Repeat Endoscopy Research Articles

All That Bleeds! Visceral Artery Pseudo Aneurysm as a Rare Cause of Recurrent Fresh Gastrointestinal Bleeding

Visceral artery aneurysm and pseudoaneurysm are rare with incidence of 0.1-2%.We report a case of pancreato-duodenal artery pseudoaneurysm presenting as recurrent upper and lower GIB. CASE PRESENTATION: A 57 year old male with past history of COPD, hypertension, GERD, chronic hepatitis C,and alcohol abuse, presented with diffuse abdominal pain.His symptoms started nearly two weeks prior with hematemesis and lower GIB. An upper endoscopy and colonoscopy failed to identify source of bleeding.Two days later he had another episode of fresh upper and lower GI bleeding. Repeat endoscopy revealed no source.On third occassion patient reported diffuse abdominal pain, followed by mild nausea,vomiting and large amount of fresh blood hematemesis and bleeding per rectum. Abdominal CT angiogram revealed acute on chronic pancreatitis, atrophy of pancreatic body and multiple pseudocysts.A 4.6x3.2 cm pseudoaneurysm anterior to splenic artery anatomically was located in close proximity to posterior gastric wall with possible erosion. During endovascular repair a small branch of gastro-duodenal artery was identified as vessel of origin. Multiple micro-catheter coils were used to fill and obliterate the sac and feeding vessel. At six month follow up pseudoaneursym was stable on imaging. DISCUSSION ETIOLOGY: True aneurysms are caused by hypertension, atherosclerosis,and connective tissue disease.Two-thirds of VAPA are secondary to pancreatitis and leaking of proteolytic enzymes.PRESENTATION:Most cases present with vague abdominal symptoms.If ruptured, patients present with anemia and hemodynamic instability.DIAGNOSIS:Color Doppler can display inflow and outflow of blood in sac, known as “yin-yang sign”.Transcatheter angiography remains gold-standard for diagnosis as it can provide definitive diagnosis, has highest sensitivity (100%) and therapeutic potential.TREATMENT: Treatment is indicated if a visceral aneurysm size is >2cm. Women of child bearing age or pregnant should also undergo treatment.A pseudoaneurysm must be treated immediately as rate of expansion is much rapid(76.3% vs 3.1%). Treatment options include endovascular(stent,embolization),percutaneous thrombin injection,and surgery(vessel ligation,arterial bypass,sac exclusion). CONCLUSION:This case reports highlights importance of including VAA and VAPA in differential diagnosis of GI bleeding and use of alternative diagnostic modalities when endoscopy and colonoscopy fail to reveal a source of bleeding.1954_A Figure 1. Non contrast CT Abdomen showing extensive pancreatic destruction1954_B Figure 2. Contrast enhanced CT showing a large pseudoaneurysm in proximity of posterior gastric wall1954_C Figure 3. Intra operative angiogram before and after the endovascular repair.

A Rare Case of Massive Gastrointestinal Bleeding From a Rectal Dieulafoy Lesion

A Dieulafoy lesion (DL) is defined as a dilated sub-mucosal vessel that erodes the overlying epithelium without evidence of a primary ulcer or erosion. DL lesions of the rectum are a rare cause of gastrointestinal bleeding that is difficult to identify and subsequently manage. We present an 84-year-old man, who presented with lower gastrointestinal bleeding secondary to a DL of the rectum. An 84-year-old man with a medical history significant for End-stage renal disease(ESRD), and hypertension presented to our emergency department with multiple episodes of rectal bleeding mixed with bowel movements. On physical examination, he was hemodynamically stable, with rectal examination notable for bright red blood on the examining finger. His initial complete blood count showed a hemoglobin of 8.4 g/dL, with other normal indices. The patient was rapidly prepped for colonoscopy. Colonoscopy revealed an actively spurting Dieulafoy lesion in the distal rectum just proximal to the pectinate line associated with underlying friable mucosa. Hemostasis was achieved with injection of 3cc of 1:10000 epinephrine, and application of 3 hemostatic clips. He remained stable, with no subsequent rectal bleeding and was discharged home. DLs first described by Gallard in 1884, is a rare cause of gastrointestinal bleeding.They are believed to account for an estimated 1-2% of all cases of acute GI bleeding and can be associated with high mortality rate. The etiology of Dieulafoy lesions are unknown. Risk factors associated with their development include male gender, hypertension, and ESRD, which were present in our patient. With regards to location, DLs are most commonly encountered in the stomach and the gastroesophageal junction. DLs of the rectum is a rare entity, observed in a mere 2% of reported cases in the literature. Bleeding episodes of DL are usually self-limited, however, they are usually recurrent and can lead to profuse rectal bleeding. Diagnosis of DLs, both gastric and rectal, can often time be challenging for the clinician. Endoscopy is the gold standard for diagnosis, but is only successful in 70% of cases, requiring the need for repeat endoscopy to establish the diagnosis. Treatment of rectal DLs is best accomplished endoscopically using a combination of epinephrine injection with bipolar probe coagulation, hemoclip placement, or thermal coagulation. Rarely angiograph and surgery is indicated in failed endoscopic therapy.1991_A Figure 1. An actively bleeding dieulafoy lesion in the distal rectum, just proximal to the pectinate line.1991_B Figure 2. Hemostasis achieved with 3 hemostatic clips.

