A case of duodenal variceal bleeding treated by Doppler-guided endoscopic cyanoacrylate injection

Video 1.

Risk of Venous Thromboembolism in Acute Necrotizing Pancreatitis: A Large Database Study

OBJECTIVES

Studies on the incidence of venous thromboembolism (VTE) in acute pancreatitis (AP) are scarce. We conducted a large database study to evaluate this relationship.

METHODS

Data were extracted from a large electronic health record (Explorys; IBM Watson Health, Armonk, NY). We identified patients with AP in 2018 and 2019, analyzing VTE incidence at 30 days after diagnosis of AP. Univariate and multivariate analyses were performed to identify risk factors associated with VTE.

RESULTS

A total of 25,620 cases of acute necrotizing pancreatitis (ANP) and 155,800 cases of acute nonnecrotizing pancreatitis (ANNP) were identified. The incidence of VTE was 7.1% for ANP, compared with 2.8% in ANNP (P < 0.001). On multivariate analysis, ANP conferred significantly greater odds of VTE (adjusted odds ratio, 2.78; 95% confidence interval, 2.73-2.84; P < 0.001), independent of other variables. In those with ANP, the presence of VTE was associated with a significantly higher mortality (23.5% vs 15.9%, P < 0.001).

CONCLUSIONS

Acute necrotizing pancreatitis carries near 2.5-fold risk of VTE, and a 3-fold risk of PE, compared with those with ANNP. Venous thromboembolism development in ANP is associated with higher mortality.

Use of Doppler Probe in Nonvariceal Upper-Gastrointestinal Bleeding Is Less Costly and More Effective Than Standard of Care

BACKGROUND & AIMS

Upper gastrointestinal bleeding is a common emergency and rebleeding is associated with an increased risk of death. Proper assessment of high-risk lesions and appropriate endoscopic hemostasis are required for the best outcomes. The endoscopic Doppler probe examination (DPE) allows for a more complete assessment of the stigmata of hemorrhage, providing better evaluation of the need for endoscopic hemostasis and determination of its completeness. We aimed to evaluate whether use of the DPE provides an additional advantage in cost and effectiveness compared with traditional endoscopic visual assessment (TEA) of high-risk stigmata in patients with nonvariceal upper gastrointestinal bleeding.

METHODS

We drew a decision tree representing the choice between DPE and TEA approaches for patients undergoing an index endoscopy for active nonvariceal upper gastrointestinal bleeding. Clinical probabilities were retrieved from randomized controlled trial data. Costs were expressed in 2017 US dollars. A third-party payer perspective was adopted. We performed deterministic and probabilistic sensitivity analyses. The adopted time horizon was 30 days after the index endoscopy.

RESULTS

We found that DPE is a dominant strategy over the TEA, in that DPE is more efficacious (92.6% of patients avoiding rebleeding vs 78.6% for TEA) and less expensive ($8502 vs $9104 for TEA). The economic dominance of DPE over TEA was robust to sensitivity analyses across all assumptions of the model when varied among ranges spanning 30% of their respective baseline values.

CONCLUSIONS

In a cost-effectiveness analysis, we found DPE to be an economically dominant strategy to TEA (the traditional approach) in the management of high-risk lesions in patients with nonvariceal upper gastrointestinal bleeding. DPE was less costly and more effective.

Unusual Causes of Upper Gastrointestinal Bleeding

Upper gastrointestinal (GI) bleeding is an important clinical condition managed routinely by endoscopists. Diagnostic and therapeutic options vary immensely based on the source of bleeding and it is important for the gastroenterologist to be cognizant of both common and uncommon etiologies. The focus of this article is to highlight and discuss unusual sources of upper GI bleeding, with a particular emphasis on both the clinical and endoscopic features to help diagnose and treat these atypical causes of bleeding.

Risk factors for acute gastrointestinal bleeding following myocardial infarction in veteran patients who are prescribed clopidogrel

OBJECTIVE

Our aim was to identify risk factors for acute gastrointestinal (GI) bleeding in patients with myocardial infarction (MI) who were prescribed clopidogrel following hospital discharge.

METHODS

Data were collected retrospectively from patients treated in Veteran Affairs hospitals in Ohio, USA, from 2001 to 2008 with a primary diagnosis of MI (International Classification of Diseases, 9th Revision) and a prescription for clopidogrel filled within 48 h of discharge. Primary outcome was acute GI bleeding after discharge.

RESULTS

Acute GI bleeding occurred in 107 of 3218 patients. Bleeding occurred in those who were elder (66.2 vs. 62.4 years, P = 0.0002), had lower glomerular filtration rate (74 vs. 81 mL/min, P = 0.024), had filled prescription for warfarin (15.9% vs. 6.9%, P = 0.0004), diagnosed as atrial fibrillation (20.6% vs. 11.1%, P = 0.003), chronic liver (5.6% vs. 2.2%, P = 0.018) or kidney disease (29.0% vs. 19.4%, P = 0.016). A risk model and GI bleed risk score were developed and showed that patients with age >65 years, use of warfarin, the presence of chronic liver or kidney disease were at increased risk for GI bleeding.

CONCLUSIONS

Veterans patients of advanced age, using warfarin and with chronic liver and kidney disease may be at increased risk of GI bleeding when prescribed clopidogrel following MI. A scoring system may help to identify patients at high risk for GI bleeding.

Endoscopic needle-knife therapy for ileal pouch sinus: a novel approach for the surgical adverse event (with video)

BACKGROUND

Pouch sinus is an adverse event in patients undergoing ileal pouch surgery.

OBJECTIVE

To evaluate the efficacy of needle-knife therapy in managing pouch sinus and to assess factors associated with the healing of pouch sinus.

DESIGN

An historical cohort study from a prospectively collected database.

SETTING

A high-volume specialized pouch center.

PATIENTS

From tertiary-care pouch center.

INTERVENTIONS

Endoscopic needle-knife therapy.

