Normal Endoscopic Findings Research Articles

Genotype pattern of H. pylori in gastritis and peptic ulcer disease in relation to normal endoscopic findings

Genotype pattern of H. pylori in gastritis and peptic ulcer disease in relation to normal endoscopic findings

Fragments of e-Cadherin as Biomarkers of Non-erosive Reflux Disease.

Approximately, 20% of patients with heartburn and normal endoscopic findings do not symptomatically improve on proton pump inhibitor (PPI) therapy making diagnosis and treatment uncertain. A biomarker distinguishing PPI-responsive from PPI-refractory heartburn is desirable. We performed a pilot study assessing whether carboxy(C)-terminal fragments (CTFs) of e-cadherin in esophageal biopsies or amino(N)-terminal fragments (NTFs) of e-cadherin in serum could serve this purpose. Twenty-nine patients with endoscopy-negative heartburn had esophageal biopsies for CTFs on Western blot and blood for serum NTFs on ELISA. All patients received dexlansoprazole 30mg daily for 4weeks, and heartburn was assessed by daily diary entry. Post-treatment blood samples were obtained for serum NTFs. A control group without GERD symptoms (n=6) had biopsies for CTFs and a second control group (n=20) blood serum for serum NTFs. Twenty-seven of 29 patients (93.1%) with endoscopy-negative heartburn, but 0 of 6 controls, were positive for CTFs. All patients and controls had measureable serum NTFs, but mean NTFs were significantly higher in those with PPI-responsive heartburn compared to those with PPI-refractory heartburn and controls. Following treatment, 24 of 29 (82.8) patients had relief of heartburn, which associated with a decline in mean NTFs compared to controls. NTFs in PPI-refractory patients (n=5) were similar to controls before and after PPI therapy. When heartburn responds to PPI, elevated serum NTFs decline to normal. These data suggest that cleaved products of e-cadherin may serve as biomarkers of NERD. Further data are needed to assess and confirm this concept.

Endoscopic analysis of early esophageal cancer and precancerous lesions in Kazakh patients

To explore the value of endoscopic narrow-band imaging in the diagnosis of early-stage esophageal cancer and precancerous lesions in Kazakh patients. A total of 106 Kazakh patients with esophageal mucosa lesions diagnosed by routine endoscopy in our hospital from January 2014 to July 2016 were enrolled in this analysis with 30 randomly selected patients with normal endoscopic findings of the esophageal mucosa as the control group. The morphological changes of papillary capillary loop (IPCL) of the esophageal epithelium in the two groups were observed by narrow-band imaging magnifying endoscopy. Pathological examinations were performed for all the patients with esophageal mucosa lesions. In patients with esophageal mucosa lesions, 10 were diagnosed to have early esophageal cancer, 16 had low-grade tumors, 11 had high-grade tumors and 69 had esophagitis. IPCL typing results showed IPCL type I in all the control subjects, predominantly type IV in patients with early esophageal carcinoma, type II and III in patients with low-grade tumor, type III in patients with high-grade tumor, and type II in patients with esophagitis. The location and size of the esophageal lesions can be observed clearly by narrow-band imaging magnifying endoscopy. The histopathology of the esophageal mucosa can be analyzed with IPCL classification for diagnosis of early esophageal cancer and precancerous lesions in Kazakhs.

Interventions for treating lymphocytic colitis.

Lymphocytic colitis is a cause of chronic diarrhea. Therapy is based mainly on case series and uncontrolled trials, or by extrapolation of data for treating collagenous colitis, a related disorder. This review was performed to identify therapies for lymphocytic colitis that have been proven in randomized controlled trials.To determine effective treatments for patients with clinically active lymphocytic colitis.The MEDLINE, PUBMED and EMBASE databases were searched using the search criteria "microscopic colitis" or "lymphocytic colitis" and "treatment" or "therapy" or "management" to identify relevant papers published between 1970 and September 2006. Manual searches from the references of identified papers and relevant review papers were performed. Abstracts from major gastroenterological meetings were searched to identify research submitted in abstract form only. Finally, the Cochrane Central Register of Controlled Trials and the Cochrane Inflammatory Bowel Disease and Functional Bowel Disorders Group Specialized Trials Register was searched for other studies.A single randomized trial published in abstract form only which studied bismuth subsalicylate was identified, and included only 5 patients with lymphocytic colitis (and 9 with collagenous colitis).Data were extracted independently by each author onto 2x2 tables (treatment versus placebo and response versus no response). For therapies assessed in one trial only, P values were derived using the chi-square test.There were 5 patients with lymphocytic colitis in the trial studying bismuth subsalicylate (nine 262 mg tablets daily for 8 weeks vs. placebo). Although all three patients on active drug experienced clinical improvement compared to none of the placebo group, there were no statistically significant differences in clinical (P = 0.10) or histological (P = 0.71) improvement.A single trial studying bismuth subsalicylate as therapy for lymphocytic colitis suggests that it may be beneficial. However, it included only 5 patients and no firm conclusions can be made from such a small trial. Larger trials studying treatments for lymphocytic colitis are warranted.

