Development of a Low-Cost Gastroscope Prototype (GP) for Potential Cost-Effective Gastric Cancer Screening in Prevalent Regions

Background Screening for gastric cancer is known to be associated with reduced mortality in populations with high prevalence. However, many countries with high prevalence do not screen, with high costs being a significant reason for this.

Aims To describe, develop, and assess the potential for a low-cost gastroscope for early cancer screening and patient risk stratification.

Methods Our interdisciplinary team used both off-the-shelf and fabricated components to create multiple gastroscope prototypes (GP) in iterative fashion based off clinician feedback. Clinician endoscopists were surveyed using Likert scales regarding device potential, video quality, and handling when testing on a GI training device. Video quality comparison to clinically standard high-definition white light endoscopy (HD-WLE) was done using the absolute categorical ratings (ACR) method.

Results A candidate cost-effective GP with clinical potential was developed. Although initial versions were scored as inferior via ACR on all views tested when compared to HD-WLE (p < 0.001), participants agreed the concept may be beneficial (M = 4.52/5, SD = 0.72). In testing improved versions, participants agreed the device had the ability to identify discrete (M = 4.62/5, SD = 0.51) and subtle lesions (M = 4/5, SD = 0.7) but most felt video quality, although improved, was still less than HD-WLE. Sufficiency of maneuverability of device to visualize gastric views was rated as equivocal (M = 2.69/5, SD = 1.25). Conclusion The presented low-cost gastroscopic devices have potential for clinical application. With further device development and refinement including the possible addition of technologies in telemedicine and artificial intelligence, we hope the GP can help expand gastric cancer screening for populations in need.

Therapeutic Impact of Deep Balloon-assisted Small Bowel Enteroscopy on Red Blood Cell Transfusion

Objective Evaluate impact of balloon-assisted deep small bowel enteroscopy on red blood cell transfusion requirement in patients with obscure gastrointestinal (GI) bleeding.

Methods Retrospective study of patients, who underwent balloon-assisted deep enteroscopy with double-balloon enteroscopy (DBE) at two tertiary care academic centers (University of Wisconsin and Aurora St. Luke’s Medical Center) over a 55-month consecutive period. Sixty-nine patients with reliable blood transfusion records were identified during this time period. DBE was preceded by small bowel capsule endoscopy (CE) within 1 year in 38 cases. Transfusion requirements 6 months prior and postintervention were measured to see if DBE had any impact on the need for blood transfusions.

Results Sixty-nine patients (25 females and 44 males) were included. Mean age ± standard deviation (SD) was 63 ± 17 years. Wilcoxon signed rank test statistics were used to find the difference in the rate of blood transfusion. There was a statistically significant decrease in rate of packed red blood cell (pRBC) transfusion post DBE and endoscopic therapy with coagulation (p < 0.001). Argon plasma coagulation was used to ablate all arteriovenous malformations (AVMs) except in one (subepithelial lesion). Those that required > 5 units pRBC transfusions pre-DBE had the most benefit.

Conclusions Our study demonstrates that transfusion requirements are significantly reduced in those undergoing therapy with DBE and coagulation for obscure GI bleed.

Impact of a novel protocol for atrial fibrillation management in outpatient gastrointestinal endoscopic procedures: a retrospective cohort study

BACKGROUND

Atrial fibrillation (AF) may result in procedure cancellations and emergency department (ED) referrals for patients presenting for outpatient GI endoscopic procedures. Such cancellations and referrals delay patient care and can lead to inefficient use of resources.

METHODS

All consecutive patients presenting in AF for a colonoscopy or upper endoscopy to the University of Wisconsin Digestive Health Center between October 2013 and September 2014 were defined as the pre-intervention group (Group 1). In 2015, a protocol was initiated for peri-procedural management of patients presenting in AF, new onset or previously known. All consecutive patients after initiation of the protocol from October 2015 to September 2016 were analyzed as the post intervention group (Group 2). Patients with heart failure, hypotension, or chest pain were excluded from the protocol.

RESULTS

One hundred nine and 141 patients were included in Groups 1 and Group 2, respectively. Following protocol initiation, patients were less likely to present to the ED (6.4% Group 1 vs. 1.4% Group 2, RR 0.22, p = 0.04). There was also a trend towards a reduction in procedure cancelations (5.5% Group 1 vs. 1.4% Group 2, RR 0.26, p = 0.08). All attempted procedures were completed and there were no complications in the intervention group.

CONCLUSIONS

Implementation of a standardized protocol for management of atrial fibrillation in patients presenting for outpatient gastrointestinal endoscopic procedures resulted in a significant decrease in emergency department visits with an additional trend toward decreased procedural cancellations without an increased risk of complications.

A tertiary care hospital's 10 years' experience with rectal ultrasound in early rectal cancer

Background and Objectives:

Rectal endoscopic ultrasound (RUS) has become an essential tool in the management of rectal adenocarcinoma because of the ability to accurately stage lesions. The aim of this study was to identify the staging agreement of early RUS-staged rectal adenocarcinoma with surgical resected pathology and ultimately determine how this impacts the management of early rectal cancer (T1–T2).

Methods:

Retrospective chart review was performed from November 2002 to November 2013 to identify procedure indication, RUS staging data, surgical management, and postoperative surgical pathology data.

Results:

There were a total of 693 RUS examinations available for review and 282 of these were performed for a new diagnosis of rectal adenocarcinoma. There was staging agreement between RUS and surgical pathology in 19 out of 20 (95%) RUS-staged T1 cases. There was staging agreement between RUS and surgical pathology in 3 out of 9 (33%) RUS-staged T2 cases. There was significantly better staging agreement for RUS-staged T1 lesions compared to RUS staged T2 lesions (P = 0.002). Nearly 60% of T1N0 cancers were referred for transanal excisions (TAEs), and 78% of T2N0 cancers underwent low anterior resection.

Conclusions:

This study identified only a small number of T1–T2 adenocarcinomas. There was good staging agreement between RUS and surgical pathology among RUS-staged T1 lesions whereas poor staging agreement among RUS-staged T2 lesions. Although TAE is largely indicated by the staging of a T1 lesion, this approach may be less appropriate for T2 lesions due to high reported local recurrence.

Endoscopic ultrasound-guided pancreatic pseudocyst cystogastrostomy using a novel self-expandable metal stent with antimigration system: A case series

Background and Objectives:

Development of symptomatic pseudocysts after acute pancreatitis is a common occurrence. Endoscopic ultrasound (EUS)-guided transmural drainage has become the treatment of choice for symptomatic pseudocysts. Following this procedure, stent migration can occur. A recently developed fully covered biliary metal stent with antimigration system has shown promise as an alternative endoprosthetic option for cystogastrostomy. The aim of this study is to describe the success and complications of using covered metal stents with antimigration system to drain pseudocysts at a single tertiary care center.

Materials and Methods:

The patients undergoing cystogastrostomy using the biliary metal stent with antimigration system over the course of a 10-month period (January-November, 2014) were retrospectively reviewed and all the pertinent information including length of the follow-up, age and sex of the patient, pseudocyst size, pseudocyst size at follow-up, and symptom improvement were recorded.