RESULTS

This cohort consisted of 65 patients. Men accounted for 76.9% (n = 50). The median interval from colectomy to the diagnosis of pouch sinus was 4.0 years (interquartile range [IQR]: 2.0-7.5). Pouch sinus was located at the anastomosis in 59 patients (90.8%), at the mid pouch suture line in 4 patients (6.2%), and at the tip of "J" in 2 patients (3.1%). The mean depth of the pouch sinus was 4.4 ± 1.8 cm. Twenty patients (30.8%) had complex pouch sinuses. After a median of 2.0 needle-knife therapies (IQR: 1.5-3.5) during a follow-up period of 1.1 years (IQR: 0.4-2.8), 28 patients (43.1%) with pouch sinus experienced a complete response, 27 (41.5%) had a partial response, and 10 (15.4%) had persistent sinus. Fifty-three patients (81.5%) maintained a functional pouch at the last follow-up. Multivariate analysis showed that a longer duration from colectomy to diagnosis of pouch sinus (odds ratio: 0.85; 95% confidence interval: 0.73-0.99; P = .033) and complex sinuses (odds ratio: 0.17; 95% confidence interval: 0.04-0.70; P = .014) were inversely associated with the healing of pouch sinuses, whereas the increased sessions of needle-knife therapy (odds ratio: 1.36; 95% confidence interval: 1.01-1.81; P = .041) improved the healing of the pouch sinuses.

LIMITATIONS

Single-center study with a relatively small number of patients.

CONCLUSION

In experienced hands, endoscopic needle-knife therapy is an efficacious and safe procedure for pouch sinuses. A longer duration from colectomy to diagnosis of pouch sinus and complex pouch sinuses appeared to be associated with a higher risk for nonhealing of the sinus, suggesting that early diagnosis and intervention have an impact on outcomes.

Immediate unprepared hydroflush colonoscopy for severe lower GI bleeding: a feasibility study

BACKGROUND

Urgent colonoscopy is not always the preferred initial intervention in severe lower GI bleeding because of the need for a large volume of oral bowel preparation, the time required for administering the preparation, and concern regarding adequate visualization.

OBJECTIVE

To evaluate the feasibility, safety, and outcomes of immediate unprepared hydroflush colonoscopy for severe lower GI bleeding.

DESIGN

Prospective feasibility study of immediate colonoscopy after tap-water enema without oral bowel preparation, aided by water-jet pumps and mechanical suction devices in patients admitted to the intensive care unit with a primary diagnosis of severe lower GI bleeding.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASUREMENTS

Primary outcome measurement was the percentage of colonoscopies in which the preparation permitted satisfactory evaluation of the entire length of the colon suspected to contain the source of bleeding. Secondary outcome measurements were visualization of a definite source of bleeding, length of hospital and intensive care unit (ICU) stays, rebleeding rates, and transfusion requirements.

RESULTS

Thirteen procedures were performed in 12 patients. Complete colonoscopy to the cecum was performed in 9 of 13 patients (69.2%). However, endoscopic visualization was thought to be adequate for definitive or presumptive identification of the source of bleeding in all procedures, with no colonoscopy repeated because of inadequate preparation. A definite source of bleeding was identified in 5 of 13 procedures (38.5%). The median length of ICU stay was 1.5 days; of hospital stay, 4.3 days. Recurrent bleeding during the same hospitalization, requiring repeated endoscopy, surgery, or angiotherapy, was seen in 3 of 12 patients (25%).

LIMITATIONS

Uncontrolled feasibility study of selected patients.

CONCLUSION

Immediate unprepared hydroflush colonoscopy in patients with severe lower GI bleeding is feasible with the hydroflush technique.

Characterization of the pancreas in vivo using EUS spectrum analysis with electronic array echoendoscopes

BACKGROUND

Spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images has been used to provide quantitative, objective information about tissue histology.

OBJECTIVE

Our purpose was to validate RF spectral analysis as a method to distinguish between chronic pancreatitis (CP) and pancreatic cancer (PC).

DESIGN AND SETTING

A prospective study of eligible patients was conducted to analyze the RF data obtained by using electronic array echoendoscopes.

PATIENTS

Pancreatic images were obtained by using electronic array echoendoscopes from 41 patients in a prospective study, including 15 patients with PC, 15 with CP, and 11 with a normal pancreas.

MAIN OUTCOME MEASUREMENTS

Midband fit, slope, intercept, correlation coefficient, and root mean square deviation from a linear regression of the calibrated power spectra were determined and compared among the groups.

RESULTS

Statistical analysis showed that significant differences were observable between groups for mean midband fit, intercept, and root mean square deviation (t test, P < .05). Discriminant analysis of these parameters was then performed to classify the data. For CP (n = 15) versus PC (n = 15), the same parameters provided 83% accuracy and an area under the curve of 0.83.

LIMITATIONS

Moderate sample size and spatial averaging inherent in the technique.

CONCLUSIONS

This study shows that mean spectral parameters of the backscattered signals obtained by using electronic array echoendoscopes can provide a noninvasive method to quantitatively discriminate between CP and PC.

New diagnostic imaging technologies in nonvariceal upper gastrointestinal bleeding

This article covers new endoscopic imaging modalities in nonvariceal upper gastrointestinal bleeding, such as Doppler ultrasound probe technology, endoscopic ultrasonography, color Doppler optical coherence tomography, and magnification endoscopy. A more in-depth discussion of these modalities and the published evidence supporting their use are included. Furthermore, the shift in focus from identification of conventional visual surface stigmata of recent hemorrhage to an assessment and understanding of subsurface blood flow as it relates to the bleeding lesion is discussed.

Prevalence and clinical significance of pancreatic cysts associated with cysts in other organs

BACKGROUND AND AIM

Von Hippel-Lindau disease is associated with serous cysts in the pancreas and kidneys. In this study we determined the prevalence of pancreatic cysts occurring concurrently with other abdominal cysts and tested the hypothesis that these patients might represent a forme fruste of Von Hippel-Lindau disease and be more likely to be serous cysts.

METHODS

A retrospective chart review of patients undergoing endoscopic ultrasound of pancreatic cysts.

RESULTS

A total of 156 patients were included in the study. Eighty-five patients (54.8%) had cyst(s) in the pancreas and at least one other intra-abdominal cyst. These cysts included 24 (27.9%) serous cysts, 30 (34.9%), mucinous cysts, 6 (7%) adenocarcinoma and 25 (29.4%) unknowns. Seventy-one patients (45.2%) had isolated pancreatic cysts. These included 17 (23.9%) serous cysts, 28 (39.5%) mucinous cysts, 4 (5.6%) adenocarcinoma and 22 (31%) unknowns. The odds of serous cysts with concurrent extra-pancreatic and pancreatic cysts compared to odds of serous cysts with pancreatic cysts alone were 1.3 (95% CI: 0.6-2.9).

CONCLUSIONS

Pancreatic cysts are associated with cysts in other abdominal organs in 54.8% patients. The prevalence of serous cysts was not higher amongst individuals with multiple organ cysts compared to those with only pancreatic cysts.