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cagA gene, a marker for the cag pathogenicity island (CagPAI) and a virulent factor in Helicobacter pylori infection codes for 120 to 145 kDa protein that is associated with cytotoxin production and more severe clinical outcomes. The aim of this study was to determine whether any correlation exists between H. pylori CagA protein and the endoscopic findings among dyspeptic patients from South-western, Nigeria and also to investigate the evolutionary relationships among H. pylori cagA gene with the GenBank strains. A total of one hundred and twenty four H. pylori positive isolates were amplified for the detection of cagA by polymerase chain reaction (PCR) and H. pylori isolates positive for cagA were further evaluated for protein expression using western blotting analysis. Also, DNA sequencing, blasting and phylogenetic analysis were performed on twelve selected isolates positive for cagA. cagA gene was detected in all the 124 samples (100%) and protein expressions of cagA by western blotting analysis was 88.7% (110/124). There was a high prevalence (91.7%) of expressed cagA strains in patients with positive endoscopic lesions than those with normal endoscopic findings (85.7%); however, association was not statistically significant (P>0.05). Also, the expressed cagA had no statistically significant association with all the positive endoscopic findings (P>0.05). Phylogenetic analysis of the selected H. pylori cagA gene showed high similarity with some GenBank strains of western cagA H. pylori. This study shows that CagA is high among dyspeptic patients in Nigeria but with no statistically significant association with the endoscopic findings. Key words: Protein expression, CagA, protein, GenBank, dyspeptic.&nbsp

Longitudinal Evaluation of Noninvasive Biomarkers for Eosinophilic Esophagitis

The diagnosis and management of eosinophilic esophagitis (EoE) often requires multiple endoscopies. Serum biomarkers can be elevated in EoE patients, but their clinical utility in diagnosis and assessing response to treatment is not well established. To evaluate serum biomarkers in EoE subjects compared with controls and assess longitudinally in response to treatment. We conducted a prospective cohort study of children and adults undergoing esophagogastroduodenoscopy for suspected EoE. After completing an 8-week course of proton-pump inhibitor therapy, esophageal mucosal biopsies were obtained, as well as, serum analysis of absolute eosinophil count (AEC), eotaxin-3, eosinophil-derived neurotoxin (EDN), eosinophil cationic protein (ECP) and interleukin-5. Subjects with normal endoscopic and histologic findings constituted controls. Those meeting criteria for EoE underwent repeat esophagogastroduodenoscopy and biomarker measurements following treatment with topical steroids for 8 weeks. Median levels of AEC (263.50 vs. 102 cu/mm, P<0.001), ECP (26.98 vs. 5.20 ng/mL, P<0.001) and EDN (31.70 vs. 14.18 ng/mL, P=0.004) were significantly elevated in EoE subjects compared with controls and correlated with esophageal eosinophilia. Levels of AEC (odds ratio, 1.79; 95% confidence interval, 1.28-2.64) and ECP (odds ratio, 1.61; 95% confidence interval, 1.23-2.36) were associated with a diagnosis of EoE. Among the 5 biomarkers evaluated, only AEC significantly predicted esophageal eosinophilia following topical steroid therapy in EoE subjects (P=0.006). AEC, ECP, and EDN were higher in EoE subjects compared with controls and correlated with degree of esophageal eosinophilia. Furthermore, AEC predicted post-treatment eosinophilia, suggesting a potential role in monitoring EoE disease activity.

Clinical and endoscopic evaluation of dyspeptic patients attending a tertiary care hospital in South India: A prospective study

