Use Of Upper Endoscopy Research Articles

A DSC Test for the Early Detection of Neoplastic Gastric Lesions in a Medium-Risk Gastric Cancer Area.

In this study, we aimed to assess the accuracy of the proposed novel, noninvasive serum DSC test in predicting the risk of gastric cancer before the use of upper endoscopy. To validate the DSC test, we enrolled two series of individuals living in Veneto and Friuli-Venezia Giulia, Italy (n = 53 and n = 113, respectively), who were referred for an endoscopy. The classification used for the DSC test to predict gastric cancer risk combines the coefficient of the patient's age and sex and serum pepsinogen I and II, gastrin 17, and anti-Helicobacter pylori immunoglobulin G concentrations in two equations: Y1 and Y2. The coefficient of variables and the Y1 and Y2 cutoff points (>0.385 and >0.294, respectively) were extrapolated using regression analysis and an ROC curve analysis of two retrospective datasets (300 cases for the Y1 equation and 200 cases for the Y2 equation). The first dataset included individuals with autoimmune atrophic gastritis and first-degree relatives with gastric cancer; the second dataset included blood donors. Demographic data were collected; serum pepsinogen, gastrin G17, and anti-Helicobacter pylori IgG concentrations were assayed using an automatic Maglumi system. Gastroscopies were performed by gastroenterologists using an Olympus video endoscope with detailed photographic documentation during examinations. Biopsies were taken at five standardized mucosa sites and were assessed by a pathologist for diagnosis. The accuracy of the DSC test in predicting neoplastic gastric lesions was estimated to be 74.657% (65%CI; 67.333% to 81.079%). The DSC test was found to be a useful, noninvasive, and simple approach to predicting gastric cancer risk in a population with a medium risk of developing gastric cancer.

157: SPONTANEOUS PNEUMOPERICARDIUM IN THE SETTING OF GASTROPERICARDIAL FISTULA: A CASE REPORT

Introduction: Though a rare cause, gastro-pericardial fistula should be considered and ruled out in the setting of non-traumatic pneumopericardium. Prior bariatric or gastrointestinal surgery should elicit the provider’s suspicion for further workup. Complications include cardiac arrhythmias, sepsis, cardiac arrest, and death. Treatment is primarily surgical with pericardial window and surgical correction of the fistula. Description: A 56-year-old male with a history of gastric bypass presents to the emergency room with dyspnea and left-sided chest pain and becomes hemodynamically unstable with tachyarrhythmia. Imaging is consistent with a pneumopericardium. The patient is taken to the operating room where Esophagogastroduodenoscopy (EGD) shows gastropericardial fistula. He undergoes surgical correction and is returned to Cardiac Care Unit (CCU) where he suffers cardiac arrest. Discussion: Pneumopericardium is a collection of gas within the pericardial cavity and is usually found as a consequence of trauma (blunt and penetrating) in about 60% of patients. In the absence of trauma, other causes of pneumopericardium should be evaluated. Fistulization (from the airways, mediastinum, gastrointestinal tract, and peritoneum), infection (abscesses, pericarditis), complications of surgery or invasive procedures, and congenital abnormalities should be considered. Gastropericardial fistula is a rare and often life-threatening condition. A review in 2016 by Azzu, V reported under 65 described cases in the literature. Chest and shoulder pain was the most common physical finding followed by dyspnea (66 and 20% respectively) with a mean age of 59 years at presentation. Diagnosis includes imaging with air in the pericardial space and echocardiography for rapid assessment of effusion and tamponade physiology. Consensus for the use of upper endoscopy is mixed but should provide visualization of the fistula. Treatment involves pericardial window, gastrointestinal tract repair, and fistula closure. Systemic antibiotic use is essential for the management of infection and septic shock. Hemodynamic and respiratory support should be implemented as necessary with nutritional support and electrolyte balance optimization.

