Routine Esophagogastroduodenoscopy Research Articles

The Effect of Esophagogastroduodenoscopy on Intraocular Pressure.

Esophagogastroduodenoscopy (EGD) is an endoscopic examination of the upper gastrointestinal tract that requires insufflation with gas, leading to intra-abdominal hypertension (IAH). There is evidence suggesting that IAH positively correlates with intracranial pressure (ICP) and possibly with intraocular pressure (IOP). The aim of this study was to examine the effect of a routine screening EGD on the IOP. In this observational study, 25 patients were recruited; 15 males with a mean age of 50 ± 18 years and 10 females with a mean age of 45 ± 14 years. EGD was conducted under sedation in 21 subjects. Both eyes' IOP measurements were performed using Tonopen Avia in the sitting and left lateral decubitus positions before sedation and the start of EGD, and subsequently in the left lateral decubitus position when the endoscope reached the duodenum (D2) and at the end of the procedure. The final measurement was performed in the sitting position 10 min after the end of the procedure. The mean IOP in the sitting position was 15.16 ± 2.27 mmHg, and in the left lateral decubitus position, 15.68 ± 2.82 mmHg. When the gastroscope entered the D2, it was 21.84 ± 6.55 mmHg, at the end of the procedure, 15.80 ± 3.25 mmHg, and 10 min later, 13.12 ± 3.63 mmHg. There was a statistically significant IOP increase when the gastroscope entered the duodenum (p < 0.01). At the end of the gastroscopy, the IOP significantly decreased compared to the one registered when the gastroscope entered the D2 (p < 0.001) and it became similar to the values measured before the EGD, in the same left lateral decubitus position (p > 0.05). Significant changes in IOP were observed during the EGD. IOP fluctuations during EGD should be taken into account, especially in patients that need repeated EGDs during their life or in patients with glaucoma. Further studies are needed to better understand the short-effect and long-effect influence of an IOP increase in these patients.

S1412 Reconsidering the Diagnostic Yield of Routine Esophagogastroduodenoscopy Prior to Transesophageal Echocardiography in Patients With Cirrhosis

S1412 Reconsidering the Diagnostic Yield of Routine Esophagogastroduodenoscopy Prior to Transesophageal Echocardiography in Patients With Cirrhosis

GERD-screening before bariatric surgery: the predictive value of the GERD-HRQL questionnaire score compared with preoperative EGD findings.

There is an ongoing debate on how to best identify patients with gastroesophageal reflux disease (GERD) before bariatric surgery. The value of routine preoperative esophagogastroduodenoscopy (EGD) is questioned, and patient reported symptoms are commonly used for screening. The goal of this study is to determine if patient reported symptoms using a validated questionnaire correlate with preoperative EGD findings. A prospective cohort study at a single institution was performed. Patients undergoing bariatric surgery between December 2020 and March 2023 were required to report symptoms of reflux by completing a preoperative GERD. Health-Related Quality of Life (GERD-HRQL) questionnaire and undergo a mandatory preoperative screening EGD. Patients were stratified into two cohorts: (group A) asymptomatic (score = 0) and (group B) symptomatic (score > 0). Statistical analysis was conducted using Pearson's chi-squared test and Wilcoxon rank-sum test in RStudio version 4.2.2. The predictive value of the GERD-HRQL score was analyzed using Areas Under the Curve (AUC; AUC = 0.5 not predictive, 0.5 < AUC ≥ 6 poor prediction & AUC > 0.9 excellent prediction) calculated from Receiver Operating Characteristic (ROC) curves. 200 patients were included; median age was 42.0years (IQR 36.0 to 49.2). There were 79 patients (39.5%) in Group A and 121 patients (60.5%) in Group B. There was no difference in the frequency esophagitis (27.8% vs 32.2%, p = 0.61) or hiatal hernias (49.4% vs 47.1%, p = 0. 867) between group A and group B, respectively. ROC analysis revealed that the total GERD HRQL scores, heartburn only scores and regurgitation only scores, were poor predictors of esophagitis found on EGD (AUC 0.52, 0.53, 0.52), respectively. In asymptomatic patients, higher BMI was significantly associated with esophagitis (OR 1.15, 95% CI 1.06-1.27, p = 0.002). Symptoms, identified through the GERD-HRQL questionnaire, are a poor indicator of esophagitis or its severity in patients undergoing workup for bariatric surgery. Therefore, liberal screening upper endoscopy is recommended for pre-bariatric surgery patients to guide appropriate procedure selection.

