Use of a Novel Artificial Intelligence System Leads to the Detection of Significantly Higher Number of Adenomas During Screening and Surveillance Colonoscopy: Results From a Large, Prospective, US Multicenter, Randomized Clinical Trial

INTRODUCTION

Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement.

METHODS

This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate.

RESULTS

In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI -9.56% to -1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01).

DISCUSSION

Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality ( ClinicalTrials.gov NCT04979962).

The various faces of autoimmune endocrinopathies: non-tumoral hypergastrinemia in a patient with lymphocytic colitis and chronic autoimmune gastritis

Serum gastrin levels exceeding 1000pg/ml (normal, <100) usually raise the suspicion for a neuroendocrine tumor (NET) that secretes gastrin. Rarely, such elevated gastrin levels are seen in patients with pernicious anemia which most commonly is associated with autoimmune gastritis (AG). AG can occur concomitantly with other autoimmune disorders including lymphocytic colitis (LC). Gastrin stimulates enterochromaffin-like cells which increase histamine secretion. Histamine excess can cause diarrhea as can bacterial overgrowth or LC. We present a 57-year-old woman with diarrhea, sporadic epigastric pain, and bloating. She also had a history of interstitial cystitis and took pentosan polysulfate and cetirizine. She had no history of ulcers, renal impairment or carcinoid syndrome. Fasting serum gastrin was 1846pg/ml. Esophagoduodenal gastroscopy and biopsies revealed chronic gastritis and a pH of 7 with low stomach acid. Serum gastrin and plasma chromogranin A were suggestive of a gastrinoma or NET. Pernicious anemia was unlikely. Imaging studies did not reveal any tumor. Random colonic biopsy was compatible with LC, possibly explaining her diarrhea, although we also considered excessive histamine from elevated gastrin, bacterial overgrowth, and pentosan polysulfate which can cause diarrhea and be misleading in this setting, pointing to the diagnosis of gastrinoma. At 4year follow-up in 2012, fasting serum gastrin was 1097pg/ml and the patient asymptomatic taking only cetirizine for nasal allergies. This case illustrates that diarrhea may be associated with very high serum gastrin levels in the setting of chronic gastritis, LC, and interstitial cystitis (pentosan use), without clear evidence for a gastrinoma or NET. If no history of ulcers or liver metastases is present in such cases, watchful observation rather than an extensive/invasive and costly search for a NET may be justified. Considering the various forms of polyglandular syndrome, this may represent a variant and we here provide an algorithm for working up such patients, while also reviewing literature on the intertwined relationship between the immune and endocrine systems.

ON THE PRESENCE IN SYPHILITIC SERUM OF ANTIBODIES TO SPIROCHETES, THEIR RELATION TO SO CALLED WASSERMANN REAGIN, AND THEIR SIGNIFICANCE FOR THE SERODIAGNOSIS OF SYPHILIS

1. In confirmation of Gaehtgens, syphilitic human sera give positive complement fixation with cultures of so called T. pallidum (Reiter strain). Syphilitic rabbit sera are equally reactive. Syphilitic human and rabbit sera agglutinate these cultures, often in high titre (Beck). 2. Normal rabbit sera react weakly with the culture to give both agglutination and complement fixation in low titre. Normal human sera, despite the fact that they contain agglutinins in low titre, fail to fix complement with the Reiter strain of cultured spirochetes. Confirming Gaehtgens, the latter reaction is therefore of practical utility for the serum diagnosis of syphilis. 3. When syphilitic serum is heated at 63°C., there is no demonstrable difference in the thermolability of the antibody to spirochetes, and of the reagin which determines the Wassermann and flocculation tests. 4. (a) The absorption of syphilitic serum by spirochetal suspensions removes all reactivity, not only for the spirochetes, but for tissue lipoids (alcoholic beef heart extract) as well; the sera become Wassermann- and flocculation-negative. (b) Absorption of syphilitic serum with tissue lipoids renders the Wassermann and flocculation tests negative, but does not demonstrably change the reactivity of the serum with spirochetes. (c) Rabbits immunized to beef heart lipoid develop spirochetal agglutinins and complement-fixing antibodies (Reiter strain) in high titre. 5. It is concluded that these cultured spirochetes contain antigenic material serologically related to a substance present in mammalian tissue, as well as other antigenic factors not present in such extracts, but equally reactive with syphilitic serum. 6. These findings support the thesis that the primary serologic change in syphilis is the development of antibodies to T. pallidum. The Wassermann and flocculation tests would be explained on the basis that the tissue extracts used as "antigen" in these tests contain one or more substances serologically related to antigenic components of T. pallidum. Similarly, the cultured Reiter strain of spirochete is apparently sufficiently close serologically to T. pallidum to be agglutinated by and to give complement fixation with the antibodies to T. pallidum present in syphilitic serum. 7. Since suspensions of cultured spirochetes contain antigenic factors which react specifically with syphilitic serum, some of which are not present in ordinary Wassermann and flocculation "antigens," they may prove even more valuable than those tissue extracts in the serodiagnosis of syphilis.