Clinical triage decision vs risk scores in predicting the need for endotherapy in upper gastrointestinal bleeding

BACKGROUND

Acute upper gastrointestinal hemorrhage (UGIH) is a common reason for hospitalization with substantial associated morbidity, mortality, and cost. Differentiation of high- and low-risk patients using established risk scoring systems has been advocated. The aim of this study was to determine whether these scoring systems are more accurate than an emergency physician's clinical decision making in predicting the need for endoscopic intervention in acute UGIH.

METHODS

Patients presenting to a tertiary care medical center with acute UGIH from 2003 to 2006 were identified from the hospital database, and their clinical data were abstracted. One hundred ninety-five patients met the inclusion criteria and were included in the analysis. The clinical Rockall score and Blatchford score (BS) were calculated and compared with the clinical triage decision (intensive care unit vs non-intensive care unit admission) in predicting the need for endoscopic therapy.

RESULTS

Clinical Rockall score greater than 0 and BS greater than 0 were sensitive predictors of the need for endoscopic therapy (95% and 100%) but were poorly specific (9% and 4%), with overall accuracies of 41% and 39%. At higher score cutoffs, clinical Rockall score greater than 2 and BS greater than 5 remained sensitive (84% and 87%) and were more specific (29% and 33%), with overall accuracies of 48% and 52%. Clinical triage decision, as a surrogate for predicting the need for endoscopic therapy, was moderately sensitive (67%) and specific (75%), with an overall accuracy (73%) that exceeded both risk scores.

CONCLUSIONS

The clinical use of risk scoring systems in acute UGIH may not be as good as clinical decision making by emergency physicians.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Endoscopic Doppler US for the prevention of ulcer bleeding after endoscopic submucosal dissection for early gastric cancer: a preliminary study (with video)

BACKGROUND

After endoscopic submucosal dissection (ESD) for early gastric cancer (EGC), delayed bleeding occurs in 1.7% to 38% of cases. Routine coagulation of all nonbleeding visible vessels (NBVVs) in post-ESD ulcers is currently performed as standard practice, but it cannot eliminate bleeding. An endoscopic Doppler US (DOP-US) probe system has possible benefits for the prediction of recurrent bleeding in peptic ulcer hemorrhage.

OBJECTIVE

To establish optimum use and evaluate feasibility of DOP-US for post-ESD ulcers.

DESIGN

Case series study.

SETTING

Cancer referral center.

PATIENTS

Eight patients with mucosal EGC larger than 2 cm without ulceration or scarring and 2 patients with EGC less than 3 cm with scarring.

INTERVENTIONS

We searched for a positive DOP-US signal (DOP-US+), which was defined as pulsatile sound at a depth of 1.5 mm, and NBVVs or areas with DOP-US+ were coagulated with hemostatic forceps. A multibending, double-channel videoendoscope that was fitted with a transparent hood was used.

MAIN OUTCOME MEASUREMENTS

Detectability of DOP-US signals in post-ESD ulcers.

RESULTS

One of 13 oozing bleeding sites, 24 (18%) of 136 NBVVs, and 7 areas without any bleeding stigmata had DOP-US+ and were coagulated until the signal became silent. One hundred twelve NBVVs (82%) and 8 adherent clots without DOP-US signals were left untreated. No delayed bleeding was experienced at 30 days. Median time required for Doppler examination was 34 minutes, but it improved to 18 and 19 minutes in patients 9 and 10, respectively.

CONCLUSIONS

DOP-US might be helpful in the endoscopic management of post-ESD ulcers in EGC. Our setting and maneuver warrant further investigation to clarify whether DOP-US can reduce delayed bleeding and avoid unnecessary coagulation for NBVVs in post-ESD ulcers.

Variability in measurements of pancreatic cyst size among EUS, CT, and magnetic resonance imaging modalities

BACKGROUND

Cyst size is an important factor in the management of pancreatic cysts, both in predicting the need for surgery and the frequency of follow-up.

OBJECTIVE

To determine agreement and precision of EUS, CT, and magnetic resonance imaging (MRI) modalities in the evaluation of pancreatic cyst diameter.

DESIGN

Retrospective chart review.

SETTING

Tertiary-care center, January 2000 to June 2009.

PATIENTS

This study involved 175 patients presenting for EUS evaluation of pancreatic cysts, with size measured by at least two of the aforementioned imaging studies within a 90-day period.

MAIN OUTCOME MEASUREMENTS

Largest cyst diameter from EUS, CT, MRI/MRCP, and surgical pathology.

RESULTS

A total of 175 patients underwent EUS. Seventy-three had CT plus EUS, 33 had MRI/MRCP plus EUS, 23 had MRI/MRCP plus CT, and 15 had all imaging studies, occurring within 90 days of each other. Median size differences between studies: EUS and CT (ie, absolute value of size determined by EUS minus size determined by CT) = 4 mm (range 0-25 mm), EUS and MRI = 4 mm (range 0-17 mm), CT and MRI = 3 mm (range 2-20 mm). Median size differences for surgical pathology specimens compared with results of 12 EUS, 13 CT, and 8 MRI/MRCP studies were as follows: EUS and pathology = 9.5 mm (range 0-20 mm), CT and pathology = 5 mm (range 0-21 mm), MRI and pathology = 5.5 mm (range 2-44 mm).

LIMITATIONS

Interobserver variability and small sample of surgical pathology cysts.

CONCLUSION

There is considerable variation in size estimates of pancreatic cysts by different imaging modalities, which practitioners should take into account when making management decisions. Use of a single imaging modality is recommended during follow-up. The precision of imaging studies for measuring pancreatic cysts must be prospectively defined if change in size is to be reliably used for clinical management.

In vivo characterization of pancreatic and lymph node tissue by using EUS spectrum analysis: a validation study

BACKGROUND

Quantitative spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images can be used to provide additional, objective information about tissue state.

OBJECTIVE

Our purpose was to validate RF spectral analysis as a method to distinguish between (1) benign and malignant lymph nodes and (2) normal pancreas, chronic pancreatitis, and pancreatic cancer.

DESIGN AND SETTING

A prospective validation study of eligible patients was conducted to compare with pilot study RF data.

PATIENTS

Forty-three patients underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes (19 from a previous pilot study and 24 additional patients).

MAIN OUTCOME MEASUREMENTS

Midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were determined.

RESULTS

Discriminant analysis of mean pilot-study parameters was then performed to classify validation-study parameters. For benign versus malignant lymph nodes, midband fit and intercept (both with t test P < .058) provided classification with 67% accuracy and area under the receiver operating curve (AUC) of 0.86. For diseased versus normal pancreas, midband fit and correlation coefficient (both with analysis of variance P < .001) provided 93% accuracy and an AUC of 0.98. For pancreatic cancer versus chronic pancreatitis, the same parameters provided 77% accuracy and an AUC of 0.89. Results improved further when classification was performed with all data.