Background: The incidence of dyspepsia has been increasing all over the world; with some having an organic cause while others have functional dyspepsia. Helicobacter pylori infection is also contributory factor. These dyspeptic patients also show a wide spectrum of symptoms.Aims and Objective: The aim of this study was to clinically and endoscopically evaluate the patients with dyspepsia; and also to assess the prevalence of Helicobacter pylori.Materials and Methods: A prospective study was conducted on 100 dyspeptic patients who were advised an upper gastrointestinal endoscopy based on clinical grounds atPondicherry Institute of Medical Sciences, Pondicherry, India.Results: Of the 100 dyspeptic patients evaluated inthis study, the mean age was 42 years, with 54% belonging to 20 to 40 years, 35% to 41 to 60 years and 11% above 60 years age groups. 61% were males and 39% females. They belonged to various occupation groups with majority leading a retired life or as homemakers (36%), followed by those with white collar jobs or as students (29%), unskilled workers (26%) and skilled workers (9%). Majority of these patients were non vegetarians (83%). Smokers and alcoholics comprised of 38% and 43% of the subjects respectively; and 31% had history of NSAID consumption. Epigastric pain and epigastric burning sensation were the main complaints among dyspeptic patients. Heartburn was more common among smokers and alcoholics; and epigastric pain among NSAID users. The main endoscopic abnormalities were erythematous and erosive gastritis (42% and 21% respectively), followed by duodenal ulcer (18%) and erosive duodenitis (15%). Duodenal ulcers were more common among males (89%). Duodenitis (89%) and duodenal ulcers (67%) were mainly seen in alcoholics. 18% of our study patients had a normal endoscopic finding. Helicobacterpylori was present in 35% of the subjects. Epigastric pain and epigastric burning sensation were the main symptoms among these patients; with erythematous gastritis being the main endoscopic finding.Conclusion: Dyspepsia was more common among younger age groups. Epigastric pain and epigastric burning sensation were the most common symptoms. Erythematous gastritis followed by erosive gastritis was the common endoscopic abnormality. Some patients also had normal findings on endoscopy. Helicobacter pylori was present in a significant number of patients. Asian Journal of Medical Sciences Vol.8(1) 2017 58-63

Diagnostic phrasing is independently correlated with the decision to treat for graft-versus-host disease: retrospective review of colon biopsies with rare apoptosis.

The risks of immunosuppression and the non-specific nature of rare crypt apoptosis has led to debate over the lower threshold for histological diagnosis of colonic graft-versus-host disease (GVHD). A recent study proposed the diagnostic category of indeterminate for GVHD (iGVHD) for cases with six or fewer apoptotic bodies per 10 crypts. Our aim was to assess colon biopsies with iGVHD histology to determine whether the diagnosis was retrospectively predictive of the decision to treat, and to correlate these findings with endoscopic and clinical findings. A retrospective search was performed for colonic biopsies taken to evaluate for GVHD from 2008 to 2014. Biopsies were blindly reviewed for the maximum number of apoptotic bodies per 10 contiguous crypts, evidence of crypt dropout, and ulceration. Clinical information was collected through chart review. One hundred and twenty-two biopsies from 84 transplant patients were included. Forty-seven cases met the histological criteria for iGVHD. Patients with an original diagnosis of iGVHD were more likely to be managed conservatively than those with a diagnosis of grade 1 GVHD (25% versus 0%). Eight symptomatic patients reclassified as iGVHD had resolution of symptoms without increased immunosuppression. A clinicopathologically similar group of 10 patients with iGVHD histology, normal or subtle endoscopic findings and no evidence of GVHD at other organ sites were treated with increased immunosuppression. On multivariate analysis, the original diagnostic category was the most significant predictor of the decision to treat. The use of the diagnostic category iGVHD alerts clinicians to the presence of minimal crypt apoptosis, and allows treatment based on clinical judgement.

