Time Of Esophagogastroduodenoscopy Research Articles

A shared group of bacterial taxa in the duodenal microbiota of undernourished Pakistani children with environmental enteric dysfunction.

Environmental enteric dysfunction (EED) is a subclinical syndrome of altered small intestinal function postulated to be an important contributor to childhood undernutrition. The role of small intestinal bacterial communities in the pathophysiology of EED is poorly defined due to a paucity of studies where there has been a direct collection of small intestinal samples from undernourished children. Sixty-three members of a Pakistani cohort identified as being acutely malnourished between 3 and 6 months of age and whose wasting (weight-for-length Z-score [WLZ]) failed to improve after a 2-month nutritional intervention underwent esophagogastroduodenoscopy (EGD). Paired duodenal luminal aspirates and duodenal mucosal biopsies were obtained from 43 children. Duodenal microbiota composition was characterized by sequencing bacterial 16S rRNA gene amplicons. Levels of bacterial taxa (amplicon sequence variants [ASVs]) were referenced to anthropometric indices, histopathologic severity in biopsies, expression of selected genes in the duodenal mucosa, and fecal levels of an immunoinflammatory biomarker (lipocalin-2). A "core" group of eight bacterial ASVs was present in the duodenal samples of 69% of participants. Streptococcus anginosus was the most prevalent, followed by Streptococcus sp., Gemella haemolysans, Streptococcus australis, Granulicatella elegans, Granulicatella adiacens, and Abiotrophia defectiva. At the time of EGD, none of the core taxa were significantly correlated with WLZ. Statistically significant correlations were documented between the abundances of Granulicatella elegans and Granulicatella adiacens and the expression of duodenal mucosal genes involved in immune responses (dual oxidase maturation factor 2, serum amyloid A, and granzyme H). These results suggest that a potential role for members of the oral microbiota in pathogenesis, notably Streptococcus, Gemella, and Granulicatella species, warrants further investigation.IMPORTANCEUndernutrition among women and children is a pressing global health problem. Environmental enteric dysfunction (EED) is a disease of the small intestine (SI) associated with impaired gut mucosal barrier function and reduced capacity for nutrient absorption. The cause of EED is ill-defined. One emerging hypothesis is that alterations in the SI microbiota contribute to EED. We performed a culture-independent analysis of the SI microbiota of a cohort of Pakistani children with undernutrition who had failed a standard nutritional intervention, underwent upper gastrointestinal tract endoscopy, and had histologic evidence of EED in their duodenal mucosal biopsies. The results revealed a shared group of bacterial taxa in their duodenums whose absolute abundances were correlated with levels of the expression of genes in the duodenal mucosa that are involved in inflammatory responses. A number of these bacterial taxa are more typically found in the oral microbiota, a finding that has potential physiologic and therapeutic implications.

Validation of a Machine Learning Algorithm, EVendo, for Predicting Esophageal Varices in Hepatocellular Carcinoma

BackgroundTreatment with atezolizumab and bevacizumab has become standard of care for advanced unresectable hepatocellular carcinoma (HCC) but carries an increased gastrointestinal bleeding risk. Therefore, patients are often required to undergo esophagogastroduodenoscopy (EGD) to rule out esophageal varices (EV) prior to initiating therapy, which can delay care and lead to unnecessary procedural risks and health care costs. In 2019, the EVendo score was created and validated as a noninvasive tool to accurately screen out patients who were at low risk for having EV that required treatment. We sought to validate whether the EVendo score could be used to accurately predict the presence of EV and varices needing treatment (VNT) in patients with HCC.MethodsThis was a retrospective multicenter cohort study of patients with HCC from 9/2004 to 12/2021. We included patients who underwent EGDs within 1 year after their HCC diagnosis. We collected clinical parameters needed to calculate an EVendo score at the time of EGD and compared the EVendo model prediction to the gold standard endoscopic report in predicting presence of VNT.Results112 with HCC were recruited to this study, with 117 qualifying EGDs. VNT occurred in 39 (33.3%) patients. The EVendo score had a sensitivity of 97.4% and a negative predictive value of 96.9%, supporting the validity in applying EVendo in predicting VNT in HCC.ConclusionIn this study, we validated the use of the EVendo score in ruling out VNT in patients with HCC. The application of the EVendo score could safely defer about 30% of EGDs for EV screening in HCC patients. Although additional validation cohorts are needed, this suggests that EVendo score can potentially be applied in patients with HCC to avoid unnecessary EGDs, which can ultimately mitigate healthcare costs and delays in initiating HCC treatment with atezolizumab and bevacizumab.