LIMITATIONS

Moderate sample size and spatial averaging inherent to the technique.

CONCLUSIONS

This study confirms that mean spectral parameters provide a noninvasive method to quantitatively discriminate benign and malignant lymph nodes as well as normal and diseased pancreas.

Use and impact of early endoscopy in elderly patients with peptic ulcer hemorrhage: a population-based analysis

BACKGROUND

Upper endoscopy performed within 1 day of presentation, or early endoscopy, has been proposed as an intervention to improve the efficiency and outcomes of care for patients with peptic ulcer hemorrhage. However, the use and outcomes have not been studied in a national, U.S.-based sample.

OBJECTIVE

To determine the prevalence and associated outcomes of early versus delayed endoscopy in bleeding peptic ulcers.

DESIGN

Using a 5% random sample of inpatient and outpatient Medicare claims from 2004 in patients aged 66 years and older (mean [standard deviation] age 78.4 +/- 7.7 years), we identified 2592 patients, all of whom underwent endoscopy.

MAIN OUTCOME MEASUREMENTS

Univariate and multivariate models were used to determine factors associated with 30-day mortality, upper GI surgery, and length of hospital stay.

RESULTS

Early endoscopy was performed in 1854 patients (71.5%) and was somewhat more common with outpatient management. Early endoscopy was independently associated with a significant decrease in the length of hospital stay (-1.95 days, 95% CI, -2.60 to -1.29 days) as well as a lower likelihood of surgery (odds ratio, 0.37; 95% CI, 0.21-0.66). Early endoscopy was not associated with 30-day mortality in either univariate or multivariate analyses.

LIMITATIONS

Use of claims data lacking clinical detail and restriction to the Medicare-age population.

CONCLUSIONS

In this population-based study of older patients with peptic ulcer hemorrhage, early endoscopy was associated with increased efficiency of care, lower rates of surgery, and potentially improved control of hemorrhage. Thus, unless specific contraindications exist, the data support the routine use of early endoscopy.

Characterization of pancreatic cancer and intra-abdominal lymph node malignancy using spectrum analysis of endoscopic ultrasound imaging

This study assessed the ability of spectral analysis of endoscopic ultrasound (EUS) RF signals acquired in humans in vivo to distinguish between (1) benign and malignant intraabdominal and mediastinal lymph nodes and (2) pancreatic cancer, chronic pancreatitis, and normal pancreas. Mean midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were computed over regions of interest defined by the endoscopist. Linear discriminant analysis was then performed to develop a classification of the resulting spectral parameters. For lymph nodes, classification based on the midband fit and intercept provided 67% sensitivity, 82% specificity, and 73% accuracy for malignant vs. benign nodes. For pancreas, classification based on midband fit and correlation coefficient provided 95% sensitivity, 93% specificity, and 93% accuracy for diseased vs. normal pancreas and 85% sensitivity, 71% specificity, and 85% accuracy for pancreatic cancer vs. chronic pancreatitis. These promising results suggest that mean spectral parameters can provide a non-invasive method to quantitatively characterize pancreatic cancer and lymph malignancy in vivo.

Outpatient management of nonvariceal upper gastrointestinal hemorrhage: unexpected mortality in Medicare beneficiaries

BACKGROUND & AIMS

Outpatient management of selected patients with nonvariceal upper gastrointestinal hemorrhage (UGIH) has been proposed as a mechanism to decrease resource utilization and expenditures. However, the true prevalence and outcomes of this practice have not been well evaluated in population-based studies.

METHODS

We identified a cohort of 9123 episodes of UGIH in 2004 Medicare claims data, including 3506 (38.4%) managed as outpatients. Clinical characteristics, treatment, and outcomes were compared between inpatient and outpatient groups. In order to adjust for potential selection bias in outpatient treatment, propensity score analysis was used to divide patients into quartiles of likelihood for inpatient treatment.

RESULTS

Inpatients tended to be older, with higher comorbidity scores, and were more likely to have a bleeding ulcer or tear. Inpatients were also more likely to undergo endoscopy, including early endoscopy and therapeutics, and require surgery. The overall 30-day mortality rate was 8.0% in the inpatient group and 6.3% in the outpatient group (P< .001), and in the quartile of patients most likely to be managed as inpatients, the 30-day mortality rate was higher in outpatients than in inpatients.

CONCLUSIONS

The prevalence of outpatient management of UGIH in the Medicare population was almost 40%, and although patients were likely selected for outpatient management based on clinical criteria, the overall mortality rate in outpatients was considerable. Any potential financial benefit should be balanced against significant mortality rates, at least some of which could possibly be avoided with hospitalization. More optimal selection of candidates for outpatient therapy is likely needed.

Creation of an effective and reproducible nonsurvival porcine model that simulates actively bleeding peptic ulcers

BACKGROUND

Efforts to develop improved endoscopic therapeutic methods for upper GI bleeding require an effective animal model.

OBJECTIVE

To develop a nonsurvival porcine model that simulates acute peptic ulcer bleeding.

DESIGN

Prospective animal (porcine) study.

SETTING

Animal laboratory.

INTERVENTIONS

A surgical seromyotomy was created along the external surface of the greater curvature of the stomach in anesthesized pigs. A submucosal plane was developed and the gastroepiploic bundle, in continuity, was placed adjacent to the mucosa, and the seromuscular tissues were re-approximated over the vascular bundle. By using EGD, a needle-knife with electrocautery was then used to incise the mucosal tissue overlying the vascular bundle. Standard endoscopic methods for bleeding control were then tested in this animal model.

MAIN OUTCOME MEASUREMENTS

To evaluate whether successful bleeding that simulates submucosal arterial bleeding from peptic ulcer disease could be achieved in a porcine animal model.

RESULTS

Successful simulation of active peptic ulcer bleeding was achieved with this nonsurvival porcine model in a total of 5 sequential pigs. Other porcine models for bleeding were tested and found to be unsatisfactory. Hemoclips and combination injection-thermal therapy were used to stop bleeding over Doppler-positive areas, with subsequent endoscopic nonimaging Doppler US probe examination of the ulcer bed revealing a negative Doppler signal.

LIMITATIONS

This was an animal laboratory study. Further human studies would be ideal once any future endoscopic interventions are proven to be safe in animals.