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We thank Dr Furnari and colleagues for their interest in our paper.1Cheng F.K.F. et al.Clin Gastroenterol Hepatol. 2015; 13: 867-873Google Scholar They raise 2 excellent points for discussion. The first is in regards to categorizing nonerosive reflux disease based on normal endoscopic findings of esophageal mucosa and number of reflux episodes on 24-hour pH and impedance monitoring without taking into account symptom association analysis. We agree that the number of reflux episodes alone may be less than ideal to assess for nonerosive reflux disease. In fact, this is what prompted Johnson and DeMeester2Johnson L.F. et al.Am J Gastroenterol. 1974; 63: 325-332Google Scholar to develop a score that incorporates other parameters besides reflux episodes. Our study classification differs from Savarino et al3Savarino E. et al.Am J Gastroenterol. 2008; 103: 2685-2693Google Scholar in that we used the results of impedance testing early in the categorization of patients with reflux who had a normal 24-hour pH score and a normal endoscopy. This method focuses on the objective role of testing rather than reliance on patient symptoms, in which limitations exist in the accuracy of patient reporting. One study showed that patients do not report most of their symptoms during the 24-hour testing period.4Kavitt R.T. et al.Am J Gastroenterol. 2012; 107: 1826-1832Google Scholar Furthermore, both symptom index and symptom association probability may be overinterpreted in patients with gastroesophageal reflux disease with day to day variability.5Slaughter J.C. et al.Clin Gastroenterol Hepatol. 2011; 9: 868-874Google Scholar, 6Vela M.F. et al.Am J Gastroenol. 2013; 108: 1658-1659Google Scholar These indices are also primarily used to assess patients with gastroesophageal reflux disease, but not in those who fail to respond to proton pump inhibitors7Wiener G.J. et al.Am J Gastroenterol. 1988; 83: 358-361Google Scholar, 8Weusten V.L. et al.Gastroenterology. 1994; 107: 1741-1745Google Scholar and are suboptimal in predicting response to therapy as outcome.9Taghavi S.A. et al.Gut. 2005; 54: 1067-1071Google Scholar Finally, the only data evaluating response to surgery in proton pump inhibitor–nonresponders are uncontrolled,10Frazzoni M. et al.Surg Endosc. 2013; 27: 2940-2946Google Scholar and more high-quality outcome studies are needed. The second point is that an impedance cutoff value of 73 reflux episodes may overestimate the number of patients classified as hypersensitive esophagus or with functional symptoms. The 73 episodes as the cutoff value for reflux episodes is in accordance with the American College of Gastroenterology guidelines.11Hirano I. et al.Am J Gastroenterol. 2007; 102: 668-685Google Scholar In a Belgian-French study, the 95% of reflux episodes is 75, nearly identical to US studies.12Shay S. et al.Am J Gastroenterol. 2004; 99: 1037-1043Google Scholar, 13Tutuian R. et al.Gastroenterology. 2006; 130: A171Google Scholar, 14Moawad F.J. et al.Aliment Pharmacol Ther. 2013; 37: 1011-1018Google Scholar Furnari et al refer to an Italian study that demonstrated the 95% value as 54 reflux episodes in a cohort that may have been influenced by consuming a Mediterranean diet.15Zentilin P. et al.Dig Liver Dis. 2006; 38: 226-232Google Scholar Although we agree that a lower cutoff value may reduce the number of false-positive episodes during testing, further high-quality studies on normal impedance values need to be performed before uniformly standardizing a lower cutoff value. The other implication is patients without acid reflux may be referred for antireflux surgery rather than be treated with a pain modulator. However, data for fundoplication in non–acid reflux, particularly in the absence of reduced lower esophageal sphincter pressure, are scarce and generally we do not advocate this as an initial approach to the management of non–acid reflux. Caution About Overinterpretation of Number of Reflux Episodes in Reflux Monitoring for Refractory Gastroesophageal Reflux DiseaseClinical Gastroenterology and HepatologyVol. 14Issue 7PreviewWe read with great interest the study by Cheng et al,1 who investigated patients with gastroesophageal reflux disease (GERD) refractory to antisecretory therapy by means of endoscopy and impedance-pH monitoring off-therapy and concluded that roughly half of these patients referred for testing actually underwent investigations and received medications with no evidence of GERD; they were affected by functional heartburn, functional disorders other than heartburn, or by undetermined disorders. These data confirm previous studies2,3 on the importance of investigating refractory patients and also emphasize the need of stopping antisecretory therapy to reduce overuse of proton pump inhibitors. Full-Text PDF

Correlation of Somatic Dysfunction With Gastrointestinal Endoscopic Findings: An Observational Study.

Gastrointestinal (GI) endoscopy provides a novel means of correlating visceral abnormalities with somatic dysfunction. To assess the correlation of palpatory findings of somatic dysfunction with GI abnormalities determined by endoscopy and to identify which types of somatic dysfunction were most commonly correlated with GI abnormalities. In this observational, cross-sectional study, participants who were scheduled to receive an esophagogastroduodenoscopy (EGD), colonoscopy, or both were examined by 2 osteopathic physicians immediately prior to endoscopy for the presence of vertebral tenderness, asymmetry, restricted range of motion, and tissue texture abnormalities (TART findings); tenderness of anterior Chapman reflex points; and tenderness of visceral sphincters. Each type of somatic dysfunction and the somatic dysfunction burden (sum of findings) were compared with the type of endoscopic procedure and abnormal endoscopic findings. Sixty-six adults participated: 43 received an EGD, 40 received a colonoscopy, and 17 received both. The incidence of vertebral TART findings ranged from 70% at T12 to 98% at the sacrum. Participants who received only EGD had a higher somatic dysfunction burden than those who received only colonoscopy and those who received both procedures (P=.002). The incidence of abnormal endoscopic findings ranged from 98% in the stomach to 0% at the ileocecal valve. Statistically significant positive associations were found between specific vertebral TART findings and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, and sigmoid colon; specific Chapman reflex point tenderness and abnormalities of the esophagus, gastroesophageal junction, pylorus, ascending colon, descending colon, sigmoid colon, and rectum; and specific visceral sphincter tenderness and abnormalities of the duodenum, ascending colon, and sigmoid colon. The current study found numerous associations between somatic dysfunction and abnormal endoscopic findings. However, the high incidence of vertebral TART findings and the lack of normal controls for many GI regions made establishing meaningful relationships between specific somatic dysfunction and specific GI abnormalities challenging. Future investigations should include more participants to ensure a higher number of normal endoscopic findings and limit the physical examination to elements of somatic dysfunction with a high level of variability between vertebrae within an individual participant and between participants, such as tenderness and tissue texture abnormalities. (ClinicalTrials.gov number NCT01394198).