Relationship between observation time and detection rate of focal lesions in Esophagogastroduodenoscopy: a single-center, retrospective study

BackgroundCurrent studies have shown that longer observation time can improve neoplastic detection rate. This study aimed to clarify whether endoscopists with longer observation times can detect more focal lesions.MethodsBased on the mean examination time for Esophagogastroduodenoscopy (EGD) without biopsy, endoscopists were divided into fast and slow groups, and the detection rate of focal lesions was compared between the two groups. Univariate analysis, multivariate analysis and restricted cubic spline were used to explore the factors of focal lesion detection rate.ResultsMean examination time of EGD without biopsy was 4.5 min. The cut-off times used were 5 min. 17 endoscopists were classified into the fast (4.7 ± 3.6 min), and 16 into the slow (7.11 ± 4.6 min) groups. Compared with fast endoscopists, slow endoscopists had a higher detection rate of focal lesions (47.2% vs. 51.4%, P < 0.001), especially in the detection of gastric lesions (29.7% vs. 35.9%, P < 0.001). In univariate and multivariate analyses, observation time, patient age and gender, expert, biopsy rate, and number of images were factors in FDR. There is a nonlinear relationship between observation time and FDR.ConclusionLonger examination time improves the detection rate of focal lesions. Observation time is an important quality indicator of the EGD examination.

Changes in impedance planimetry (EndoFLIP) measurements at follow-up after peroral endoscopic myotomy (POEM).

Numerous studies show changes in functional lumen imaging probe (FLIP) measurements after myotomy during peroral endoscopic myotomy (POEM), but few report on FLIP measurements at follow-up esophagogastroduodenoscopy (EGD). The purpose of this study was to compare perioperative FLIP measurements to those at follow-up EGD. Patients who underwent POEM with FLIP in the operating room and POEM patients who had EGD with FLIP at follow-up were included. FLIP measurements, including diameter (Dmin), pressure, cross-sectional area (CSA), and distensibility index (DI), were analyzed at a 30-mL balloon fill. Differences between measurements at different timepoints were assessed using a two-tailed Wilcoxon signed-rank test. A total of 97 patients who underwent POEM and 28 who underwent EGD with FLIP were analyzed. The average age was 63 ± 18years and 46.4% of the patients were male. Mean preoperative Eckardt score was 6.5 ± 4.8, decreasing to 1.6 ± 2.0 at follow-up. EGDs were performed at a median of 15months after surgery. When compared to mean measurements obtained post-myotomy, at the time of EGD, pressure was found to be significantly lower (p = 0.007) and DI significantly higher (p = 0.045). Of the patients who underwent EGD, 70.8% had an increase in DI, 55.6% had evidence of reflux esophagitis, and 81.0% met diagnostic criteria for reflux on esophageal pH monitoring. However, there was no correlation with the development of esophagitis or reflux and increase or decrease in DI at follow-up. There are significant changes in FLIP measurements between the time of surgery and at follow-up EGD. These results suggest that esophageal remodeling may cause changes in lower esophageal sphincter geometry after POEM and postoperative FLIP targets immediately post-myotomy may need to be adjusted to account for these changes.

Gastric mucosa condition in patients with coronary artery disease and high risk of gastrointestinal bleeding (register REGATTA-1)

To assess the upper gastrointestinal mucosal condition by endoscopic and histological methods in patients with stable coronary arteries disease receiving long-term antiplatelet therapy with gastrointestinal bleeding (GIB) history or with high risk of this complication. The study included patients from the single-center prospective registry of long-term antithrombotic therapy REGATTA-1. The gastric mucosa endoscopic examination with biopsy was performed in 20 patients with gastrointestinal bleeding history less than 1 year ago and in 24 patients without GIB, which have concomitant risk factors such as erosions and ulcers history and/or persistent dyspepsia clinical signs. The mucosal condition (erosions and ulcers) was estimated using a modified Lanz scale. The presence of Helicobacter pylori was determined by Histological verification. The inflammatory process characteristics were evaluated according to the modified Sydney classification. All participants received antithrombotic therapy at the time of esophagogastroduodenoscopy; 81.8% of patients received proton pump inhibitors. Chronic inflammation (93.2%), atrophy (59.1%), multiple erosions (45.5%) or ulcers (18.2%) were the most frequent endoscopic finding. H. pylori infection, found in mucosal samples in 90.9% of patients was one of the most important pathogenesis mechanism, which support the gastrointestinal mucosa damage. Mucosal damage endoscopic signs remains despite long-term proton pump inhibitors therapy in patients with coronary arteries disease and concomitant GIB risk factors, receiving antithrombotic therapy. H. pylori contamination may be the cause of these changes. Therefore, its active screening and eradication is necessary in such patients.

Eosinophilic Esophagitis Symptom Scores Are High in Children Without Eosinophilic Disease.