CONCLUSIONS

This active bleeding ulcer model can be used to develop future endoscopic therapies and for training purposes.

Artificial neural network as a predictive instrument in patients with acute nonvariceal upper gastrointestinal hemorrhage

BACKGROUND & AIMS

Triage of patients with acute upper gastrointestinal hemorrhage (UGIH) has traditionally required urgent upper endoscopy. The aim of this study is to evaluate the use of artificial neural network for nonendoscopic triage.

METHODS

A cohort of 387 patients was used to train (n = 194) and internally validate (n = 193) the neural network, which was then externally validated in 200 patients and compared with the clinical and complete Rockall score. Two outcome variables were assessed: major stigmata of recent hemorrhage and need for endoscopic therapy. Patient cohort data from 2 independent tertiary-care medical centers were prospectively collected. Adult patients hospitalized at both sites during the same time period with a primary diagnosis of acute nonvariceal UGIH.

RESULTS

In predicting the 2 measured outcomes, sensitivity of neural network was >80%, with high negative predictive values (92-96%) in both cohorts but with lower specificity in the external cohort. Both Rockall scores had adequate sensitivity (>80%) but poor specificity (<40%) at outcome prediction. Comparing areas under receiver operating characteristic curves, the clinical Rockall score was significantly inferior to neural network in both cohorts (</=0.65 vs. >/= 0.78), while in the external cohort, neural network performed similarly to the complete Rockall score (>/= 0.78).

CONCLUSIONS

In acute nonvariceal UGIH, artificial neural network (nonendoscopic triage) performed as well as the complete Rockall score (endoscopic triage) at predicting stigmata of recent hemorrhage and need for endoscopic therapy, even when tested in an external patient population.

EUS spectrum analysis for in vivo characterization of pancreatic and lymph node tissue: a pilot study

BACKGROUND

EUS is limited by variability in the examiner's subjective interpretation of B-scan images to differentiate among normal, inflammatory, and malignant tissue. By using information otherwise discarded by conventional EUS systems, quantitative spectral analysis of the raw radiofrequency (RF) signals underlying EUS images enables tissue to be characterized more objectively.

OBJECTIVE

Our purpose was to determine the feasibility of using spectral analysis of EUS data for characterization of pancreatic tissue and lymph nodes.

DESIGN AND SETTING

A pilot study of eligible patients was conducted to analyze the RF data obtained during EUS by using spectral parameters.

PATIENTS

Twenty-one subjects who underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes.

MAIN OUTCOME MEASUREMENTS

Linear regression parameters of calibrated power spectra of the RF signals were tested to differentiate normal pancreas from chronic pancreatitis and from pancreatic cancer as well as benign from malignant-appearing lymph nodes.

RESULTS

The mean intercept, slope, and midband fit of the spectra differed significantly among normal pancreas, adenocarcinoma, and chronic pancreatitis when all were compared with each other (P < .01). On direct comparison, mean midband fit for adenocarcinoma differed significantly from that for chronic pancreatitis (P < .05). For lymph nodes, mean midband fit and intercept differed significantly between benign- and malignant-appearing lymph nodes (P < .01 and P < .05, respectively).

LIMITATIONS

Small sample population and spatial averaging inherent to this technique.

CONCLUSIONS

Mean spectral parameters in EUS imaging can provide a noninvasive method to discriminate normal from diseased pancreas and lymph nodes.

Postprocedure radiologist's interpretation of ERCP x-ray films: a prospective outcomes study

OBJECTIVE

To prospectively determine if the current practice of radiologists' interpretation of post-ERCP spot images sent by endoscopists resulted in discrepancies in interpretation, affected subsequent management of patients, and resulted in additional costs.

METHODS

A prospective analysis of 145 consecutive patients who underwent ERCP over the course of 4 months was performed. A separate endoscopist, not involved in the patient's care, reviewed the radiologist's report of the ERCP x-ray films to determine whether there was either concordance or discordance with the procedural findings. All patients' clinical courses were prospectively followed for a minimum of 6 months to determine whether clinical decision-making was affected by the radiologists' interpretation of the x-ray films. Secondarily, the cost of the current practice of postprocedure interpretation of ECRP radiographs was measured.

SETTING

This study took place at University Hospitals of Cleveland, which is a tertiary care facility.

RESULTS

In total, there were 61 (47%) discordant interpretations of 130 cholangiograms and 27 (38%) discordant interpretations of 72 pancreatograms, with an overall discordance between an endoscopist and a radiologist in 80 (55%) of the 145 cases. Clinical management was subsequently affected in 3 (2.1%) cases, all of which involved a discordant reading. In each of the 3 cases, further testing validated the gastroenterologist's initial findings at the time of the procedure. Radiologists were reimbursed $5395 for interpretation of ERCP x-ray films. Extrapolated over the course of a year, the reimbursement at this single tertiary care hospital would be greater than $16,000. Additional testing based on discordant reports resulted in $2510 of reimbursement for 3 patients.

LIMITATION

The limitation of this study is that it reflects data from only one academic institution.

CONCLUSIONS

Radiologists' interpretation of postprocedure ERCP films were inadequate, with a 47% discordance rate among cholangiograms and a 38% discordance rate among pancreatograms. The routine practice of postprocedure ERCP x-ray film interpretation by radiologists altered clinical practice in 2.1% of cases; subsequent care did not confirm radiologists' findings and imparted increased risk to the patients. This practice proved to be a misallocation of resources and should not be continued.

Endoscopic Doppler US probe for the diagnosis of gastric varices (with videos)

BACKGROUND

Gastric varices may appear similar to enlarged gastric folds and submucosal neoplasms at endoscopy. A simple endoscopic method to diagnose variceal blood flow without formal EUS could be clinically useful.

OBJECTIVE

To demonstrate the use of Doppler US (DOP-US) in the diagnosis of gastric varices.

DESIGN

Case series.

SETTING

A tertiary-care U.S. academic medical center.

PATIENTS

Eight patients with findings of gastric submucosal lesions of uncertain etiology on EGD.

INTERVENTIONS

EGD with DOP-US examination, with or without standard EUS.

MAIN OUTCOME MEASUREMENTS

Presence or absence of audible DOP-US signal and EUS findings for gastric submucosal lesions.

RESULTS

DOP-US demonstrated a reproducible continuous venous hum in 5 cases of gastric varices (confirmed by EUS in 2 cases). A sixth case of gastric varices demonstrated pulsatile flow with DOP-US (confirmed by EUS). In 1 case of a GI stromal tumor (GIST) in the stomach, no signal was heard when the lesion itself was examined by DOP-US. In a final case of Menetrier's disease, no signal was heard when the giant gastric folds were examined.