Results:

Five patients underwent endoscopic cystogastrostomy using a biliary metal stent with antimigration system. The average age of the patients was 57 years, with all the patients being males. The average size of the largest dimension of pseudocyst was 9 cm. The average follow-up time to repeat imaging was 30 days. All the patients had a significant improvement in their pseudocyst size, with two patients having complete resolution, one patient with a residual 2 cm cyst, and another with a residual 5 cm pseudocyst at follow-up. The average size at follow-up was 2 cm. No complications occurred during the follow-up period. No episodes of stent migration occurred. All the patients had symptom improvement at follow-up.

Conclusion:

Using a novel biliary covered self-expandable metal stent with antimigration system with EUS guidance to drain pseudocysts appears to be a safe and effective procedure in certain settings. Our experience shows rapid cyst resolution with no complications and no stent migration. This stent gives the providers another option when performing cystogastrostomy.

Endoscopic ultrasound in the evaluation of pancreatic neoplasms-solid and cystic: A review

Pancreatic neoplasms have a wide range of pathology, from pancreatic adenocarcinoma to cystic mucinous neoplasms. Endoscopic ultrasound (EUS) with or without fine needle aspiration (FNA) is a helpful diagnostic tool in the work-up of pancreatic neoplasms. Its utility in pancreatic malignancy is well known. Over the last two decades EUS-FNA has become a procedure of choice for diagnosis of pancreatic adenocarcinoma. EUS-FNA is highly sensitive and specific for solid lesions, with sensitivities as high as 80%-95% for pancreatic masses and specificity as high as 75%-100%. Multiple aspects of the procedure have been studied to optimize the rate of diagnosis with EUS-FNA including cytopathologist involvement, needle size, suctioning and experience of endoscopist. Onsite pathology is one of the most important elements in increasing diagnostic yield rate in EUS-FNA. EUS-FNA is valuable in diagnosing rare and atypical pancreatic neoplasms including neuroendocrine, lymphoma and metastatic disease. As more and more patients undergo cross sectional imaging, cystic lesions of the pancreas are becoming a more common occurrence and EUS-FNA of these lesions can be helpful for differentiation. This review covers the technical aspects of optimizing pancreatic neoplasm diagnosis rate, highlight rare pancreatic neoplasms and role of EUS-FNA, and also outline the important factors in diagnosis of cystic lesions by EUS-FNA.

From Capsule Endoscopy to Balloon-Assisted Deep Enteroscopy: Exploring Small-Bowel Endoscopic Imaging

In the past 15 years, the use of endoscopic evaluations in patients with obscure gastrointestinal bleeding has become more common. Indications for further endoscopic interventions include iron deficiency anemia, suspicion of Crohn's disease or small-bowel tumors, assessment of celiac disease or of ulcers induced by nonsteroidal anti-inflammatory drugs, and screening for familial adenomatous polyposis. Often, capsule endoscopy is performed in concert with other endoscopic studies and can guide decisions regarding whether enteroscopy should be carried out in an anterograde or a retrograde approach. Retrograde endoscopy is beneficial in dealing with disease of the more distal small bowel. Multiple studies have examined the diagnostic yield of balloon-assisted deep enteroscopy and have estimated a diagnostic yield of 40% to 80%. Some of the studies have found that diagnostic yields are higher when capsule endoscopy is performed before balloon-assisted deep enteroscopy in a search for small-bowel bleeds. Each of these procedures has a role when performed alone; however, research suggests that they are especially effective as complementary techniques and together can provide better-directed therapy. Both procedures are relatively safe, with high diagnostic and therapeutic yields that allow evaluation of the small bowel. Because both interventions are relatively new to the world of gastroenterology, much research remains to be done regarding their overall efficacy, cost, and safety, as well as further indications for their use in the detection and treatment of diseases of the small bowel.

Differentiating primary pancreatic lymphoma from adenocarcinoma using endoscopic ultrasound characteristics and flow cytometry: A case-control study

Background:

Primary pancreatic lymphoma (PPL) is a rare pancreatic neoplasm that is difficult to diagnose. PPL has a vastly different prognosis and treatment regimen than other pancreatic tumors; therefore, accurate diagnosis is vital. In this article, we describe the characteristic presentation, endoscopic ultrasound (EUS) features, and the role of fine-needle aspiration (FNA) in the diagnosis of PPL compared with pancreatic adenocarcinoma.

Materials and Methods:

This was a retrospective case-control study of 11 patients diagnosed with PPL via EUS between 2002 and 2011. The clinical and EUS features of the cases were then compared with age-matched controls with adenocarcinoma in a 1:3 ratio.

Results:

There were 11 patients with PPL and 33 with adenocarcinoma. At last follow-up, 7 of 11 PPL patients were alive, and 3 of 33-adenocarcinoma patients were alive (P < 0.001). The most common presenting symptoms for PPL were pain 73%, weight loss 45%, and jaundice 18%, while patients with adenocarcinoma presented with pain 52% (P = 0.3), weight loss 30% (P = 0.47) and jaundice 76% (P = 0.001). The EUS appearance was similar in the two groups in that ultrasound imaging of the pancreas lesions tended to be hypoechoic and heterogenous, but the PPL group was more likely to have peripancreatic lymphadenopathy (LAD) (64% vs. 18%, P = 0.008) and were larger (4.8 cm × 5.3 cm vs. 3.2 cm × 3.1 cm, P < 0.001). The PPL group was less likely to have vascular invasion (18% vs. 55%, P = 0.045) and less likely to be found in the head of the pancreas (36% vs. 85%, P = 0.004). FNA and cytology (without flow cytometry [FC]) made the diagnosis in 28% of PPL patients compared with 91% of adenocarcinoma patients (P = 0.002). In the PPL group, 7 of 11 FNA samples were sent for FC. If FC was added, then the diagnosis of PPL was increased to 100%.

Conclusions:

Compared with adenocarcinoma, pancreatic lymphoma has a better prognosis, is less likely to present with jaundice and less likely to have vascular invasion. PPL is more likely to be located outside the head of the pancreas and to include peripancreatic LAD, and is less likely to be diagnosed with cytology. The diagnostic accuracy of FNA for PPL is improved greatly with the addition of FC.

Probe-Based Confocal Laser Endomicroscopy to Guide Real-Time Endoscopic Therapy in Barrett's Esophagus with Dysplasia

Probe-based confocal laser endomicroscopy (pCLE) is a novel imaging technique which utilizes a low-power laser light passed through a fiber-optic bundle, within a miniprobe that is advanced into the working channel, to obtain microscopic images of the mucosa. This allows the endoscopist to evaluate the microarchitecture of the gastrointestinal epithelium in real time. At this time pCLE cannot replace histopathology, but it can provide diagnostic information as well as guide therapeutic management in patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). We describe a retrospective case series in which four patients with BE and biopsy-proven HGD underwent endoscopy with pCLE to direct real-time endoscopic ablation therapy and/or endoscopic mucosal resection (EMR), which was performed in conjunction with pCLE. All four patients had pCLE showing features of HGD. After either EMR or radiofrequency ablation (RFA), pCLE was again used to evaluate the margins after therapy to assure accuracy. In one case, pCLE had features of dysplasia at the margin and further repeat EMR was immediately performed. Another case had a normal-appearing esophagus, but pCLE found features of BE in discrete areas and targeted biopsies were performed, which confirmed BE. This patient subsequently underwent RFA therapy of the residual areas of BE. In conclusion, in patients with BE and dysplasia, pCLE is an effective tool used to target biopsies, guide endoscopic therapy and assess the accuracy of EMR or RFA.