The Pediatric Eosinophilic Esophagitis (EoE) Symptom Score version 2 (PEESSv2.0) is an EoE-specific validated metric for disease monitoring, but its use has not been explored outside of EoE. Our aim was to determine if PEESSv2.0 scores differentiate between children with EoE and non-EoE esophageal dysfunction undergoing initial esophagogastroduodenoscopy (EGD). A prospective cohort study of pediatric subjects was conducted. Children ages 1-18 undergoing initial EGD for esophageal dysfunction were enrolled. Demographics, clinical history, and child self-report and parent-proxy report PEESSv2.0 symptom scores were collected at the time of EGD. Esophageal biopsies were reviewed, and EoE was defined as >15 eosinophils/high powered field (hpf) seen in any level of the esophagus. Non-EoE was defined as <15 eosinophils/hpf. Seventy-one children were included in the study from 2015 to 2018 [59% (42/71) males; mean age 9.2 years; range 1-17 years]. Fifty-eight percent (41/71) met criteria for EoE, and 42% (30/71) were labeled non-EoE. Non-EoE children and their parents had higher/worse median PEESSv2.0 total scores than those with EoE [47.0 vs 28.0 (P = 0.001) and 40.5 vs 26.5 (P = 0.012), respectively]. Non-EoE children reported higher median GERD [9.0 vs 4.0 (P = 0.003)], nausea/vomiting [9.0 vs 4.0 (P = 0.003)], and pain [11.0 vs 6.0 (P = 0.001)] subdomain scores compared to those with EoE. PEESSv2.0 dysphagia subdomain scores (child and parent-proxy) did not differ between EoE and non-EoE groups [22.0 vs 15.0 (P = 0.184) and 18.5 vs 17.4 (P = 0.330), respectively]. Total PEESSv2.0 scores were worse in non-EoE group compared to EoE group. Although PEESSv2.0 is validated for use in monitoring EoE therapy, it does not distinguish children with EoE from non-EoE esophageal dysfunction at the time of diagnostic EGD.

A126 GIST – GLUE IN STROMAL TUMOR

Abstract Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and typically located in the stomach. Gastrointestinal bleeding is a frequent complication of GISTs with surgery being the treatment of choice. Managing GIST bleeding endoscopically can be challenging by an underlying friable neovascularization. The use of cyanoacrylate basis glue has well-established utility in the endoscopic management of variceal bleeding. However, the role of cyanoacrylate basis glue in the management of GIST bleeding is exceptionally rare. Aims We present a case of a bleeding GIST that was successfully managed through the utilization of cyanoacrylate basis glue allowing for elective surgical resection. Methods A chart review was undertaken. Also, a literature review of the topic was also conducted using the terms “GIST, Cyanoacrylate Glue, Bleeding” Results A 75-year-old male presented with a four week history of exertional chest pain. He had noticed persistent black stools for the previous two weeks. His past medical history was relevant for coronary artery disease; two years earlier he had drug eluting stents placed. His medications included ASA 81mg PO OD and Pantoprazole 40mg OD. Physical examination revealed stable vital signs, a soft abdomen and melena on rectal examination. Laboratory investigations showed a hemoglobin of 75 g/L, and 2 weeks prior his hemoglobin had been 120 g/L. Platelets were 149. His liver enzymes and liver function tests were unremarkable. His BUN was 9.9 mmol/L and creatinine of 96.0 umol/L. An esophagogastroduodenoscopy (EGD) revealed a 5cm smooth mass with a central deep depression, in the antrum, that was actively bleeding. Attempts to clip were unsuccessful due to the width of the central depression which was the source of bleeding. (See image 1). The endoscopist chose to inject 1cc of cyanoacrylate basis glue directly into the bleeding site. A subsequent CT scan revealed a 5.2cm polypoid mass in the gastric antrum, favored to be a GIST with no evidence of metastatic disease. Surgery and Cardiology were involved in the care of this patient, and emergency surgery was delayed due to the patient having an intercurrent acute coronary syndrome. Post EGD, the patient underwent an angiogram and the culprit coronary artery was stented and patient was started on dual antiplatelet therapy. Patient then successfully underwent a laparoscopic gastric wedge resection for his GIST, this was completed 1 week after EGD. The pathology of the resected area was in keeping with a GIST. Of note, the patient’s hemoglobin had been stable from the time of EGD until surgical intervention. Conclusions Managing GIST bleeding endoscopically can be challenging, and surgical resection is the recommended treatment modality. In situations where surgical intervention is contraindicated, endoscopic therapy with cyanoacrylate basis glue can be considered to achieve hemostasis in GIST bleeding. Funding Agencies None

The Role of Symptom Association Analysis in Gastroesophageal Reflux Testing.

