Repeat Endoscopy Research Articles

Utility of Combined Endoscopic Therapy With Balloon Dilation and Onabotulinum Toxin A Injection in a Patient With Gastroparesis Secondary to Hypertrophic Pylorus

Introduction: Gastroparesis is a motility disorder of the gastrointestinal tract characterized by delayed gastric emptying. The diagnosis requires endoscopic evaluation to exclude mechanical obstruction and imaging; such as gastric emptying scintigraphy, to confirm delayed gastric emptying. Pharmacological therapy for gastroparesis is limited. Metoclopramide is the only FDA-approved medication with unproven long-term efficacy. Intrapyloric botulinum toxin injection is not currently a recommended treatment modality for gastroparesis. Here, we present a case with severe gastroparesis secondary to diffuse pylorospasm which improved with endoscopic botulinum toxin injection and pyloric dilation. Case report: A 70-year-old female patient with a history of asthma and a paraoesophageal hernia repair presented to our clinic for persistent nausea and vomiting. Physical examination and initial laboratory tests including complete blood counts, comprehensive metabolic panel, and thyroid function test were all unremarkable. She underwent an upper endoscopy that showed intact paraoesophageal hernia repair, normal gastric mucosa, but thickened and hypertrophied pylorus that was traversed with moderate resistance. Duodenum appeared normal. Nuclear gastric emptying scintigraphy showed markedly delayed gastric emptying with 14% gastric emptying at 4 hours. She underwent a repeat endoscopy with CRE pyloric balloon dilation from 12 mm to 15 mm, followed by intrapyloric onabotulinum toxin A injection in a 4 quadrant fashion. Her follow-up in 6 months showed a great improvement in her symptoms. Discussion: Endoscopic botulinum toxin injection has shown benefit in many gastrointestinal motility disorders, however, it is not currently recommended as a therapy for patients with gastroparesis by our gastrointestinal society. Botulinum toxin is a potent inhibitor of neuromuscular transmission and can improve spasm in tight gastrointestinal sphincters. Several open-label trials demonstrated clinical benefits of endoscopic intrapyloric botulinum toxin injection in patients with refractory gastroparesis. Herein, we describe a patient who benefited from combined therapy using balloon dilation and intrapyloric botulinum toxin injection. The therapy appeared effective and safe with no immediate or delayed complications. Further studies are needed to identify subset of patients who might benefit from combined endoscopic therapy with intrapylroic botulinum injection and balloon dilation.

Pressure Gastric Ulcer From an Over-Inflated Gastrostomy Tube Balloon: An Unusual Cause of Upper Gastrointestinal Bleeding

Percutaneous endoscopic gastrostomy (PEG) is one of the most commonly performed endoscopic procedures used for the establishment of enteral feedings in patients with dysphagia and in the elderly population with poor oral intake. Approximately 160,000-200,000 endoscopic PEG tube placement are performed each year in the United States. Despite its high success rate (>95%), major complications have been reported in 1% to 3% of cases. Endoscopically placed PEG tubes are more durable and longer lasting because an internal bumper of the tube holds the gastric wall firmly against anterior abdominal wall. This prevents easy dislodgement of the tube and minor leakage around the stoma. Dislodged endoscopic PEG tubes with a mature gastro cutaneous fistula can be replaced at the bedside with a PEG tube with a balloon. This avoids the need for a repeat endoscopy. Though cost effective the clinician should be properly trained about proper technique to avoid adverse outcomes. One such outcome is described in this case report. 80-year-old female with dementia and multiple co-morbidities presented from a nursing home with complaints of hematemesis and bleeding around PEG tube. Clinically she was noted to be tachycardic (HR 113 bpm), febrile (100.6 degrees). Blood work revealed anemia (Hgb 6.8 gm/dl) and high Blood Urea Nitrogen. On exam, a 22 Fr balloon PEG (15 cc balloon) with dried blood in and around the tubing was observed with melena on rectal exam. EGD revealed a large gastric ulcer with a visible vessel at the point of contact with an overinflated balloon. The internal balloon of the PEG tube appeared to be overinflated (at least 25 cc in a 15 cc balloon), compressing and ulcerating the stomach wall at the area of contact between the balloon and the gastric wall (Figure 1). Successful hemostasis was achieved endoscopically and a new bumper PEG tube placed under endoscopic guidance. Overinflated PEG tube balloon resulting in a large gastric pressure ulcer is an uncommon etiology of upper GI bleeding. This report can be used to emphasize the importance of following the PEG tube manufacturers recommendations and exercise proper technique and caution.Figure: Internal balloon of PEG appeared to be overinflated and compressing the stomach wall in area of ulcer.