The effectiveness of a computer-aided system in improving the detection rate of gastric neoplasm and early gastric cancer: study protocol for a multi-centre, randomized controlled trial

BackgroundThis protocol is for a multi-centre randomised controlled trial to determine whether the computer-aided system ENDOANGEL-GC improves the detection rates of gastric neoplasms and early gastric cancer (EGC) in routine oesophagogastroduodenoscopy (EGD).MethodsStudy design: Prospective, single-blind, parallel-group, multi-centre randomised controlled trial.Settings: The computer-aided system ENDOANGEL-GC was used to monitor blind spots, detect gastric abnormalities, and identify gastric neoplasms during EGD.Participants: Adults who underwent screening, diagnosis, or surveillance EGD.Randomisation groups:1. Experiment group, EGD examinations with the assistance of the ENDOANGEL-GC;2. Control group, EGD examinations without the assistance of the ENDOANGEL-GC.Randomisation: Block randomisation, stratified by centre.Primary outcomes: Detection rates of gastric neoplasms and EGC.Secondary outcomes: Detection rate of premalignant gastric lesions, biopsy rate, observation time, and number of blind spots on EGD.Blinding: Outcomes are undertaken by blinded assessors.Sample size: Based on the previously published findings and our pilot study, the detection rate of gastric neoplasms in the control group is estimated to be 2.5%, and that of the experimental group is expected to be 4.0%. With a two-sided α level of 0.05 and power of 80%, allowing for a 10% drop-out rate, the sample size is calculated as 4858. The detection rate of EGC in the control group is estimated to be 20%, and that of the experiment group is expected to be 35%. With a two-sided α level of 0.05 and power of 80%, a total of 270 cases of gastric cancer are needed. Assuming the proportion of gastric cancer to be 1% in patients undergoing EGD and allowing for a 10% dropout rate, the sample size is calculated as 30,000. Considering the larger sample size calculated from the two primary endpoints, the required sample size is determined to be 30,000.DiscussionThe results of this trial will help determine the effectiveness of the ENDOANGEL-GC in clinical settings.Trial registrationChiCTR (Chinese Clinical Trial Registry), ChiCTR2100054449, registered 17 December 2021.

AB-452654-1 ESOPHAGEAL PROTECTION STRATEGIES FOR ABLATION OF ATRIAL FIBRILLATION: COMPARATIVE RESULTS BASED ON CONSECUTIVE ENDOSCOPIC EVALUATION

Catheter ablation is an effective treatment for restoring sinus rhythm in AF and has become a worldwide procedure. Although rare, atrioesophageal fistula (AEF) is among the most common lethal complications of this procedure. Several strategies have been employed to prevent esophageal lesions, including single and multi-sensor esophageal probes, different energy strategies, esophageal displacement and regular esophageal monitoring using esophagogastroduodenoscopy (EGD) to identify asymptomatic esophageal lesions that could evolve to AEF. As the occurrence of AEF is rare, one of the approaches to evaluate which strategy is more effective in preventing esophageal lesions is studying the incidence of asymptomatic on routine endoscopy. The objective of this study is to present the five-year experience of a systematic endoscopic surveillance of esophageal injury after AF catheter ablation and analyse if there is an appropriate strategy related to a lower incidence of lesions. This is a retrospective single center registry of all AF ablation procedures performed from 2016 to 2021, in which an endoscopy was performed after ablation in all cases. A total of 660 AF ablation procedures in 626 different patients were performed in that period. A control EGD data could be recorded in 609 ablation procedures (92,3%). Most of the patients were male with paroxysmal AF. Esophageal temperature monitoring with single Sensor Probe was performed in 48.4% and with multi–sensor probe in 24.4% of the cases. Most of the patients presented no esophageal lesions (71.8%). Mild lesion was found on 90 patients (14.8%) and severe lesion was found on 56 (9.2%) of them. The use of multisensor esophageal probe (P<0.001), male gender (P=0.007) and the use of PVAC (P=0.018) were correlated with less frequent thermal lesions on multivariate analysis. Most of the lesions were healed on control endoscopy. The incidence of esophageal lesions on routine EGD after AF catheter ablation is high, but most of the cases the lesion is spontaneously healed. The use of multisensor probe, PVAC and male gender were correlated to fewer thermal lesions.

