Negative Endoscopy Research Articles

How Useful Are Breath Tests in the Diagnosis of SIBO or Carbohydrate Intolerance

Purpose: Assess the diagnostic yield of glucose, lactose and fructose breath tests and the predictive value of GI symptoms (pre-test and during test) with test results. Methods: Over two years, patients with a negative endoscopy and radiology studies and suspected SIBO underwent glucose (75g) breath test (GBT), and those with suspected CHO intolerance had lactose (25g) (LBT) or fructose (25g) (FBT) breath tests. H2 and CH4 levels were assessed (Quintron®). Frequency, duration and intensity (score 1-3) of abdominal pain, cramping, bloating, fullness, nausea, belching, indigestion, diarrhea, and gas/flatulence were assessed at baseline and during test. Correlation of symptoms to test results was analyzed using linear regression and Spearman's correlation. Positive test = >20ppm of H2 or >15ppm CH4 over baseline. Results: 595 patients with long standing symptoms (> 5 years) were examined mean age 45±16; some had more than one test. Diagnostic yield is shown (Table). Patients with methanogenic flora and a positive test had higher baseline CH4 values. There was no overall correlation between symptoms during the test and peak H2/CH4 levels. Pre-test symptoms were not predictive of positive or negative GBT, FBT or LBT (p>0.05).Table: [313]Conclusion: Approximately 1/3rd of patients with persistent bloating, gas and fullness had a positive test for SIBO or CHO intolerances. However, pre-test symptoms do not appear to predict a positive or negative GBT, FBT or LBT, suggesting a need for objective breath tests. Methane assessment increases the diagnostic yield by 6-10%. Thus, breath testing is both clinically useful and essential for a diagnosis of common GI problems and should be adopted more widely. Acknowledgement: NIH Grant R01 DK057100.Figure: [313]

A Diagnostic and Therapeutic Challenge: Campylobacter Colitis Triggers Ulcerative Colitis and the Peril of Clostridium difficile

Introduction: Microbial causation of inflammatory bowel disease (IBD) remains unproven. Initiation or relapse of IBD may be facilitated by infection in genetically vulnerable individuals. Diagnosis of IBD during hospitalization is more common in patients with recent positive stool culture. Distinction by exclusion of infection is critical as immunosuppressive therapies will exacerbate active infectious disease. Case Description: A previously healthy 27-year-old with no family history of IBD presented to his family doctor after four weeks of profuse watery bowel movements and fever. He had no known allergy and did not take medication. Campylobacter jejuni stool culture was positive and metabolic panel revealed severe hypokalemia. He was admitted for severe sepsis [tachycardia (124 bpm), fever (39.5-degrees Celsius) and infectious diarrhea]. Exam was benign and skin was without lesion. Laboratory studies revealed potassium 1.9 mmol/L (3.5-5.1 mmol/L, leukocytosis, anemia, and hypoalbuminemia. Stool culture, ova and parasite, and Clostridium difficile PCR were negative. Serology for celiac disease was negative and upper endoscopy was unremarkable. Colonoscopy revealed pancolitis with diffusely bleeding ulcers and endoscopically normal terminal ileum. Histopathology revealed chronic inflammatory disease and diagnosis of UC was established. The patient was treated with mesalamine and finished azithromycin course; corticosteroids and azathioprine were avoided in setting of active infection. At six weeks, the patient had no relapse and continued mesalamine. Nine months after initial episode, he presented to the hospital with dyspnea and diagnosed with alcoholic hepatitis. Steroids were administered. Shortly after, he developed severe Clostridium difficile colitis and was transferred to the intensive care unit in multiple system organ failure (APACHE-II score of 25, 65.3% hospital mortality). To date, he remains dialysis dependent in liver failure (MELD score of 40). Discussion: UC diagnosis requires bloody diarrhea with cramping, fecal urgency, anemia, low albumin, negative stool culture, endoscopic evidence and tissue sampling. Clinically and endoscopically, it can be indistinguishable from other causes. Post-infectious diagnosis considers negative stool culture, histology, and course of disease. Clostridium difficile associated disease is prevalent in UC patients and is associated with poor clinical outcome. This clinical scenario exposes the diagnostic and therapeutic challenges of UC in the setting of infectious colitis and emphasizes microbial consideration in the natural history of inflammatory bowel disease.

