complaints of epigastric pain & bloody vomiting. She initially had epigastric discomfort & 2 episodes of hematemesis. She denied alcohol use. Abdominal examination was unremarkable except for mild epigastric tenderness. Laboratory analysis revealed hemoglobin of 10.5 mg/dl with normal liver function tests and aminotransferases. An upper gastrointestinal endoscopic examination was done which revealed grade 4 esophageal varices with fresh blood in the distal esophagus which were subsequently ligated. She was started on octreotide and propranolol. She had another episode of GI bleed requiring emergent endoscopic intervention. She underwent a liver biopsy. Pathology revealed focal mild portal fibrosis with mild micro & macro vesicular steatosis but no cirrhosis. A Doppler Ultrasound revealed portal vein thrombosis and concomitant portal hypertension. An extensive hypercoaguable work up was done which included protein C & S levels, anti thrombin III, Prothrombin gene mutation G20210A, Factor V Leiden, Lupus anticoagulant, Anticardiolipin antibodies, Homocysteine level & they were all negative. We also tested her blood for flow-cytometry for CD 55 and CD 59 but the test was normal and in the process effectively ruled out paroxysmal nocturnal hemoglobinuria. She also was also tested for the JAK 2 mutation. It was negative. We gave her the clinical diagnosis of chronic idiopathic non-cirrhotic portal vein thrombosis. She subsequently had a meso-caval shunt done to relieve the portal hypertension. She was started on warfarin anticoagulation 3 days later with close monitoring for bleeding. She clinically got better and was then discharged home. Discussion: Non-cirrhotic portal vein thrombosis can be acute or chronic. Acute cases need at least 3 months of anticoagulation. Chronic cases needs porto-systemic shunting. The use of anticoagulation in chronic cases should be decided upon on a case by case basis weighing the risk of bleeding versus thrombosis. We opted to give longterm anticoagulation to our patient to prevent re-thrombosis of the mesocaval shunt/graft.

Increasing insulin resistance is associated with increased severity and prevalence of gastro-oesophageal reflux disease

The diagnosis of gastro-oesophageal reflux disease (GERD) is based on reflux symptoms. Although metabolic syndrome has been linked to erosive oesophagitis (EO), the impact of insulin resistance, the core of the metabolic syndrome, on reflux symptoms remains to be elucidated. To assess the effects of insulin resistance on GERD, including both endoscopic findings and symptoms. A total of 743 sonographic noncirrhotic adult subjects, who underwent an upper gastrointestinal endoscopic examination, completed a gastro-oesophageal reflux questionnaire and had available fasting insulin data were included. Endoscopic findings were classified according to the Los Angeles classification. Homeostatic model assessment-insulin resistance (HOMA-IR) index was used to evaluate the status of insulin resistance. Univariate and multivariate approaches were used to evaluate the associations between insulin resistance and GERD. Older age, male gender, smoking and alcohol consumption increased the prevalence of EO, but not GERD symptoms. A large waist circumference, high fasting blood glucose levels and high number of metabolic syndrome components were associated with increased prevalence of both EO and GERD symptoms, while high blood pressure was associated with increased prevalence of EO only. Moreover, higher scores in the gastro-oesophageal reflux questionnaire were associated with higher HOMA-IR index, and higher HOMA-IR index was associated with increased prevalence of EO (adjusted odds ratio 1.14, 95% CI 1.03-1.26, P = 0.012). Our findings demonstrate clear associations between insulin resistance, metabolic syndrome and GERD. Whether reducing insulin resistance may improve GERD symptoms or EO deserves prospective study.

Results of gastrointestinal endoscopic examinations in patients with iron defıciency anemia

Results of gastrointestinal endoscopic examinations in patients with iron defıciency anemia

Glándulas sebáceas ectópicas en esófago. Reporte de tres casos

Sebaceous glands typically are located in the pilosebaceous unit located in the superficial layers of the skin. Thus, ectopic sebaceous glands in the esophagus are a very unusual condition. Since 1962 when De la Pava and Pickren described that sebaceous glands could be ectopically located in the esophagus, no more than 30 cases have been reported in the literature. Macroscopically, single or multiple nodular yellowish lesions are found, and most of the times are overlooked. In this paper, we describe 3 cases (2 female and one male) of ectopic sebaceous glands in the esophagus incidentally detected during routine upper gastrointestinal tract endoscopic examination. Histopathology diagnoses were supported using immunohistochemestry for AE1/AE3 citokeratins and epithelial membrane antigen.