Importance of endoscopic and histological evaluation in the management of immune checkpoint inhibitor-induced colitis

BackgroundImmune checkpoint inhibitors (ICPI) are efficacious treatments for advanced malignancies but can result in immune mediated diarrhea and colitis (IDC). Currently, the guidelines for the treatment of IDC depend only on clinical symptoms. Endoscopic and histologic features of such adverse events are not well studied in a manner that can help to gauge treatment plans. We aimed to characterize endoscopic and histologic features of IDC and to assess their association with clinical outcomes.MethodsOur study included patients who had undergone endoscopy for IDC (1/2010 to 3/2018). Patients with GI infection at time of onset were excluded. High-risk endoscopic features were ulcers deeper than 2 mm, larger than 1 cm, and extensive colonic involvement. Univariate and multivariate logistic regression were performed to assess the association of endoscopic and histological features with clinical outcomes.ResultsA total of 182 patients was included; most were white (92%), males (65%) with a mean age of 60 years. Median time from ICPI initiation to IDC was 7 weeks. Fifty-three percent had grade 3–4 diarrhea, and 32% grade 3–4 colitis. Forty-nine patients had mucosal ulcerations, 66 non-ulcerative inflammation and 67 normal endoscopy. Calprotectin was higher in patients with ulceration (P = 0.04). The sensitivity of lactoferrin to detect histologic and endoscopic inflammation was 90% and 70% respectively. Patients who underwent endoscopy earlier than 7 days after IDC onset had shorter duration of IDC symptoms and duration of steroid treatment than those who underwent endoscopy after 7 days of IDC onset (P = 0.026 and P = 0.053, respectively). Patients who underwent endoscopy > 30 days of symptom onset required longer duration of steroids (P = 0.02), had more recurrent symptoms (P < 0.01) and received later infliximab/vedolizumab add-on therapy than did those who underwent endoscopy ≤30 days (P = 0.03). High-risk features were associated with more frequent (P = 0.03) and longer duration (P = 0.02) hospitalization and infliximab/vedolizumab requirement (P < 0.01). Patients with active histological inflammation had more recurrence (P < 0.01) and repeat endoscopy (P < 0.01). Repeat endoscopy was required in 47 patients. A multivariate logistic regression revealed that longer ICPI treatment was associated with more frequent hospitalizations (OR 1.00; 95%CI 1.00–1.01; P < 0.01) and high-risk endoscopic features were associated with the requirement of infliximab/vedolizumab (OR 3.89; 95%CI 1.68–9.01; P < 0.01).ConclusionHigh risk endoscopic features and active histologic inflammation represent important markers of disease severity with clinical implications and should be used in a timely manner to devise IDC-focused treatment algorithms.

Helicobacter pylori‐associated peptic ulcer disease: A retrospective analysis of post‐treatment testing practices

Guidelines recommend that patients with Helicobacter pylori (H.pylori)-associated peptic ulcer disease (PUD) receive H.pylori eradication therapy followed by post-treatment testing to prove eradication; however, post-treatment testing rates are suboptimal and barriers to testing are poorly understood. Our aim was to identify factors that predicted receipt of post-treatment testing. We performed a retrospective cohort study of 152 patients with H.pylori-associated PUD diagnosed between 2007 and 2015 at a large tertiary medical center in the United States, who received standard eradication therapy and ambulatory follow-up within one year. The primary outcome of interest was receipt of post-treatment testing. Logistic regression models compared post-treatment testing rates in those diagnosed while outpatient vs inpatient, patients with vs without repeat endoscopy, and patients with vs without gastroenterology (GI) clinic follow-up. Propensity scores controlled for age, sex, race, ulcer location, and symptom persistence. Among 152 patients, 67 (44%) patients received post-treatment testing. There were significant differences in post-treatment testing rates in those diagnosed as outpatients vs inpatients (57% vs 33%; OR 3.87, P=0.001) and in patients with vs without GI follow-up (62% vs 11%; OR 9.85, P<0.0001). The rate of testing for eradication after treatment in patients with H.pylori- associated PUD was low. However, this was significantly improved in patients who have GI follow-up and whose diagnosis was made in the outpatient setting. Our study demonstrates a clear opportunity for quality improvement initiatives.