Imipramine for Treatment of Esophageal Hypersensitivity and Functional Heartburn: A Randomized Placebo-Controlled Trial.

Tricyclic antidepressants could be effective in the treatment of symptoms related to hypersensitive esophagus through their pain-modulating effect. We therefore assessed the benefit of imipramine in patients with esophageal hypersensitivity and functional heartburn. Patients with normal endoscopy findings and typical reflux symptoms despite standard-dose proton-pump inhibitor therapy underwent 24-h pH-impedance monitoring. Patients with established esophageal hypersensitivity or functional heartburn were randomly assigned to receive 8 weeks of either once-daily imipramine 25 mg (n=43) or placebo (n=40). The primary end point was satisfactory relief of reflux symptoms, defined as a >50% reduction in the gastroesophageal reflux disease score. The secondary end point was improvement in quality-of-life (QoL) as assessed by the 36-Item Short Form Health Survey score. Patients receiving imipramine did not achieve a higher rate of satisfactory relief of reflux symptoms than did patients receiving placebo (intention-to-treat (ITT) analysis: 37.2 vs. 37.5%, respectively; odds ratio (OR), 0.99; 95% confidence interval (CI), 0.41-2.41; per-protocol (PP) analysis: 45.5 vs. 41.2%, respectively; OR, 1.19; 95% CI, 0.45-3.13). Subgroup analysis to assess the efficacy of imipramine for either esophageal hypersensitivity or functional heartburn yielded similar results. Treatment with imipramine provided significant improvement of QoL by PP analysis (72±17 and 61±19, respectively; P=0.048), but ITT analysis did not reveal any differences between imipramine and placebo (68±19 and 61±19, respectively; P=0.26). Adverse events were similar in both groups; however, constipation was more common with imipramine than placebo (51.2 vs. 22.5%, respectively; P=0.01). Although low-dose imipramine shows potential QoL benefits, it does not relieve symptoms more effectively than does placebo in patients with either esophageal hypersensitivity or functional heartburn.

Endoscopic Findings in Patients with Dyspepsia in Iran

Background: It is necessary to know the causes of dyspepsia to establish the therapeutic approach. Dyspepsia is a frequent syndrome our country, while there are restrictions to endoscopy and high prevalence of Helicobacter pylori (H. pylori) infection. This study was conducted to evaluate the endoscopic findings of the syndrome, in an outpatient screening clinic of the Baqiyatallah Hospital in Tehran, Iran. Material and methods: Between 20 March and 20 November 2015 and according to Rome III criteria, outpatients with uninvestigated dyspepsia, answered Dyspepsia Hong Kong Index Questionnaire and underwent esophagogastroduodenoscopy. The Rapid Urease Test was applied to fragments of the antral mucosa, and epidemiological data were collected from the studied population. Normal endoscopic findings were analyzed with different variables to verify statistically significant associations. Results: Eventually 400 patients (57.5% males and 42.5% females) with the mean age of 51.32±17.98 years were evaluated. About 55% of them were smokers and 45% used NSAID. H. pylori (80%) were the most endoscopic findings between Endoscopic findings. Among positive and negative H. pylori patients, 56.25% and 50% were smokers respectively. All patients with gastric adenocarcinoma (100%) and 13.2% patients without gastric adenocarcinoma were with fundus, body or antrum ulcer. Conclusions: Predominance of functional disease was showed in our setting by the endoscopic diagnosis of uninvestigated dyspepsia. Although the prevalence of H. pylori was high, cancer was an uncommon finding.