Cost-minimization analysis of jumbo reusable forceps versus disposable forceps in a high-volume ambulatory endoscopy center

BACKGROUND

Endoscopists worldwide are faced with the challenge of choosing the most cost-effective and durable equipment. There are limited data comparing the 2 major options for endoscopic forceps: disposable and reusable. Disposable forceps are marketed as the cost-effective alternative to reusable forceps.

OBJECTIVE

This study was designed to provide a prospective assessment of the survival and cost of reusable versus disposable forceps to allow more educated decisions when purchasing endoscopic equipment.

DESIGN

A 24-month prospective study in a high-volume ambulatory endoscopy center (AEC) with 71 Olympus jumbo reusable forceps (OJRF). A "cost of OJRF per procedure" was generated to compare to the estimated cost of disposable forceps per procedure.

SETTING

Gastrointestinal Associates PA of Jackson, Mississippi, which performs approximately 24,000 outpatient procedures per year.

PATIENTS

General patient population of this AEC undergoing colonoscopy.

MAIN OUTCOME MEASUREMENTS

Mean cost of forceps per procedure and survival of reusable forceps. Cost was derived from purchase price, cleaning costs, repair/maintenance costs, and number of uses.

RESULTS

Over the 24-month period, the total cost per procedure was $3.27. The mean number of uses per OJRF was 166.3. Sixty-eight percent of the forceps required no repair throughout the 2-year study, and only 1 forceps was deemed beyond repair. For comparison, disposable forceps were assigned a cost per procedure of $10.00 on the basis of conservative market price. Over a 2-year period this cost-per-procedure difference resulted in a cost savings of $79,482.

LIMITATIONS

Failure to determine the average life-span of OJRF because 98% were still functioning properly after 2 years and an average of 166.3 procedures. Evaluation did not include storage and disposal costs, which would add a miniscule additional cost to disposable costs. The study also does not address some of the other arguments for disposables such as performance (quality of specimen) compared with reusables. The estimated average number of uses and durability was only studied for the OJRF. Other forceps may have different average cost per use and durability.

CONCLUSIONS

In a large-volume AEC, OJRF are vastly more durable than resusable forceps reported in prior studies and are vastly more cost-effective than disposable forceps. A longer study period would have only revealed more dramatic cost savings and durability.

Epinephrine volume reduction of giant colon polyps facilitates endoscopic assessment and removal

BACKGROUND

Management of giant colon polyps (>3 cm) can be a challenge for the therapeutic endoscopist, especially the endoscopist in training. Challenges include the potential for bleeding and the difficult technical aspects of removing giant polyps. Years of clinically observing the effects of epinephrine injection to reduce bleeding revealed epinephrine's pronounced volume-reducing effect. This epinephrine volume reduction (EVR) greatly facilitates assessment and removal of giant polyps while decreasing the need for piecemeal resection.

OBJECTIVE

Our purpose was to demonstrate the use of EVR in facilitating the evaluation and removal of giant colon polyps.