S2696 An Unusual Cause of GI Blood Loss

Introduction: Gastric adenomas are relatively rare, estimated to represent 10% of all gastric polyps. These typically arise in the setting of chronic mucosal inflammation and are thought to represent a premalignant phase along the inflammation-dysplasia-neoplasia sequence during which intervention can prevent or minimize progression to carcinoma. Foveolar-type adenomas, however, typically arise in areas of relatively unremarkable gastric mucosa and are generally less aggressive than other adenoma subtypes. These lesions are commonly associated with hereditary tumor syndromes such as familial adenomatous polyposis but can also occur sporadically. We present a case of newly identified iron deficiency anemia (IDA) that was found to have a gastric foveolar-type adenoma as a rare cause of GI blood loss. Case Description/Methods: A 73-year-old male with granulomatous hepatitis and metabolic syndrome presented for evaluation of IDA. Colonoscopy was notable for one 3 mm polyp in the transverse colon. EGD revealed a 15 mm gastric polyp with a raspberry appearance in the cardia with stigmata of bleeding and a 5 mm sessile polyp with mild central depression in the gastric body. Histology revealed that the larger polyp had low-grade polypoid dysplasia consistent with a foveolar-type adenoma. The smaller polyp was found to be a well-differentiated neuroendocrine tumor. The singular colonic polyp returned as a simple tubular adenoma. A repeat EGD was performed 6 months after polypectomies with no residual lesions. It was determined that the foveolar adenoma located at the cardia was the source of IDA, while the neuroendocrine tumor was just an incidental finding. (Figure) Discussion: While sporadic foveolar-type adenomas and GNET’s in helicobacter pylori- uninfected stomachs are infrequently encountered in clinical practice, their incidence is continuing to rise, due to the increased use of upper endoscopy as a diagnostic tool. Although foveolar-type adenomas are usually benign, this case had low-grade dysplasia and chronic oozing blood as the main reason for iron-deficiency anemia. In addition, this patient also needed prompt evaluation regarding the management of GNET as angioinvasion and metastasis are common. Although these lesions are typically identified incidentally, it is important for the gastroenterologist to keep them in the differential for common complaints such as gastrointestinal bleeding (GIB). This case highlights the importance of early endoscopic evaluation of GIB.Figure 1.: A. Gastric polyp with raspberry-like appearance located in the cardia. Stigmata of recent bleeding seen. B. Histology of gastric foveolar-type adenoma showing surface papillary projections lined with foveolar-type epithelium. Surface epithelium with cytoplasmic neutral mucins.

Can we use non-invasive parameters to predict the development of gastroesophageal varices in cirrhotic patients with and without portal vein thrombosis? An observational study from the western region of Saudi Arabia

BackgroundThe prevention of portal hypertensive complications, including upper gastrointestinal bleeding, is critically important and achieved only through the use of upper endoscopy for the management of oesophageal gastric varices (EGVs). There is a paucity of data and limited utilization of non-invasive predictive parameters to guide the selection of patients who may benefit from endoscopic surveillance, especially in cirrhotic patients with coexistent portal vein thrombosis.ResultsThe study was conducted in eight hospitals in the western region of Saudi Arabia over the period of 2015–2017. Among 1349 chronic liver disease patients, eighty-five patients with complete endoscopic findings were included in the study. Twenty-eight patients were diagnosed with non-malignant PVT. Twenty-five patients (89%) developed oesophageal varices, compared with 57 patients with cirrhosis without PVT. A predictive factor for the development of oesophageal varices of statistical significance was hypoalbuminemia in PVT patients (p=0.04). No statistically significant differences were found in other biochemical markers (p<0.05) between the PVT and non-PVT groups.ConclusionsThe prevalence of oesophageal varices is increased in PVT patients. Serum albumin can be utilized as a predictor of varices development in cirrhosis patients.