Gastroesophageal reflux disease is characterized by the reflux of gastric contents into the esophagus with an estimated worldwide prevalence of 8%-33%. The current paradigm in gastroesophageal reflux disease diagnosis relies on recognition of symptoms and/or the presence of mucosal disease at the time of esophagogastroduodenoscopy. Recognition of symptoms, however, can arise with challenges, particularly when patients complain of less typical symptoms. Since first reported in 1969 by Spencer et al., the application of prolonged intraesophageal pH monitoring to identify pathologic reflux has evolved considerably. Utility of pH monitoring aims to investigate the degree of acid burden and frequency of reflux episode, and the relationship between symptoms and acid reflux events. This relationship is represented by either the Symptom Index, Symptom Sensitivity Index, Symptom Association Probability, or Ghillebert Probability Estimate. This article reviews symptom-association analysis during esophageal reflux testing, covering the literature on current methods of reflux testing, interpretation of symptom association, and practical issues that can arise during symptom analysis.

Effects of Sedation Performed by an Anesthesiologist on Pediatric Endoscopy: a Single-Center Retrospective Study in Korea.

BackgroundEndoscopy is used for diagnosing and treating various digestive diseases in children as well as in adults. However, in pediatric patients, it is recommended that sufficient sedation should be ensured before conducting endoscopy, since insufficient sedation may cause serious complications. However, in Korea, no studies have yet described the types of sedation drugs, effects of sedation, and efficiency of endoscopy with respect to the sedation instructor. Thus, we investigated the effectiveness of sedative procedures performed by anesthesiologists.MethodsWe retrospectively reviewed the medical records of patients aged < 18 years who underwent endoscopy during March 2014–July 2019. Data of sedation instructors, sedation drugs and their doses, complications, and the recovery after sedation were evaluated.ResultsOf 257 patients, 217 underwent esophagogastroduodenoscopy (EGD) and 40 underwent colonoscopies. Before EGD, 29 patients (13.4%) underwent sedation by the pediatric endoscopist and 188 (86.6%) were sedated by the anesthesiologist. The anesthesiologist performed the sedation for all 40 patients who underwent colonoscopy. Endoscopic examinations performed by the anesthesiologist were relatively more time-consuming (401.0 ± 135.1 seconds vs. 274.9 ± 106.1 seconds, P < 0.001). We observed that in patients who underwent EGD, there was a difference in the dose of midazolam administered (P = 0.000). When comparing EGD and colonoscopy in patients undergoing sedation by the anesthesiologist, there were no significant differences in the doses of midazolam and ketamine, but the dose of propofol increased for colonoscopy (2.50 ± 0.95 mg/kg vs. 4.71 ± 1.66 mg/kg, P = 0.000). The cognitive recovery time according to drug dose was associated with propofol only in EGD with a shorter endoscopy time. The longer cognitive recovery time in colonoscopy and the discharge time of EGD and colonoscopies were not associated with propofol use.ConclusionWhen sedation is performed by an anesthesiologist, various drugs are used with sufficient doses and complications are reduced, but the discharge time does not change. For performing pediatric endoscopy in Korea, anesthesiologists should be considered for inducing anesthesia.

373 Routine EGD Has Minimal Impact on Refractory GERD Management

INTRODUCTION: Routine diagnostic esophagogastroduodenoscopy (EGD) is recommended for refractory gastro-esophageal reflux disease (GERD) symptoms despite lack of evidence that it impacts management or outcomes. This study aims to determine if diagnostic EGD impacts management in patients with refractory GERD compared to esophageal manometry, pH testing and intra-luminal impedance. METHODS: We performed an observational study of patients with refractory GERD who underwent EGD from 2013 to 2018 at a tertiary hospital. Among 1,213 patients with GERD, we strictly excluded patients with alarm features such as dysphagia, dyspepsia; history of gastroesophageal surgery, or EGD done for other diagnostic procedures, and identified 339 patients who underwent EGD solely for persistent reflux symptoms. We then identified those who had esophageal manometry or pH-impedance studies for further evaluation of GERD, as well as if the findings of these tests resulted in a change in management (medication change or de-escalation, referral for Nissen fundoplication, etc). RESULTS: Among 339 patients with refractory GERD, 80.5% of patients were taking PPIs prior to and/or at the time of EGD. The majority of patients had completely normal (163/339, 48.1%) or solely benign or incidental findings (106/339, 31.3%) on EGD. Only 10.6% of patients had esophageal manometry or pH-impedance studies for refractory reflux symptoms, of those, 6.2% followed EGD and only 7 patients had these studies after a completely normal EGD. The majority of patients undergoing manometry had normal studies or minor abnormalities (23/32, 71.8%). All patients who had been ordered for intraluminal impedance or 24 hr pH testing alone could not tolerate the procedure. Six of 15 patients (40%) undergoing 24 hr pH-impedance testing had findings leading to a change in management. Undergoing pH-impedance testing after EGD was associated with a change in management (OR 7.33, P = 0.018). PPI use was not associated DeMeester score or with results of manometry, impedance, or pH testing. CONCLUSION: Most patients who underwent EGD for refractory GERD symptoms alone did not have pathological findings prompting a change in management. There were no demographic variables that predicted pathologic findings on EGD. Very few patients underwent subsequent or concomitant esophageal manometry, impedance or pH testing. pH-impedance after EGD was associated with a change in management, and may be a better first step in evaluating patients with refractory GERD symptoms, than EGD.