Publication of "Evidence-based Guidebook of Routine Esophagogastroduodenoscopy" for Standardization of Upper Gastrointestinal Endoscopy

Publication of "Evidence-based Guidebook of Routine Esophagogastroduodenoscopy" for Standardization of Upper Gastrointestinal Endoscopy

An interpretable artificial neural network model for predicting hypoxemia via an online tool in adult (18-64) patients during esophagogastroduodenoscopy.

The hypoxemia risk in adult (18-64) patients treated with esophagogastroduodenoscopy (EGD) under sedation often poses a dilemma for anesthesiologists. We aimed to establish an artificial neural network (ANN) model to solve this problem, and introduce the Shapley additive explanations (SHAP) algorithm to further improve the interpretability. The relevant data of patients underwent routine anesthesia-assisted EGD were collected. Elastic network was used to filter the optimal features. Airway-ANN and Basic-ANN models were established based on all collected indicators and remaining variables excluding airway assessment indicators, respectively. The performance of Basic-ANN, Airway-ANN and STOP-BANG was evaluated by the area under the precision-recall curve (AUPRC) on temporal validation set. The SHAP was used for revealing the predictive behavior of our best model. 999 patients were eventually included. The AUPRC value of Airway-ANN model was significantly higher than Basic-ANN model in the temporal validation set (0.532 vs 0.429, P < 0.05). And the performance of both two ANN models was significantly better than that of STOP-BANG score (both P < 0.05). The Airway-ANN model was deployed to the cloud (http://njfh-yxb.com.cn:2022/airway_ann). Our online interpretable Airway-ANN model achieved satisfying ability in identifying the hypoxemia risk in adult (18-64) patients undergoing EGD.

Endoscopic Endolooping for giant Brunner’s gland adenoma

Brunner's gland adenoma (BGA) is a rare benign tumor of the duodenum, it is most found during routine esophagogastroduodenoscopy (EGD). a 52-year-old male patient presented with melena and severe anemia, EGD showed a large wide base polypoidal lesion arise from the anterior wall of duodenal bulb, biopsy taken by biopsy forceps, revealed BGA. After patient's consent, EGD and Endolooping done aiming for ischemia and autoamputation, 2 weeks later I repeat EGD with complete loss of duodenal lesion, we report this technique for the first time to treat large BGA.

Prevalence and risk factors for Candida esophagitis among human immunodeficiency virus-negative individuals.

Candida esophagitis (CE) is among the commonest esophageal infections and is known as an opportunistic fungal infection mostly affecting people living with the human immunodeficiency virus (HIV). However, some medical conditions might predispose HIV-negative individuals to esophageal candidiasis. The epidemiology and associated endoscopic findings of CE among people without HIV have rarely been reported. To investigate the prevalence of CE among HIV-negative persons, and determine risk factors predicting CE. Between January 2015 and December 2018, all consecutive outpatients who underwent routine esophagogastroduodenoscopy as part of health check-ups at their own expense at the Health Check-up Center of the Kaohsiung Veterans General Hospital, Taiwan, were recruited in this study. Those with positive HIV serology results were excluded. Sociodemographic and clinical characteristics including age, gender, economic status, smoking history, alcohol consumption, tea and coffee consumption, underlying diseases, body fat percentage, body mass index, endoscopic findings, and Helicobacter pylori infection status were carefully reviewed. CE was confirmed by endoscopic biopsy and pathological assessment with hematoxylin and eosin and periodic acid-Schiff staining. To evaluate independent factors predicting the development of CE, we conducted a univariate analysis of clinical characteristics. The variables found to be significant via univariate analysis were subsequently included in a multivariable analysis of potential risk factors for CE development. A total of 11802 participants were included in this study. Forty-seven (0.4%) were confirmed as having CE by pathological examination. Univariate analysis identified older age, the presence of chronic kidney disease, alcohol consumption, and steroid use (P = 0.023, < 0.001, 0.033, and 0.004, respectively) as significantly associated with CE. Multivariable analysis revealed older age [adjusted odds ratio (OR) = 1.027; 95%CI: 1.001-1.053; P = 0.045], chronic kidney disease (adjusted OR = 13.470; 95%CI: 4.574-39.673; P < 0.001), alcohol consumption (adjusted OR = 2.103; 95%CI: 1.151-3.844; P = 0.016), and steroid use (adjusted OR = 24.255; 95%CI: 5.343-110.115; P < 0.001) as independent risk factors for CE development. The presence of dysphagia was associated with severe CE (P = 0.021). The prevalence of CE among HIV-negative persons was 0.4% in Taiwan. Independent risk factors for CE were older age, chronic kidney disease, alcohol consumption, and steroid use.