The pathology of gastric and duodenal polyps: current concepts

The liberal use of upper endoscopy has led to an increased detection of gastric and duodenal polyps, which are identified in as many as 6 and 4.6% of patient examinations, respectively. Gastroduodenal polyps are a heterogeneous group of lesions that can be neoplastic or non-neoplastic (e.g. hyperplastic or heterotopical). Most polyps present characteristic topographical features, as well as endoscopic appearance and size. Evaluation of the surrounding mucosa is essential in assessing the underlying pathology (e.g. Helicobacter pylori, autoimmune gastritis or inherited polyposis syndromes). Phylogenetically, gastric and duodenal polyps can be classified according to the epithelial compartment from which they derive. Polyps that arise from the surface epithelium can either be of foveolar or intestinal type, and they can develop from either the native mucosa or the metaplastic epithelium (gastric intestinal metaplasia or duodenal foveolar metaplasia). Other polyps develop from the deeper glandular component, such as pyloric/oxyntic gland derived subtypes. In this review we focus upon epithelial polyps, with an emphasis on the most common and clinically relevant lesions, and present recently described entities.

S2979 Type III Gastric Neuronendocrine Tumor: Case Report of a Rare Gastric Carcinoma

INTRODUCTION: Gastric neuroendocrine tumors (GNETs) are rare lesions that compromise 0.1-0.6% of all gastric cancers. The average of GNETs is 2.5 cases per 100,000 per year, with recently increased incidence in the United States due to widespread use of upper endoscopy. GNETs are classified into three groups, based on pathogenesis and histomorphologic characteristics; these types differ in biologic behavior and prognosis, ranging from benign to highly malignant with extremely poor prognosis. Type I is the major subtype of GNETs, associated with chronic atrophic/ autoimmune gastritis with pernicious anemia. Type II GNETs is associated with multiple endocrine neoplasia-1, and Zollinger-Ellison syndrome. Type III GNETs represent the second most common type, which behaves aggressively with rates of metastasis higher than 50%, and tumor related death over 25-30%. CASE DESCRIPTION/METHODS: The patient was a 63 year old who presented for reevaluation of recurrent anemia. Upon readmission, patient was found to be anemic and required PRBC transfusions. Repeat EGD showed a large 2-3cm ulcerated mass with clean base ulcer and rolled over edges in the proximal body/ greater curvature of the stomach, multiple biopsies taken. Tissue was sent for an expert opinion and was reported an unusual neuroendocrine carcinoma. Three endocrine marker stains: chromogranin, synaptophysin, and CD56, all tested strongly positive confirming the diagnosis. DISCUSSION: Type III NETs develop in the absence of hypergastrinemia, and tend to pursue an aggressive clinical course compared to Type I and Type II NETs. Type III NETs have the greatest potential to generate metastasis, with survival also being worse (75-80% at five years compared to 90-95% for Type I). They are sporadic and usually present as a single large ( >2cm) mass with normal gastrinemia. Immunohistochemical analysis is essential in GNETs, which allows diagnostic confirmation and permits classifying lesions according to histological grades. For diagnostic confirmation chromogranin A and synaptophysin are necessary; while for prognostic definition proliferation index Ki-67 and number of mitoses per high magnification field are required. Poor prognosis factors are: lesion >2cm, deep submucosal invasion or beyond; Ki-67 > 3%, vascular invasion, low degree of structural differentiation, presence of atypia and/or necrosis. Type III lesions should be managed aggressively with total or subtotal gastrectomy, if metastasis are found systemic cytotoxic chemotherapy should be provided.Figure 1.: Type III Gastric Neuroendocrine Tumor.Figure 2.: Type III GNET (retroflexion).

OC.04.5: Audit Methodology Focused on Chronic Gastritis Could Improve Appropriate use of Upper Endoscopy in Clinical Practice

OC.04.5: Audit Methodology Focused on Chronic Gastritis Could Improve Appropriate use of Upper Endoscopy in Clinical Practice

PTU-031 What is The Value of Performing An Endoscopy in Patients Under The Age of 50 With Symptoms of Gastro-Oesophageal Reflux Disease