Cytosponge for Histologic Response to Therapy in Eosinophilic Esophagitis

As symptoms do not consistently correlate with histologic response to treatment of eosinophilic esophagitis (EoE), repeat endoscopy and biopsies are

Lack of Mucosal Healing From Modified Specific Carbohydrate Diet in Pediatric Patients With Crohn Disease.

Exclusive enteral nutrition is effective in pediatric Crohn disease but challenging as maintenance therapy. There is interest in food-based therapies such as the specific carbohydrate diet (SCD) but paucity of data on efficacy and effect on mucosal healing, an evolving target of IBD therapy. We conducted a retrospective review of the mucosal healing effect of the SCD in pediatric Crohn disease (CD). The endoscopic findings for children younger than 18 years with CD treated exclusively with the SCD or modified SCD (mSCD; SCD + addition of "illegal foods") were reviewed before and after the diet. Ileocolonoscopic examinations were scored according to the Simple Endoscopic Score for CD and findings on upper endoscopy were described. Seven subjects were identified, all on mSCD. The average age at starting the SCD was 11 ± 3.4 years and median duration of SCD/mSCD therapy was 26 months. All subjects reported no active symptoms before repeat endoscopic evaluation on mSCD, the majority had consistently normal C-reactive protein, albumin and hematocrit assessments, and mildly elevated fecal calprotectin (>50 μg/g, median 201, range 65-312) at any point within 3 months before the repeat endoscopy. One patient showed complete ileocolonic healing but persistent upper gastrointestinal tract ulceration. Complete macroscopic mucosal healing of both the ileocolon and upper gastrointestinal tract was not seen in any patient.

EUS-guided drainage of postsurgical fluid collections using lumen-apposing metal stents: a multicenter study

Postsurgical fluid collections (PSFCs) are traditionally drained either percutaneously or surgically. Endoscopic drainage offers several advantages compared with either percutaneous or surgical approaches, including avoiding repeat surgery or the need to have a percutaneous drain in place for weeks. There are very little data regarding the use of lumen-apposing metal stents (LAMSs) in the drainage of PSFCs. We aim to study the technical and clinical success and adverse events (AEs) of using LAMSs in the drainage of PSFCs. Collaborators from 8 centers retrospectively reviewed their endoscopic databases to find procedures using LAMSs for drainage of PSFCs. Technical success (successful placement of LAMSs into the fluid collection), clinical success (complete resolution of the fluid collection on repeat imaging or endoscopy), and intraprocedure and postprocedure AEs were measured. Forty-seven patients were identified with PSFCs after various surgeries. Thirteen patients had failed previous percutaneous or surgical drainage attempts. Fluid collections averaged 78.6mm (range, 47-150mm) in size. The most common site of stent placement was transgastric, followed by rectum and duodenum. Technical success rate was 93.6% and clinical success rate 89.3%. The intraprocedural AE rate was 4.25% and postprocedural AE rate 6.4%. There was 1 death unrelated to the procedure. The use of LAMSs to drain PSFCs has a high technical and clinical success rate with low AEs. For collections that are favorably located adjacent to the stomach, duodenum, or rectum, LAMS placement is a viable alternative to repeat surgery or percutaneous drainage.

Application of a multi-gene next-generation sequencing panel to a non-invasive oesophageal cell-sampling device to diagnose dysplastic Barrett's oesophagus.