Guía de práctica clínica sobre el manejo del paciente con dispepsia. Actualización 2012

The aim of the Clinical Practice Guideline (CPG) on the Management of Patients with Dyspepsia is to generate recommendations on the optimal approach to dyspepsia in the primary care and specialized outpatient setting. The main objective of this CPG is to help to optimize the diagnostic process, identifying patients with a low risk of a serious organic disease (mainly tumoral), who could be safely managed without the need for invasive diagnostic tests and/or referral to a specialist. The importance of this aim lies in the need to accurately diagnose patients with esophagogastric cancer and correctly treat peptic ulcer while, at the same time, reduce negative endoscopies in order to appropriately use the available healthcare resources.This CPG reviews the initial strategies that can be used in patients with uninvestigated dyspepsia and evaluates the possible decision to begin empirical therapy or to investigate the existence of a lesion that could explain the symptoms. This CPG also discusses functional dyspepsia, which encompasses all patients with dyspepsia with no demonstrable cause on endoscopy. Recommendations for the diagnosis and treatment of peptic ulcer and Helicobacter pylori infection are also made.To classify the scientific evidence and strengthen the recommendations, the GRADE (Grading of Recommendations Assessment, Development and Evaluation Working Group) system has been used (http://www.gradeworkinggroup.org/).

Long-Term Outcomes and Prognostic Factors for Patients with Endoscopy-Negative Iron Deficiency

Iron deficiency anemia (IDA) is a common problem among the elderly, and often no cause is identified after routine upper endoscopy and colonoscopy exams. The purpose of this study was to determine the long-term outcomes and predictors of gastrointestinal pathology and death in patients with endoscopy-negative IDA. This was a retrospective review of consecutive endoscopy negative-IDA patients during 2002-2004 at the VA San Diego Healthcare System. Mean age was 69.3 years (range 42-93), and included 105 men and nine women. Mean length of follow-up was 65.1 months. IDA resolved in 56 patients. None of these patients developed evidence of any clinically significant gastrointestinal pathology. The remaining 58 patients had persistent anemia (n = 47) or recurrent anemia (n = 11). Only 2/47 patients with persistent anemia were found to have clinically significant but benign gastrointestinal pathology during follow-up. In contrast, 6/11 patients with recurrent anemia were subsequently found to have gastrointestinal pathology. Deaths during follow-up occurred in 7 (12.5 %) patients with resolved anemia, compared with 20 (34.5 %) patients with recurrent or persistent anemia (p = 0.006). Significant independent predictors of death included persistent or recurrent anemia, anti-platelet or anticoagulant use, and congestive heart failure. Patients with iron deficiency anemia and negative upper endoscopy and colonoscopy often have a favorable outcome, especially if the anemia resolves with treatment. In patients with recurrent anemia a malignancy within reach of standard endoscopy and colonoscopy are possible, and repeating these procedures is warranted before consideration of further investigations.

The untold story of Dabigatran etexilate: alveolar hemorrhage in an elderly patient with interstitial pulmonary fibrosis

We report an 85-year-old male, with history of interstitial pulmonary fibrosis (IPF), who was presented with progressive dyspnea, hypoxia, and anemia of 2 months duration. Six months before presentation, the patient was placed on Dabigatran etexilate (Dabigatran) (110mg BID) for atrial fibrillation. His prior anemia workup included a negative upper endoscopy and colonoscopy. Bronchoscopy revealed copious amounts of bloody secretions. The bronchial tree was washed and Dabigatran was discontinued. The patient's medical condition improved and was subsequently discharged home. Our case illustrates the failure of current literature to predict the isolated bronchoalveolar bleed secondary to Dabigatran therapy.