Introduction For gastro-esophageal reflux (GORD), upper endoscopy may be indicated in older men with chronic GORD symptoms (greater than 5 years) and additional risk factors such as elevated body mass index and tobacco use, to increase detection of Barretts oesophagus and esophageal adenocarcinoma. Upper endoscopy is indicated in patients with GORD and alarm symptoms such as dysphagia, weight loss, bleeding, anaemia and recurrent vomiting. Without alarm symptoms upper endoscopy is only indicated when symptoms of GORD persist or progress despite appropriate medical therapy. Inappropriate use of upper endoscopy does not improve the health of patients, exposes them to preventable harms, can lead to unnecessary interventions and result in unnecessary costs with no benefit. Our aim was to assess the findings at upper endoscopy performed in patients under the age of 50 presenting with GERD without alarm symptoms. Methods A single centre, retrospective analysis in a large London NHS Foundation Hospital was performed. All patients endoscoped for reflux were identified using Unisoft Endoscopy reporting software across a period of 10 years (June 2005-May2015). Data from the patients’ electronic records was reviewed for histological diagnosis of Barrett’s or cancer. Results 124 of the 1772 patients endoscoped for reflux symptoms alone were found to have Barrett’s (7%). 627 of the 1772 patients were under the age of 50 at time of endoscopy Out of the patients under the age of 50, 23 (3.6%) were identified as having Barrett’s at the time of endoscopy but histologically proven in only 13 (2%) the others were shown to have reflux oesophagitis only. No patients were found to have cancer of the oesophagus or stomach. Out of the 13 patients with proven Barrett’s 4 patients had a length longer than 3 cm with a maximum length of 6 cm. All other patients had short segments of Barrett’s (less than 3 cm) and none had evidence of dysphasia or malignancy. Conclusion The role of endoscopy in patients under the age of 50 with symptoms of GORD only would appear to be an inappropriate first line investigation. In our case series only 2% patients endoscoped under the age of 50 were identified a histological positive diagnosis of Barrett’s. Inview of current guidelines only 0.3% would require surveillance endoscopy but this in itself remains questionable. Disclosure of Interest None Declared

Airway observations during upper endoscopy predicting obstructive sleep apnea.

BackgroundThis pilot study examined airway characteristics during upper endoscopy to determine who is at high risk for obstructive sleep apnea.MethodsPatients undergoing routine upper endoscopy were divided into 2 groups according to the Berlin Questionnaire (high and low risk for sleep disordered breathing). Patients underwent routine upper endoscopy using propofol sedation. The airway was then evaluated for no, partial, or complete collapse at the levels of the palate/uvula/tonsils, the tongue base, the hypopharynx, and the larynx. They were given a score of 0 for no collapse, 1 for partial collapse, and 2 for complete collapse. The score for each of these levels was added to give a total score or severity index. The larynx was also evaluated for lateral pharyngeal collapse (minimal, up to 50%, >50%, or 100%).ResultsWe found that patients with a partial obstruction at the level of the palate/uvula/tonsils, tongue base, hypopharynx, or larynx, or complete obstruction at any level more often had a positive Berlin questionnaire. Patients with a positive Berlin questionnaire were more often of increased weight (mean 197 vs 175 lbs, P=0.19), increased body mass index (31.2 vs 27.42 kg/m2, P=0.11), increased neck circumference (36.7 vs 34.7 cm, P=0.23), and had a higher total airway score (2.61 vs 1.67, P=0.09).ConclusionsThe results of our pilot study represent preliminary data regarding the use of upper endoscopy as a potential tool to evaluate patients for obstructive sleep apnea.

Usefulness of Upper Endoscopy for Pre-bariatric Surgery Clearance: A Look at a Predominantly Minority Population