S1892 A Double Take on a 20-Year Double J-Stent

Introduction: The double J biliary stent is commonly used to relieve obstructions and aid in draining of pancreatic fluid. Indwelling or forgotten stents are rarely seen and their sequelae are unknown. We present the case of a patient who was lost to follow-up over twenty years ago following cholecystectomy and placement of double J stent. A routine esophagogastroduodenoscopy (EGD) for variceal surveillance was performed and discovered an ampullary fungating mass. Case Description/Methods: A 79 y/o female with a history of hypertension presented to the ED with worsening abdominal distention. She was a poor historian but denied alcohol use, drug use, or any history of liver disease. Her workup included an abdominal paracentesis removing greater than 7 liters of fluid with a SAAG indicating portal hypertension. She had abnormal liver function tests (LFTs) and CT imaging was consistent with cirrhotic morphology of the liver and a double-J stent present in CBD (Figure A). An EGD for further evaluation and for variceal vein monitoring was done revealing grade 2 varices but more significantly, at the site of ampulla of vater a large fungating mass was noted. The mass was medium-sized and polypoid with no bleeding. The CBD stent was in place with noted hyperproliferation of the tissue of the ampulla vs a periampullar duodenal mass (Figure B). A repeat EDG with EUS was performed, finding the hypoechoic non-circumferential mass endosonographically within the ampulla. The mass measured 24 mm by 14 mm in maximal cross-sectional diameter (Figure C). The lesion extended from the mucosa to the muscularis mucosa. The endosonographic borders were well-defined. There was sonographic evidence suggesting invasion into the deep mucosa (Layer 2). Filamentous microorganisms were identified on HE and GMS stain. No individual atypical AE1/AE3 positive epithelial cells were identified. Discussion: This case highlights the unusual sequelae of a retained double-J stent in a patient who was lost to follow up. It’s unknown why the stent was placed, likely during an intraoperative cholangiogram, and the patient did not recall her follow-up instructions. Several questions arise surrounding the mass such as, did it have malignant potential and what role, if any, did the stent have in the formation of the mass? Did colonization represent an increased risk of ascending cholangitis? The stent was left in at the conclusion of the case and the patient was extensively educated about follow-up and maintenance endoscopy.Figure 1.: CT evidence of pneumobilia, ampullary fungating mass, and EUS imaging.

The utility of endoscopy prior to bariatric surgery: an 11-year retrospective analysis of 885 patients.