Undigested Food Trapped in a Pre-Pyloric Ulcer

CASE REPORT An 85-year-old woman was sent to the emergency department for weakness of 1-week duration. She recently broke her left hip and was status-post surgical repair. She had been taking naproxen 500 mg by mouth twice a day since the surgery. In the emergency department, her hemoglobin was 6.4 mg/dL. She responded appropriately to blood transfusions. Esophagogastroduodenoscopy (EGD) revealed a 4-cm, deeply cratered, clean-based ulcer located above the pylorus. In the ulcer was an undigested mushroom (Figure 1). On further questioning, the patient revealed that she hated mushrooms and would never eat them. However, she was at a catered event one week earlier where mushrooms were the only available vegetable, so she had swallowed one whole. The mushroom remained undigested in the ulcer cavity until the time of EGD, when it was removed.Figure 1.: An undigested mushroom situated in a 4-cm, deeply cratered, clean-based ulcer located above the pylorus.This case raises the question of whether the ulcer was caused by the naproxen and ended up trapping the mushroom, or if the mushroom initially caused pressure necrosis, which was worsened by the naproxen use and ended up causing an ulcer. To this end, many studies and national guidelines have documented the risk of ulcer formation with nonsteroidal antiinflammatory drug (NSAID) consumption.1 There is wide variability in bleeding rates caused by individual NSAIDs. Naproxen is associated with an intermediate risk of bleeding that increases with age, a history of previous gastrointestinal event, concomitant use of anticoagulants, corticosteroids, other NSAIDs, and chronic debilitating disorders.2,3 However, the morphology of our patient's ulcer was less suspicious for naproxen-induced injury because these tend to be much smaller in diameter (<2 cm). Benign or malignant neoplasms can also lead to ulcer formation. Up to 6% of gastric ulcers have been associated with underlying malignancy. However, our patient did not have a history or symptoms of malignancy, and imaging and biopsy studies were negative for neoplastic etiologies. To our knowledge, no cases of food-related foreign bodies being trapped in an ulcer have been reported in the literature. After removing the mushroom, the patient was given a course of proton pump inhibitors, and on follow-up she reported no further bleeding complications. DISCLOSURES Author Contributions: All authors contributed to the writing and editing of this submission equally. V. Shahnazarian is the article guarantor.

Undigested Food Trapped in a Pre-Pyloric Ulcer

CASE REPORT An 85-year-old woman was sent to the emergency department for weakness of 1-week duration. She recently broke her left hip and was status-post surgical repair. She had been taking naproxen 500 mg by mouth twice a day since the surgery. In the emergency department, her hemoglobin was 6.4 mg/dL. She responded appropriately to blood transfusions. Esophagogastroduodenoscopy (EGD) revealed a 4-cm, deeply cratered, clean-based ulcer located above the pylorus. In the ulcer was an undigested mushroom (Figure 1). On further questioning, the patient revealed that she hated mushrooms and would never eat them. However, she was at a catered event one week earlier where mushrooms were the only available vegetable, so she had swallowed one whole. The mushroom remained undigested in the ulcer cavity until the time of EGD, when it was removed.Figure 1.: An undigested mushroom situated in a 4-cm, deeply cratered, clean-based ulcer located above the pylorus.This case raises the question of whether the ulcer was caused by the naproxen and ended up trapping the mushroom, or if the mushroom initially caused pressure necrosis, which was worsened by the naproxen use and ended up causing an ulcer. To this end, many studies and national guidelines have documented the risk of ulcer formation with nonsteroidal antiinflammatory drug (NSAID) consumption.1 There is wide variability in bleeding rates caused by individual NSAIDs. Naproxen is associated with an intermediate risk of bleeding that increases with age, a history of previous gastrointestinal event, concomitant use of anticoagulants, corticosteroids, other NSAIDs, and chronic debilitating disorders.2,3 However, the morphology of our patient's ulcer was less suspicious for naproxen-induced injury because these tend to be much smaller in diameter (<2 cm). Benign or malignant neoplasms can also lead to ulcer formation. Up to 6% of gastric ulcers have been associated with underlying malignancy. However, our patient did not have a history or symptoms of malignancy, and imaging and biopsy studies were negative for neoplastic etiologies. To our knowledge, no cases of food-related foreign bodies being trapped in an ulcer have been reported in the literature. After removing the mushroom, the patient was given a course of proton pump inhibitors, and on follow-up she reported no further bleeding complications. DISCLOSURES Author Contributions: All authors contributed to the writing and editing of this submission equally. V. Shahnazarian is the article guarantor.