Introduction: Obesity has reached epidemic proportions in the US. More than third the U.S population is estimated to have a BMI of > 30. As per CDC, the prevalence of obesity is highest in African Americans. The annual medical cost of obesity in the U.S. was estimated at $147 billion in 2008 U.S. dollars. In recent years, bariatric surgery is garnering increasing attention as a modality of weight reduction. From 1994 to 2005, there was a tenfold increase in the number of bariatric surgeries performed in the United States and it is expected to be one of the most common procedures in the next twenty years. Many physicians perform pre-operative esophagogastroduodenoscopy (EGD) before performing a bariatric surgery. Finding significant pathology on endoscopy could potentially alter the course of management and the patient's eligibility for bariatric surgery. However, due to a lack of studies the true efficacy of performing an endoscopy in this case remains unknown. Methods: In this retrospective study, we reviewed all upper endoscopies done for pre-operative evaluation of bariatric surgery over a period of two years from December 2012 to December 2014. Outcome data of endoscopic and pathological finding were analyzed. Results: 119 patients were included in the study. The average age was 39 years. 86.5% were female. 54.6% were African Americans and 13.4% were Hispanics. The average BMI was 48.7, 48.2 and 47.2 in the total population, African Americans and Hispanics respectively. Chronic gastritis was the most common finding on pathology (74.7% total study population, 76.9% African Americans and 68.7% Hispanics). 42.8% of total study population had reactive gastropathy which was more common in African Americans than in Hispanics (46.1% Vs 25 %). H. pylori was more common in Hispanics than African Americans (43.7% vs 35.3% respectively). Hiatus hernia was present in 28.5% of total population, 46.1% of African Americans and 18.7% of Hispanics. 10.9% of total population had gastric ulcers. All ulcers were superficial, white based and non-bleeding. 50% of the gastric ulcers had positive H. pylori. Intestinal metaplasia was found in 4.2 % of population. There was no significant difference in endoscopic and pathological finding in patients with BMI < 40 vs. 40-50 vs. > 50. Conclusion: This study appears to indicate an important role for upper endoscopy prior to bariatric surgery particularly in a minority population.

Optimal management of biopsy-proven low-grade gastric dysplasia.

Gastric adenocarcinoma generally culminates via the inflammation-metaplasia-dysplasia-carcinoma sequence progression. The prevalence of gastric adenomas shows marked geographic variation. Recently, the rate of diagnosis of low-grade dysplasia (LGD) has increased due to increased use of upper endoscopy. Many investigators have reported that gastric high-grade dysplasia has high potential for malignancy and should be removed; however, the treatment for gastric LGD remains controversial. Although the risk of LGD progression to invasive carcinoma has been reported to be inconsistent, progression has been observed during follow-up. Additionally, the rate of upgraded diagnosis in biopsy-proven LGD is high. Therefore, endoscopic resection (ER) may be useful in the treatment and diagnosis of LGD, especially if lesions are found to have risk factors for upgraded histology after ER, such as large size, surface erythema or depressed morphology. Fatal complications in endoscopic submucosal dissection (ESD) are extremely low and its therapeutic and diagnostic outcomes are excellent. Therefore, ESD should be applied preferentially instead of endoscopic mucosal resection.

Appropriateness of Upper Gastrointestinal Endoscopy in Patients With Gastroesophageal Reflux Disease (GERD): A Single-Center Experience

Introduction: GERD accounts for a large number of outpatient clinic visits and is the most common diagnosis of all presenting GI related complaints. The diagnosis is often made clinically but upper endoscopy is commonly used in its diagnosis and management. In this study, we sought to examine the appropriateness of upper endoscopy in patients with GERD in our center according to guidelines. Methods: We reviewed the records of patients diagnosed with GERD at the East Orange VA Medical Center from 01/2012 to 01/2013 for demographics, duration of symptoms, failure of treatment (twice daily PPI therapy for at least 6-8 weeks with lifestyle changes), presence of alarm symptoms (dysphagia, odynophagia, persistent vomiting, >5% weight loss, GI bleeding, anemia) and reasons for upper endoscopy if performed. Performing endoscopy was judged inappropriate in patients with GERD who did not meet any of the following criteria: failure of medical treatment, presence of alarm symptoms or screening for Barrett’s esophagus (> 50 year old Caucasian males with symptoms >5 years). Fisher’s exact test was used to analyze the influence of demographics on the appropriate use of upper endoscopy. Statistical analysis was done using SPSS. Results: There were 101 patients diagnosed with GERD. Ninety-six had sufficient data for review and were analyzed. Median age was 77 (42-98) years. 49% (47) of patients had endoscopy performed. Among them, 83 (39%) of endoscopies were defined as appropriate. Among the 49 patients who did not have endoscopies, an endoscopy would have been appropriate in 16 (32.7%) of them according to guidelines. On univariate analysis, there was no significant difference by age, race or sex as an influence on appropriate use of upper endoscopies. Conclusion: Upper endoscopy is the most widely used investigative procedure for GERD but its limitations and potential for overuse should be recognized. At our center, 17% of endoscopies performed for the management and treatment of GERD were inappropriate. More studies are needed to explore factors associated with inappropriate use of upper endoscopy in the management of GERD.Table 1: Indications for Upper Endoscopy in Patients With GERD