Our aim was to evaluate the diagnostic yield of routine preoperative esophagogastroduodenoscopy (p-EGD) in patients undergoing bariatric surgery. Many medical problems that are common in patients with obesity, including gastroesophageal reflux disease (GERD) and hiatal hernias, have important implications for patients undergoing bariatric surgery. While p-EGD is considered standard of care prior to antireflux surgery, the role of p-EGD in bariatric surgery patients remains controversial. We performed a retrospective chart review of 885 patients who underwent primary bariatric surgery at a university hospital-based bariatric surgery program between March 2011 and February 2022. Clinical history, demographics, and preoperative EGD reports were reviewed for abnormal findings. Of the 885 patients evaluated in this study, one or more abnormal EGD findings were observed in 83.2% of patients. More than half of our patients (54.7%) presented with history of heartburn, reflux, or GERD. EGD findings demonstrated a hernia in 43.1% of patients [(Type I: 40.6%; Type II: 0.5%; Type III: 2.1%)]. 68.0% of patients were biopsied. Among patients who were biopsied, other findings included gastritis (32.4%), esophagitis (8.0%), eosinophilic esophagitis (4.7%), or duodenitis (2.7%). We found ulcers in 6.7% of patients. Pathology was consistent with H. pylori in 9.8% of biopsies taken and consistent with BE in 2.7%. Following routine p-EGD, 11.2% of patients were placed on PPI and 8.3% were recommended to stop NSAIDs. Gastroesophageal reflux disease and associated pathology are common in the bariatric population. Preoperative EGD in patients undergoing bariatric surgery frequently identifies clinically significant UGI pathology. This may have important implications for medical and surgical management. Given the rate of abnormal preoperative endoscopic findings in obese patients, the work-up for bariatric surgery should align with the current recommendations for foregut surgery.

A self-assessment tool for predicting discomfort and tolerance in Chinese patients undergoing esophagogastroduodenoscopy

BackgroundFor patients taking esophagogastroduodenoscopy (EGD), sedation should ideally be used individually based on patients’ comfort and tolerance level. However, currently there is no valid predictive tool. We undertook this study to develop and temporally validate a self-assessment tool for predicting discomfort and tolerance in Chinese patients undergoing EGD.MethodsWe recruited 1522 patients undergoing routine diagnostic EGD without sedation. We collected candidate predictor variables before endoscopy and evaluated discomfort and tolerance with a 5-point visual analogue scale after the procedure. We developed logistic regression predictive models based on the first 2/3 of participants, and evaluated the calibration and discrimination of the models in the later 1/3 of patients.Results30.2% and 23.0% participants reported severe discomfort or poor tolerance to EGD respectively. The predictive factors in the model for discomfort included sex, education, expected level of discomfort, and anxiety before endoscopy. The model for tolerance included income, expected level of discomfort, and anxiety before endoscopy. In the validation population, the established models showed a moderate discriminative ability with a c-index of 0.74 for discomfort and 0.78 for tolerance. Hosmer–Lemeshow test suggested the models had fine calibration ability (discomfort: P = 0.37, tolerance: P = 0.41).ConclusionsEquations for predicting discomfort and tolerance in Chinese patients undergoing EGD demonstrated moderate discrimination and variable calibration. Further studies are still required to validate these tools in other population.Trial registrationChinese Clinical Trial Registry (ChiCTR1800020236).

Congenital Tracheoesophageal Fistula Presenting in an Asymptomatic Adult- A Case Report

Introduction: Congenital tracheoseophageal fistula (TEF) involve an abnormal pathological connection between the oesophagus and trachea. Congenital TEF presenting in adults is extremely rare and literature is limited to case series of significantly symptomatic patients. Case presentation: An asymptomatic 41 year-old gentleman presented to clinic, having been diagnosed with a congenital tracheoesophageal fistula 10 years ago on a routine oesophagogastroduodenoscopy (OGD) in Brazil. He underwent a barium contrast swallow revealing contrast in the left main bronchi and significant pooling in the upper trachea. A computerised tomography (CT) scan of the neck and thorax with contrast revealed a small fistula measuring 6mm in diameter between the trachea and the oesophagus at the level of the second thoracic vertebral body. A microlaryngobronchoscopy and examination under anaesthesia visualised a fistula measuring 1.8cm to 2cm superior to inferiorly and similar in transverse dimension, 6-7cm below the level of the glottis. Management and outcome: He opted to have surgical treatment to prevent symptoms developing in the future. A trans-cervical approach was performed, and the oesophageal defect and tracheal defect underwent primary closure with sutures. The oesophageal defect repair was oversewn with the sternohyoid. He recovered well post-operatively but due to the considerable rotation and retraction of the trachea, he suffered a vocal cord palsy. This is improving at the latest follow-up. Discussion: Otolaryngologist (ENT) surgeons need to be aware of asymptomatic adult patients presenting with congenital tracheoesophageal fistulas and the investigation and management options available.