The early detection and endoscopic treatment of patients with the dysplastic stage of Barrett's oesophagus is a key to preventing progression to oesophageal adenocarcinoma. However, endoscopic surveillance protocols are hampered by the invasiveness of repeat endoscopy, sampling bias, and a subjective histopathological diagnosis of dysplasia. In this case‐control study, we investigated the use of a non‐invasive, pan‐oesophageal cell‐sampling device, the Cytosponge™, coupled with a cancer hot‐spot panel to identify patients with dysplastic Barrett's oesophagus. Formalin‐fixed, paraffin‐embedded (FFPE) Cytosponge™ samples from 31 patients with non‐dysplastic and 28 with dysplastic Barrett's oesophagus with good available clinical annotation were selected for inclusion. Samples were microdissected and amplicon sequencing performed using a panel covering >2800 COSMIC hot‐spot mutations in 50 oncogenes and tumour suppressor genes. Strict mutation criteria were determined and duplicates were run to confirm any mutations with an allele frequency <12%. When compared with endoscopy and biopsy as the gold standard the panel achieved a 71.4% sensitivity (95% CI 51.3–86.8) and 90.3% (95% CI 74.3–98.0) specificity for diagnosing dysplasia. TP53 had the highest rate of mutation in 14/28 dysplastic samples (50%). CDKN2A was mutated in 6/28 (21.4%), ERBB2 in 3/28 (10.7%), and 5 other genes at lower frequency. The only gene from this panel found to be mutated in the non‐dysplastic cases was CDKN2A in 3/31 cases (9.7%) in keeping with its known loss early in the natural history of the disease. Hence, it is possible to apply a multi‐gene cancer hot‐spot panel and next‐generation sequencing to microdissected, FFPE samples collected by the Cytosponge™, in order to distinguish non‐dysplastic from dysplastic Barrett's oesophagus. Further work is required to maximize the panel sensitivity.

Regional Variability of Repeat Esophagogastroduodenoscopy Use in the National Veteran Population.

Esophagogastroduodenoscopy (EGD) procedures are performed frequently to evaluate gastrointestinal disease and symptoms. To determine regional practice variability of repeat EGDs in a national population. The study sample included US Veterans with an outpatient index EGD from 1/1/2008 to 12/2010. We determined risk of repeat endoscopy from 1/2008 to 10/1/2014. A logistic regression model was used to assess the association between the odds of repeated EGD and patient demographics, ICD diagnostic codes, and geographic region. Multivariable logistic regression was performed to obtain the adjusted odds ratio and predicted probabilities of repeat EGDs by region. A total of 202,086 patients had an index endoscopy from 1/2008 to 12/2010. Unique patients with an index endoscopy were predominantly male (93.2%), white (72.8%), and on average 61years. A total of 58,469 patients (28.9%) had one or more repeat EGDs, accounting for 103,253 repeat procedures through 10/2014. ICD-9-CM codes associated with increased risk of repeat procedures were Barrett's esophagus (OR 3.6, 95% CI 3.5-3.7), dysphagia (OR 1.3, 95% CI 1.2-1.3), ulcer (OR 1.3, 95% CI 2.2-2.4), stricture (OR 1.8, 95% CI 1.7-1.9), and esophageal varices (OR 2.8, 95% CI 2.7-3.0). There was a significant difference in the probability of repeat EGD by VA region, with the Midwest region having the highest probability (31.2%) and Southeast the lowest probability (27.3%). This difference would account for 400 more EGD procedures per 10,000 Veterans, after adjusting for patient demographics and diagnosis codes. Regional practice variability accounts for a substantial volume of repeat EGD procedures, regardless of patient characteristics and associated diagnoses.

Post-polypectomy bleeding in the English National Health Service Bowel Cancer Screening Programme.