PWE-203 Capsule endoscopy: a district general hospital experience in a multiethnic community

IntroductionCapsule endoscopy (CE) is a useful tool to assess the small bowel (SB). The 2008 British Society of Gastroenterology (BSG) guidelines detailed the use of CE in occult gastrointestinal bleeding...

PMO-218 Colonoscopy in patients presenting with melaena and a normal upper gastrointestinal endoscopy: a retrospective review from a single UK centre

IntroductionColonoscopy is frequently performed in patients presenting with melaena who have a negative upper gastrointestinal endoscopy (UGIE). Published literature suggests a diagnostic yield of 8%–30%, the most common pathologies being...

Small bowel tumors: What is the contribution of video capsule endoscopy?

Intestinal tumors represent less than 6% of digestive tumors and, because of the limitations of intestinal investigations, these tumors are difficult to diagnose. In this context, capsule endoscopy (CE) has proven effective especially in patients with obscure digestive bleeding. The aim of the present study was to calculate the frequency, and evaluate the diagnostic and therapeutic impact of CE in cases of small bowel tumors. A total of 95 patients (57 males and 38 females, mean age of 56 years) with negative endoscopy and colonoscopy results were directed to undergo CE examination. Of the 95 patients, 13 (13.7%) were diagnosed with small bowel tumors. The main indications for CE were obscure (occult and overt) gastrointestinal bleeding. The mean duration of symptoms before diagnosis was 10 months. The final histological diagnosis was established through surgery. In our patients, this included gastrointestinal stromal tumor (nine cases), adenocarcinoma (two cases) and carcinoid tumor (two cases). This study revealed that the prevalence of intestinal tumors appears to be higher than expected in patients through the use of CE.

18F-FDG PET/CT in a Recurrent Diffuse Malignant Peritoneal Mesothelioma

Peritoneal mesothelioma is a rare and aggressive tumor. Early diagnosis of the disease is difficult, delaying effective treatment. We report a case of recurrent, biphasic, diffuse, malignant peritoneal mesothelioma. Initial abdominal computed tomography showed abnormal but nonspecific findings suggestive of an ovarian malignancy, with a negative endoscopy and laboratory studies. An abdominal exploratory laparotomy found widespread malignancy within the peritoneum with a pathological diagnosis of peritoneal mesothelioma. A PET/CT imaging showed diffusely increased metabolic activity throughout the peritoneum, with no evidence of thoracic or pleural involvement. This case demonstrates the PET/CT findings seen with malignant recurrent peritoneal mesothelioma.

Diagnosis of Type-I hiatal hernia: a comparison of high-resolution manometry and endoscopy

Sliding Type-I hiatal hernia is commonly diagnosed using upper endoscopy, barium swallow or less commonly, esophageal manometry. Current data suggest that endoscopy is superior to barium swallow or esophageal manometry. Recently, high-resolution manometry has become available for the assessment of esophageal motility. This novel technology is capable of displaying spatial and topographic pressure profiles of gastroesophageal junction and crural diaphragm in real time. The objective of the current study was to compare the specificity and sensitivity of high-resolution manometry and endoscopy in the diagnosis of sliding hiatal hernia in patients with gastroesophageal reflux disease. Data were analyzed retrospectively for 83 consecutive patients (61% females, mean age 52 ± 13.2 years) with objective gastroesophageal reflux disease who were considered for laparoscopic antireflux surgery between January 2006 and January 2009 and had preoperative high-resolution manometry and endoscopy. Manometrically, hiatal hernia was defined as separation of the gastroesophageal junction >2.0 cm from the crural diaphragm. Intraoperative diagnosis of hiatal hernia was used as the gold standard. Sensitivity, specificity and likelihood ratios of a positive test and a negative test were used to compare the performance of the two diagnostic modalities. Forty-two patients were found to have a Type-I sliding hiatal hernia (>2 cm) during surgery. Twenty-two patients had manometric criteria for a hiatal hernia by high-resolution manometry, and 36 patients were described as having a hiatal hernia by preoperative endoscopy. False positive results were significantly fewer (higher specificity) with high-resolution manometry as compared with endoscopy (4.88% vs. 31.71%, P= 0.01). There were no significant differences in the false negative results (sensitivity) between the two diagnostic modalities (47.62% vs. 45.24%, P= 0.62). Analysis of likelihood ratios of a positive and negative test demonstrated that high-resolution manometry is better than endoscopy both to rule out and rule in a hiatal hernia. A significant discordance was also observed between the two tests (P= 0.033). High-resolution manometry has better specificity and ability to rule out an overt Type-I sliding hiatal hernia (greater likelihood ratio of a positive test) in patients with GERD. Because of high false negative results, both high-resolution manometry and endoscopy are unreliable for ruling in a hiatal hernia. Negative result for a hiatal hernia by either modality mandates additional testing.