CONCLUSIONS

DOP-US can help differentiate gastric varices from other gastric submucosal lesions. The use of DOP-US may obviate the need for EUS to confirm gastric varices when the EGD diagnosis is uncertain.

Endoscopic Doppler ultrasound versus endoscopic stigmata-directed management of acute peptic ulcer hemorrhage: a multimodel cost analysis

Recurrent bleeding from acute peptic ulcer hemorrhage is problematic. Studies have shown that Doppler ultrasound (DOP-US) is useful in decreasing rebleeding. We analyzed associated costs and outcomes to better define the role of DOP-US versus Conventional (Forrest classification endoscopic stigmata) in the management of acute peptic ulcer bleeding. Two separate decision analyses were constructed. Recurrent bleeding, failed esophagogastroduodenoscopy (EGD) hemostasis, complications, and surgery rates were derived from medical literature. Costs were based on Medicare data. DOP-US is preferred over Conventional in acute peptic ulcer bleeding with average cost savings per patient ranging from 853 dollars (decision-tree modeling) to 1,160 dollars (Monte Carlo simulation). High-dose intravenous proton-pump inhibitors lowered rates of recurrent bleeding for both Conventional and DOP-US, resulting in a lower but still persistent average cost savings per patient for DOP-US (decision-tree modeling = 328 dollars, Monte Carlo simulation = 560 dollars). This decision analyses identified DOP-US as the preferred cost-minimizing strategy in acute peptic ulcer hemorrhage. Results of cost analyses were most dependent on hospitalization costs and recurrent bleeding rates.

Accuracy of endoscopic optical coherence tomography in the detection of dysplasia in Barrett's esophagus: a prospective, double-blinded study

BACKGROUND

Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imaging technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett's epithelium, but this has not been established in a prospective blinded study. This study evaluated the accuracy of EOCT for the diagnosis and the exclusion of dysplasia in patients with Barrett's esophagus.

METHODS

A 2.4-mm diameter EOCT probe was modified for use with a cap-fitted, two-channel endoscope. Pairs of EOCT image streams and jumbo biopsy specimens were obtained. Endoscopy/EOCT procedures were performed by 4 endoscopists who separately reviewed the EOCT digital images for the absence or the presence of dysplasia (low grade, high grade, or cancer) for each biopsy specimen obtained. The endoscopists were blinded to the interpretation of the pathology. An experienced pathologist blinded to the endoscopic/EOCT findings evaluated each biopsy for the absence or the presence of dysplasia. The setting of the study was a major academic medical center. Adult patients with documented Barrett's esophagus greater than 2 cm were included in the study. The main outcome measurement was the accuracy of EOCT in the detection of dysplasia in patients with Barrett's esophagus.

RESULTS

A total of 314 usable EOCT image stream/biopsy pairs were obtained in 33 patients. By using histology as the standard, the performance of EOCT was sensitivity, 68%; specificity, 82%; positive predictive value, 53%; negative predictive value, 89%; and diagnostic accuracy, 78%. Diagnostic accuracy for the 4 endoscopists ranged from 56% to 98%. Limitations of the study were the variability in endoscopists' accuracy rates, difficulty in real-time interpretation, and the need for refined criteria of dysplasia by EOCT imaging.

CONCLUSIONS

The current EOCT system has an accuracy of 78% for the detection of dysplasia in patients with Barrett's esophagus. EOCT could be used to target biopsies to areas of Barrett's epithelium with a higher probability for the presence of dysplasia. However, further modifications, including increased resolution and identification of further potential OCT characteristics of dysplasia, are needed before EOCT can be used clinically.

The yield of bleeding scans in acute lower gastrointestinal hemorrhage

GOALS/BACKGROUND

Previous studies have demonstrated low yield and conflicting results as to the ability of technetium-99m labeled red blood cell (TRBC) scintigraphy to accurately localize the site of bleeding in acute lower gastrointestinal hemorrhage. Our objective was to evaluate the accuracy of TRBC scintigraphy in clinical day-to-day practice at our institution and to determine predictors of a positive test.

METHODS

A retrospective medical records review of all patients who underwent TRBC scintigraphy over a 5-year period was conducted at a single academic medical center. The site of bleeding found on TRBC scintigraphy was correlated with the endoscopic, angiographic, surgical, and pathologic findings in each patient.

RESULTS

A total of 127 scans were performed in 115 patients. Forty-nine scans were positive (39%) and 78 were negative (61%). Forty-two patients had further evaluation after a positive scan, and the bleeding site was confirmed to be accurate in 20 of 42 patients (48%). A contradictory bleeding site was found in 5 of 49 positive scans (10%). Patients transfused greater than 2 units of packed red blood cells within 24 hours preceding the TRBC scan were twice as likely to have a positive scan (64%) than those transfused 2 units or less (32%) (P = 0.002). Multivariate analysis demonstrated that the number of units of blood transfused within 24 hours prior to the TRBC scan and the lowest recorded hematocrit were significantly different between patients with positive and negative scans. There was no difference in the rate of endoscopy between patients with a positive or negative scan result.

CONCLUSIONS

TRBC scintigraphy has a relatively low yield in the evaluation of acute lower gastrointestinal bleeding. Objective selection criteria such as number of units of packed red blood cells transfused prior to obtaining the scan may increase the overall yield.

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUND

Impaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication.

METHODS

Two reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated.

RESULTS

Five trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement.

CONCLUSIONS

Prophylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUND

Impaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication.

METHODS

Two reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated.

RESULTS

Five trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement.

CONCLUSIONS

Prophylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.

Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES

Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care.

METHODS

A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines.

RESULTS

The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively.

CONCLUSION

A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.

Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model

BACKGROUND

Models based on artificial neural networks (ANN) are useful in predicting outcome of various disorders. There is currently no useful predictive model for risk assessment in acute lower-gastrointestinal haemorrhage. We investigated whether ANN models using information available during triage could predict clinical outcome in patients with this disorder.

METHODS

ANN and multiple-logistic-regression (MLR) models were constructed from non-endoscopic data of patients admitted with acute lower-gastrointestinal haemorrhage. The performance of ANN in classifying patients into high-risk and low-risk groups was compared with that of another validated scoring system (BLEED), with the outcome variables recurrent bleeding, death, and therapeutic interventions for control of haemorrhage. The ANN models were trained with data from patients admitted to the primary institution during the first 12 months (n=120) and then internally validated with data from patients admitted to the same institution during the next 6 months (n=70). The ANN models were then externally validated and direct comparison made with MLR in patients admitted to an independent institution in another US state (n=142).