Background and study aims Colonoscopic polypectomy reduces colorectal cancer incidence, but is associated with complications including post-polypectomy bleeding (PPB). PPB ranges in severity from minor to life-threatening, making interpretation and comparison difficult. No previous studies have examined PPB rate according to a standardized severity grading system. We aimed to determine the PPB rate stratified by severity grading, explore factors that contribute to PPB severity grading, and describe PPB management. Methods Data relating to PPB were prospectively collected from all colonoscopies performed in one region of the English NHS Bowel Cancer Screening Programme (BCSP) from 06/12/2010 to 15/07/2014. PPB was defined and stratified into major, intermediate, and minor according to BCSP standardized definitions based on the American Society for Gastrointestinal Endoscopy adverse events lexicon. Results A total of 15 285 colonoscopies (23 766 polypectomies) were analyzed. The PPB rate per colonoscopy was 0.44 % (95 % confidence interval [CI] 0.34 - 0.54) and the rate per polypectomy was 0.29 % (95 %CI 0.20 - 0.38); 2.9 % of PPBs were major and 42.6 % were intermediate. Repeat endoscopy occurred in 27.9 % and was the most common reason for bleeding being categorized as of intermediate severity, although therapy was applied in only 36.8 % of these cases. A therapeutic intervention was significantly more common in patients with PPB who had either a hemoglobin drop ≥ 2 g/dL and/or a blood transfusion (P = 0.04, relative risk 3.47, 95 %CI 1.05 - 11.52). Conclusions This study specifically examined colonoscopic PPB rate, stratified using standardized criteria. The rates of PPB were low, with the majority of PPB being of minor severity. Current stratification of PPB severity combines measures of bleed severity with interventions. Using only hemoglobin drop ≥ 2 g/dL and/or blood transfusion as markers of PPB severity may simplify stratification, and allow a better assessment of the necessity and impact of an intervention.

Endoscopic management of erosion after banded bariatric procedures

BackgroundProsthetic materials wrapped around a portion of the stomach have been used to provide gastric restriction in bariatric surgery for many years. Intraluminal erosion of adjustable and nonadjustable gastric bands typically occurs many years after placement and results in various symptoms. Endoscopic management of gastric band erosion has been described and allows for optimal patient outcomes. ObjectivesWe will describe our methods and experience with endoscopic management of intraluminal gastric band erosions after bariatric procedures. SettingUniversity hospital in the United States. MethodsA retrospective review of our bariatric surgery database identified patients undergoing removal of gastric bands. A chart review was then undertaken to confirm erosion of prosthetic material into the gastrointestinal tract. Baseline characteristics, operative reports, and follow-up data were analyzed. ResultsSixteen patients were identified with an eroded gastric band: 11 after banded gastric bypass, 3 after laparoscopic adjustable gastric band (LAGB), and 2 after vertical banded gastroplasty. All patients were successfully treated with endoscopic removal of the prosthetic materials using either endoscopic scissors or ligation of the banding material with off-label use of a mechanical lithotripter device. Complications included a postoperative gastrointestinal bleed requiring repeat endoscopy, 1 patient with asymptomatic pneumoperitoneum requiring observation, and 1 with seroma at the site of LAGB port removal. ConclusionsEndoscopic management of intraluminal prosthetic erosion after gastric banded bariatric procedures can be safe and effective and should be considered when treating this complication. Erosion of the prosthetic materials inside the gastric lumen allows for potential endoscopic removal without free intraabdominal perforation. Endoscopic devices designed for dividing eroded LAGBs may help standardize and increase utilization of this approach.

Burden of Disease for Urethral Stricture Managed by Repeat Endoscopic Treatment vs Single Endoscopic Treatment or Urethroplasty in the Veterans Affairs Population

IntroductionMale urethral stricture disease is a challenging urological condition that affects nearly a third of men 65 years old or older. Management options include dilation and urethrotomy as well as urethroplasty, an open approach with increased morbidity and durability. Presently optimal management remains debated. In this study we focus on emergent procedures required by male patients in the Veterans Health Administration after stricture treatment as an indicator of clinically significant complications, comparing treatment approaches. MethodsWe performed an institutional review board approved, retrospective, cohort study of male veterans with urethral stricture from 2005 to 2014. Our independent variable was immediate or delayed urethroplasty or continued endoscopic treatments. Our dependent variable was a stricture related procedure performed in the emergent or urgent care setting. We used a binary logistic regression model to model the likelihood of an adverse outcome as predicted by treatment type. ResultsIn our cohort of 9,632 patients 1.8% underwent immediate urethroplasty and 3% underwent delayed urethroplasty. Of the operated men 5.3% had an adverse outcome (5% following delayed urethroplasty or continued endoscopic treatments and 1% after immediate urethroplasty, p = 0.04). On multivariate analysis repeat endoscopy and delayed urethroplasty trended toward worsening odds of adverse outcomes (p = 0.07 and p = 0.08, respectively). ConclusionsIn the Veterans Health Administration system men who undergo repeated scheduled endoscopic treatments for urethral stricture may be at increased risk for emergent procedures, even if they eventually progress to urethroplasty, compared to men who undergo urethroplasty immediately after a failed endoscopic intervention.