PPI therapy is equally effective in well‐defined non‐erosive reflux disease and in reflux esophagitis: a meta‐analysis

Symptomatic response to proton pump inhibitor (PPI) therapy in patients with non-erosive reflux disease (NERD) is often reported as lower than in patients with erosive reflux disease (ERD). However, the definition of NERD differs across clinical trials. This meta-analysis aims to estimate the rate of symptom relief in response to PPI in NERD patients. MEDLINE (1966-2010), Cochrane Comprehensive Trial Register (1997-2010) and EMBASE (1985-2010) databases were searched and manual searches from studies' references were performed. Randomized clinical trials were selected that included patients with heartburn, and analyzed the effect of short-term PPI treatment. The primary outcome of selected studies was defined as complete or partial heartburn relief. Two reviewers independently extracted data and assessed study quality of selected articles. Random effects models and meta-regression were used to combine and analyze results. The pooled estimate of complete relief of heartburn after 4 weeks of PPI therapy in patients with ERD was 0.72 (95% CI 0.69-0.74) (32 studies), vs 0.50 (0.43-0.57) (eight studies) in empirically treated patients, 0.49 (0.44-0.55) (12 studies) in patients defined as non-erosive by negative endoscopy, and 0.73 (0.69-0.77) (two studies) in patients defined as non-erosive by both negative endoscopy and a positive pH-test. In well-defined NERD patients, the estimated complete symptom response rate after PPI therapy is comparable to the response rate in patients with ERD. The previously reported low response rate in studies with patients classified as NERD is likely the result of inclusion of patients with upper gastrointestinal symptoms that do not have reflux disease.

Iron deficiency anaemia

Iron deficiency anaemia (IDA) is the most common form of anaemia worldwide. In men and postmenopausal women the commonest cause of IDA is blood loss from lesions in the gastrointestinal tract, making it a common cause of referral to gastroenterologists. Causes of IDA relate either to blood loss or iron malabsorption. After confirmation with laboratory tests, gastrointestinal evaluation is almost always indicated to exclude gastrointestinal malignancy. Specific patient groups such as premenopausal women, patients with low-normal ferritin and iron-deficient patients without anaemia may need an individualized approach. A small proportion of patients have recurrent or persistent IDA despite negative standard endoscopies. These patients with obscure gastrointestinal bleeding usually require evaluation of the small bowel with capsule endoscopy or double balloon enteroscopy. Treatment should involve prompt iron replacement plus diagnostic steps directed towards correcting the underlying cause of IDA. Oral iron replacement is cheap and effective, but parenteral (intravenous) therapy may be required due to intolerance, noncompliance or treatment failure with oral therapy.