Pediatric Collagenous Gastritis and Colitis: A Case Series and Review of the Literature.

Collagenous gastritis is a rare disease characterized by the subepithelial deposition of collagen bands. Two phenotypes of the disease have been described: a pediatric-onset and an adult-onset type. The adult-onset form is associated with collagenous colitis and autoimmune disorders. No effective treatment has been identified to date. We aim to describe the clinical features and outcomes of patients in our cohort and provide a summary of published pediatric cases with collagenous gastritis and colitis reported to date to gather information that will contribute to improved knowledge of this rare condition. A retrospective chart review of all patients with collagenous gastritis and/or colitis who were treated at the Royal Children's Hospital, Melbourne, was performed. A literature review was also conducted. A total of 12 cases of collagenous gastritis were reviewed. Three of 12 (25%) patients had associated collagenous colitis. The most common clinical presentation was iron deficiency anemia. Nine (75%) patients were followed up, and repeat endoscopies were performed in 8 (67%). Iron deficiency anemia resolved in all patients on oral iron supplementation. Histologic improvement was only identified in one patient with the adult phenotype who had been treated with oral corticosteroids and azathioprine. Collagenous gastritis is a rare condition in children. A small proportion of children develop features of the "'adult" phenotype at a very young age. Patients with collagenous gastritis require long-term follow-up and monitoring of their disease. Further randomized clinical trials are needed to establish an effective therapeutic strategy.

How effective is endoscopic stenting in management of post-cholecystectomy bile duct injuries – experience of a tertiary care hepatobiliary center in a developing country

Iatrogenic bile duct injury(IBDI) is the most serious complication of cholecystectomy. Endoscopic stenting is an alternative to surgery in managing IBDI and data on this aspect is scarce in our setting. Post cholecystectomy ERCPs(suspecting IBDI) were analysed and categorized into Bismuth-Strasberg classification(A-E). E(1–5) were considered as major injuries. The stented patients were evaluated for symptom improvement, need of repeat endoscopy and complications. Eighty seven IBDI was detected during ERCP(2007–2016, 70% following Laparoscopic cholecystectomy). Male:female was 1:3 and mean age was 38.6 years(range 28–70). 53% had minor injuries(Bismuth-Strasburg A-D). Cystic stump leak was the commonest single injury(36%). All the minor injuries(n = 46) were stented with 7Fr or 10 Fr plastic stents. All stented patients needed repeat ERCP(two monthly in most cases) with a median number of 5(range 2–11) and 81% underwent serial dilatation and multiple stenting. All the patients had symptom improvement within three months of the initial intervention. In stented group 5 patients(10%) needed surgery as they developed chronic CBD stricture which were not improved with at least 6 attempts of serial dilatation(after 3 years of initial surgery). Zero mortality was reported in stented group. Minor IBDI can be effectively managed with ERCP and stenting according to our data. Serial dilatation with repeated ERCP is needed in most of the cases but avoiding a major surgery would be an advantage. The number of serial dilations attempts before deciding on reconstructive surgery should be evaluated further as many patients improved after multiple attempts of dilatation.

Impact of fellow training level on adverse events and operative time for common pediatric GI endoscopic procedures

Previous studies on pediatric endoscopic training have not examined in detail if adverse events (AEs) are affected by the fellow's training level. We aimed to determine whether trainee presence and educational level increase AEs or operative time (OT) for pediatric intestinal endoscopy. This was a prospective observational study of AEs for all endoscopic procedures and retrospective analysis of OT (time of endoscope insertion until removal) for a sample of specified procedures at a tertiary children's hospital. AEs were categorized by severity grades: 1, home management; 2, outpatient evaluation; 3, hospitalization and/or repeat endoscopy; 4, surgery and/or intensive care unit admission; and 5, death. A total of 15,886 procedures (6257 with trainee) including 1627 therapeutic procedures (733 with trainee) were analyzed for AEs. Four hundred thirteen total AEs (2.60%) and 213 AEs grade 2 to 4 (1.34%) were identified. Fellow presence at any training level did not increase AE rates for any procedures. Median OT for 3762 EGDs decreased from 17 to 11 minutes from the first quarter to the fourth quarter of first-year fellowship and then remained stable. EGDs without fellows were shorter (9 minutes, P< .0001) compared with any training level. Median times of 1291 colonoscopies with EGD decreased from 55 to 51 to 47 minutes for fellows in the first half, second half of first-year fellowship, and second and third year, respectively. Attendings alone were faster (37 minutes, P< .0001). Current pediatric endoscopic training for is safe regardless of fellow training level. Trainee efficiency improves during and after fellowship.