A case of takotsubo cardiomyopathy with ventricular fibrillation after gastroenterological endoscopy.

We describe a case of takotsubo cardiomyopathy with ventricular fibrillation after gastroenterological endoscopy in a 66-year-old woman. Ten minutes after the upper and lower gastrointestinal endoscopic examinations, the patient lost consciousness, went into respiratory arrest, and became cyanotic; an electrocardiogram (ECG) showed ventricular fibrillation. Electrical defibrillation was applied three times resulting in the patient's recovery. Subsequently, the ECG showed ST elevation in V2-V3; ultrasound cardiography showed a severely hyperkinetic base of the left ventricle, with the rest of the ventricle akinetic; and cardiac catheterization disclosed a normal coronary artery and normal contraction of the left ventricle.

Endoscopic Diagnosis of Open-Type Atrophic Gastritis Is Related to the Histological Diagnosis of Intestinal Metaplasia and Cdx2 Expression

Long-term Helicobacter pylori infection results in atrophic gastritis and intestinal metaplasia (IM) with Cdx2 expression. We have tried to determine if there was a link between endoscopic and histological diagnosis of IM based on the status of aberrant Cdx2 expression. One hundred and one subjects agreed to upper gastrointestinal endoscopic examination, with biopsy sampling for histology, Giemsa, and Cdx2 immunohistochemical staining before and after the treatment. On endoscopic examination, atrophic gastritis was defined as discoloration with blood vessel transparency, and was classified as either closed or open. Metaplastic gastritis was defined by the presence of whitish patches, whitish plaques, and/or homogeneous whitish discoloration. Histologic analysis was performed to determine H. pylori density, intensity of acute polymorphonuclear cell infiltrates and chronic mononuclear infiltrates, gastric atrophy, and IM as demonstrated using immunohistochemistry for cdx2. Cdx2 protein expression (P=0.018) and the prevalence of histologically detected IM (P=0.011) were higher in cases of endoscopically diagnosed open-type atrophic gastritis and metaplastic gastritis than in closed-type atrophic gastritis and nonatrophic/nonmetaplastic cases. The degree of activity (P=0.006) and inflammation (P=0.007) improved significantly after four weeks of successful H. pylori eradication treatment, whereas the degree of atrophy, metaplasia, and Cdx2 expression did not. Unlike endoscopic diagnosis of closed-type atrophic gastritis, that of open-type atrophic gastritis is highly correlated with the histological diagnosis of IM and Cdx2 expression. Endoscopically diagnosed open-type atrophic gastritis and endoscopically diagnosed metaplastic gastritis have similar histological features, which suggests that a high percentage of IM cases are diagnosed as open-type atrophic gastritis by endoscopic examination.

A rare case of gastroduodenal fistula following gastric resection and radiotherapy: First case in the literature

Because of the suspicion of a gastro-intestinal malignancy, a gastro-intestinal endoscopic examination was performed. During the endoscopic examination a vegetative, papillary mass was seen in the antral region of the stomach and punch biopsies were taken from the mass and the surrounding tissue. The pathological diagnosis confi rmed the suspicion of malignancy as adenocarcinoma of the stomach (Figure 1).

Malignant Pleural Effusion and Osteoblastic Metastases as the Initial Manifestation of Occult Gastric Cancer :

A 53-year-old man was admitted to our hospital because of lumbago. Gastrointestinal endoscopic examination performed on admission did not reveal any gross gastric abnormalities. Lumbar radiography and bone scintigraphy revealed multiple bone osteoblastic changes. Chest radiography showed right pleural effusion. The findings of the chest computed tomography and cytological examination of the pleural effusion were strongly suggestive of lung cancer. The patient was refractory to chemotherapy, and he died of cancer and disseminated intravascular coagulation. The autopsy revealed absence of primary lung cancer and the presence of tumor emboli in the right lung field. Swollen perigastric lymph nodes, tiny signet-ring cell carcinoma at the posterior wall of the stomach corpus, and severe vascular invasion were also observed at autopsy. Therefore, signet ring cell carcinoma of the stomach should be considered as a possible diagnosis in early-stage gastric cancer patients who develop osteoblastic metastasis and pleural effusion.