Platelet and INR Are Poor Predictors of Bleeding Risk in Patients With Cirrhosis Undergoing Ambulatory EGD

Introduction: There are currently no clear practice guidelines for correction of coagulopathy and thrombocytopenia prior to ambulatory esophagogastroduodenoscopy (EGD). In our endoscopy unit, we do not routinely transfuse fresh frozen plasma (FFP) and platelets (PLT) prior to ambulatory endoscopy. Post-EGD bleeding events have been rare. The purpose of this study is to investigate the frequency of significant bleeding episodes and to determine if an association exists between bleeding episodes and degree of coagulopathy and thrombocytopenia in patients with cirrhosis undergoing ambulatory EGD. Methods: We retrospectively reviewed the charts of all cirrhotic patients who underwent ambulatory EGD at the University of Southern California, consecutively from February 20th, 2013 to August 6th, 2014. None of the patients received FFP or PLT transfusions prior to their EGD. We defined bleeding episodes as those requiring inpatient hospitalization or blood product transfusion within one week after EGD. Statistical analysis was done using Stata software. Results: We reviewed a total of 250 procedures. There were 160 (64%) male patients. The mean age observed was 58.3 (SD 9.3) at time of EGD, mean platelet was 90,300 (SD 57.2), mean INR 1.27 (SD 0.26). Out of the 250 total procedures, two bleeding episodes were observed. The characteristics of these two patients are outlined in Table 1. Of the patients who bled, both were female, with a mean age of 54.3, mean platelet of 72, mean INR 1.25, mean Child score of 6.5, mean MELD 9.5, and mean MELD-Na 11.5. The first patient had a platelet count of 37,000 and INR of 1.4. The second patient had a platelet count of 107,000 and INR of 1.1. Statistical analysis using exact logistic showed that none of these variables were associated with bleeding episodes. Specifically, neither platelet count (odds ratio 0.99, P-value 0.8) nor INR (odds ratio 0.69, P-value 0.9) were statistically significant in relationship to bleeding events.Table: Table. Characteristic of Patients with Cirrhosis Who Had a Bleeding Episode After an EGDConclusion: In our study, post-EGD bleeding rates were low despite the lack of routine pre-EGD correction of coagulopathy and thrombocytopenia, even in patients undergoing high-risk procedures (i.e. variceal ligation). Bleeding episodes were not associated with gender, age, platelet count, INR, Child score, MELD scores, presence of esophageal or gastric varices, or performance of ligation. Routine correction of coagulopathy and thrombocytopenia in patients with cirrhosis prior to ambulatory EGD appears to be unwarranted.

Examination time as a quality indicator of screening upper gastrointestinal endoscopy for asymptomatic examinees.

The significance of examination time of esophagogastroduodenoscopy (EGD) for asymptomatic examinees is yet to be established. We aimed to clarify whether endoscopists who allot more examination time can detect higher numbers of neoplastic lesions among asymptomatic examinees. We reviewed a database of consecutive examinees who underwent EGD in our hospital from April 2010 to September 2015. Staff endoscopists were classified into fast, moderate, and slow groups based on the mean examination time of EGD without a biopsy. Neoplastic lesion detection rate among these groups was compared using multiple logistic regression. Of the 55 786 consecutive examinees who underwent EGD, 15 763 asymptomatic examinees who were screened by staff doctors were analyzed. Mean examination time of 13 661 EGD without biopsy was 6.2 min (range, 2-18 min). When cut-off times of 5 and 7 min were used, four endoscopists were classified into the fast (mean duration, 4.4 ± 1.0 min), 12 into the moderate (6.1 ± 1.4 min), and four into the slow (7.8 ± 1.9 min) groups. Neoplastic lesion detection rates in the fast, moderate, and slow groups were 0.57% (13/2288), 0.97% (99/10 180), and 0.94% (31/3295), respectively. Compared with that in the fast group, odds ratios for the neoplastic lesion detection rate in the moderate and slow groups were 1.90 (95% confidence interval [CI], 1.06-3.40) and 1.89 (95% CI, 0.98-3.64), respectively. Endoscopists who do not allot adequate examination time may overlook neoplastic lesions in the upper gastrointestinal tract.