Real-Time Multi-Label Upper Gastrointestinal Anatomy Recognition from Gastroscope Videos

Esophagogastroduodenoscopy (EGD) is a critical step in the diagnosis of upper gastrointestinal disorders. However, due to inexperience or high workload, there is a wide variation in EGD performance by endoscopists. Variations in performance may result in exams that do not completely cover all anatomical locations of the stomach, leading to a potential risk of missed diagnosis of gastric diseases. Numerous guidelines or expert consensus have been proposed to assess and optimize the quality of endoscopy. However, there is a lack of mature and robust methods to accurately apply to real clinical real-time video environments. In this paper, we innovatively define the problem of recognizing anatomical locations in videos as a multi-label recognition task. This can be more consistent with the model learning of image-to-label mapping relationships. We propose a combined structure of a deep learning model (GL-Net) that combines a graph convolutional network (GCN) with long short-term memory (LSTM) networks to both extract label features and correlate temporal dependencies for accurate real-time anatomical locations identification in gastroscopy videos. Our methodological evaluation dataset is based on complete videos of real clinical examinations. A total of 29,269 images from 49 videos were collected as a dataset for model training and validation. Another 1736 clinical videos were retrospectively analyzed and evaluated for the application of the proposed model. Our method achieves 97.1% mean accuracy (mAP), 95.5% mean per-class accuracy and 93.7% average overall accuracy in a multi-label classification task, and is able to process these videos in real-time at 29.9 FPS. In addition, based on our approach, we designed a system to monitor routine EGD videos in detail and perform statistical analysis of the operating habits of endoscopists, which can be a useful tool to improve the quality of clinical endoscopy.

New endoscopic capsule vs upper gastrointestinal endoscopy in preoperative work-up of obese candidate for bariatric surgery: Relevance of a pilot study in the COVID-19 era.

Background and study aims Obesity represents a major health concern; bariatric surgery is the most effective treatment reducing and maintaining weight loss. The role of a routine esophagogastroduodenoscopy (EGD) prior bariatric surgery is still debated. Moreover, in this scenario of COVID-19 pandemic, EGD is even more questionable due to the procedural risk of viral transmission. A new model of video-endoscopic capsule (VEC) recently has been introduced as a good alternative to the EGD. The aim of this study was to determine if this new capsule is an adequate diagnostic alternative to EGD in the work-up of patients selected for bariatric surgery, particularly in the setting of COVID-19. Patients and methods From January to November 2020, 27 patients selected for bariatric surgery were enrolled in this pilot study to assess for noninferiority of VEC compared to EGD in detection of upper gastrointestinal disease. Results VEC had sensitivity, specificity, and positive and negative predictive values in identification of significant lesions of 91.3 %, 83.33 %, 98.01 %, and 51.57 %, respectively, compared with EGD as the standard criterion. The accuracy was 90.51 % (95 % CI, 73.75 %-98.18 %) and the chi-square statistic is 0.1153 ( P = 0.73). Conclusions Our report confirms the diagnostic noninferiority of VEC in preoperative work-up of patients selected for bariatric surgery, compared to EGD. This is very important, particularly during the COVID-19 pandemic, given the high risk of contamination with EGD. Larger multicenter studies are required to confirm our preliminary results.

Endoscopic Findings and Treatment of Gastric Neoplasms in Familial Adenomatous Polyposis.