FINDINGS

Clinical features were similar for training and validation groups. The predictive accuracy of ANN was significantly better than that of BLEED (predictive accuracy in internal validation group for death 87% vs 21%; for recurrent bleeding 89% vs 41%; and for intervention 96% vs 46%) and similar to MLR. During external validation, ANN performed well in predicting death (97%), recurrent bleeding (93%), and need for intervention (94%), and it was superior to MLR (70%, 73%, and 70%, respectively).

INTERPRETATION

ANN can accurately predict the outcome for patients presenting with acute lower-gastrointestinal haemorrhage and may be generally useful for the risk stratification of these patients.

Criteria for the diagnosis of dysplasia by endoscopic optical coherence tomography

BACKGROUND

Endoscopic optical coherence tomography provides images of the GI mucosa and submucosa in microscopic detail. It is unknown whether endoscopic optical coherence tomography can reliably detect dysplasia. Colon polyps were used as a model to determine whether dysplasia in GI tissue has characteristic optical coherence tomography imaging features.

METHODS

Endoscopic optical coherence tomography images of colon polyps and normal colon tissue were obtained at colonoscopy. In real time, endoscopists compared tissue organization and light scattering for polyps and normal mucosa with endoscopic optical coherence tomography. Imaged polyps were removed and evaluated histopathologically. Organization and light scattering, as assessed by endoscopic optical coherence tomography at colonoscopy, were compared for adenomas versus hyperplastic polyps. A computer program also quantified and compared the degree of light scattering for hyperplastic polyps and adenomas.

RESULTS

A total of 44 polyps were imaged in 24 patients (30 adenomas, 14 hyperplastic polyps). Endoscopic optical coherence tomography images of adenomas had significantly less structure (p = 0.0005) and scattered light to a lesser degree than hyperplastic polyps (p = 0.0007). Hyperplastic polyps were significantly closer in organization (p = 0.0003) and light scattering (p = 0.0006) to normal mucosa as compared with adenomas. By digital image analysis, the light-scattering property of hyperplastic polyps was closer to normal mucosa compared with adenomas (14.86 vs. 45.81; p = 0.0001).

CONCLUSIONS

Real-time endoscopic optical coherence tomography imaging differentiated adenomas, hyperplastic polyps, and normal colon tissue. By using the colon adenoma as a model, the endoscopic optical coherence tomography characteristics of dysplasia are loss of tissue organization and reduced light scattering.

Prospective evaluation of 4-mm diameter endoscopes for esophagoscopy in sedated and unsedated patients

BACKGROUND

Unsedated esophagoscopy with small-diameter endoscopes is generally well tolerated but of limited sensitivity for the diagnosis of esophageal mucosal disease. This study evaluated the sensitivity of esophagoscopy performed with new 4-mm diameter prototype battery-powered and video endoscopes. Patient tolerance for an unsedated examination with the 4-mm endoscopes was assessed and the performance characteristics of the battery-powered and video 4-mm endoscopes were compared.

METHODS

Patients referred for EGD were recruited to undergo an additional examination with a 4-mm endoscope. A prototype 60-cm long, 4-mm diameter battery-powered fiberoptic esophagoscope was used in the first 24 patients and a prototype 60-cm long, 4-mm diameter video esophagoscope in the next 27 patients. Examiners who were unaware of patient history and procedure indications recorded esophageal findings, ease of intubation, optical quality (5-point visual scale), and time for examination of the esophagus and then recorded esophageal findings after the standard EGD.

RESULTS

The sensitivity, specificity, and accuracy for identification of Barrett's esophagus was 100%; overall sensitivity, accuracy, and specificity for detecting esophageal lesions were, respectively, 91%, 98%, and 99%. Patient tolerance (assessed by symptom scores for choking, pain, and discomfort) and acceptability of unsedated esophagoscopy with the 4-mm diameter instruments were significantly better than in a historical group of patients examined with a 3-mm diameter endoscope. The optical quality of video endoscope was rated as superior to that of battery-powered endoscope, and esophageal examination was performed significantly quicker with the video versus the battery-powered endoscope (68 vs. 137 seconds; p = 0.001).

CONCLUSIONS

Unsedated esophagoscopy with 4-mm diameter endoscopes may be an alternative to EGD for screening for Barrett's esophagus. Given the current state of endoscopic technology, a minimum diameter of 4 mm is required for satisfactory esophageal imaging.

Effectiveness of open-access endoscopy in routine primary-care practice

BACKGROUND

Direct referral of patients for endoscopic procedures without prior consultation (open-access endoscopy) has become commonplace. However, the effect of open-access endoscopy on the care of patients in routine clinical practice has not been studied.

METHODS

The impact of open-access endoscopy was examined in 168 consecutive patients referred from 8 primary-care practices to our tertiary hospital-based endoscopy center. The effectiveness of open-access endoscopy was assessed by review of office medical records at the primary-care practice sites for a minimum follow-up period of 6 months. Outcome measures evaluated included postprocedure communication between primary-care physician and patient, primary-care physician adherence to postprocedure recommendations, and the need for subsequent diagnostic evaluation and/or consultation.

RESULTS

The mean age of the 168 patients was 60 years; 56 (33%) underwent EGD and 112 (67%) had colonoscopy; 65% were from hospital-based practices and 35% from community practices. The indication(s) for 77% of the procedures met American Society for Gastrointestinal Endoscopy guidelines for the appropriate use of endoscopy. An office follow-up was noted for 82% of patients after the open-access procedure. Discussion of results was documented in 61% of the patient charts. Compliance with diagnostic and therapeutic recommendations was documented, respectively, in 75% and 90% of patient charts. A follow-up GI consultation was requested for only 7% of the patients.

CONCLUSION

Open-access endoscopy in the primary-care setting is effective to the extent that subsequent GI consultations are rare and the level of compliance with endoscopist recommendations is high. However, documentation of communication of the results of endoscopy with the patient can be improved.

Safety of ERCP during pregnancy

OBJECTIVES

There are few data in the literature regarding the indications, therapy, and safety of endoscopic management of pancreatico-biliary disorders during pregnancy. We report the largest single center experience with ERCP in pregnancy.

METHODS

We reviewed 15 patients that underwent ERCP during pregnancy. In all patients, the pelvis was lead-shielded and the fetus was monitored by an obstetrician. Fluoroscopy was minimized and hard copy radiographs taken only when essential.