Investigating Iron Deficiency Anemia without Clinical Evidence of Gastrointestinal Blood Loss

Iron deficiency anemia is a common indication for referral to gastroenterologists. The referral triage process includes complete blood count including mean corpuscular volume, iron status by serum ferritin, iron and transferrin saturation and celiac serology. An often posed question is whether to investigate patients with iron deficiency without anemia – these patients, if older than 50 years of age, are at a higher risk of gastrointestinal malignancy compared with subjects with normal iron status and, therefore, should be investigated for gastrointestinal blood loss (1). All patients should undergo a detailed medical history and examination to exclude dietary insufficiency and menorrhagia. An ultrasound scan of the abdomen and pelvis may be useful to rule out a gynecological cause or a renal carcinoma. Patients with iron deficiency anemia and no overt or occult evidence of gastrointestinal bleeding are generally investigated by upper and lower gastrointestinal endoscopy. Patients with a hemoglobin concentration <100 g/L should be investigated urgently. It is reasonable to perform both upper endoscopy and colonoscopy – an effective strategy in those older than 50 years of age of age might be to perform colonoscopy with ileoscopy first and, if negative, perform upper endoscopy or limited push enteroscopy. Symptoms are a poor guide to the diagnostic yield of either procedure. Small intestinal biopsies should be taken irrespective of celiac serology. Patients with iron deficiency anemia with no overt or occult evidence of gastrointestinal bleeding and negative upper endoscopy and colonoscopy present a diagnostic challenge. The available options include proceeding to small intestinal investigations, iron supplementation and proceeding to small intestinal investigations if anemia persists despite adequate iron supplementation, discontinuation of any potentially incriminating drugs, such as nonsteroidal anti-inflammatory drugs, despite negative investigations or simply wait and see with hemoglobin monitoring if the anemia is mild or hemoglobin is normal with iron deficiency. Wireless capsule endoscopy is commonly used in these patients as a first-line small intestinal investigation. The study published in the current issue of the Canadian Journal of Gastroenterology by Tong et al (2) (pages 687–690), demonstrated that patients investigated with negative endoscopies for iron deficiency anemia without evidence of bleeding were generally managed with supportive therapy irrespective of positive or negative findings at wireless capsule endoscopy. Many of the positive findings at wireless capsule endoscopy were within the reach of conventional endoscopies. Therefore, while obscure upper gastrointestinal bleeding is the most common indication for referral for wireless capsule endoscopy, a meaningful clinical decision change as a result of the findings is uncommon. Therefore, better selection criteria for referral to wireless capsule endoscopy are required (3). Otherwise, the impact of wireless capsule endoscopy in patients with iron deficiency anemia with no overt or occult bleeding and negative upper and lower gastrointestinal tract endoscopy is likely to be very limited. The extent to which these challenging patients are investigated depends on comorbidities, the severity of anemia, whether the anemia is symptomatic, whether alternative routes of blood loss have been excluded and the rapidity with which anemia recurs after iron supplementation (4). The role of cross-sectional imaging, such as computed tomography (CT) or magnetic resonance-enterography, CT-angiography or double-balloon enteroscopy, in this specific patient group is uncertain. These investigations are generally performed in patients with definite clinical evidence of gastrointestinal blood loss. A practical approach in these patients may be to institute supportive treatment with iron supplementation after negative upper and lower gastrointestinal tract endoscopies. If hemoglobin levels are restored and maintained on long-term iron supplementation, a watch-and-wait policy may be best. If hemoglobin levels cannot be normalized or drop while on iron supplementation, repeat upper and lower endoscopies may be performed before wireless capsule endoscopy. Double-balloon enteroscopy may be performed for confirming significant abnormalities detected at wireless capsule enteroscopy and to perform therapeutic interventions such as for vascular lesions (Figure 1). Small intestinal tumours or Crohn disease may require CT or magnetic resonance-enterography. Figure 1) A pragmatic algorithm for investigating iron deficiency anemia with no evidence of overt or occult gastrointestinal bleeding

In the workup of patients with obscure gastrointestinal bleed, does 64-slice MDCT have a role?