Long-Term Effectiveness, Safety and Mortality Associated with the Use of TC-325 for Malignancy-Related Upper Gastrointestinal Bleeds: A Multicentre Retrospective Study

Background and Study AimsMalignant-related upper gastrointestinal bleeding (MRUGIB) is difficult to treat by conventional endoscopic methods. We sought to determine the efficacy, safety and mortality associated with the use of TC-325 for the treatment of MUGIB.Patients and MethodsThis is a multicentre, retrospective study at the University of Calgary and University of Ottawa performed between January 1, 2010, and July 30, 2016. TC-325 use was identified via staff polling, product order forms and endoscopic records review. Once identified, patient charts and online records were examined to identify MRUGIB cases and to assess our primary and secondary endpoints.OutcomesThe primary outcome was hemostasis at seven days. Secondary outcomes include immediate hemostasis, early hemostasis, hemostasis at 14 days, 30-day mortality, adverse events related to TC-325 therapy and the need for repeat endoscopic intervention, surgery or transarterial embolization.ResultsTwenty-five patients were identified. The median age was 62 years (interquartile range [IQR] 52.5–76), and most were male (64%). TC-325 was the primary treatment modality in 20 patients (80%). Hemostasis was 88%, 89%, 58% and 50% at 24 hours, 72 hours, 7 days and 14 days, respectively. Five patients underwent repeat endoscopy, two patients required surgical intervention, and transarterial embolization was not required. Twelve patients died by 30 days (48%). There were no complications directly attributed to the use of TC-325.ConclusionsTC-325 is effective for achieving and maintaining hemostasis in patients with malignancy-related upper gastrointestinal bleeding, and most patients do not require additional interventions. The 30-day mortality risk in this group of patients is high.

Simplified versus standard regimen for focal radiofrequency ablation of dysplastic Barrett's oesophagus: a multicentre randomised controlled trial

For focal radiofrequency ablation of Barrett's oesophagus, a simplified regimen (3 × 15 J/cm2, without cleaning) has proven to be as effective as the standard regimen (2 × 15 J/cm2, followed by cleaning, followed by 2 × 15 J/cm2). However, this simplified regimen seemed to be associated with a higher stenosis rate. Therefore, we lowered the radiofrequency energy and hypothesised that this new simplified regimen would be as effective and safe as the standard regimen. This randomised non-inferiority trial included patients with dysplastic Barrett's oesophagus or residual Barrett's oesophagus after endoscopic resection or circumferential radiofrequency ablation, in five European tertiary referral centres. Patients were randomly assigned (1:1) to the new simplified regimen (3 × 12 J/cm2, without cleaning) or the standard regimen, with variable block sizes of four, six, and eight patients, stratified by participating hospital. Focal radiofrequency ablation was done every 3 months, up to a maximum of three treatments, until all Barrett's oesophagus was eradicated. The primary outcome was complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments, assessed in the intention-to-treat population. Non-inferiority was assessed on the basis of the difference between groups in the median percentage of Barrett's oesophagus surface regression, with a non-inferiority margin of -15%. This study is registered with www.trialregister.nl, number NTR4994, and is completed. Between March 25, 2015, and July 25, 2016, 84 patients were randomly assigned to treatment: 44 to receive the simplified regimen and 40 to receive the standard regimen. One patient assigned to the simplified regimen and four assigned to the standard regimen were excluded because they weree found not to be eligible; therefore the final intention-to-treat population consisted of 43 patients in the simplified ablation group and 36 in the standard ablation group. Complete endoscopic and histological regression of dysplasia and intestinal metaplasia after two focal radiofrequency ablation treatments was achieved in 32 (74%, 95% CI 59-87) patients treated with the simplified protocol, versus 30 (83%, 95% CI 67-94) patients treated with the standard protocol (p=0·34). Median Barrett's oesophagus surface regression after two focal radiofrequency ablation sessions was 98% (IQR 95-100) in the simplified regimen group and 100% (97-100) in the standard regimen group. The difference between medians was 2% (95% CI -0·562 to 3·162); thus the simplified regimen was deemed non-inferior to the standard regimen. Stenoses requiring dilatation were observed in four (9%) of 43 patients in the simplified regimen group and four (11%) of 36 in the standard regimen group. Post-procedural bleeding requiring repeat endoscopy occurred in one (2%) patient in the simplified ablation group and three (8%) patients in the standard ablation group. One patient (2%) in the simplified treatment group died 36 days after the second radiofrequency ablation procedure, due to an unknown cause. Based on the results of this study, we conclude that the simplified regimen is the preferred regimen for focal radiofrequency ablation of Barrett's oesophagus. None.