RESULTS

The mean patient age was 28.9 yr (15-36 yr). The mean duration of gestation was 25 wk (12-33 wk); one patient was in the first, five in the second, and nine in the third trimester. The indications were gallstone pancreatitis (n = 6), choledocholithiasis on ultrasound (n = 5), elevated liver enzymes and a dilated bile duct on ultrasound (n = 2), abdominal pain and gallstones (n = 1), and chronic pancreatitis (n = 1). ERCP findings were bile duct stones (n = 6), patulous papilla (n = 1), bile duct debris (n = 1), normal bile duct and gallstones or gallbladder sludge (n = 3), dilated bile duct and gallstones (n = 1), normal bile duct and no gallstones (n = 2), and chronic pancreatitis (n = 1). Six patients underwent sphincterotomies and one a biliary stent insertion. One sphincterotomy was complicated by mild pancreatitis. All infants delivered to date have had Apgar-scores >8, and continuing pregnancies are uneventful. Mean fluorosocopy time was 3.2 min (SD +/- 1.8). An estimated fetal radiation exposure was 310 mrad (SD +/- 164) which is substantially below the accepted teratogenic dose.

CONCLUSIONS

ERCP in pregnancy seems to be safe for both mother and fetus; however, it should be restricted to therapeutic indications with additional intraprocedure safety measures.

Endoscopic retrograde cholangiopancreatography in children and adolescents

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is becoming a more frequently used diagnostic and therapeutic tool in children. We sought to determine the indications, feasibility, safety, and effect on patient management of ERCP in pediatric patients of varying age.

METHODS

All ERCPs performed during a 4-year period in patients aged 18 years or less at an academic hospital were retrospectively reviewed. The indications, type of anesthesia administered, type of duodenoscope used, diagnostic findings, therapeutic interventions, complication rate, and effect on management were compared between children (age 0-12 years) and adolescents (age 13-18 years).

RESULTS

A total of 53 procedures were performed in 43 patients whose median age was 13.5 years. ERCP was successful in 50 of 53 cases (94%) with a complication rate of 6%. Endoscopic therapy was provided in 24 of 53 cases (45%). Compared with adolescents (n = 28), children (n = 25) were more likely to receive general anesthesia (96% vs. 29%; P < 0.001) and undergo ERCP with a pediatric duodenoscope (0% vs. 40%). ERCP affected management in 73% of cases, equally in both groups.

CONCLUSION

ERCP is a successful and safe diagnostic and therapeutic modality in a variety of pancreatobiliary disorders that directly affects management in children of all ages.

Risk factors for complications after performance of ERCP

BACKGROUND

ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified.

METHODS

Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications.

RESULTS

Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure.

CONCLUSIONS

The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Risk factors for complications after performance of ERCP

BACKGROUND

ERCP has become widely available for the diagnosis and treatment of benign and malignant pancreaticobiliary diseases. In this prospective study, the overall complication rate and risk factors for diagnostic and therapeutic ERCP were identified.

METHODS

Data were collected prospectively on patient characteristics and endoscopic techniques from 1223 ERCPs performed at a single referral center and entered into a database. Univariate and multivariate analyses were used to identify risk factors for ERCP-associated complications.

RESULTS

Of 1223 ERCPs performed, 554 (45.3%) were diagnostic and 667 (54.7%) therapeutic. The overall complication rate was 11.2%. Post-ERCP pancreatitis was the most common (7.2%) and in 93% of cases was self-limiting, requiring only conservative treatment. Bleeding occurred in 10 patients (0.8%) and was related to a therapeutic procedure in all cases. Nine patients had cholangitis develop, most cases being secondary to incomplete drainage. There was one perforation (0.08%). All other complications totaled 1.5%. Variables derived from cannulation technique associated with an increased risk for post-ERCP pancreatitis were precut access papillotomy (20%), multiple cannulation attempts (14.9%), sphincterotome use to achieve cannulation (13.1%), pancreatic duct manipulation (13%), multiple pancreatic injections (12.3%), guidewire use to achieve cannulation (10.2%), and the extent of pancreatic duct opacification (10%). Patient characteristics associated with an increased risk of pancreatitis were sphincter of Oddi dysfunction (21.7%) documented by manometry, previous ERCP-related pancreatitis (19%), and recurrent pancreatitis (16.2%). Pain during the procedure was an important indicator of an increased risk of post-ERCP pancreatitis (27%). Independent risk factors for post-ERCP pancreatitis were identified as a history of recurrent pancreatitis, previous ERCP-related pancreatitis, multiple cannulation attempts, pancreatic brush cytology, and pain during the procedure.

CONCLUSIONS

The most frequent ERCP-related complication was pancreatitis, which was mild in the majority of patients. The frequency of post-ERCP pancreatitis was similar for both diagnostic and therapeutic procedures. Bleeding was rare and mostly associated with sphincterotomy. Other complications such as cholangitis and perforation were rare. Specific patient- and technique-related characteristics that can increase the risk of post-ERCP complications were identified.

Patient tolerance and acceptance of unsedated ultrathin esophagoscopy

BACKGROUND

Unsedated endoscopy has not gained wide acceptance in the United States. Factors that may predict tolerance and acceptance of unsedated endoscopy are ill defined.

METHODS

Outpatients referred for standard EGD were recruited to undergo unsedated ultrathin esophagoscopy (UUE) with a new 3.1-mm battery-powered esophagoscope before sedated EGD. They rated preprocedure and postprocedure anxiety levels with the Profile of Mood States Tension/Anxiety subscale (POMS-SF T/A). They also rated symptoms and overall acceptability and listed procedural preference between EGD and UUE. Patients who refused UUE noted a reason for refusal and also completed the anxiety questionnaire.

RESULTS

Fifty-two of 98 patients recruited agreed to participate, and underwent both UUE and EGD. Patients who refused UUE were significantly more anxious (mean anxiety score, 8.2 vs. 4.5, p < 0.005). Participants reported no significant difference between preprocedural (4.6 vs. 5.3) or postprocedural (3.5 vs. 2.6) anxiety for UUE versus standard EGD. After undergoing both procedures, only 46% stated they would prefer UUE to EGD in the future. Patients who chose the peroral approach were more likely to prefer UUE than those who chose the transnasal approach (58% vs. 23%, p = 0.02).

CONCLUSIONS

Patient acceptance of unsedated endoscopy even with an ultrathin instrument is limited. Anxiety assessment by the POMS-SF T/A can identify patients willing to undergo UUE. Patients who choose transoral UUE may be more willing to repeat the procedure.