Esophagogastroduodenoscopy-assisted bowel preparation for colonoscopy

To compare the quality and tolerance of esophagogastroduodenoscopy (EGD)-assisted and conventional split-dose polyethylene glycol electrolyte solution for inpatient colonoscopy. The study was a randomized controlled trial in hospitalized patients. Hospitalized patients undergoing colonoscopy the day following EGD for evaluation of gastrointestinal (GI) bleeding or other symptoms. Patients randomized to either EGD-assisted bowel prep [2 L polyethylene glycol (PEG) administered endoscopically into distal duodenum at time of EGD, plus 1 L PEG orally the following day] or conventional-PEG (2 L PEG orally the evening prior and 1 L PEG orally the following day). The main outcome measurements are bowel preparation quality and patient tolerance of bowel prep. Forty-two patients randomized to EGD-assisted bowel prep and 40 patients to conventional-PEG. Overall mean ± SD preparation quality was superior for EGD-PEG (4.1 ± 2.8) vs conventional-PEG (6.5 ± 3.1; P = 0.0005). Seventy-four percent of patients rated EGD-PEG as easy or slightly difficult to tolerate compared to 46% for standard-PEG (P = 0.0133). Mean EGD-procedural time was greater for EGD-assisted subject (24 ± 10 min) compared to conventional-PEG prep subjects (15 ± 7 min; P < 0.0001). Conscious sedation requirements did not differ between groups. There were no significant prep-related adverse events in either group. In selected hospitalized patients, compared to a conventional split-dose regimen, use of EGD to administer the majority of PEG solution improves patient tolerance and quality of bowel preparation for colonoscopy.

Erythromycin decreases the time and improves the quality of EGD in patients with acute upper GI bleeding.

To evaluate the efficacy of erythromycin to decrease the time and improves the quality of EGD in patients with acute upper GI bleeding. The diagnostic and therapeutic value of esophagogastroduodenoscopy (EGD) in patients with upper GI bleeding is often limited by the presence of residual blood or clots. Infused erythromycin (3 mg/kg) before EGD, a potent gastro kinetic drug, might improve the quality of EGD in patients with upper GI bleeding and decrease the time of EGD and second- look EGD. In a prospective, randomized, double-blind controlled trial, 40 patients with acute upper gastrointestinal bleeding in Taleghani hospital, Tehran, Iran were studied. The patients were randomized into 2 groups: 1) nasogastric tube placement receiving placebo, and 2) intravenous erythromycin infusion (3mg/kg at 30 min) combined with nasogastric tube placement. The primary end point was endoscopic yield, as assessed by objective and subjective scoring systems and endoscopic duration. Secondary end points were the need for a second look, blood units transfused, and length of hospital stay and mortality. A clear stomach was found more often in the erythromycin group (100% vs. 25%; P < 0.001). Erythromycin shortened the endoscopic duration (14 vs. 32 minutes in the placebo group; P < 0.001) and reduced the need for second-look endoscopy (1 vs. 3; P < 0.001), admission duration (2 vs 5; P < 0.001) and reduced the blood units transfused (2 vs 4; P < 0.001). In patients with acute upper GI bleeding, infusion of erythromycin before endoscopy significantly decreases the time and improves the quality of EGD.

Upper Gastro-Intestinal Foreign Bodies: Etiology and Patient Characteristics Based on a Single Center Experience

Purpose: To retrospectively analyze our experience in patients with upper gastro-intestinal tract (UGIT) foreign bodies (FB). Methods: A list was generated from our endoscopy database of all the patients who had undergone esophagogastroduodenoscopy (EGD) between 01/01/2006 and 10/31/2009 for a presumed diagnosis of FB in the UGIT. Data were collected for demographics, clinical presentation, underlying medical history, EGD findings, and type of FB. Patients were grouped based on the age at the time of EGD: pediatric (0-21 years) and adult (>21 years). Adults were further sub-divided into 2 groups based on the type of FB: acute food bolus obstruction (AFBO) and unusual/sharp objects (USO). Results: Demographics: A total of 73 endoscopic procedures were performed in 61 patients; 44 (72.1%) were males. Mean age was 39.3 (range: 1-92 years). There were 17 (28%) pediatric subjects, 26 (42.6%) adults with AFBO and 18 (29.4%) adults with USO; this latter group had 30 presentations. Pediatric Patients with FB: Mean age was 5.6 (range 1-16 yrs). Coins comprised the majority (80%) in younger children (0-5 years) and 28% in the older children (6-21 years). Other FB included batteries, beer bottle cap, pin, and fruit seed. There was one EGD failure due to impacted FB at the crico-pharyngeus; this was succesfully removed in the operating room by an ENT surgeon. Patients with AFBO: Mean age was 56 (range 22-92 yrs). Esophageal biopsies were obtained in 12 (46.1%) patients. Biopsy rates for the years 2006-2007 and 2008-2009 were 5/14 (35.7%) and 7/9 (77.7%), respectively. Esophageal pathology was found in 14 (53.8%) cases, as shown in the table. Of note, all 3 patients (11.5%) with eosinophilic esophagitis (EoE), were adult males under the age of 40. There were no EGD failures or complications. Patients with USO: Mean age was 47 (range 27-69 yrs). Underlying mental disorder was present in 8/18 (44.4%) and in all 5 patients (27.7%) with recurrent USO ingestion. Protective measures were used in two instances for the removal of a razor blade (hood) and chicken bone (intubation). There were no EGD failures or complications. Conclusion: The most common FB was AFBO in adults and coins in children. Underlying esophageal pathology is often seen in adult patients with AFBO. USO ingestion and repeated presentations are more common in patients with underlying mental disorders. Endoscopic management of FB in UGIT is safe and highly successful.Table: Underlying esophageal pathology found on EGD in AFBO group