Fiscal analysis of establishment of a double-balloon enteroscopy program and reimbursement

BACKGROUND & AIMS

As double-balloon enteroscopy (DBE) programs continue to be established, further research is needed to assess their financial impact. We evaluated actual financial outcomes and compared them with estimated return on investment (ROI) projections for DBE.

METHODS

We retrospectively compared the predicted and actual financial results for outpatients referred for DBE at an academic tertiary referral center.

RESULTS

The ROI analysis was based on a 5-year time frame. The analysis projected a net present value of $64,623 and an internal rate of return of 24.6%. The projected first-year volume was 52 outpatient cases; however, the actual experience was 20 outpatient cases. The predicted percent margin for these outpatient cases was 16.6%; the actual margin was 24.4%. After 37 months, 52 outpatient cases were completed, and the actual percent margin was 4.6%. Payer type had a significant influence on the financial outcomes when projected activity and actual activity were compared.

CONCLUSIONS

Institutions interested in establishing a DBE program should be aware of the financial implications of program establishment, which can be evaluated in a return on investment analysis. Payer mix significantly influences DBE reimbursement and collection rates.

CT portography with gastric variceal volume measurements in the evaluation of endoscopic therapeutic efficacy of tissue adhesive injection into gastric varices: a pilot study

BACKGROUND

N-butyl-2-cyanoacrylate (NBCA) injection is used for treating gastric varices (GV). Determining the degree of obliteration of GV is not readily evident at endoscopy.

AIMS

The aim of this study was to evaluate CT portography with gastric variceal volume calculations to assess endoscopic therapeutic efficacy of NBCA injection.

METHODS

The study design is a retrospective series pilot study. The setting is a single, tertiary care academic medical center. Ten patients underwent esophagogastroduodenoscopy (EGD) with NBCA injection of GV and had biphasic CT scans performed before and after injection therapy. Based on portal venous images, 3D reconstruction and semi-automated volume calculations of GV were performed. Pre and post injection GV volume calculations were compared.

RESULTS

The mean pre-procedure GV volume was 89.84 cm3. Eight patients had significant improvement in GV volume from pre-treatment versus post-treatment (95.65 cm3 vs. 49.65 cm3, P-value 0.04). Pre-procedure GV volume was not significantly different in patients treated for active hemorrhage versus no hemorrhage (101.66 cm3 vs. 72.11 cm3, P-value 0.33). Two patients had a subsequent GV hemorrhage after NBCA injection. The mean residual GV volume in these patients versus those that did not re-bleed was significantly more (127.77 cm3 vs. 38.00 cm3, P-value 0.005).

CONCLUSIONS

CT portography with measurement of GV volume is a potentially useful tool in determining the therapeutic efficacy NBCA injection of GV. Patients with higher residual GV volumes are at increased risk of hemorrhage and may benefit from repeat injection to reach ideal GV volumes.

EUS and ERCP complication rates are not increased in elderly patients

BACKGROUND

Further studies evaluating the safety of advanced endoscopic procedures in elderly patients are needed.

AIM

To evaluate the safety of endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in the elderly.

METHODS

The study population, consisting of 1,000 patients who underwent ERCP or EUS, was divided into two cohorts. The elderly cohort consisted of patients ≥ 75 years old. The nonelderly cohort consisted of patients <75 years old. The data collected included demographic information, type of procedure completed, procedure medication used, and endoscopic intervention performed. Complications included any event which occurred during the procedure or up to 1 month post procedure.

RESULTS

A total of 600 ERCPs and 400 EUS were included. The mean age of the elderly cohort was 80 years (range 75-95 years, n = 184) versus 54 years (range 13-74 years, n = 816) for the nonelderly cohort. The ERCP complication rate was 10.0% in the elderly versus 10.6% (P = 1.0) for the nonelderly. The EUS complication rate was 4.8% in the elderly versus 3.1% in the nonelderly (P = 0.49). The overall complication rates were identical at 7.6% (P = 1.0). Sedation doses were lower for the elderly cohort (P < 0.001). There was a higher rate of procedure bleeding in the elderly cohort (P = 0.016).

CONCLUSION

Advanced age is not a contraindication for advanced endoscopic procedures. There is no significant increase in the rate of overall procedure-related complications seen with either ERCP or EUS in elderly patients; however, elderly patients have a higher risk of bleeding. Less procedure-related sedation medication is required for elderly patients.

Impact of a CT colonography screening program on endoscopic colonoscopy in clinical practice

OBJECTIVE

The potential effect of CT colonography (CTC) on endoscopic colonoscopy (EC) has been the topic of much speculation. The aim of this study was to evaluate the impact of a CTC screening program on colonoscopy in clinical practice.

METHODS

At our institution a third-party reimbursed CTC colorectal cancer (CRC) screening program was established in 2004. The number of CTC monthly exams performed, monthly EC total and screening exams performed, EC with polypectomy performed, and the number of referrals for EC screening exams requested were prospectively examined in the first 33 months after introduction of a CTC CRC screening program.

RESULTS

The mean number of overall (378.5 vs 413.1) and screening (150.7 vs 162.9) colonoscopy exams performed per month did not change significantly after screening CTC was introduced. The mean number of monthly CTC exams performed rose significantly throughout the first year of the study from 39 initially to a peak of 147.6 cases per month but decreased slightly to 114.3 monthly exams at the end of 2006. A mean 10.0 patients per month were sent for EC after a positive CTC exam. The mean number of monthly colonoscopies with polypectomy remained constant after the introduction of CTC (197.0 vs 180.2). Monthly referrals for screening EC exams initially decreased but were unchanged 3 yr after institution of a CTC screening program (255.0 vs 253.5).

CONCLUSIONS

(a) In our tertiary care center the initiation of a screening CTC program did not result in a decrease in the number of total colonoscopy exams, screening colonoscopy exams performed, nor requests for screening colonoscopy. (b) Only a small number of CTC exams were referred for EC with polypectomy, therefore a CTC screening program may not increase the overall number of therapeutic colonoscopies performed.

Evaluation of submucosal lesions of the large intestine: part 2. Nonneoplastic causes

Various nonneoplastic entities may manifest as submucosal abnormalities at colorectal evaluation, and it may be difficult to distinguish between those with an intramural origin and those with an extramural origin on the basis of optical colonoscopy alone. Cross-sectional radiologic imaging, which allows evaluation of the entire bowel wall and the surrounding tissues, plays an important role in the localization and characterization of these abnormalities. However, some superficial submucosal lesions that are initially detected at computed tomographic colonography or barium enema studies may be better characterized with colonoscopy; thus, it is important to recognize the complementary uses of these diagnostic tests. In addition, modalities such as transrectal ultrasonography and magnetic resonance imaging may be useful for the identification and characterization of some abnormalities. For timely and effective management, it is especially important that submucosal neoplasms of the large intestine be accurately distinguished from nonneoplastic entities such as lymphoid polyps, vascular lesions, and cystic lesions, as well as from extracolonic abnormalities (eg, endometriosis, uterine fibroids) and normal extracolonic structures (eg, uterus, vasculature).