Purpose:The purpose was to prospectively determine the sensitivity of 64-slice MDCT in detecting and diagnosing the cause of obscure gastrointestinal bleed (OGIB).Materials and Methods:Our study included 50 patients (male 30, female 20) in the age range of 3–82 years (average age: 58.52 years) who were referred to our radiology department as part of their workup for clinically evident gastrointestinal (GI) bleed or as part of workup for anemia (with and without positive fecal occult blood test). All patients underwent conventional upper endoscopy and colonoscopy before undergoing CT scan. Following a noncontrast scan, all patients underwent triple-phase contrast CT scan using a 64-slice CT scan system. The diagnostic performance of 64-slice MDCT was compared to the results of capsule endoscopy, 99m-technetium-labeled red blood cell scintigraphy (99mTc-RBC scintigraphy), digital subtraction angiography, and surgery whenever available.Results:CT scan showed positive findings in 32 of 50 patients. The sensitivity, specificity, positive predictive value, and negative predictive values of MDCT for detection of bleed were 72.2%, 42.8%, 81.2%, and 44.4%, respectively. Capsule endoscopy was done in 15 patients and was positive in 10 patients; it had a sensitivity of 71.4%. Eleven patients had undergone 99mTc-RBC scintigraphy prior to CT scan, and the result was positive in seven patients (sensitivity 70%). Digital subtraction angiography was performed in only eight patients and among them all except one patient showed findings consistent with the lesions detected on MDCT.Conclusion:MDCT is a sensitive and noninvasive tool that allows rapid detection and localization of OGIB. It can be used as the first-line investigation in patients with negative endoscopy and colonoscopy studies. MDCT and capsule endoscopy have complementary roles in the evaluation of OGIB.

Clinical efficacy of a short course of systemic steroids in nasal polyposis

Although oral steroids are widely used for the treatment of nasal polyposis, a subset of patients shows an unfavorable therapeutic outcome. The aim of this study was to evaluate the efficacy of a short course of oral prednisolone in nasal polyposis and to evaluate which, if any, clinical variables can predict treatment outcome in these patients. Using a 3:2 randomization ratio, 63 patients with nasal polyposis received 50 mg of prednisolone and 46 patients received placebo daily for 14 days. Clinical response was evaluated by total nasal symptoms score (TNSS), peak expiratory flow index (PEFI) and total nasal polyps score (TNPS). Potential predictor variables were assessed by clinical history, nasal endoscopy, allergy skin test and sinus radiography. The prednisolone-treated group showed significantly greater improvements in all nasal symptoms, nasal flow and polyp size than the placebo-treated group (p < 0.001, all). In the prednisolone-treated group, patients with grade 3 polyps and positive nasal endoscopy showed significantly less improvement in TNSS, PEFI and TNPS than patients with grades 1-2 size and with negative nasal endoscopy. A short course of oral steroids showed good clinical efficacy in the treatment of nasal polyposis, however, polyps size grade 3 and/or positive nasal endoscopy predispose to a poorer treatment outcome.

Upfront computed tomography scanning is more cost‐beneficial than empiric medical therapy in the initial management of chronic rhinosinusitis

Current treatment algorithms for patients with symptoms of chronic rhinosinusitis (CRS) recommend a trial of empiric medical therapy prior to obtaining a sinus computed tomography (CT) scan, even in cases of negative nasal endoscopy. This empiric approach evolved in an era when same day conventional CT was both impractical and economically irresponsible. The objective of this work was to determine whether upfront CT scanning is more cost-beneficial than empiric medical therapy for patients presenting with CRS symptoms but negative endoscopic findings. A Markov economic model was employed. Medication costs, CT costs, treatment response rates, and treatment associated adverse event rates were included as model parameters. Treatment cost values were derived from Medicare. There is a clear cost advantage to the upfront CT algorithm over empiric therapy regardless of the availability of point-of-care CT scanning (POC-CT). This advantage persists during the sensitivity analysis when costs and response rates are fully biased toward empiric therapy. If POC-CT is available, upfront CT can save $320.50 per patient (range, $138.5-671.5). When POC-CT CT is unavailable, upfront CT savings persist at $296.60 (range, $106.09-655.40). In patients meeting symptom criteria for CRS but without endoscopic evidence of inflammation, upfront CT scanning is more cost-beneficial than empiric medical therapy. Adopting upfront CT scanning can save the U.S. healthcare system $1.2 billion dollars per year. Further, POC-CT can offer same day diagnosis, facilitate prompt treatment, and decrease unnecessary antibiotic prescriptions.