Editorial: Endoscopic Missed Rates of Upper Gastrointestinal Cancers: Parallels With Colonoscopy

Recent publications assessing colonoscopy missed rates of colorectal cancer have generated efforts toward colonoscopy quality improvement. To date, esophagogastroduodenoscopy (EGD) has escaped similar scrutiny in Western populations. Raftopoulos et al. (1) report an upper gastrointestinal cancer missed rate of up to 6.7% in a cohort of 28,000 patients who underwent EGD at a hospital-based endoscopy unit in Perth, Western Australia. Of the missed esophageal and gastric cancers, approximately 80% of patients had alarm symptoms and 73% had abnormalities reported at the time of EGD. The missed cancers may not have been visualized, or were visualized and either not biopsied or biopsied inadequately, or interpreted incorrectly by pathologists. There was no difference in survival between the missed cancers and those detected at the index EGD.

Accuracy and interobserver agreement of small-caliber vs. conventional esophagogastroduodenoscopy for evaluating esophageal varices

Advances in endoscope design have allowed high-quality imaging using small-caliber endoscopes (< 6 mm), and these have been proposed as providing an accurate modality for evaluating esophageal varices in several small studies. We aimed to evaluate the accuracy and interobserver agreement of small-caliber esophagogastroduodenoscopy (EGD) compared with conventional EGD for evaluating esophageal varices in a large prospective cohort. A total of 115 patients with end-stage liver disease and/or portal hypertension were prospectively enrolled into the study. EGD procedures were performed using conventional (8.6-mm) and small-caliber (4.9-mm) endoscopes, back to back and under standard sedation, by two different endoscopists. Esophageal varices were graded at the time of EGD (the "real-time" grade); and by retrospective review of photographs by three endoscopists, when a "consensus" grade (i. e. a grading agreed by two out of the three endoscopists) was used as the final result. Of the 115 patients, 33 patients (29 %) were classified as Child's class A, 47 patients (41 %) as Child's class B, and 35 patients (30 %) as Child's class C. The mean model for end-stage liver disease (MELD) score was 13.6. Thirty-six patients (31 %) had undergone previous ligation of esophageal varices. Compared with conventional EGD, the accuracy of small-caliber EGD for esophageal varices grading was 94 % (consensus grade) and 95 % (real-time grade). Excellent concordance was demonstrated between real-time grade and consensus grade, with a kappa of 0.95 for both types of EGD. There was excellent interobserver agreement between endoscopists, regardless of the type of EGD. The severity of hepatic dysfunction and the presence or absence of a history of previous esophageal varices ligation did not have any impact on the accuracy or interobserver agreement. Small-caliber EGD performed under sedation via oral intubation is a highly accurate and reliable modality for evaluating esophageal varices in patients with end-stage liver disease and/or portal hypertension, regardless of the degree of hepatic dysfunction or history of previous esophageal varices ligation.

Reply to V. Maunoury et al.

We wish to thank Drs. Maunoury and Bulois for their insightful comments. We are in complete agreement and do indeed recommend that, in addition to duodenal biopsies being obtained at the time of esophagogastroduodenoscopy (EGD), gastric biopsies are taken as well. Gastric biopsies should be obtained from both the gastric antrum and body. Histopathological evaluation of gastric biopsies may well provide important additional information, including microscopic evidence for atrophic gastritis and Helicobacter pylori infection, as to the cause of the iron deficiency anemia. Additional serological testing, including that for fasting gastrin levels, anti-parietal cell antibodies, and celiac disease, may also be carried out on a case-by-case basis at the discretion of the treating physician.