Evaluation of submucosal lesions of the large intestine: part 1. Neoplasms

At luminal evaluation of the large intestine, any masslike protrusion that is covered by normal mucosa, whether the underlying process is intramural or extramural in origin, may be reported as a submucosal lesion. The full characterization of submucosal lesions may be difficult with optical colonoscopy alone, and endoscopic biopsy is often nondiagnostic. Cross-sectional radiologic imaging studies allow evaluation of the entire thickness of the bowel wall and surrounding tissues and often provide additional information with regard to lesion origin, internal composition, and extent of disease. Likewise, it may be difficult to distinguish submucosal lesions from mucosal polyps on radiologic images, and optical colonoscopy may provide complementary information about superficial submucosal soft-tissue lesions that are detected at computed tomographic (CT) colonography or barium imaging. Depending on the specific clinical situation, colonoscopy, CT colonography, transrectal ultrasonography, and magnetic resonance imaging all may play an important role in the diagnostic evaluation of submucosal lesions of the large intestine. It is important that radiologists be familiar with the multimodality imaging appearances of such entities so that neoplasms--especially those that are malignant--can be accurately identified and characterized and effectively managed.

CT colonography versus colonoscopy for the detection of advanced neoplasia

BACKGROUND

Advanced neoplasia represents the primary target for colorectal-cancer screening and prevention. We compared the diagnostic yield from parallel computed tomographic colonography (CTC) and optical colonoscopy (OC) screening programs.

METHODS

We compared primary CTC screening in 3120 consecutive adults (mean [+/-SD] age, 57.0+/-7.2 years) with primary OC screening in 3163 consecutive adults (mean age, 58.1+/-7.8 years). The main outcome measures included the detection of advanced neoplasia (advanced adenomas and carcinomas) and the total number of harvested polyps. Referral for polypectomy during OC was offered for all CTC-detected polyps of at least 6 mm in size. Patients with one or two small polyps (6 to 9 mm) also were offered the option of CTC surveillance. During primary OC, nearly all detected polyps were removed, regardless of size, according to established practice guidelines.

RESULTS

During CTC and OC screening, 123 and 121 advanced neoplasms were found, including 14 and 4 invasive cancers, respectively. The referral rate for OC in the primary CTC screening group was 7.9% (246 of 3120 patients). Advanced neoplasia was confirmed in 100 of the 3120 patients in the CTC group (3.2%) and in 107 of the 3163 patients in the OC group (3.4%), not including 158 patients with 193 unresected CTC-detected polyps of 6 to 9 mm who were undergoing surveillance. The total numbers of polyps removed in the CTC and OC groups were 561 and 2434, respectively. There were seven colonic perforations in the OC group and none in the CTC group.

CONCLUSIONS

Primary CTC and OC screening strategies resulted in similar detection rates for advanced neoplasia, although the numbers of polypectomies and complications were considerably smaller in the CTC group. These findings support the use of CTC as a primary screening test before therapeutic OC.

Endoscopic placement of the small-bowel video capsule by using a capsule endoscope delivery device

BACKGROUND

Capsule endoscopy performed via the traditional peroral route is technically challenging in patients with dysphagia, gastroparesis, and/or abnormal upper-GI (UGI) anatomy.

OBJECTIVE

To describe the indications and outcomes of cases in which the AdvanCE capsule endoscope delivery device, which has recently been cleared by the Food and Drug Administration, was used.

DESIGN

Retrospective, descriptive, case series.

SETTING

Tertiary care, university hospital.

PATIENTS

We report a case series of 16 consecutive patients in whom the AdvanCE delivery device was used. The study period was May 2005 through July 2006.

INTERVENTIONS

Endoscopic delivery of the video capsule to the proximal small bowel by using the AdvanCE delivery device.

MAIN OUTCOME MEASUREMENTS

Indications, technique, and completeness of small bowel imaging in patients who underwent endoscopic video capsule delivery.

RESULTS

The AdvanCE delivery device was used in 16 patients ranging in age from 3 to 74 years. The primary indications for endoscopic delivery included inability to swallow the capsule (10), altered UGI anatomy (4), and gastroparesis (2). Of the 4 patients with altered UGI anatomy, 3 had dual intestinal loop anatomy (ie, Bilroth-II procedure, Whipple surgery, Roux-en-Y gastric bypass) and 1 had a failed Nissen fundoplication. In all cases, the capsule was easily deployed without complication, and complete small intestinal imaging was achieved.

LIMITATIONS

Small patient size.

CONCLUSIONS

Endoscopic placement of the Given PillCam by use of the AdvanCE delivery device was safe and easily performed in patients for whom capsule endoscopy would otherwise have been contraindicated or technically challenging.

Endoscopic ultrasound for the evaluation of Nissen fundoplication integrity: a blinded comparison with conventional testing

BACKGROUND

For patients whose symptoms develop after Nissen fundoplication, the precise mechanism of anatomic failure can be difficult to determine. The authors have previously reported the endosonographic hallmarks defining an intact Nissen fundoplication in swine and the known causes of failure. The current clinical trial tested the hypothesis that a defined set of endosonographic criteria can be applied to determine fundoplication integrity in humans.

METHODS

The study enrolled seven symptomatic and nine asymptomatic subjects at a mean of 6 years (range, 1-30 years) after Nissen fundoplication. A validated gastroesophageal reflux disease (GERD)-specific questionnaire and medication history were completed. Before endoscopic ultrasound (EUS), all the patients underwent complete conventional testing (upper endoscopy, esophagram, manometry, 24-h pH). A diagnosis was rendered on the basis of combined test results. Then EUS was performed by an observer blinded to symptoms, medication use, and conventional testing diagnoses. Because EUS and esophagogastroduodenoscopy (EGD) are uniformly performed in combination, the EUS diagnosis was rendered on the basis of previously established criteria combined with the EGD interpretation. The diagnoses then were compared to examine the contribution of EUS in this setting.

RESULTS

The technique and defined criteria were easily applied to all subjects. All symptomatic patients had heartburn and were taking proton pump inhibitors (PPI). No asymptomatic patients were taking PPI. All diagnoses established with combined conventional testing were detected on EUS with upper endoscopy. Additionally, EUS resolved the etiology of a low lower esophageal sphincter pressure in two symptomatic patients and detected the additional diagnoses of slippage in two subjects. Among asymptomatic subjects, EUS identified additional diagnoses in two subjects considered to be normal by conventional testing methods.

CONCLUSION

According to the findings, EUS is a feasible method for evaluating post-Nissen fundoplication hiatal anatomic relationships. The combination of EUS and EGD allows the mechanism of failure to be detected in patients presenting with postoperative symptoms after Nissen fundoplication.

The role and clinical value of EUS in a multimodality esophageal carcinoma staging program with CT and positron emission tomography

BACKGROUND

EUS, CT, and positron emission tomography (PET) have all been used in the preoperative staging of esophageal cancer separately or in various combinations.

OBJECTIVE

Our purpose was to determine the value and role of EUS when used in conjunction with CT and PET imaging in staging cancer of the esophagus and gastroesophageal junction.

DESIGN

Retrospective single-center clinical trial.

SETTING

Academic tertiary care center.

PATIENTS

Data were examined for 56 patients who concomitantly underwent examination with EUS, CT, and PET in a multimodality staging program.

MAIN OUTCOME MEASUREMENTS

EUS, CT, and PET were examined for their ability to detect the primary tumor, local tumor stage, locoregional adenopathy, and distant metastases. With use of surgical resection as baseline therapy, the frequency at which EUS, CT, and PET affected and changed management was examined.