Prevalence of microscopic colitis in Upper Egypt among patients with chronic diarrhea and patients with irritable bowel syndrome

Aim The aim of this study was to evaluate the prevalence of microscopic colitis (MC) in patients with chronic watery diarrhea and irritable bowel syndrome–diarrhea (IBS-D) predominant. Patients and methods We studied 61 patients with chronic nonbloody diarrhea and normal endoscopic findings prospectively for 2 years' duration; 37 patients had chronic watery diarrhea for investigation and 24 had IBS-D predominant. Results Our results showed that 18 (29.5%) patients had MC, 10 (16.4%) patients had collagenous colitis, and eight (13.1%) had lymphocytic colitis. Four (16.7%) patients out of the 24 patients with IBS-D predominant had MC. Abdominal pain, nocturnal diarrhea, and weight loss are the most common clinical presentation in MC. Conclusion MC is not uncommon in Upper Egypt patients with chronic watery diarrhea and normal colonoscopic findings. Biopsy of normal colonic mucosa in patients with chronic watery diarrhea is emphasized to reach to definite diagnosis of MC.

Wireless Capsule Enteroscopy in Healthy Volunteers.

The aim of our prospective study was to define endoscopy appearance of the small bowel in healthy volunteers. Forty-two healthy volunteers underwent wireless capsule endoscopy, clinical investigation, laboratory tests, and completed a health-status questionnaire. All subjects were available for a 36-month clinical follow-up. Eleven subjects (26%) had fully normal endoscopy findings. Remaining 31 persons (74%), being asymptomatic, with normal laboratory results, had some minor findings at wireless capsule endoscopy. Most of those heterogeneous findings were detected in the small intestine (27/31; 87%), like erosions and/or multiple red spots, diminutive polyps and tiny vascular lesions. During a 36-month clinical follow-up, all these 42 healthy volunteers remained asymptomatic, with fully normal laboratory control. Significant part of healthy subjects had abnormal findings at wireless capsule endoscopy. These findings had no clinical relevance, as all these persons remained fully asymptomatic during a 36-month follow-up. Such an endoscopic appearance would be previously evaluated as "pathological". This is a principal report alerting that all findings of any control group of wireless capsule endoscopic studies must be evaluated with caution.

Correlation between Histological Activity and Endoscopic, Clinical, and Serologic Activities in Patients with Ulcerative Colitis.

Objectives. Recent studies suggest that histological healing is a treatment goal in ulcerative colitis (UC). We aimed to evaluate the correlation between histological activity and clinical, endoscopic, and serologic activities in patients with UC. Methods. We retrospectively reviewed medical records from patients with UC who underwent colonoscopy or sigmoidoscopy with biopsies. The Mayo endoscopic subscore was used to assess endoscopic activity. Biopsy specimens were reviewed by two blinded pathologists and scored using the Geboes scoring system. Results. We analyzed 154 biopsy specimens from 82 patients with UC. Histological scores exhibited strong correlation with endoscopic subscores (Spearman's rank correlation coefficient r = 0.774, p < 0.001) and moderate correlation with C-reactive protein levels (r = 0.422, p < 0.001) and partial Mayo scores (r = 0.403, p < 0.001). Active histological inflammation (Geboes score ≥ 3.1) was observed in 6% (2 of 33) of the endoscopically normal mucosa samples, 66% (19 of 29) of mild disease samples, and 98% (90 of 92) of moderate-to-severe disease samples. Conclusions. Histological activity was closely correlated with the endoscopic, clinical, and serologic UC activities. However, several patients with mild or normal endoscopic findings exhibited histological evidence of inflammation. Therefore, histological assessment may be helpful in evaluating treatment outcomes and determining follow-up strategies.

Granulomatous Microscopic Colitis Due to Allopurinol

Introduction: Microscopic colitis is a diarrheal Inflammatory Bowel Disease with essentially normal endoscopic findings in the colon but with significant chronic inflammation seen under the microscope in the form of Collagenous colitis or Lymphocytic colitis. We report a rare case of microscopic colitis with predominant granulomatous chronic inflammation. Case: A 77 year-old Caucasian male presented to the Gastroenterology clinic with explosive diarrhea and tenesmus for 10 months. He had Gout and Benign Prostatic Hypertrophy. His medications included allopurinol, tamsulosin, finasteride, aspirin 81 mg/day, fish oil, garlic, Viatmin D and atorvastatin. BMI was 39.1 kg/m2; abdominal exam was normal. Colonoscopy showed subtle loss of vascularity throughout the colon but no ulcers and normal appearing terminal ileum. Microscopic exam of the colonic biopsies showed diffuse mucosal inflammation with an abundance of lymphocytes in the crypt epithelium. Thickened collagen bands were seen focally in some biopsies from the right colon. The submucosa was normal. Several epithelioid granulomas were noticed in the colonic biopsies and at least one granuloma was seen in the terminal ileum. The ileal mucosa was normal otherwise. Clinically, a diagnosis of microscopic form of inflammatory bowel disease was preferred over Crohn's disease because of the lack of characteristic endoscopic findings. The patient was treated with budesonide starting at 9 mg/day for 30 days. At 1 month, his symptoms were almost completely resolved. He was then tapered to budesonide 6 mg/day for 4 weeks and then to 3 mg/day for 2 weeks and then stopped completely. At last follow-up, his diarrhea is completely resolved. Discussion: This case is unique because of the presence of granulomas in the setting of what otherwise appears to be microscopic colitis. Prior reports of granulomas in microscopic colitis have mostly described crypt rupture granulomas but granulomas seen in this case are well-formed, epithelioid granulomas. In retrospect, we think our case could be related to drug reaction because of the nature of the granulomas. Allopurinol could have been the culprit medication because of similar cases reported in literature. Our patient had been on allopurinol for several years prior to presentation. Since he responded well to a short course of budesonide, allopurinol was not stopped.Figure 1Figure 2Figure 3