DESIGN

Case reports defining the technique of EVR.

SETTING

Busy ambulatory endoscopy center with more than 22,000 cases in 2006.

PATIENTS

General population of patients treated in this ambulatory endoscopy center for giant colon polyps.

INTERVENTIONS

EVR and polypectomy.

OUTCOME MEASUREMENTS

Pre-EVR and post-EVR volumes in giant polyps. Relative ease of removal of pre-EVR versus post-EVR polyp and observations for complications.

RESULTS

Typically greater than 80% reduction in polyp volume was achieved, greatly easing endoscopic evaluation and removal while virtually eliminating the need for piecemeal resection. EVR was associated with no acute or delayed bleeding complications.

LIMITATIONS

May be limited by inexperienced endoscopist's lack of injection and polypectomy skills. The technical difficulty in objective measurements of in vivo size and lack of blinded observations with a control group present the potential for observer bias.

CONCLUSIONS

The use of EVR is a simple, cheap, and practical tool that facilitates giant polyp assessment and removal. This technique may greatly benefit endoscopists in the management of giant colon polyps. A prospective controlled trial of EVR should be undertaken to further define the optimal methods and benefits for the removal of giant colon polyps.

Crystal-storing Histiocytosis due to Massive Accumulation of Charcot-Leyden Crystals: A Unique Association Producing Colonic Polyposis in a 78-year-old Woman With Eosinophilic Colitis

Crystal-storing histiocytosis is a rare diagnosis that to date has only been associated with 2 conditions: intracytoplasmic accumulation of crystallized immunoglobulins in patients with lymphoproliferative disorders or plasma cell dyscrasias, and histiocytic accumulations of phagocytosed clofazimine, a drug used to treat lepromatous leprosy. We describe a 78-year-old woman with a past medical history of dermatologic mastocytosis and peripheral eosinophilia who presented with diarrhea and weight loss, and was found at colonoscopy to have polyposis limited to the right and transverse colon. She eventually underwent subtotal colectomy to remove the segment of polyposis. At gross examination, the colonic mucosa contained numerous polyps ranging from 1 to 7 mm which on histologic evaluation proved to represent mucosal and submucosal collections of histiocytes whose cytoplasm was distended by numerous brightly eosinophilic crystals. An intense eosinophilic infiltrate surrounded the histiocyte collections and also mildly involved the intervening colonic mucosa and superficial submucosa. Electron microscopy confirmed the presence of intracytoplasmic material identical to Charcot-Leyden crystals within histiocytes, representing the breakdown products of degranulated eosinophils. This is the first reported case of crystal-storing histiocytosis produced by massive accumulation of Charcot-Leyden crystals in eosinophilic colitis.

Effects of a motilin receptor agonist (ABT-229) on upper gastrointestinal symptoms in type 1 diabetes mellitus: a randomised, double blind, placebo controlled trial

INTRODUCTION

Erythromycin, a motilin agonist, is a potent prokinetic. ABT-229 is a specific motilin agonist that dose dependently accelerates gastric emptying. Dyspepsia and gastroparesis are common problems in type 1 diabetes mellitus. We aimed to evaluate the efficacy of ABT-229 in symptomatic diabetic patients with and without delayed gastric emptying.

METHODS

Patients with type 1 diabetes and postprandial symptoms were randomised (n=270). Based on a validated C(13) octanoic acid breath test, patients were assigned to either the delayed or normal gastric emptying strata. Patients received one of four doses of ABT-229 (1.25, 2.5, 5, or 10 mg twice daily before breakfast and dinner) or placebo for four weeks following a two week baseline. A self report questionnaire measured symptoms on visual analogue scales; the primary outcome was assessment of change in the total upper abdominal symptom severity score (range 0-800 mm) from baseline to the final visit.