RESULTS

EUS is the only imaging test that identified all primary tumors and provided tumor staging. EUS identified a significantly greater number of patients (58.9%) with locoregional nodes than did CT (26.8%), P = .0006, or PET (37.5%), P = .02. CT identified 14.3% and PET identified 26.8% of patients with distant metastases. With CT alone, 15.2% of patients were not taken to surgery, whereas PET affected management by preventing surgery because of metastatic disease in 28.3% of patients. EUS changed management by guiding the need for neoadjuvant therapy in 34.8% of patients.

LIMITATIONS

Retrospective study, nonblinded study, lack of pathologic reference standard.

CONCLUSION

The primary strength of EUS in a multimodality staging strategy is in identifying patients with locally advanced disease and guiding the need for preoperative neoadjuvant therapy. EUS is not suited to determine resectability of esophageal cancer alone and thus is most effective when used in conjunction with other imaging tests such as CT and PET.

Placement of gastrostomy tubes in patients with ventriculoperitoneal shunts does not result in increased incidence of shunt infection or decreased survival

The objective of this study was to examine if G-tube (G-tube) placement in patients with ventriculoperitoneal (VP) shunts results in shunt infection or impacts patient survival. We performed a retrospective cohort study. Patients underwent VP shunt and G-tube placement. Incidence of shunt infection and patient survival were calculated. Fifty-five patients qualified for the study. Shunt infection occurred in seven patients (12.5%). The incidence of shunt infection did not differ between surgically placed G-tubes (2/7=29%) and PEG tubes (5/7=71%; P=0.69). There was no difference in the risk of VP infection based on the order of placement (OR=0.61 [0.12-3.02]; P=0.69). No predictors for shunt infection were identified. Kaplan-Meier mortality estimates demonstrated a 21% 1-year mortality rate. There were no predictors of patient survival. We conclude that placement of G-tubes in patients with shunts is safe. The order of placement of G-tube and VP shunt does not affect the incidence of shunt infection or survival.

Extracolonic tumors of the gastrointestinal tract detected incidentally at screening CT colonography

PURPOSE

The aim of this article is to report our experience with incidental detection of extracolonic tumors of the gastrointestinal tract identified prospectively at screening CT colonography.

METHODS

A total of 2014 patients (1097 females, 917 males; mean age, 56.9 years) underwent primary CT colonography evaluation at our institution over an 18-month period. Following cathartic preparation and colonic distention, supine and prone multidetector CT scans were obtained with thin-collimation low-dose technique without intravenous contrast. We reviewed our database for lesions of the extracolonic gastrointestinal tract that were detected during the prospective reading.

RESULTS

Focal extracolonic gastrointestinal tract lesions were prospectively detected in 10 (0.5 percent) of 2014 patients (8 females; 2 males; mean age, 58.5 years). All patients were asymptomatic. Tumor locations included ileum (n = 3), stomach (n = 3), jejunum (n = 2), and appendix (n = 2). Mean tumor size was 2.2 (range, 0.8-3.4) cm. Lesions in eight patients were subsequently confirmed by conventional or capsule endoscopy and/or by intravenous contrast-enhanced CT. Seven lesions were surgically excised and one was removed at endoscopy; two patients with lipomas did not undergo further evaluation or treatment. Final diagnoses were benign in all cases and included lipoma (n = 3), small-bowel hamartoma (n = 2), appendiceal mucinous cystadenoma (n = 2), gastric leiomyoma (n = 1), small-bowel lymphangioma (n = 1), and gastric fundic gland polyp (n = 1).

CONCLUSIONS

Incidental extracolonic tumors of the gastrointestinal tract detected at screening CT colonography were all asymptomatic and benign but often prompted more invasive workup. Although the incidence of these tumors was relatively low, widespread population screening with CT colonography would result in new surgical referrals for these findings.

Screening for colorectal neoplasia with CT colonography: initial experience from the 1st year of coverage by third-party payers

PURPOSE

To evaluate our experience in the 1st year of computed tomographic (CT) colonography screening since the initiation of local third-party payer coverage.

MATERIALS AND METHODS

This HIPAA-compliant study was approved by the institutional review board, and informed consent was waived. Over a 1-year period that ended on April 27, 2005, 1110 consecutive adults (585 women, 525 men; mean age, 58.1 years) underwent primary CT colonography screening. More than 99% were covered by managed care agreements. CT colonographic interpretation was performed with primary three-dimensional polyp detection, and the final results were issued within 2 hours. Patients with large (> or =10-mm) polyps were referred for same-day optical colonoscopy, and patients with medium-sized (6-9-mm) lesions had the option of immediate optical colonoscopy or short-term CT colonography surveillance.

RESULTS

Large colorectal polyps were identified at CT colonography in 43 (3.9%) of 1110 patients. Medium-sized lesions were identified in 77 (6.9%) patients, 31 (40%) of whom chose optical colonoscopy and 46 (60%) of whom chose CT colonography surveillance. Concordant lesions were identified in 65 of 71 patients who underwent subsequent optical colonoscopy (positive predictive value, 91.5%). Sixty-one (86%) of 71 optical colonoscopic procedures were performed on the same day as CT colonography, thereby avoiding the need for repeat bowel preparation. The actual endoscopic referral rate for positive findings at CT colonography was 6.4% (71 of 1110 patients). The demand for CT colonography screening from primary care physicians and their patients increased throughout the study period.

CONCLUSION

As a primary colorectal screening tool, CT colonography covered by third-party payers has an acceptably low endoscopic referral rate and a high concordance of positive findings at optical colonoscopy.

Surface visualization at 3D endoluminal CT colonography: degree of coverage and implications for polyp detection

BACKGROUND & AIMS

Effective colonoscopic screening for polyps, whether by optical or virtual means, requires adequate visualization of the entire colonic surface. The purpose of this study was to assess prospectively the degree of surface coverage at 3-dimensional (3D) endoluminal computed tomography colonography (CTC) after retrograde fly-through, combined retrograde-antegrade fly-through, and review of remaining missed regions.

METHODS

The study group consisted of 223 asymptomatic adults (mean age, 57.8 +/- 7.2 y; 111 men, 112 women) undergoing primary CTC screening. CTC studies were interpreted by experienced readers using a primary 3D approach. The CTC software system that was used continually tracks the percentage of endoluminal surface visualized. The degree of coverage was assessed prospectively after retrograde and combined retrograde-antegrade navigation. The added effect of reviewing missed regions was also assessed prospectively.

RESULTS

The mean surface coverage after only retrograde 3D endoluminal fly-through from rectum to cecum was 76.6% +/- 4.8% (range, 63%-92%); coverage was 80% or less in 181 (81.2%) patients. Antegrade navigation back to the rectum increased the overall coverage to 94.1% +/- 2.3% (range, 84%-99%; P < .0001). A review of missed regions 300 mm(2) or larger increased coverage to 97.9% +/- 1.1% (range, 93%-99%; P < .0001) and added 21.4 +/- 11.4 seconds to the interpretation time (range, 3-67 s).

CONCLUSIONS

Combined bidirectional retrograde and antegrade 3D navigation, supplemented by rapid review of missed regions, effectively covers the entire evaluable surface at CTC. Unidirectional retrograde 3D fly-through typically excludes 20% or more of the endoluminal surface, which may provide insight into potential limitations at optical colonoscopy.

Comparison of the effect of non-ionic and ionic contrast agents on pancreatic histology in a canine model

CONTEXT

Pancreatitis is the most frequent complication of endoscopic retrograde cholangiopancreatography. Controversy exists whether low osmolarity non-ionic contrast agents lessen the rate of pancreatitis and pancreatic injury. To evaluate we used a canine model to compare pancreatography performed with ionic and non-ionic contrast.