Tu1192 THE LEARNING CURVE OF PERORAL ENDOSCOPIC MYOTOMY IN LATIN AMERICA: A SLIDE TO THE RIGHT ?

Per Oral Endoscopic Myotomy (POEM) is a minimally invasive option for achalasia for the past 10 years. The procedure has been increasingly used in Latin America where Chagas disease is prevalent. Studies have suggested that Chagas disease makes POEM more technically challenging due to significant submucosal scarring. The aim of this study was to determine the learning curve for POEM in Latin America. Consecutive patients undergoing POEM in Latin America by a single operator were included from a prospective registry from June 2013 to August 2017. Demographics, procedure info, post-procedure follow-up data, and adverse events were collected. Non-linear regression and CUSUM analyses was conducted for the learning curve. Technical success was successful completion of the myotomy. Clinical success was an Eckardt score of ≤ 3 at 3 months. 125 patients were included (52%M, mean age 59 years). A majority of patients had type II achalasia (n=80, 64%); 33 (26%) had type III, 9 (7%) had type I, 3 (2%) had other esophageal motility disorders. Approximately one third of patients had Chagas disease (n=38, 30%). Most patients had no prior treatment (n=84, 67%), the remaining patients were post-heller myotomy (n=18, 14%), pneumatic dilation (n=17, 13.6%), or botox injection (n=6, 4.8%). The average pre-procedure Eckardt score was 6.79. Technical success was achieved in 93.5% of patients (n=117). 99 patients had a posterior POEM, 26 had anterior. Clinical success was achieved in 88.8% of patients. The mean post-procedure Eckardt score 1.87. Adverse events were noted in 27 patients (22%): bleeding n=4 (coagulation graspers), pneumothorax n=4 (chest tube x 3), mucosal perforation n=13 (closed with clips), mediastinitis n=2 (antibiotics alone), leak n=4 (repeat endoscopy with clips). Average length of stay was 1.98 days; average follow-up was 16months. Median procedure time was 97 minutes (range 45-196 mins, mean 102.7 mins). CUSUM chart (Figure 1) shows 96 minute procedure time was achieved at the 61st procedure hence indicating efficiency. Apart from outliers, procedure durations further reduced with consequent procedures with the last 10 procedures under 50 mins almost approaching a plateau (nonlinear regression p value P<0.0001) (Figure 2). A further evaluation of the next 40-50 cases could potentially reveal a plateau indicating mastery. Endoscopists experienced in POEM are expected to achieve a reduction in procedure time over successive cases. In Latin America, efficiency was reached at 97 minutes and a learning rate of 61 cases with continuing improvement. POEM in Latin American is a technically difficult procedure requiring a higher volume of cases to reach efficiency and seems to be associated with a higher number of adverse events likely due to the increased challenges from Chagas disease patients.Tabled 1POEM demographicsN=125Gender M:F65:60Age (years)59.14 (12.48)Mean (SD)ACHALASIA-Type I-9-Type II-80-Type III-33-Jackhammer esophagus-2-Nutcracker esophagus-1Chagas disease (%)38 (30.4%)Orientation26 : 99Anterior: PosteriorDevice for closure125ClipsPre-procedureMean Eckardt score (SD)6.79 (2.05)Mean LES Pressures mmHg29.04Technical success117 (93.5%)Clinical success111 (88.8%)Complications27-Bleeding4-Pneumothorax4-Mucosal perforation13-Mediastinitis2-Leak4Interventions for complicationsHemoclips (mucosal perforations)12Overscope clips (mucosal perforations)-1Needle decompression (pneumothorax)-11Chest tubes (pneumothorax)-3Coagulation (bleeding)-1Reclips (leaks)-4Antibiotics (mediastinitis)-2Procedure time in minutes (SD)102.65 (42.48)Hospital stay in days (SD)1.98 (0.97)Follow up in months (SD)16 (12.89)Post-procedure (3 months)Mean Eckardt score (SD)1.87 (2.15)Mean LES Pressures mmHg22.56Reinterventions13-Heller myotomy5-Pneumatic dilation8 Open table in a new tab