Effect of scheduled second-look endoscopy on peptic ulcer bleeding: a prospective randomized multicenter trial

This study aimed to investigate the effectiveness of scheduled second-look endoscopy (EGD) with endoscopic hemostasis on peptic ulcer rebleeding and to identify the risk factors related to the need for second-look EGD. We prospectively randomized patients who had endoscopically confirmed bleeding peptic ulcer with stigmata of active bleeding, visible vessel, or adherent clot into 2 groups between August 2010 and January 2013. Hemoclip application or thermal coagulation and/or epinephrine injection were allowed for initial endoscopic therapy. The same dosage of proton pump inhibitor was injected intravenously. The study group received scheduled second-look EGD 24 to 36 hours after the initial hemostasis, and further therapy was applied if endoscopic stigmata persisted, as above. Those patients who developed rebleeding underwent operation or radiologic intervention despite the additional endoscopic therapy. Outcome measures included rebleeding, amount of transfusion, duration of hospitalization, and mortality. After initial endoscopic hemostasis, 319 eligible patients were randomized into 2 groups. Sixteen(10.1%) and 9 (5.6%) patients developed rebleeding (P= .132), respectively. There was also no difference in surgical intervention (0, 0% vs 1, .6%, P >.999) or radiologic intervention (3, 1.9% vs 2, 1.2%, P= .683), median duration of hospitalization (6.0 vs 5.0 days, P= .151), amount of transfusion (2.4±1.7 vs 2.2 ± 1.6 units, P= .276), and mortality (2, 1.3% vs 2, 1.2%, P > .999) between the 2 groups. Multivariate analysis showed that grades 3 to 4 of endoscopists' estimation to success of initial hemostasis, history of nonsteroidal anti-inflammatory drug (NSAID) use, and larger amounts of blood transfusions (≥4units of red blood cells) were the independent risk factors of rebleeding. A single EGD with endoscopic hemostasis is not inferior to scheduled second-look endoscopyin terms of reduction in rebleeding rate of peptic ulcer bleeding. Repeat endoscopy would be helpful in the patients with unsatisfactory initial endoscopic hemostasis, use of NSAIDs, and larger amounts of transfused blood. (Clinical trial registration number: KCT0000565; 4-2010-0348.).

EUS-guided drainage of peripancreatic fluid collections with lumen-apposing metal stents and plastic double-pigtail stents: comparison of efficacy and adverse event rates

Transmural drainage with double-pigtail plastic stents (DPPSs) was the mainstay of endoscopic therapy for symptomatic peripancreatic fluid collections (PPFCs) until the introduction of lumen-apposing covered self-expanding metal stents (LAMSs). Currently, there are limited data regarding the efficacy and adverse event rate of LAMSs compared with DPPSs. A retrospective analysis of EUS-guided PPFC drainage at a single tertiary care center between 2008 and 2015 was performed. Patients were classified based on drainage method: DPPSs and LAMSs. Adverse event rates, unplanned endoscopic procedures/necrosectomies, and PPFC resolution within 6 months were recorded. Significant bleeding was defined as necessitating transfusion or requiring endoscopic treatment/radiographic embolization. Subsequent endoscopic procedures were defined as unplanned procedures; stent removals were excluded. A total of 103 patients met inclusion criteria (84 DPPSs, 19 LAMSs). PPFCs were classified as walled-off necrosis (WON) in 23 (14 DPPSs, 9 LAMSs). There were significantly more bleeding episodes in the LAMS group (4 [19%]: 2 splenic artery pseudo-aneurysms, 1 collateral vessel bleed, 1 intracavitary variceal bleed; P= .0003) than in the DPPS group (1 (1%]: stent erosion into the gastric wall). One perforation occurred in the DPPS group.Unplanned repeat endoscopy was more frequent in the LAMS group (10% vs 26%, P= .07). Among retreated LAMS patients in with WON, 5 (56%) had obstruction by necrotic debris. In patients for whom follow-up was available, 67 of 70 (96%) with DPPSs and 16 of 17 (94%) with LAMSs had resolution of PPFCs within 6 months (P= .78). DPPSs and LAMSs are effective methods for treatment of PPFCs. In our cohort, use of LAMSs was associated with significantly higher rates of procedure-related bleeding and greater need for repeat endoscopic intervention.