Gastric neoplasia is a common manifestation of familial adenomatous polyposis (FAP). This study aimed to elucidate the clinical characteristics, endoscopic features including fundic gland polyposis (FGPsis), and treatment outcomes of gastric neoplasms (GNs) in patients with FAP. A total of 35 patients diagnosed with FAP, including nine patients from four pedigrees who underwent esophagogastroduodenoscopy (EGD), were investigated regarding patient characteristics, GN morphology, and treatment outcomes. Twenty-one patients (60.0%) had 38 GNs; 33 (86.8%) and 5 (13.2%) were histologically diagnosed with adenocarcinoma and adenoma, respectively. There were no specific patient characteristics related to GNs. Nodule-type GNs were more prevalent in patients with FGP than without (52.2% vs. 0.0%, P=0.002) in the upper body of the stomach. Conversely, depressed-type GNs were fewer in patients with FGPsis than in those without (13.0% vs. 73.3%, P<0.001). Slightly elevated-type GNs were observed in both groups (34.8% vs. 20.0%, P=0.538). Even within pedigrees, the background gastric mucosa and types of GNs varied. In total, 24 GNs were treated with endoscopic submucosal dissection (ESD) and eight with endoscopic mucosal resection (EMR). EMR was selected for GNs with FGPsis because of the technical difficulty of ESD, resulting in a lower en bloc resection rate (62.5% vs. 100%, P=0.014). Our study indicates the necessity of routine EGD surveillance in patients diagnosed with FAP. Notably, the morphology and location of GNs differed between patients with and without FGPsis. Endoscopic treatment and outcomes require more attention in cases of FGPsis.

S3592 Cameron Lesions Resulting in Occult GI Bleeding and Anemia

Introduction: Cameron lesions are ulcerations which develop in the sac of hiatal hernias at the diaphragmatic hiatus. They occur in about 3-12% of patients with hiatal hernias. The overall prevalence of Cameron lesions in all patients is less than 1%. Nonsteroidal anti-inflammatory drugs (NSAIDs) are also associated with the development of Cameron lesions. These lesions can present with either occult or overt gastrointestinal bleeding. They are often missed on routine endoscopy given their diminutive size and inconspicuous location which requires thorough antegrade and retrograde examination. We describe a case of a woman with a large hiatal hernia and Cameron lesions with resulting symptomatic iron deficiency anemia. Case Description/Methods: A 50-year-old woman with obstructive sleep apnea, chronic lymphedema, and major depressive disorder underwent routine esophagogastroduodenoscopy (EGD) due to several months of dysphagia and odynophagia. She was found to have grade B esophagitis and a large hiatal hernia with multiple Cameron lesions. Proton pump inhibitor was prescribed. A few months later, patient presented to clinic with orthostatic dizziness and weakness; Hemoglobin (Hgb) was 6.0 mg/dL (previously normal two years prior). She was admitted to the hospital and received red blood cell transfusions with an appropriate response in Hgb and oral iron supplementation; anti-reflux medications were continued on discharge. After one year of strict adherence to anti-reflux regimen and iron supplementation, her hemoglobin levels normalized. Repeat EGD was obtained eighteen months later due to continued dysphagia and odynophagia and showed resolution of Cameron lesions and esophagitis but progression in the size of the hiatal hernia. She was referred to a general surgeon and underwent laparascopic para-esophageal repair and partial fundoplication with resolution of her symptoms. Discussion: Cameron lesions may cause overt and occult gastrointestinal bleeding with resulting iron deficiency anemia. These lesions have been mostly described in association with large hiatal hernias and routine NSAID use. Medical treatment with a proton pump inhibitor and discontinuation of NSAIDs is usually sufficient to treat these ulcerations but some patients may require endoscopic or surgical management in severe cases. Gastroenterologists should give special attention to the mucosa of the diaphragmatic hiatus in patients with a hiatal hernia and suspicion for gastrointestinal bleeding to evaluate for Cameron lesions.Figure 1.: Cameron lesions seen on retrograde view during endoscopy.

Role of Preoperative Esophagogastroduodenoscopy (EGD) in Bariatric Treatment.