Su1473 - Patients Who do not Receive a Repeat Endoscopy after Initial Endoscopic Esophageal Variceal Ligation have an Increased Risk of Death

Su1473 - Patients Who do not Receive a Repeat Endoscopy after Initial Endoscopic Esophageal Variceal Ligation have an Increased Risk of Death

A Man with Diarrhea

ABSTRACTDiarrhea, a common presenting complaint which we come across in our day‑to‑day practice, is often self‑limited but can be challenging at times. Here, we report one such patient. A 54‑year‑old male presented with diarrhea, abdominal pain, anorexia, and weight loss. Routine blood and stool examination was not helpful. A colonoscopy done elsewhere showed a fistulous opening in the anal canal for which he underwent a fistulectomy. Esophagogastroduodenoscopy revealed severe esophagitis, multiple duodenal ulcers, and a fundic gland polyp from which biopsies were taken. The fundic gland polyp showed oxyntic gland hyperplasia. Basal acid output and serum fasting gastrin subsequently measured were also high. A diagnosis of Zollinger–Ellison syndrome was made, and the patient was started on high‑dose proton‑pump inhibitors, to which he had excellent response. Repeat endoscopy showed resolutions of all lesions. Endoscopic ultrasound (EUS) and DOTA (Gallium (68Ga) DOTA-TATE) scan revealed a tumor in the duodenum and pylorus, respectively. On surgical exploration, the tumor was identified in the second part of the duodenum and was removed. The patient has remained asymptomatic since then.

An elderly patient’s complete response to steroid therapy for collagenous gastritis

An 85-year-old woman presented with 9.1 kg (20 lb) weight loss over 5 months and an acute onset crampy abdominal pain. Examination revealed a diffusely tender abdomen, with gastric wall thickening noted on CT scan. Upper endoscopy showed diffuse severe erythema and friability. Histologic examination with hematoxylin and eosin staining revealed collagenous gastritis characterized by active chronic inflammation with sub-epithelial collagen deposition and erosion. The patient was started on steroid therapy with rapid clinical improvement and tapered off over 2.5 months. At 6 months, the patient reported an improved appetite with resolution of her abdominal pain. Repeat endoscopy revealed a grossly normal stomach and normal mucosal biopsies. She remains without complaints 1 year later. Collagenous gastritis, rare in the elderly, is a histologic diagnosis characterized by the deposition of a sub-epithelial collagen band thicker than 10 µm with an inflammatory infiltrate. In all ages the mucosa typically appears nodular and erythematous, caused by an uneven inflammation in the surrounding depressed mucosa with atrophic changes. Specific therapy has not been well-established, and the prognosis and potential for endoscopic or histological resolution remains unclear. While anecdotal, the success of steroids may offer a reasonable starting point for treatment of similar cases.

Diagnostic utility of staging abdominal computerized tomography and repeat endoscopy in detecting localization errors at initial endoscopy in colorectal cancer.

Colonoscopy has a reported localization error rate as high as 21% in detecting colorectal neoplasms. Preoperative repeat endoscopy has been shown to be protective against localization errors. There is a paucity of literature assessing the utility of staging computerized tomography (CT) and repeat endoscopy as diagnostic tools for detecting localization errors following initial endoscopy. The objective of this study is to determine the diagnostic characteristics of staging CT and repeat endoscopy in correcting localization errors at initial endoscopy. A retrospective cohort study was conducted at a large tertiary academic center between January 2006 and August 2014. All patients undergoing surgical resection for CRC were identified. Group comparisons were conducted between (1) patients that underwent only staging CT (staging CT group), and (2) patients that underwent staging CT and repeat endoscopy (repeat endoscopy group). The primary outcome was localization error correction rate for errors at initial endoscopy. 594 patients were identified, 196 (33.0%) in the repeat endoscopy group, and 398 (77.0%) patients in the staging CT group. Error rates for each modality were as follows: initial endoscopy 8.8% (95% CI 6.5-11.0), staging CT 9.3% (95% CI 6.5-11.0), and repeat endoscopy 2.6% (95% CI 0.3-4.7); p < 0.01. Repeat endoscopy was superior to staging CT in correcting localization errors for left-sided / rectal lesions (81.2% vs. 33.3%; p < 0.01), right-sided lesions (80.0% vs. 54.5%; p = 0.21), and overall lesions (80.8% vs. 42.3%; p < 0.01). Repeat endoscopy compared to staging CT demonstrated relative risk reduction of 66.7% (95% CI 22-86%), absolute risk reduction of 38.5% (95% CI 14.2-62.8%), and odds ratio of 0.18 (95% CI 0.05-0.61) for correcting errors at initial endoscopy. Repeat endoscopy in colorectal cancer is superior to staging CT as a diagnostic tool for correcting localization-based errors at initial endoscopy.