Bouveret Syndrome Missed by a Whisker: A Case Report

Background: Gallstones ileus is a rare cause of intestinal obstruction secondary to gall stone causing bilioenteric fistula. The stone commonly lodges in the distal ileum, colon or duodenum and the least common site of obstruction is the proximal duodenum/pylorus causing gastric outlet obstruction (Bouveret's syndrome). We present a case of endoscopic removal of a large gallstone impacted in the first part of duodenum. Case summary: A 61-year-old male patient, presented with symptomatic choledocholithiasis and cholelithiasis. He underwent ERC, sphincterotomy, bile duct clearence and stenting 3 months back. He was planned for cholecystectomy. Laparoscopy could not separate gall bladder from its fossa and was converted to open surgery. But open cholecystectomy was abandoned in view of dense adhesions and adherent gall bladder. He had nausea and epigastic pain for 2 weeks without jaundice or vomitting or constipation. Endoscopy was performed which showed a large cholecystoduodenal fistula on the posterior wall of first part of duodenum. Endoscopic stone retrival was attempted but failed inspite of use of snare forceps/roth net forceps. He was admitted for evaluation and reattempt under anaesthesia. He had routine blood investigations which were normal. MRCP abdomen was done which showed contracted gall bladder with calculi and wall thickening, adhered to duodenum with perilesional lymphnode. Repeat endoscopy was attempted under general anaesthesia and the stone was retrieved peicemeal using roth net forceps and basket. Conclusion: Endoscopic stone retrieval can be attempted in cases of large cholecystoduodenal fistula. The authors have none to declare.

Efficacy of a 4-Food Elimination Diet for Children With Eosinophilic Esophagitis

A 6-food elimination diet induces remission in most children and adults with eosinophilic esophagitis (EoE). The effectiveness of empiric elimination of only 4 foods has not been studied in children. We performed a prospective observational outcome study in children with EoE treated with dietary exclusion of cow's milk, wheat, egg, and soy. The objective was to assess the clinical, endoscopic, and histologic efficacy of this treatment in EoE. We recruited children (1-18 years old, diagnosed per consensus guidelines) from 4 medical centers. Study participants (n= 78) were given a proton pump inhibitor twice daily and underwent a baseline esophagogastroduodenoscopy. Subjects were instructed on dietary exclusion of cow's milk, wheat, egg, and soy. Clinical, endoscopic, and histologic assessments were made after 8 weeks. Responders had single foods reintroduced for 8 weeks, with repeat endoscopy to assess for recurrence of active disease. The primary endpoint was histologic remission (fewer than 15 eosinophils per high-powered field). Secondary endpoints included symptom and endoscopic improvements and identification of foods associated with active histologic disease. After 8 weeks on 4-food elimination diet, 50 subjects were in histologic remission (64%). The subjects' mean baseline clinical symptoms score was 4.5, which decreased to 2.3 after 8 weeks of 4-food elimination diet (P < .001). The mean endoscopic baseline score was 2.1, which decreased to 1.3 (P < .001). After food reintroduction, the most common food triggers that induced histologic inflammation were cow's milk (85%), egg (35%), wheat (33%), and soy (19%). One food trigger that induced recurrence of esophageal inflammation was identified in 62% of patients and cow's milk-induced EoE was present in 88% of these patients. In a prospective study of children with EoE, 8 weeks of 4-food elimination diet induced clinical, endoscopic, and histologic remission in more than 60% of children with EoE. Although less restrictive than 6-food elimination diet, 4-food elimination diet was nearly as effective, and can be recommended as a treatment for children with EoE.