DESIGN

Dogs were anesthetized and underwent open transduodenal cannulation of the main pancreatic duct under fluoroscopic control until complete acinarization was achieved to maximize injury. Three dogs received diatrozate, an ionic contrast agent with osmolarity of 1,415 mosM and three dogs were injected with omnipaque a non-ionic agent with osmolarity of 672 mosM.

MAIN OUTCOME MEASURES

Serial amylase and white cell counts were followed for 48 hours at which time dogs were sacrificed. Each pancreas was then examined for evidence of pancreatitis and cellular injury with both light and electron microscopy.

RESULTS

All animals developed significant hyperamylasemia and elevated white blood cell counts, without significant difference in the mean peak amylase (10,721 U/L vs. 9,367 U/L, P=0.876) or white cell counts (25.8 k/mL vs. 24.1 k/mL, P=0.586) between the ionic and non-ionic contrast groups. Light microscopy showed no evidence of pancreatitis in either group of dogs. Electron microscopy showed cellular injury of the ductal cells in two dogs injected with non-ionic contrast.

CONCLUSION

In a pancreatic canine model, low osmolarity, non-ionic contrast does not appear to lessen cellular injury.

EUS characteristics of Nissen fundoplication: normal appearance and mechanisms of failure

BACKGROUND

In patients who develop symptoms after Nissen fundoplication, the precise mechanism of failure can be difficult to determine. Current testing modalities do not demonstrate sufficient anatomic detail to definitively determine the mechanism. This observational study establishes that EUS can determine fundoplication integrity and hiatal anatomic relationships after Nissen fundoplication.

METHODS

EUS was performed on the native esophagogastric junction and after Nissen fundoplication in two swine. The EUS characteristics of a properly performed fundoplication were determined. Subsequently, complications of Nissen fundoplication were created, and EUS was performed on each. The EUS criteria of each mechanism of failure were defined.

RESULTS

EUS provided sufficient axial resolution to distinguish the esophagus, the fundoplication, and the surrounding hiatal structures within a single image. US of the native esophagogastric junction discerned the length of intra-abdominal esophagus, esophagogastric junction, crura, and anterior hiatus, and, thus, the point of entry into the abdominal cavity. EUS of Nissen fundoplication revealed a 5-layered pattern in a 360 degree configuration. These layers represent the following: (1) the esophageal wall, (2) the space between the esophagus and the fundoplication, (3) the inner gastric wall of the fundoplication, (4) the gastric lumen, and (5) the outer gastric wall of the fundoplication. A slipped repair was identified by the presence of an echogenic gastric serosa within the fundoplication. A tight fundoplication results in attenuation of the gastric walls, thickening of the esophageal wall, and loss of the 5-layer pattern secondary to obliteration of the potential spaces of the gastric lumen. Dehiscence of the fundoplication was evidenced by a less than 360 degree 5-layer pattern.

CONCLUSIONS

EUS of hiatal anatomic relationships is feasible and provides detailed information regarding the integrity and the position of a Nissen fundoplication. EUS may enable a precise determination of the anatomic causes of failure after antireflux surgery.

Laryngopharyngeal reflux symptoms better predict the presence of esophageal adenocarcinoma than typical gastroesophageal reflux symptoms

OBJECTIVE

To determine whether the presence of laryngopharyngeal reflux symptoms is associated with the presence of esophageal adenocarcinoma (EAC).

BACKGROUND

Most patients diagnosed with EAC have incurable disease at the time of detection. The majority of these patients are unaware of the presence of Barrett's esophagus prior to cancer diagnosis and many do not report typical symptoms of gastroesophageal reflux disease (GERD). This suggests that the current GERD symptom-based screening paradigm may be inadequate. Data support a causal relation between complicated GERD and laryngopharyngeal reflux symptoms. We theorize that laryngopharyngeal reflux symptoms are not recognized expeditiously, resulting in chronic esophageal injury and an unrecognized progression of Barrett's esophagus to EAC.

METHODS

This is a case-comparison (control) study. Cases were patients diagnosed with EAC (n = 63) between 1997 and 2002. Three comparison groups were selected: 1) Barrett's esophagus patients without dysplasia (n = 50), 2) GERD patients without Barrett's esophagus (n = 50), and 3) patients with no history of GERD symptoms or antisecretory medication use (n = 56). The risk factors evaluated included demographics, medical history, lifestyle variables, and laryngopharyngeal reflux symptoms. Typical GERD symptoms and antisecretory medication use were recorded. Multivariate analysis of demographics, comorbid risk factors, and symptoms was performed with logistic regression to provide odds ratios for the probability of EAC diagnosis.

RESULTS

The prevalence of patients with laryngopharyngeal reflux symptoms was significantly greater in the cases than comparison groups (P = 0.0005). The prevalence of laryngopharyngeal reflux symptoms increased as disease severity progressed from the non-GERD comparison group (19.6%) to GERD (26%), Barrett's esophagus (40%), and EAC patients (54%). Symptoms of GERD were less prevalent in cases (43%) when compared with Barrett's esophagus (66%) and GERD (86%) control groups (P < 0.001). Twenty-seven percent (17 of 63) of EAC patients never had GERD or laryngopharyngeal reflux symptoms. Fifty-seven percent of EAC patients presented without ever having typical GERD symptoms. Chronic cough, diabetes, and age emerged as independent risk factors for the development of EAC.

CONCLUSIONS

Symptoms of laryngopharyngeal reflux are more prevalent in patients with EAC than typical GERD symptoms and may represent the only sign of disease. Chronic cough is an independent risk factor associated with the presence of EAC. Addition of laryngopharyngeal reflux symptoms to the current Barrett's screening guidelines is warranted.

Endoscopic appraisal of the gastroesophageal valve after antireflux surgery

OBJECTIVES

Little consensus exists regarding the endoscopic assessment of the esophagogastric junction after antireflux surgery. The purpose of this report is to characterize the gastroesophageal valve appearance unique to each type of antireflux procedure and to introduce an endoscopic lexicon by which to describe this anatomic region.

METHODS

Endoscopic images were obtained from patients who had undergone any one of the following procedures: Nissen, Collis-Nissen, Toupet, and Dor fundoplications and Hill repair. Images were excluded if patients had any symptoms of heartburn, regurgitation, dysphagia, chest pain, or gas bloat or if they were using antisecretory medication. Seven photographs per operation type were evaluated by experienced surgeons and gastroenterologists tasked with describing defining characteristics of each procedure.

RESULTS

Ten valve criteria were developed to uniquely identify and quantify the ideal endoscopic appearance of each procedure. Illustrations were created to clearly depict those traits.

CONCLUSIONS

Using 10 gastroesophageal valve criteria, the key components of a successful functional repair of the esophagogastric junction were defined. These criteria can be employed when evaluating upper gastrointestinal complaints after antireflux surgery and may ultimately serve as a dependable outcome measure.