Eosinophilic Esophagitis in Children: Endoscopic Findings at Diagnosis and Post-intervention

The goal of this review is to present and summarize studies on endoscopic findings in eosinophilic esophagitis (EoE), at diagnosis and in response to treatment, utilizing rigorous peer-reviewed literature in children wherever possible and to introduce a recently proposed standardized endoscopic evaluation system. Gold standard of diagnosis and assessment of response to therapy in EoE requires multiple endoscopies with biopsies for histology, which allows for observation of the esophageal mucosa. Typical endoscopic findings in patients with EoE include edema, exudate, furrowing, concentric rings, and strictures. Endoscopic findings have been broadly characterized into inflammatory features (edema, exudate, furrowing) and fibro-stenotic features (rings, stricture), in order to better reflect their underlying pathophysiology. Recent studies suggest strong correlations between endoscopic findings, through composite scoring systems, and histology, and therefore may be helpful as part of disease surveillance. The EoE Endoscopic Reference Score (EREFS) classification system was proposed in 2013 as an outcome metric for standardization in reporting endoscopic signs of EoE. Subsequent studies support utility of composite scoring, which utility has similarly been seen in pediatric treatment trials. Endoscopy in children provides insight into the natural history of EoE, with progressively more fibro-stenotic features occurring over time, giving an additional perspective into esophageal remodeling and response to treatment. Recognition of typical endoscopic findings at diagnosis and upon repeat endoscopy has allowed a clinician to monitor visual changes in esophageal mucosal health. Further studies to assess the role of composite scoring in disease management are needed.

Etiology of Upper GI Bleeding on Endoscopy

Background: Several circumstances and conditions lead to UGIB. The commonest among them peptic ulcer to an approximation of 50% in cases. The second major cause may be esoghageal varices and third is mallory-weis tears. There are also other causes, which may include erosins, tumors and other malformations like arteriovenous. Methods: This was an observational retrospective study of all patients referred to endoscopy. The study exclusion criteria include all patients who had repeat endoscopies within one month of the previous endoscopy whereas all the patients with UGIB were included in this study. Results: We retrieved data of total 150 patients who had experienced upper gastrointestinal endoscopy during the selected time period covered in the study, March 2015 to February 2016. The mean age of the patients was 43.3 ± 13.80. 80 (53.3%) of the patients were male and 70 (46.7%) were females. Exploring more into UGIB causes the majority of patients were with esophageal varices 68 (45.3%) with male to female share was 2:1. The second most cause was esophagitis (n = 22, (14.67%)), the distribution of the cause was similar in male to female. Conclusion: We may conclude from our findings that the most common cause of UGIB is esophageal varices in our population.

Endoscopic Collagen Spray A Novel Method Which can be Used as an Adjunct to Conventional Hemostatic Techniques in Peptic Ulcer Bleeding

Aim: To study endoscopic collagen spray as a hemostatic agent in peptic ulcer bleeding not controlled by conventional therapy. Methods: In this prospective study, endoscopic collagen spray, VGM’s Haemoseal spray has been used in the treatment of peptic ulcer bleeding, as a single agent or in combination with other agents. Haemoseal Spray Kit consists of air pump, Haemoseal probe, a 7.5 Fr spray catheter, 230 cm in length and a pre-loaded collagen cartridge that contains 5 grams of powder. A maximum of 2 grams is applied depending on the area to be covered. Results: Eighteen consecutive patients, who presented with peptic ulcer bleeding were included. There were sixteen patients with duodenal ulcer and two patients with gastric ulcer. The hemorrhagic ulcers were Forrest classification category Ib in sixteen patients and Ia in two patients. After spraying collagen, the bleeding stopped within seconds in all the patients. Repeat endoscopy after 48 hours showed no rebleeding. One patient had an arterial spurt from duodenal ulcer. Collagen spray was used initially as there was poor visibility. After 24 hours, repeat endoscopy revealed visible vessel with no bleeding. Hemoclipping could be achieved. There were no side effects experienced by the patients. Conclusion: Collagen spray is a safe and effective endoscopic hemostatic agent in treatment of peptic ulcer bleeding not controlled by conventional therapy.