The Predictive Value of Pre-Operative Symptoms Including Upper Gastrointestinal Endoscopy Before Laparoscopic Cholecystectomy for Elective Symptomatic Cholecystolithiasis

It has always been a challenge to distinguish between upper gastrointestinal symptoms due to gall stones or any other causes. The persistence of abdominal symptoms even after cholecystectomy is highly discouraging for surgeons. To evaluate the value of preoperative (UGE) as a routine investigative tool in patients with gall stone disease and to assess the outcome of cholecystectomy in patients with gallstones on preoperative abdominal symptoms. This is a prospective study conducted on 96 cases at the Department of Surgery, Dhulikhel Hospital among ultrasonographically proven gall bladder stones irrespective of age and sex. After the examination, all the patients were subjected to UGE, and biopsy were obtained for histopathology if required. The statistical analysis were performed using spss version 16. Out of total patients, 84(87.5%) were females and 12(12.5%) were males with a M: F ratio of 1:7. Both the sexes were comparable in age groups. Out of total 96 patients, 53(55.2%) presented with typical pain and 43(44.8%) presented with atypical pain. All the patients were subjected to upper gastrointestinal endoscopy (UGE) and 53(55.2%) had normal findings and 43(44.8%) had various lesions. Patients with typical pattern of pain had normal endoscopic findings and those with atypical pain had pathology in upper gastroendoscopy (p<0.001). Serious pathology resulting to change of the planned treatment was found in three cases (3.12%). Among them two had gastric carcinoma and one had active peptic ulcer disease. The relief rate after the cholecystectomy was significant in patients with typical pain than among those with atypical pain (p<0.001). The commenest post cholecystectomy symptoms were heart burn (10%), abdominal discomfort (9%) and dyspepsia (7%). Presence of atypical pain in patients with gall stones is highly likely to have other coexisting upper gastrointestinal pathologies. Hence, upper gastrointestinal endoscopy prior to elective cholecystectomy in patients with gall stones can be clinically helpful.

Sucrose Permeability: A Simple Non-Invasive Marker of Gastro-Duodenal Damage in Dyspepsia

Introduction: Diagnosis of gastro-duodenal mucosal damage usually requires endoscopy, an invasive procedure. An attempt has been made to assess the clinical validity of sucrose permeability test as a non-invasive marker of gastro-duodenal damage.Methods: The test was carried out in 65 patients of dyspepsia evaluated by endoscopy and 21 healthy controls. On endoscopy, gastro-duodenal epithelial damage was assessed in all patients of dyspepsia and grouped as: group 1 (normal gastro-duodenal mucosa, n=18), group 2 (Gastric ulcer, n=15), group 3 (Duodenal ulcer, n=10), group 4 (Gastritis, n=12) and group 5 (Duodenitis, n=10).Results: The mean urinary sucrose excretions (mg) in 5 hours after 100g oral load was found to be significantly higher in patients of gastric ulcers (183.6 ±169.7, p value &lt; 0.001), duodenal ulcers (151.7± 79.2, p value &lt;0.001), gastritis (115.6±59.2, p value &lt;0.001) and duodenitis (105.2± 122.2, p value &lt;0.05) as compared to controls (35.2±17.2). However, the mean sucrose excretion in patients of dyspepsia with normal endoscopic findings (42.5±14.8 mg) was almost similar to the control group (p value &gt;0.05). A ROC curve analysis taking endoscopic findings as gold standard was undertaken to find the optimum cut-off to detect gastro-duodenal epithelial damage.Conclusions: The cut-off value of 64.5 mg/5h for urinary sucrose excretion provided the best sensitivity and specificity in the diagnosis of both surgical (gastric and duodenal ulcer) and non-surgical (gastritis and duodenitis) gastro-duodenal mucosal damage. At this cutoff sucrose permeability test provided a sensitivity of 72 % and specificity of 92%. Similarly, a cut-off value of 66.5 mg/5h of urinary sucrose excretion provided the best sensitivity and specificity in the diagnosis of surgical gastro-duodenal mucosal damage with sensitivity of 72% and specificity of 97%.