Use of Upper Endoscopy in Solid Organ Transplant Recipients to Determine Utility as a Pretransplant Procedure

Introduction: Gastrointestinal bleeding (GIB) from gastro-duodenal ulcerations have been commonly observed in patients receiving solid organ transplantation. Several factors have been postulated, including the use of immunosuppressive medications such as steroids. Some centers have opted for pre-transplant upper gastrointestinal evaluations to predict these complications. However, there have been no outcome studies assessing a large number of patients undergoing various solid organ transplantations. Aim: To determine the frequency of upper endoscopy performed in post-transplant patients and report the frequency of GIB. Methods: We reviewed the charts of all patients who underwent solid organ transplant (kidney, liver, lung or heart) from 2009-2013 at a single transplant center. Data for up to 1 year post-transplant was reviewed. Patients were excluded if they died within 48 hours of transplant or had no follow-up. Results: Two hundred forty-three patients were identified who underwent solid organ transplantations. Twenty-one patients were excluded for lack of follow-up or early mortality. For the 222 patients included, the mean age was 57.0 years with a 72.5% male predominance. Mean length of follow-up was 335 days. The organs of transplant were: 31.1% liver, 28.8% kidney, 27.9% lung, 9.5% heart, and 2.7% heart-lung. Among this population, 94.6% were taking steroids, 48.2% were taking non-steroidal anti-inflammatory drugs (NSAIDs) or aspirin, 12.2% were taking anti-coagulants, and 6.8% were on a combination of both. 11.3% of patients had thrombocytopenia (platelets <100). 68.5% were on a proton-pump inhibitor [PPI] and 13.1% on H2 receptor antagonists (H2RA). Of the 16/222 (7.2%) patients requiring an upper endoscopy, only 3 (1.4%) were performed for overt GIB. None of the three patients with GIB had thrombocytopenia or coagulopathy. Two with GIB were on aspirin, NSAIDs, and prednisone, and 1 was not on either PPI or H2RA. Conclusion: Clinically significant GIB in the 1-year post-transplant was seen in only 1.4% of the recipients. While many of the recipients were on acid suppression medication, these patients did have multiple risk factors for upper GIB, including the use of steroids, NSAIDs, and anti-coagulants. Despite these high-risk states, the incidence of GIB remains low. This study does not support the need for routine pre-transplant upper endoscopy.

Impact of Pediatric Rome III Criteria of Functional Dyspepsia on the Diagnostic Yield of Upper Endoscopy and Predictors for a Positive Endoscopic Finding

Pediatric Rome III criteria of functional dyspepsia (FD) has eliminated the mandatory use of upper endoscopy and recommended a symptom-based approach. In the absence of alarm symptoms, FD can be positively diagnosed in children having normal physical findings without exclusionary investigations. We aimed to investigate the effectiveness of Rome III guidelines to discriminate organic diseases from FD and to identify the predictors for positive endoscopic findings. A prospective study was conducted on consecutive children fulfilling Rome III criteria of FD. Upper endoscopy was performed in all subjects, both with and without alarm features. Eighty consecutive children ages 7 to 15 were recruited. Nine (11.3%) had experienced alarm features. Five (6.3%) had organic diseases confirmed in upper endoscopy: duodenal ulcer (n = 2), duodenitis with erosion (n = 2), and gastritis with erosion (n = 1), 33.3% of children having alarm features had organic pathology, compared with 2.8% of those without (P < 0.01). A male predominance (80% vs 25.3%, P < 0.01), higher prevalence of alarm features (60% vs 8%, P < 0.01), and higher prevalence of Helicobacter pylori infection (80% vs 5.3%, P < 0.01) were found in children with organic diseases, compared with FD. Multivariate analysis identified H pylori infection (odds ratio 23.2; 95% confidence interval 1.5-333) and nocturnal pain (odds ratio 26.3; 95% confidence interval 1.2-500) to be independent predictors for positive endoscopic findings. Rome III recommendations of screening dyspeptic children for alarm features and investigation for H pylori are effective to identify children who have a higher likelihood of organic diseases and require upper endoscopy before making a diagnosis of FD.