Endoscopic Management of Biliary Complications After Orthotopic Liver Transplantation

After orthotopic liver transplantation (OLT), biliary duct complications can occur in as many as 10% to 35% of patients. In the early medical and surgical literature, surgical therapy was the primary mode of management of biliary tract complications and was the eventual course of operative intervention in up to 70% of cases. However, with recent advances in therapeutic biliary endoscopy, the current endoscopic and transplantation literature suggests that endoscopic management with techniques such as endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy, biliary stenting, and stone removal techniques can be successfully applied for the majority of post-OLT biliary complications. The most common biliary complications after OLT include biliary strictures (anastomotic and nonanastomotic); bile duct leaks, common bile duct stones, and biliary casts; sphincter of Oddi/ampullary muscle dysfunction/spasm; and disease recurrence (eg, primary sclerosing cholangitis). Predisposing factors for biliary complications after OLT include hepatic artery thrombosis, impaired perfusion of the biliary tree, portal vein thrombosis, and preservation or harvesting injuries, which can increase the incidence of complications as much as 40%. Use of immunosuppressive agents such as cyclosporine can lead to cholesterol/bile stasis and stone formation. Outside of endoscopic therapy, there is little medical or dietary management that can be applied for post-OLT biliary complications. Ursodiol (ursodeoxycholic acid) has often been used as a neoadjuvant to ERCP therapy in the setting of common bile duct stones/casts, and low-fat diets may be recommended in this setting, but no large, randomized trials have advocated medical or conservative management alone.

Graft failure from severe recurrent primary sclerosing cholangitis following orthotopic liver transplantation

Speculation that primary sclerosing cholangitis (PSC) may recur in the transplanted liver is based on the relative increase in frequency of biliary abnormalities and histologic evidence of periportal fibrosis without other causes. A recent study demonstrated almost 9% of patients undergoing liver transplantation (OLT) for primary sclerosing cholangitis (PSC) develop recurrent sclerosing cholangitis although the patient and graft survival is not different from those in whom recurrence does not develop. Most reports of PSC recurrence post-OLT estimate rates of 1% to 14%, but to date, no center has reported rapidly progressive fibro-obliterative cholangitis leading to graft failure.

CASE REPORT

DV was a 39-year-old white man with ulcerative colitis, since age 21, who developed jaundice and pruritus in 1992. ERCP and liver biopsy were consistent with PSC, and he developed thrombocytopenia and bleeding esophageal varices. He underwent an uneventful OLT in May 1994 with an ABO-compatible organ and normal ischemic times. There was no evidence of postoperative cytomegalovirus infection, hepatic artery thrombosis, or rejection. In October 1994, mild abnormalities of liver function tests (LFTs) led to liver biopsy that revealed inflammatory infiltrate in triad with spillover into lobules and mild periportal fibrosis. LFTs normalized without any treatment, but in February 1995 repeat liver biopsy for increased LFTs revealed moderate periportal fibrosis with inflammatory cells in triads and lobules. Viral shell and CMV titers were negative. No evidence of infectious etiology or rejection was noted. The patient was started on ursodeoxycholic acid at that time and percutaneous transhepatic cholangiogram (PTC) revealed marked narrowing of the intrahepatic ducts. Esophagogastroduodenoscopy (EGD) revealed esophageal varices. Hepatic arteriogram and Doppler ultrasound were negative. He developed progressive graft failure, and died at home while awaiting re-transplant.

CONCLUSIONS

Although most series report mild recurrence of PSC following OLT, this case illustrates that early, severe recurrence of PSC may occur, leading to graft failure and need for re-transplantation.

Risk factors for dysplasia in patients with Barrett's esophagus (BE): results from a multicenter consortium

Studies show Barrett's esophagus prevalence increases with age, while mean length of Barrett's esophagus is unchanged. Few data are available about the relationship between age and length on the development of dysplasia. Our aim was to assess age and length as risk factors for dysplasia. Consecutive patients with Barrett's esophagus were enrolled in a multicenter study establishing a tissue bank of Barrett's esophagus patients 1994 and 1998. Demographics, length of Barrett's esophagus (centimeters), and histology were recorded. Risk factors for dysplasia were assessed, including patient age, gender, and length of Barrett's esophagus. Statistical analysis was performed comparing prevalence of dysplasia (which included the presence of any carcinoma and high- or low-grade dysplasia) to age and length. In all, 309 patients were studied [278 (90%) male and 31 (10%) female]: 5 had adenocarcinoma of the esophagus, 11 had high-grade dysplasia, and 29 had low-grade dysplasia. Patients with Barrett's esophagus without dysplasia were younger than those with dysplasia [62 +/- 0.8 years vs 67 +/- 1.7 years (mean +/- SEM, P = 0.02)]. The risk of dysplasia increased by 3.3%/yr of age. Mean length of Barrett's esophagus in patients with Barrett's alone vs dysplasia was 4.0 +/- 0.2 cm vs 5.4 +/- 0.4 cm (P = 0.003). Patients with Barrett's esophagus length > or = 3 cm had a significantly greater prevalence of dysplasia compared to length < 3 cm (23% vs 9%, P = 0.0001). The risk of dysplasia increased by 14%/cm of increased length. Multivariate analysis showed age and length to be independent risk factors. In conclusions: prevalence of dysplasia is strongly associated with age and length of Barrett's esophagus. These preliminary results can be used to develop a strategy for screening/surveillance based on age and length of Barrett's epithelium.

Risk factors for dysplasia in patients with Barrett's esophagus (BE): results from a multicenter consortium

Studies show Barrett's esophagus prevalence increases with age, while mean length of Barrett's esophagus is unchanged. Few data are available about the relationship between age and length on the development of dysplasia. Our aim was to assess age and length as risk factors for dysplasia. Consecutive patients with Barrett's esophagus were enrolled in a multicenter study establishing a tissue bank of Barrett's esophagus patients 1994 and 1998. Demographics, length of Barrett's esophagus (centimeters), and histology were recorded. Risk factors for dysplasia were assessed, including patient age, gender, and length of Barrett's esophagus. Statistical analysis was performed comparing prevalence of dysplasia (which included the presence of any carcinoma and high- or low-grade dysplasia) to age and length. In all, 309 patients were studied [278 (90%) male and 31 (10%) female]: 5 had adenocarcinoma of the esophagus, 11 had high-grade dysplasia, and 29 had low-grade dysplasia. Patients with Barrett's esophagus without dysplasia were younger than those with dysplasia [62 +/- 0.8 years vs 67 +/- 1.7 years (mean +/- SEM, P = 0.02)]. The risk of dysplasia increased by 3.3%/yr of age. Mean length of Barrett's esophagus in patients with Barrett's alone vs dysplasia was 4.0 +/- 0.2 cm vs 5.4 +/- 0.4 cm (P = 0.003). Patients with Barrett's esophagus length > or = 3 cm had a significantly greater prevalence of dysplasia compared to length < 3 cm (23% vs 9%, P = 0.0001). The risk of dysplasia increased by 14%/cm of increased length. Multivariate analysis showed age and length to be independent risk factors. In conclusions: prevalence of dysplasia is strongly associated with age and length of Barrett's esophagus. These preliminary results can be used to develop a strategy for screening/surveillance based on age and length of Barrett's epithelium.

Diseases of the rectum and anus: a clinical approach to common disorders

Diseases of the rectum and anus are common, and the prevalence in the general population is probably much higher than that seen in clinical practice since most patients with symptoms referable to the anorectum do not seek medical attention. The examination and diagnosis of certain anorectal disorders can be challenging, and the physical examination of the anorectum is often inadequately performed in clinical practice. This article reviews the important features of the anorectal examination and the diagnosis and treatment of benign anorectal disorders such as hemorrhoids, fissures, fistulas, solitary rectal ulcer syndrome, fecal incontinence, and pruritus ani. Approaches to staging and managing malignant neoplasms of the anus and rectum are outlined.