Giant Brunner's gland adenoma as an unusual cause of anaemia: report of a case

BackgroundBrunner’s gland adenoma (BGA) is a rare benign duodenal tumour proliferating from Brunner’s glands. Here, we present a giant BGA leading to anaemia, with its clinical, endoscopic, radiological, surgical and pathological findings.Case report.A 48-year-old Turkish man complained of a six months history of vague epigastric discomfort, loss of appetite and nausea after meals without vomiting. The physical examination had no unremarkable finding. Laboratory findings, including liver function tests, were within normal limits except a hypochromic, microcytic anaemia. The upper gastrointestinal endoscopic examination revealed a lobulated, red, polypoid tumour with a smooth surface covered with normal mucosa. The tumour was located on the anterior surface of duodenal bulb and had a wide base measuring 3.5 × 4 cm in size. Endoscopic ultrasonography revealed a submucosal polypoid mass located at the anterior surface of duodenal bulb. The endoscopic excision was tried but was not successful. The patient was operated and transduodenal polypectomy was done. The postoperative period was uneventful and the pathologic diagnosis was assessed as Brunner’s gland adenoma. During the follow-up period, the endoscopic examination was normal at 12th month postoperatively.ConclusionsBGA is a rare benign cause of anaemia that can be treated with excellent results.

Primary gastric Hodgkin lymphoma and metachronous early gastric carcinoma: a case report

Primary Gastric Hodgkin lymphoma is seen very rarely. Primary gastric Hodgkin lymphoma and gastric carcinoma in same patient is very very rare entity. Almost all of the primary gastric lymphoma cases are non-Hodgkin lymphoma type. We report the case of 45-year-old man with 3-month history of abdominal pain and weight loss. Upper gastrointestinal endoscopic examination revealed an ulcerated polypoid mass on greater curve of stomach and histopathological examination of biopsy showed adenocarcinoma. After near total gastrectomy, gastric Hodgkin lymphoma diagnosis was made, and postoperative 4 courses of doxorubicin, bleomycin, vinblastine, dacarbazine (ABVD) regimen were administered, and then total 3,600 cGy radiotherapy was delivered. After 7 years, during control examination, early gastric carcinoma was diagnosed. Our case is very rare entity of gastric Hodgkin lymphoma and metachronous gastric carcinoma. This case also shows the importance of follow-up of patients not only for the relapse of primary disease but also for the development of secondary malignancy which can be diagnosed at early curable stage.

Source authenticity in the UMLS – A case study of the Minimal Standard Terminology

As the UMLS integrates multiple source vocabularies, the integration process requires that certain adaptation be applied to the source. Our interest is in examining the relationship between the UMLS representation of a source vocabulary and the source vocabulary itself. We investigated the integration of the Minimal Standard Terminology (MST) into the UMLS in order to examine how close its UMLS representation is to the source MST. The MST was conceived as a “minimal” list of terms and structure intended for use within computer systems to facilitate standardized reporting of gastrointestinal endoscopic examinations. Although the MST has an overall schema and implied relationship structure, many of the UMLS integrated MST terms were found to be hierarchically orphaned, and with lateral relationships that do not closely adhere to the source MST. Thus, the MST representation within the UMLS significantly differs from that of the source MST. These representation discrepancies may affect the usability of the MST representation in the UMLS for knowledge acquisition. Furthermore, they pose a problem from the perspective of application developers. While these findings may not necessarily apply to other source terminologies, they highlight the conflict between preservation of authentic concept orientation and the UMLS overall desire to provide fully specified names for all source terms.

Successful embolization therapy for bleeding from jejunal varices after choledochojejunostomy: Report of a case

We report a case of successful embolization of jejunal varices that were the cause of massive gastrointestinal bleeding from a choledochojejunostomy site, resulting from obstruction of the extrahepatic portal vein. A 42-year-old man who had undergone choledochojejunostomy for intrahepatic and choledochal stones was readmitted after he started passing massive dark bloody stools. Gastrointestinal endoscopic examination and angiography could not identify the source of bleeding. Percutaneous transhepatic portography showed obstruction of the right branches of the portal vein. The formation of jejunal varices at the site of choledochojejunostomy was revealed by portography and by cholangioscopy, suggesting the varices as the cause of massive bleeding. Bleeding could not be controlled long-term by cholangioscopic sclerosing therapy. We finally stopped the bleeding by embolizing a jejunal vein to the afferent loop.