When does testing for GERD become cost effective in an integrated health network?

Gastroesophageal reflux (GERD) is the most common gastrointestinal disorder, affecting as many as 14% of the US population. Rising rates of esophageal adenocarcinoma are seen in this population, and chronic proton pump inhibitor (PPI) use does not normalize cancer risk. It has also been demonstrated that up to one-third of patients on PPI therapy did not actually have GERD and could be taken off the medication. These facts form the basis for a quality-assurance study of care provided to patients in an integrated health care network who were on high-dose, long-term PPI therapy. A cost-benefit analysis of patients who were on double-dose PPI therapy for more than 6 months was performed. Pharmacy, facility, physician reimbursement, and radiologic data from a cohort who were both primary-care patients and insured in our system were utilized. Two hundred and twenty-four patients were prescribed a double dose of this medication for over 6 months. Utilizing a 4.5% discount rate, our break-even analysis showed that Bravo testing [with esophagogastroduodenoscopy (EGD)] needed to identify those patients who could be taken off PPI therapy paid for itself in 33 months. Bravo + EGD + manometry testing needed to screen for other possible pathologies paid for itself in 38 months. Bravo + barium swallow + EGD testing to screen patients for possible esophageal adenocarcinoma paid for itself in 42 months. Bravo + barium swallow + manometry + EGD testing paid for itself in 47 months. Significant savings can be realized through early use of upper endoscopy, Bravo testing, barium swallow, and manometry to identify patients that are taking double-dose PPIs unnecessarily based on presumptive diagnosis of GERD. This early testing also has the potential to diagnose a variety of other clinically important pathologic conditions more readily.

Resection of Benign Duodenal Neoplasms

Primary small bowel neoplasms (PSBN) are uncommon, accounting for less than 15 per cent of all gastrointestinal tumors. Benign duodenal neoplasms (BDN) are rare, comprising only 10 to 20 per cent of all PSBN. The treatment is generally surgical resection ranging from local excision to pancreaticoduodenectomy depending on size, location, and number of lesions. Patients undergoing surgical treatment for BDN at Vanderbilt University Medical Center from July 1984 to April 2006, were identified and reviewed retrospectively. Medical records were examined for demographics, operative details, results, and complications. Twenty-six patients were identified of which 56 per cent were male and the mean age was 56 +/- 14 years. Lesions were found throughout the duodenum, but the majority (62%) were ampullary. Nearly 75 per cent were adenomas, including over half with dysplasia. Operative interventions and complication rates were: duodenal resection with primary anastomosis (n=3, 0%), local excision (n=6, 50%), ampullary resection (n=10, 30%), and pancreaticoduodenectomy (n=7, 86%). There were no reoperations or mortalities. Mean followup was 14 months. BDN are an increasingly common problem in an era of frequent use of upper endoscopy. The surgical management of these lesions must be tailored to their size, number, location, and malignant potential. A wide variety of surgical procedures can be performed with acceptable morbidity.