Duration of antiviral therapy for cholestatic HCV recurrence may need to be indefinite

Progressive liver allograft injury related to hepatitis C virus (HCV) recurrence occurs in 20% to 30% of liver transplant recipients within the first 5 years. In particular, the subset of patients who develop the severe cholestatic variant has an extremely high mortality. We report our center's experience with 7 cholestatic patients who were treated with interferon alfa-2b (3 million IU three times per week initially) in combination with ribavirin. In 4 of the 7 patients, HCV-RNA in serum became undetectable, and in an additional patient, normalization of serum bilirubin was achieved despite persistent viremia. Discontinuation of antiviral therapy by patient choice, intolerance of side effects, or occurrence of infection were followed temporally by rapid relapses of the cholestatic syndrome, allograft failure, and death. The only 2 patients alive in remission of this syndrome have been maintained on antiviral therapy for an average of 32 months. Thus, based on our experience, we recommend that duration of antiviral therapy in the subset of patients with cholestatic HCV recurrence should be indefinite.

Brunner's gland hamartoma: a rare cause of gastrointestinal bleeding -- case report and review of the literature

An unusual cause of upper gastrointestinal bleeding is described in a previously healthy 45-year-old man who was admitted to hospital with weakness and fatigue, and had experienced an episode of melena two days before admission. His medical and surgical history was unremarkable. Upon admission to hospital, he showed evidence of iron-deficiency anemia, with a hemoglobin concentration of 61 g/L (normal range 135 to 175 g/L), a mean corpuscular volume of 73 fL (normal range 85.0 to 95.0 fL) and a ferritin concentration of 1.0 microg/L (normal range in males 15 to 400 microg/L). Upper gastrointestinal endoscopy revealed a 3.5 cm ulcerated submucosal mass in the third portion of the duodenum, for which mucosal biopsies were nondiagnostic. A subsequent endoscopic ultrasound revealed a 2.7 x 4.0 cm hyperechoic, cystic, submucosal tumour in the third portion of the duodenum. Endoscopic ultrasound-guided fine needle aspiration revealed no malignant cells. The patient eventually underwent a resection of the third portion of his duodenum. Surgical pathology revealed that this tumour was a Brunner's gland hamartoma, 4.5 cm in its greatest dimension.

Another look at Barrett's esophagus. Current thinking on screening and surveillance strategies

Barrett's esophagus remains a major health problem and a risk factor for the development of esophageal adenocarcinoma. Given the low incidence of this disorder, efforts should be made to identify risk factors that target patients with GERD or known Barrett's esophagus who would most benefit from screening and surveillance strategies. It is clear that identifying esophageal adenocarcinoma at an early and treatable stage reduces morbidity and mortality. However, currently available screening tools (endoscopy with surveillance biopsies every 2 years) are expensive and not easily applied. Identification of tumor markers and other specific risk factors may be helpful in predicting who is at risk for dysplasia. Current therapeutic strategies are successful in the treatment of GERD symptoms, but further research and longer follow-up studies are needed to determine if these strategies bring about regression of Barrett's esophagus, reversal of dysplasia, or prevention of cancer.

Solitary rectal ulcer syndrome presenting with rectal prolapse, severe mucorrhea and eroded polypoid hyperplasia: case report and review of the literature

A case of solitary rectal ulcer syndrome in a 36-year-old woman presenting with severe, persistent mucorrhea and eroded polypoid hyperplasia as the predominant clinical features, who was ultimately noted to have symptoms of rectal prolapse, is presented. Endoscopically, she had multiple (50 to 60) small, whitish polypoid lesions in the rectum that were initially misinterpreted as being a carpeted villous adenoma, juvenile polyposis or atypical proctitis. The lesions were treated with argon plasma coagulation with resolution, but a solitary rectal ulcer developed. The patient then admitted to a history of massive rectal prolapse over the preceding six months and underwent surgical treatment. Severe mucorrhea as the presenting feature and the presence of multiple polypoid lesions consistent with a histological diagnosis of eroded polypoid hyperplasia make the present case unique.

Treatment of progressive hepatitis C recurrence after liver transplantation with combination interferon plus ribavirin

Hepatitis C virus (HCV) recurrence after orthotopic liver transplantation (OLT) is common, although the majority of cases are mild. A subset of transplant recipients develops progressive allograft injury, including cirrhosis and allograft failure. Minimal data are available on the safety and efficacy of antiviral treatment in this group of patients. The aim of this study is to review our experience in the treatment of moderate to severe HCV recurrence with combination interferon-alpha2b and ribavirin (IFN/RIB). Between October 1993 and October 1999, a total of 197 patients underwent OLT for HCV-related liver failure. This study describes 12 transplant recipients with moderate to severe recurrence treated with IFN/RIB. All patients met at least 1 of the following inclusion criteria: (1) moderate to severe inflammation (grade III to IV) on allograft biopsy, (2) bridging fibrosis on allograft biopsy, or (3) severe cholestasis attributable solely to HCV recurrence. Two patients had undergone re-OLT for allograft cirrhosis secondary to HCV recurrence and now had evidence of progressive HCV in their second allografts. Appropriate dose reductions of both IFN and RIB, as well as initiation of granulocyte colony-stimulating factor (G-CSF), for marked leukopenia were recorded. IFN/RIB therapy was started 60 to 647 days post-OLT, and duration of therapy ranged from 39 to 515 days. Seven patients were administered G-CSF to successfully treat leukopenia. Six of the 12 patients (50%) became HCV RNA negative by polymerase chain reaction. One of these 6 patients (no. 1) was HCV RNA negative at 6 months but chose to discontinue therapy because of intolerable side effects, experienced a relapse, and was HCV RNA positive at 12 months. Two of the remaining 5 patients were HCV RNA negative at 2 and 9 months off therapy. For the entire group, there was a statistically significant decrease in serum biochemical indices assessed at initiation of therapy and 1, 3, and 6 months into therapy. Most patients required dose reductions of both IFN and RIB. Five patients died; 3 patients died of liver-related complications that included severe intrahepatic biliary cholestasis, severe HCV recurrence, and chronic rejection with profound cholestasis. In the subset of HCV-positive liver transplant recipients with moderate to severe recurrence, combination IFN/RIB therapy resulted in complete virological response (serum RNA negative) in 6 of 12 patients ( approximately 50%). However, only 1 of 12 patients (8.3%) had sustained virological clearance after cessation of IFN/RIB therapy. Dose reductions of both IFN and RIB were required in most patients. The use of G-CSF (sometimes preemptively) allowed correction of leukopenia and full-dose antiviral therapy. Multicenter trials using combination therapy to identify factors predictive of response are needed in the subset of patients with progressive allograft injury.

Abnormal findings on liver function tests. Interpreting results to narrow the diagnosis and establish a prognosis

Evaluating abnormal liver test results requires careful attention to the corresponding clinical data obtained during history taking and physical examination. Generally, it is helpful to separate liver tests into three categories: tests that assess synthetic function, tests that assess hepatocellular necrosis (hepatocellular enzymes), and tests that assess cholestasis. The clinical setting together with the specific pattern of liver function abnormalities can narrow differential diagnosis and provide a cost-effective approach to assessing patients and identifying those who need liver biopsy.