Small Bowel Evaluation in Asymptomatic Fecal Immunochemical Test-Positive Patients with a Negative Colonoscopy: Is It Necessary?

Screening for colorectal cancer (CRC) and its precursors by fecal occult blood test (FOBT) is widely recommended and is being applied more than ever [1–3]. Although annual or biennial guaiac fecal occult blood test (gFOBT) screening has been proved to reduce the mortality of CRC [4], the gFOBT has been faulted for its low sensitivity [5, 6]. More recently, the fecal immunochemical test (FIT) has been introduced as an alternative to the gFOBT. The FIT is currently preferred over the gFOBT due to its higher sensitivity and improved detection rate for advanced neoplasia [5, 7–10]. Besides its diagnostic performance, the FIT has several advantages over the gFOBT including no need for dietary restriction, easier stool collection method, and automated analysis [11]. Furthermore, quantitative FIT allows for the adjustment of the cutoff value for an abnormal result based on population characteristics and available colonoscopy resources. Due to these characteristics, quantitative FIT is more favored as a screening tool than qualitative FIT [11]. The FIT selectively reacts with the globin moiety of human hemoglobin [12]. Because globin is rapidly degraded by proteases in the upper gastrointestinal (GI) tract, the FIT dose not detect small amounts of blood in the upper GI tract and selectively recognizes occult bleeding of colorectal origin [12]. With regard to small bowel lesions, although there is a possibility that some small bowel occult bleeding could be identified by FIT, no data are currently available regarding this issue. In the current issue of Digestive Diseases and Sciences, Chiba et al. [13] present the results of their prospective study on small bowel evaluation in asymptomatic FIT-positive subjects with a negative colonoscopy. In this, the first study to evaluate the small bowel with capsule endoscopy (CE) in asymptomatic FIT-positive patients with a negative colonoscopy, 53 asymptomatic patients with FIT-positivity and a negative total colonoscopy and esophagogastroduodenoscopy underwent CE. The CE findings were classified into three categories: P0, no abnormalities or findings without potential for bleeding; P1, findings with uncertain potential for bleeding; and P2, findings with high potential for bleeding. The cecal completion rate was 92.5%. There were no cases of P2, 19 cases of P1, and 34 cases of P0. Moreover, no abnormalities were identified in five patients who underwent additional diagnostic evaluations that were considered necessary based on the individual clinical results. No clinically significant small bowel lesions were found in the asymptomatic FIT-positive patients with negative bidirectional endoscopy. Although FIT has been widely accepted as a CRC screening tool, 40–60% of subjects with a positive FIT are found to have no lesions in their colon or rectum to explain their positive status [5, 14, 15]. How then do we explain the discrepancy between the results of FIT and colonoscopy? There are several possible explanations for this discrepancy. First, this may reflect true false-positive results of FIT for advanced neoplasia. Quantitative FIT results are subjected to predetermined cut-off values for fecal hemoglobin; this methodology could inevitably yield some true false positives. Additionally, medications that can increase the likelihood of GI bleeding may cause false-positive FIT J. J. Park Department of Internal Medicine, Kyung Hee University Hospital at Gangdong, Kyung Hee University, Seoul, Korea

Negative predictive value of normal nasal endoscopy for sinus disease as a cause of isolated facial pain