RESULTS

The treatment arms were similar regarding baseline characteristics. There was symptom improvement on placebo and a similar level of improvement on active therapy for the upper abdominal discomfort severity score (mean change from baseline -169, -101, -155, -143, and -138 mm for placebo, and 1.25, 2.5, 5, and 10 mg ABT-229, respectively, at four weeks by intent to treat). The results were not significantly different in those with and without delayed gastric emptying. The severity of bloating, postprandial nausea, epigastric discomfort, heartburn, and acid regurgitation worsened dose dependently in a greater number of patients receiving ABT-229 than placebo. Overall, 63% of patients on placebo reported a good or excellent global response, and this was not different from the active treatment arms.

CONCLUSIONS

The motilin agonist ABT-229 was not efficacious in the relief of postprandial symptoms in diabetes mellitus in the presence or absence of delayed gastric emptying.

A double-blind, randomized, sham-controlled trial of the gastric bubble for obesity

We investigated the effect of an endoscopically placed gastric balloon, the Garren-Edwards gastric bubble (GEGB), on weight loss in obese patients. Fifty-nine obese patients were entered into a prospective double-blind study and randomized into two groups. In one group (34 patients) the GEGB was inserted, and in the other group (25 patients) a sham insertion was done. All patients participated in a standard weight loss program consisting of dietary therapy, behavior modification, and physical exercise. The bubble was removed endoscopically after 3 months from both groups. Patients were followed for an additional 9 months after bubble removal and weight loss was monitored. Weight loss was the same in both groups at 3 months (18.7 lb vs. 17.2 lb). This was true whether determined by change in pounds, percentage of body weight, or body mass index. We concluded that the GEGB was of no added benefit as compared with sham insertion, when combined with a standard weight loss program. Because of the lack of proven efficacy and the relatively high cost, we recommend that such devices be restricted to controlled studies until significant benefits are proven.

Studies of the prevalence and significance of radiolabeled bile acid malabsorption in a group of patients with idiopathic chronic diarrhea

We studied radiolabeled fecal bile acid excretion in 11 normal subjects and 17 patients with idiopathic chronic diarrhea for three major purposes: to establish normal values for this test in the presence of increased stool volumes (induced in normal subjects by ingestion of poorly absorbable solutions); to test for bile acid malabsorption in the patients and to correlate this with an independent test of ileal function, the Schilling test; and to compare the results of the bile acid excretion test with the subsequent effect of a bile acid binding agent (cholestyramine) on stool weight. In normal subjects fecal excretion of the radiolabel was increased with increasing stool volumes. As a group, patients with idiopathic chronic diarrhea excreted radiolabeled bile acid more rapidly than normal subjects with induced diarrhea (t1/2 56 +/- 8 vs. 236 +/- 60 h, respectively, p less than 0.005). There was a statistically significant positive correlation between t1/2 of radiolabeled bile acid and Schilling test results in these patients. Although 14 of 17 patients absorbed labeled taurocholic acid less well than any of the normal subjects with comparable volumes of induced diarrhea, cholestyramine had no statistically significant effect on stool weight in the patient group, and in none of the patients was stool weight reduced to within the normal range. In summary, most patients with idiopathic chronic diarrhea have bile acid malabsorption (as measured by fecal excretion of labeled bile acid), but they do not respond to cholestyramine therapy with a significant reduction in stool weight. Although the significance of these findings was not clearly established, the most likely interpretation is that bile acid malabsorption is a manifestation of an underlying intestinal motility or absorptive defect rather than the primary cause of diarrhea.

Percutaneous endoscopic gastrostomy--to push or pull. A prospective randomized trial

A prospective randomized study was undertaken to evaluate the Ponsky-Gauderer and Sachs-Vine types of gastrostomy kits. The techniques, complications, morbidity, and mortality with each type of device are compared. Both devices are found to compare favorably to the traditional surgically placed gastrostomy.

Preliminary experience with hydrostatic balloon dilation of gastric outlet obstruction

In treating a group of 15 patients with gastric outlet obstruction, 12 (80%) had good to excellent relief of symptoms. Two patients required surgical intervention. One patient has symptoms that were persistent but mild enough to forego surgery. Balloon dilation offers an alternative to the surgical management of gastric outlet obstruction.