Background: The recommendations for routine preoperative esophagogastroduodenoscopy (EGD) in patients qualified for bariatric surgeries are still a matter of debate. The aim of this study was to analyze the pathologies on preoperative EGD in patients qualified for bariatric surgeries. Materials and Methods: This study included 222 patients, divided into two groups. The obesity group consisted of patients with obesity (BMI ≥ 40 kg/m2), for whom EGD was a routine part of the preparation for laparoscopic sleeve gastrectomy (LSG). The control group of patients with normal body weight (BMI) qualified for EGD because of gastrointestinal ailments. Results: Regarding preoperative EGD in patients qualified for bariatric surgeries, we analyzed the prevalence of endoscopic pathologies in various gastrointestinal tract segments. Patients with obesity were shown to present with esophageal pathologies significantly more often than persons in the control group (n = 23, 20.91% vs. n = 12, 10.91%, p = 0.042). The odds ratio of esophageal pathologies in patients with obesity versus the control group equaled 2.15 (95%CI: 1.01–4.59). In turn, the odds ratio of duodenal pathologies in patients from the control group was 3.31 (95%Cl: 1.16–9.47), which means that persons from this group were approximately three times more likely to be diagnosed with those pathologies compared to obese patients. Moreover, patient sex was a significant predictor of duodenal pathologies, with an odds ratio of 4.03 (95%CI: 1.53–10.61). Conclusions: Preoperative EGD can identify a broad spectrum of pathologies in obese patients, which suggests a routine examination before bariatric surgery.

Routine Intra-Operative Esophagogastroduodenoscopy in 1727 patients

Background: Routine esophagogastroduodenoscopy (EGD) before bariatric surgery remains controversial. This study was undertaken to determine the feasibility, safety, and effectiveness of routine intraoperative esophagogastroduodenoscopy (EGD) before bariatric surgery, the incidence of pathological EGD findings in patients undergoing bariatric surgery, the incidence of altered surgical plans because of the EGD findings, and to correlate patient symptoms with the EGD findings. Methods: This is a Prospective ongoing, interventional study that was started on March 1st, 2018 with this preliminary report covering the cases up to September 30th, 2019. Routine intraoperative pre-bariatric procedure EGD was done and findings recorded. Patients consented for the endoscopy and the possibility of altering the planned operation was discussed with the patient. Results: Routine intraoperative EGD was done on 1727 patients. Nine hundred twenty-two (53.4%) were female. Three hundred fifty-one (20.3%) patients had preoperative history of or symptoms of gastroesophageal reflux disease out of which 84(29%) had positive findings on endoscopy. One hundred twenty (6.9%) had esophagitis and only 22(18.3%) had symptoms of gastroesophageal reflux disease (GERD) preoperatively. Two hundred ninety (16.7%) had gastritis, 392(22.3%) had bile in stomach, 105(6.07%) had duodenitis and 50 (2.9%) had a hiatus hernia. Our primary plan of surgery was changed based on endoscopic findings in 47(2.7%) of patients. Conclusion: Intraoperative EGD is do-able, cost-effective, safe and convenient for both the patient and surgeon. We found asymptomatic significant upper gastrointestinal (UGI) pathologies that altered the planned procedure in 2.7% of the patients.

White Spot, a Novel Endoscopic Finding, May Be Associated with Acid-Suppressing Agents and Hypergastrinemia.

White globe appearance (WGA) is defined as a microendoscopic white lesion with a globular shape underlying the gastric epithelium and is considered a marker of gastric cancer. We recently reported that endoscopically visualized white spot (WS) corresponding to WGA appeared on the nonatrophic mucosa of patients with acid-suppressing agents (A-SA) use. We evaluated patients undergoing routine esophagogastroduodenoscopy and divided the patients into an A-SA group (n = 112) and a control group (n = 158). We compared the presence of WS in both groups. We also compared WS-positive- (n = 31) and -negative (n = 43) groups within the A-SA group regarding these patients’ backgrounds and serum gastrin concentrations. Comparing the A-SA group with controls, the prevalence of WS was significantly higher (31/112 vs. 2/158; p < 0.001). The number of patients with high serum gastrin concentrations was significantly higher in the WS-positive group (18/31) vs. the WS-negative group (5/43) (p < 0.001). Within the A-SA group, the prevalence of WS was also significantly higher in patients taking potassium-competitive acid blockers vs. proton-pump inhibitors (21/31 vs. 10/31, p < 0.001). The WS-positive group had a significantly greater percentage of patients, with a high serum gastrin level (p < 0.001). WS may be associated with hypergastrinemia and potassium-competitive acid blockers.