Liver Abscess as a Complication of Esophgeal Balloon Dilation

Purpose: Despite the increase use of upper endoscopy, the complication rate has remained low. Infectious complications of EGD include transmission of infection by contaminated endoscopes or ancillary equipment, bacteremia and aspiration pneumonia. Here, we are reporting a liver abscess followed a routine upper endoscopy dilation in patient with gastric bypass. Methods: A 59 year old patient with history of gastric bypass 19 years ago presented with intermittent dysphagia has been going on for the last few months. Her upper endoscopy was remarkable for schatzki ring and gastric pouch contained undigested food. The gastrointestinal anastomosis was patent. The schatzki ring was dilated using CRE balloon 15–18 mm with evidence of breaking the mucosa at 16.5 and 18 mm. Her other past medical history was significant otherwise for thyroid cancer, thyroidectomy 20 years ago, tobacco and ETOH abuse. Patient presented with right upper quadrant pain 2 days after the EGD to outside facility. She was treated symptomatically. Pain returned and patient developed fever and chills. CT scan of the abdomen performed at our facility 2 weeks after the EGD showed left hepatic lobe abscess. US guided drainage grew Candida Albicans, streptococcus Solivarius, and Beta Hemolytic Strep Group B. Esophagogram failed to show any leak or perforation. The abscess resolved with IV antibiotic and percutaneous drainage without the need for surgery. Results: The timing between the onset of her symptoms and the EGD suggest causal relationship. This is most likely related to transient bacteremia secondary to the dilation. Her altered anatomy, gastroparesis and ETOH intake, probably predisposed her for the bacteremia and the immune suppression status. Conclusion: Esophageal dilation has the highest incidence of bacteremia of all gastrointestinal endoscopic procedures, occurring in approximately 45 percent of cases. In spite of this, complications of bacteremia such as endocarditis are rare. The most common reported complication is endocarditis, and less frequently meningitis. Antibiotic prophylaxis is not warranted in most patients undergoing esophageal dilation except for those at high risk. People with immunosupressed status or altered anatomy might need to be considered for prophylaxis.

Appropriateness of upper-GI endoscopy: an Italian survey on behalf of the Italian Society of Digestive Endoscopy

Open-access endoscopy allows physicians to directly schedule endoscopic procedures for their patients without prior consultation. An evaluation of both appropriateness and diagnostic yield of endoscopic procedures is critical when assessing the costs and benefits of endoscopy in an open-access setting. The aim of this Italian multicenter study was to assess the appropriate use of upper endoscopy (EGD) in an open-access system and to establish the yield of diagnostic information relevant to patient care. Cross-sectional, prospective, multicenter study. A total of 6270 patients referred to 44 Italian centers for open-access EGD during 1 month were prospectively enrolled. The American Society for Gastrointestinal Endoscopy (ASGE) guidelines were used to assess the relation between the appropriate use of EGD and the presence of relevant endoscopic findings. The rate for "generally not indicated" EGDs was 22.9%: 29.4% for primary care physicians and 12.9% for specialists (P < .01). A relevant endoscopic finding was detected in 2929 examinations (46.7%). The diagnostic yield was significantly higher for "generally indicated" EGDs compared with "generally not indicated" procedures (52% vs 29%; odds ratio [OR] 2.65, 99% confidence interval [CI] 2.23-3.20; P < .01). Of the 133 malignant lesions diagnosed, all but 1 were diagnosed in patients with an appropriate indication (OR >20, 99% CI 3 to >100; P < .01). Open-access EGD is an useful procedure for clinical practice. Because most of the relevant findings were detected during examinations performed for appropriate indications, the use of ASGE guidelines emerges as crucial to the cost-effectiveness of an open-access system.

Esophageal Overtube Facilitation of Transesophageal Echocardiography in Patients with Previously Difficult Esophageal Intubation

In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

Use of upper endoscopy to evaluate patients with a positive faecal occult blood test and negative colonoscopy: Is it appropriate?

e i 3 i d positive FOBT who have a negative colonoscopy. Among the 99 patients, 70 had a normal colonoscopic xamination and 29 had a potential source of occult bleeding dentified by colonoscopy. Overall, the authors found that 5 of the 99 patients (35%) had an abnormal EGD. Interestngly, the proportion of patients who had an abnormal EGD id not differ between subjects with a normal colonoscopy in diameter (17–27%) is low [6,11,12]. There are several reasons that may explain the low positive predictive value of FOBT for CRC and large polyps, including use of the test in a low-risk screening population, bleeding from trivial colonic lesions other than CRC or large polyps, blood loss from the upper gastrointestinal tract, non-compliance