Sa1220 Repeat Endoscopy for Diarrhea, Constipation and Dysphagia Is Low Yield and Unlikely to Change Diagnosis or Management

Sa1220 Repeat Endoscopy for Diarrhea, Constipation and Dysphagia Is Low Yield and Unlikely to Change Diagnosis or Management

The clinical and cost implications of failed endoscopic hemostasis in gastroduodenal ulcer bleeding.

The aim of this article is to evaluate the clinical and cost implications of failed endoscopic hemostasis in patients with gastroduodenal ulcer bleeding. A retrospective claims analysis of the Medicare Provider Analysis and Review (MedPAR) file was conducted to identify all hospitalizations for gastroduodenal ulcer bleeding in the year 2012. The main outcome measures were to compare all-cause mortality, total length of hospital stay (LOS), hospital costs and payment between patients managed with one upper gastrointestinal (UGI) endoscopy versus more than one UGI endoscopy or requiring interventional radiology-guided hemostasis (IRH) or surgery after failed endoscopic attempt. The MedPAR claims data evaluated 13,501 hospitalizations, of which 12,242 (90.6%) reported one UGI endoscopy, 817 (6.05%) reported >1 UGI endoscopy, 303 (2.24%) reported IRH after failed endoscopy and 139 (1.03%) reported surgeries after failed endoscopy. All cause-mortality was significantly lower for patients who underwent only one UGI endoscopy (3%) compared to patients requiring >1 endoscopy (6%), IRH (9%) or surgery (14%), p < 0.0001. The median LOS was significantly lower for patients who underwent only one UGI endoscopy (four days) compared to patients requiring >1 endoscopy (eight days), IRH (nine days) or surgery (15 days), p < 0.0001. The median hospital costs were significantly lower for patients who underwent one UGI endoscopy ($10,518) compared to patients requiring >1 endoscopy ($20,055), IRH ($34,730) or surgery ($47,589), p < 0.0001. Failure to achieve hemostasis at the index endoscopy has significant clinical and cost implications. When feasible, a repeat endoscopy must be attempted followed by IRH. Surgery should preferably be reserved as a last resort for patients who fail other treatment measures.

Terlipressin Administered Only Prior To Endoscopic Therapy in The Management of Bleeding Esophageal Varices Does Not Increase the Risk of Re-bleeding Compared to Standard 3-5 Days Regime

Background & Aims: Terlipressin is recommended therapy for 3-5 days in esophageal variceal bleeding. The aim of this study was to determine the feasibility of administering terlipressin only prior to band ligation. Methods: Patients with esophageal variceal bleeding received terlipressin 2mg intravenous bolus followed by 1mg 6 hourly until undergoing endoscopic band ligation. They were monitored for re-bleeding for 5 days. Results: 67 patients, 38 (57%) male and 29 (43%) female, mean age 50+4 years, received terlipressin until undergoing endoscopic band-ligation. Etiology of liver disease was HCV in 62 (92.5%), HBV & HCV in 2 (3%), HCV & ethanol in 2 (3%) and unknown in 1 (1.5%) patient. 13 (19%) patients underwent band ligation after a single 2 mg dose of terlipressin, 16 (24%) after two doses (6 hours therapy), 11 (16%) after 3 (12 hours therapy), 6 (9%) after 4 (18 hours therapy), 6 (9%) after 5 doses (24 hours therapy) and 15 (22%) after more than 24 hours therapy. Banding was done within 12 hours in 40 (60%) patients and within 24 hours in 12 (18%) patients. Endoscopy was delayed beyond 24 hours in 15 (22%) patients due to Sengstaken-Blakemore tube placement, encephalopathy and blood transfusion requirements. 3 (4.9%) patients had rebleeding. Repeat endoscopy showed post-banding ulcers in 2 patients (managed with I.V omeprazole and oral sucralfate). One patient had varices with red signs requiring repeat band ligation. Two patients died due to hepatorenal syndrome and persistent encephalopathy. No drug related adverse effects were noted. Conclusion: Once band-ligation has been performed, terlipressin may be safely discontinued. This can result in reduction in cost of treatment with no significant increase in morbidity and mortality.