Endoscopic assessment 1 day after esophagectomy for predicting cervical esophagogastric anastomosis-relating complications.

There are no useful methods for predicting anastomosis-relating complications after esophagectomy; however, anastomotic leakage remains one of the most serious postoperative complications. We retrospectively investigated the appropriateness of endoscopic examinations on postoperative day 1 (POD 1) for assessing esophageal reconstruction by analyzing the endoscopic findings 1 day after the operation and evaluating the healing process at the site of anastomosis in patients treated with esophageal reconstruction. Between 2010 and 2013, we performed esophageal reconstructive surgery using a retrosternal gastric graft and cervical anastomosis and conducted endoscopic examinations to assess the esophagogastric anastomosis on POD 1 in 153 patients. On endoscopy performed on POD 1, we identified mucosal color change (MCC) in the proximal gastric graft as an important finding that may be indicative of local circulatory failure in gastric grafts. One week after the operation, endoscopic examinations subsequently showed significant mucosal defects around the site of anastomosis that were expected to result in anastomotic leakage as a marker of poor healing of anastomosis as well as leakage. We identified the findings of MCC in 36 patients evaluated with endoscopic examinations performed on POD 1. Furthermore, the endoscopic examinations performed 1 week after the operation revealed poor healing of the anastomosis site in 23 patients, including one patient with major anastomotic leakage. Therefore, poor healing of the anastomosis site more frequently occurred in 20 of the 36 patients (55.6%) who exhibited MCC on the endoscopic examinations performed on POD 1 than in three of the 117 patients (2.6%) who had normal endoscopic findings on POD 1 (p < 0.001). Early endoscopy performed on POD 1 helps to predict the development of poor healing of esophagogastric anastomosis around 1 week after the operation by identifying the findings of MCC in the proximal gastric graft.

PTU-161 An opportunity missed in diagnosing coeliac disease: Abstract PTU-161 Table 1

Introduction The prevalence of coeliac disease (CD) is around 1% in the UK. The ‘gold standard’ diagnosis of CD requires a distal duodenal (D2) biopsy when the patient is on a gluten containing diet and in most cases positive serology (eg tissue transglutaminase antibodies, tTG ab). CD is confirmed when histological criteria as set out in the Marsh classification [increased intraepithelial lymphocytosis, crypt hyperplasia, villous atrophy (VA)] are met. The diagnosis of CD may be delayed as it can present with a wide range of signs and symptoms including iron deficiency anaemia, weight loss, osteoporosis, neuropathy and vague abdominal symptoms. Many patients with vague abdominal symptoms undergo upper GI endoscopy (OGD), however, in the majority D2 biopsies to look for CD are not obtained. Endoscopic examination may reveal classical features of VA such as ‘scalloping’ of the duodenal mucosa but may also be normal. The aim of the study was to evaluate the range of duodenal endoscopic findings in patients with proven CD and VA on D2 biopsy. Method A single centre, retrospective analysis of patients with histologically proven CD (Marsh 3 classification) on D2 biopsies in a London district general hospital was performed. Data was obtained from the hospital’s histology database, endoscopy reporting software and electronic patient record system. Information on the patients’ demographics, symptoms, index endoscopy findings, histology and coeliac serology prior to a gluten free diet was scrutinised. Results 65 patients had a confirmed diagnosis of CD with VA. 6 patients were excluded from our analysis as endoscopy reports were unavailable. Of the remaining 59, there were 36 females and 29 males. Indications for endoscopy based on patients presenting symptoms were as follows: 18/59 for iron deficiency anaemia, 12/59 (abdominal pain/bloating), 11/59 (diarrhoea), 10/59 (asymptomatic but positive tTG ab), 6/59 (weight loss) and 2/59 for fatigue. tTG ab was positive in 50/59 patients, negative in 7 and not tested in 2. The Table 1below shows the endoscopy findings in these 59 patients with CD. Conclusion Over half of our CD patient cohort had normal endoscopic findings on diagnosis despite confirmed VA on D2 biopsies. 17% of patients were asymptomatic at diagnosis and 12% of patients were tTG ab negative. Given the wide ranging clinical presentation of CD and its overall prevalence, D2 biopsies should not be limited to patients presenting with classical symptoms as we may be missing the opportunity to diagnose this easily treatable condition. We recommend that all patients presenting to OGD for vague abdominal symptoms have duodenal biopsies to exclude CD. Disclosure of interest None Declared.