To determine the negative predictive value of normal nasal endoscopy in assessing paranasal sinus disease as the cause of isolated facial pain in the sinus regions. The study group comprised 42 consecutive adult patients presenting with the isolated symptom of facial pain, and a negative nasal endoscopy. Patients underwent sinus computed tomography to determine whether radiographic findings indicated a sinugenic aetiology. Patients comprised 27 women and 15 men, with a median age of 38 years. Twenty patients had unilateral pain, 33 per cent had sinus radiographic findings that might explain their facial pain, and 10 per cent had imaging demonstrating mucosal disease in one or more sinuses correlating with the location of the facial pain. Thirty-one per cent had anatomical radiographic findings that could potentially obstruct the osteomeatal unit. Normal nasal endoscopy had a negative predictive value of 67 per cent in excluding a sinugenic cause of isolated facial pain, if radiographically determined anatomical factors and mucosal disease were both included as positive findings; this rose to more than 90 per cent if only those patients with mucosal sinus disease were considered as true positive patients.

Foreign body aspiration and language spoken at home: 10-year review

To review foreign body aspiration cases encountered over a 10-year period in a tertiary paediatric hospital, and to assess correlation between foreign body type and language spoken at home. Retrospective chart review of all children undergoing direct laryngobronchoscopy for foreign body aspiration over a 10-year period. Age, sex, foreign body type, complications, hospital stay and home language were analysed. At direct laryngobronchoscopy, 132 children had foreign body aspiration (male:female ratio 1.31:1; mean age 32 months (2.67 years)). Mean hospital stay was 2.0 days. Foreign bodies most commonly comprised food matter (53/132; 40.1 per cent), followed by non-food matter (44/132; 33.33 per cent), a negative endoscopy (11/132; 8.33 per cent) and unknown composition (24/132; 18.2 per cent). Most parents spoke English (92/132, 69.7 per cent; vs non-English-speaking 40/132, 30.3 per cent), but non-English-speaking patients had disproportionately more food foreign bodies, and significantly more nut aspirations (p = 0.0065). Results constitute level 2b evidence. Patients from non-English speaking backgrounds had a significantly higher incidence of food (particularly nut) aspiration. Awareness-raising and public education is needed in relevant communities to prevent certain foods, particularly nuts, being given to children too young to chew and swallow them adequately.

A randomized trial examining the effect of pretreatment point‐of‐care computed tomography imaging on the management of patients with chronic rhinosinusitis symptoms

Recent consensus statements on the diagnosis of chronic rhinosinusitis (CRS) now require endoscopic or radiographic evidence of paranasal sinus inflammation. The timing of point-of-care (POC) computed tomography (CT) scan in the workup of these patients remains to be elucidated, particularly when endoscopy is negative. The objective of this research was to prospectively evaluate 2 algorithms for the initial management of patients with symptoms of CRS who manifest a normal nasal endoscopic examination. A total of 40 such patients were randomized to 1 of 2 pathways: POC-CT at the initial visit followed by medical therapy based upon CT results (pre-CT group; n = 20), or empiric medical therapy (EMT) followed by POC posttreatment CT if symptoms persisted (EMT group; n = 20). The 2 groups were demographically and symptomatically similar with regard to 2003 Task Force major criteria. Otolaryngology follow-up was recommended in 11 of 20 pre-CT patients, all of whom (100%) returned. In contrast, only 10 of 20 EMT patients (50%) followed up as instructed (p < 0.05). Radiographic confirmation of CRS was found in 8 of 20 pre-CT patients, and only 2 of 9 patients after EMT (p = 0.61). EMT patients received more antibiotic prescriptions (relative ratio [RR], 2.50; 95% CI, 1.46-4.27), while pre-CT patients received more CT scans (RR, 2.22; 95% CI, 1.37-3.61). Overall prescriptions costs were similar to the EMT group ($253 vs $218; p = 0.37) and the overall number of otolaryngology visits was similar. In patients with symptoms of CRS but negative endoscopy, POC at initial presentation results in substantially less unnecessary antibiotic prescriptions and significantly greater compliance with otolaryngology care but does result in a higher utilization of radiographic imaging.