T-cell repertoires in refractory coeliac disease

ObjectiveRefractory coeliac disease (RCD) is a potentially hazardous complication of coeliac disease (CD). In contrast to RCD type I, RCD type II is a precursor entity of enteropathy-associated T-cell lymphoma...

A Tissue Systems Pathology Test Detects Abnormalities Associated with Prevalent High-Grade Dysplasia and Esophageal Cancer in Barrett's Esophagus.

There is a need for improved tools to detect high-grade dysplasia (HGD) and esophageal adenocarcinoma (EAC) in patients with Barrett's esophagus. In previous work, we demonstrated that a 3-tier classifier predicted risk of incident progression in Barrett's esophagus. Our aim was to determine whether this risk classifier could detect a field effect in nondysplastic (ND), indefinite for dysplasia (IND), or low-grade dysplasia (LGD) biopsies from Barrett's esophagus patients with prevalent HGD/EAC. We performed a multi-institutional case-control study to evaluate a previously developed risk classifier that is based upon quantitative image features derived from 9 biomarkers and morphology, and predicts risk for HGD/EAC in Barrett's esophagus patients. The risk classifier was evaluated in ND, IND, and LGD biopsies from Barrett's esophagus patients diagnosed with HGD/EAC on repeat endoscopy (prevalent cases, n = 30, median time to HGD/EAC diagnosis 140.5 days) and nonprogressors (controls, n = 145, median HGD/EAC-free surveillance time 2,015 days). The risk classifier stratified prevalent cases and non-progressor patients into low-, intermediate-, and high-risk classes [OR, 46.0; 95% confidence interval, 14.86-169 (high-risk vs. low-risk); P < 0.0001]. The classifier also provided independent prognostic information that outperformed the subspecialist and generalist diagnosis. A tissue systems pathology test better predicts prevalent HGD/EAC in Barrett's esophagus patients than pathologic variables. The results indicate that molecular and cellular changes associated with malignant transformation in Barrett's esophagus may be detectable as a field effect using the test. A tissue systems pathology test may provide an objective method to facilitate earlier identification of Barrett's esophagus patients requiring therapeutic intervention. Cancer Epidemiol Biomarkers Prev; 26(2); 240-8. ©2016 AACR.

Value of IgA tTG in Predicting Mucosal Recovery in Children With Celiac Disease on a Gluten-Free Diet.

Our objective was to determine the rate of mucosal recovery in pediatric patients with celiac disease on a gluten-free diet. We also sought to determine whether immunoglobulin A tissue transglutaminase (tTG) correlates with mucosal damage at the time of a repeat endoscopy with duodenal biopsy in these patients. We performed a retrospective chart review of 103 pediatric patients, younger than 21 years, with a diagnosis of celiac disease defined as Marsh 3 histology, and who underwent a repeat endoscopy with duodenal biopsy at least 12 months after initiating a gluten-free diet. We found that 19% of pediatric patients treated with a gluten-free diet had persistent enteropathy. At the time of the repeat biopsy, tTG was elevated in 43% of cases with persistent enteropathy and 32% of cases in which there was mucosal recovery. Overall the positive predictive value of the autoantibody tTG was 25% and the negative predictive value was 83% in patients on a gluten-free diet for a median of 2.4 years. Nearly 1 in 5 children with celiac disease in our population had persistent enteropathy despite maintaining a gluten-free diet and immunoglobulin A tTG was not an accurate marker of mucosal recovery. Neither the presence of symptoms nor positive serology were predictive of a patient's histology at the time of repeat biopsy. These findings suggest a revisitation of monitring and management criteria of celiac disease in childhood.