Histologic improvement after 6 weeks of dietary elimination for eosinophilic esophagitis may be insufficient to determine efficacy.

BackgroundElimination diets are used to treat eosinophilic esophagitis (EoE), with success (remission) defined at endoscopy and oesophageal biopsy as fewer than 15 eosinophils per high power field (HPF). Response is assessed after 6 weeks of treatment by convention, but we have observed that this period of time may be insufficient.ObjectiveTo characterise a subset of patients with EoE who require prolonged (>6 weeks) of dietary therapy to achieve histologic remission.MethodsA retrospective search of electronic medical records of 2 cohorts with EoE attending the Department of Gastroenterology, University of Chapel Hill North Carolina, and Eastern Health, Melbourne Australia. Patients who underwent elimination diet, had esophageal biopsy after 6 or more weeks of dietary restriction that demonstrated ongoing esophageal inflammation (>15 eosinophils per HPF), and who then continued dietary therapy followed by repeat endoscopy demonstrating remission (<15 eosinophils per HPF) were included.ResultsSeven patients met inclusion criteria, average esophageal eosinophil counts prior to diet was 38.5 (range, 15–65). Following the initial period of diet (mean of 6 weeks and 4 days) eosinophil count decreased (average, 21.5/HPF; range 15–40/HPF). After extended dietary elimination (mean, 13 weeks; range, 7–22 weeks), histological resolution was achieved (average peak eosinophil count of 5.2; range, 0–14) in all cases. Endoscopic appearance and symptoms both improved following the initial period of dietary elimination, thereby preceding the histological resolution, and were sustained.ConclusionA subset of patients has full histologic response to prolonged elimination diet, that lags initial symptomatic and endoscopic improvement.

An Incidental Finding of AL‑associated Amyloidosis Presenting as Gastric Ulcers

ABSTRACTGastrointestinal tract amyloidosis has been reported in rare instances and related symptoms are usually nonspecific to the disease process. We present a patient who initially had melena on anticoagulation and endoscopy revealed a bleeding gastric ulcer. Hemostasis was achieved. The patient had a recurrence of symptoms despite being off anticoagulation months later and at that time repeat endoscopy showed multiple gastric ulcers with surrounding friable mucosa. Biopsy results were significant for light chain associated‑amyloidosis. This case represents a rare cause of gastric ulcer.

Acetic acid-guided biopsies in Barrett's surveillance for neoplasia detection versus non-targeted biopsies (Seattle protocol): A feasibility study for a randomized tandem endoscopy trial. The ABBA study.

Background and study aims Barrett’s esophagus is a potentially pre-cancerous condition, affecting 375,000 people in the UK. Patients receive a 2-yearly endoscopy to detect cancerous changes, as early detection and treatment results in better outcomes. Current treatment requires random mapping biopsies along the length of Barrett’s, in addition to biopsy of visible abnormalities. As only 13 % of pre-cancerous changes appear as visible nodules or abnormalities, areas of dysplasia are often missed. Acetic acid chromoendoscopy (AAC) has been shown to improve detection of pre-cancerous and cancerous tissue in observational studies, but no randomized controlled trials (RCTs) have been performed to date. Patients and methods A “tandem” endoscopy cross-over design. Participants will be randomized to endoscopy using mapping biopsies or AAC, in which dilute acetic acid is sprayed onto the surface of the esophagus, highlighting tissue through an whitening reaction and enhancing visibility of areas with cellular changes for biopsy. After 4 to 10 weeks, participants will undergo a repeat endoscopy, using the second method. Rates of recruitment and retention will be assessed, in addition to the estimated dysplasia detection rate, effectiveness of the endoscopist training program, and rates of adverse events (AEs). Qualitative interviews will explore participant and endoscopist acceptability of study design and delivery, and the acceptability of switching endoscopic techniques for Barrett's surveillance. Results Endoscopists’ ability to diagnose dysplasia in Barrett’s esophagus can be improved. AAC may offer a simple, universally applicable, easily-acquired technique to improve detection, affording patients earlier diagnosis and treatment, reducing endoscopy time and pathology costs. The ABBA study will determine whether a crossover “tandem” endoscopy design is feasible and acceptable to patients and clinicians and gather outcome data to power a definitive trial.