A. Fugazza

Elucidating the gut microbiome of ulcerative colitis: bifidobacteria as novel microbial biomarkers

Ulcerative colitis (UC) is associated with a substantial alteration of specific gut commensals, some of which may be involved in microbiota-mediated protection. In this study, microbiota cataloging of UC patients by 16S rRNA microbial profiling revealed a marked reduction of bifidobacteria, in particular the Bifidobacterium bifidum species, thus suggesting that this taxon plays a biological role in the aetiology of UC. We investigated this further through an in vivo trial by testing the effects of oral treatment with B. bifidum PRL2010 in a wild-type murine colitis model. TNBS-treated mice receiving 10(9) cells of B. bifidum PRL2010 showed a marked reduction of all colitis-associated histological indices as well as maintenance of mucosal integrity as it was shown by the increase in the expression of many tight junction-encoding genes. The protective role of B. bifidum PRL2010, as well as its sortase-dependent pili, appears to be established through the induction of an innate immune response of the host. These results highlight the importance of B. bifidum as a microbial biomarker for UC, revealing its role in protection against experimentally induced colitis.

Confocal Laser Endomicroscopy in Gastrointestinal and Pancreatobiliary Diseases: A Systematic Review and Meta-Analysis

Confocal laser endomicroscopy (CLE) is an endoscopic-assisted technique developed to obtain histopathological diagnoses of gastrointestinal and pancreatobiliary diseases in real time. The objective of this systematic review is to analyze the current literature on CLE and to evaluate the applicability and diagnostic yield of CLE in patients with gastrointestinal and pancreatobiliary diseases. A literature search was performed on MEDLINE, EMBASE, Scopus, and Cochrane Oral Health Group Specialized Register, using pertinent keywords without time limitations. Both prospective and retrospective clinical studies that evaluated the sensitivity, specificity, or accuracy of CLE were eligible for inclusion. Of 662 articles identified, 102 studies were included in the systematic review. The studies were conducted between 2004 and 2015 in 16 different countries. CLE demonstrated high sensitivity and specificity in the detection of dysplasia in Barretts esophagus, gastric neoplasms and polyps, colorectal cancers in inflammatory bowel disease, malignant pancreatobiliary strictures, and pancreatic cysts. Although CLE has several promising applications, its use has been limited by its low availability, high cost, and need of specific operator training. Further clinical trials with a particular focus on cost-effectiveness and medicoeconomic analyses, as well as standardized institutional training, are advocated to implement CLE in routine clinical practice.

Successful endoscopic closure of iatrogenic duodenal perforation with the new Padlock Clip

Although duodenal perforations are rare [1], they represent one of the most critical complications of endoscopic ultrasound (EUS) and may be fatal in elderly patients. Following the introduction of endoscopic clips, stents, and over-thescope systems into clinical practice, endoscopic management of perforations has became the first therapeutic option [2, 3]. We present the case of a 62-year-old man with jaundice, who was referred to the Digestive Endoscopy Unit of Humanitas Research Hospital (Rozzano, Italy) to undergo EUS-guided fine-needle aspiration of a solid lesion in the pancreatic head (▶Fig. 1). The EUS was performed using a linear echoendoscope (GF-UCT140; Olympus Optical Co., Tokyo, Japan), CO2 insufflation, and with the patient under deep sedation with propofol. During scope withdrawal through the duodenum, we observed a type-1 [4], full-thickness defect, of 13mm in diameter, at the upper duodenal knee (▶Fig. 2). A stiff guidewire was placed in the duodenum to help expose the defect. A twin grasper (Ovesco Endoscopy AG, Tübingen, Germany) was used to approximate the mucosal edges of the perforation. Then, a gastroscope loaded with the new Padlock Clip (Aponos Medical Co., King-

EUS-Guided Biliary Drainage Versus ERCP for the Primary Palliation of Malignant Biliary Obstruction: An Unfair Comparison

To the Editor: We read with great interest the study by Paik et al. [1] “EUS-guided biliary drainage versus ERCP for the primary palliation of malignant biliary obstruction: a multicenter randomized clinical trial”. The authors reported their recent multicenter experience in biliary drainage for unresectable malignant biliary obstruction. The primary objective of the study was to compare technical success between EUS and ERCP as primary modality for biliary drainage. Other outcomes included adverse events and clinical success. Of the 125 randomized patients, technical success rates were 90.2% (55/61) for ERCP and 93.8% (60/64) for EUS-BD (p = 0.003), confirming non-inferiority for the EUS-based approach. These findings are not surprising and are in line with similar observations made in large, multicenter, retrospective studies [2]. Conversely, the reported difference in AEs between cohorts require further examination. First, an overall AE rate of 39.1% in the ERCP group (considering both early and late AEs) seems to be exceedingly high. Consequently, even considering only early AEs, there is still an imbalanced if not unfair comparison with EUS-BD (19.7% vs. 6.3%, respectively, p = 0.03). Although the authors listed several reasons explaining why the rate of PEP (14.8%) was higher than described in the literature [3], in our opinion the main reason may be related to lack of any prophylactic measures to prevent pancreatitis, such as use of NSAIDs or pancreatic stent placement or Ringers lactate infusion. All these strategies are well known to considerably reduce the risk of PEP [4] and should be routinely administered in high-risk patients or when ductal access is challenging. In our opinion, had these measures been undertaken, the reported rate of adverse events would have likely been lower in the ERCP cohort. In conclusion, even if EUS-BD has the potential to be considered as an alternative to ERCP, further knowledge is needed to definitively confirm its safety profile. Although the results of the current study contribute to that knowledge, we believe that the difference in rates of adverse events is overrated.

Intrabiliary resection of metastasis originating from colorectal carcinoma during direct peroral cholangioscopy: a new tool for biliary palliation

Intrabiliary growth of a liver metastasis originating from colorectal carcinoma is a rare manifestation of metastatic liver carcinoma, with only a few cases reported in the literature [1–3]. Radiological characteristics of the “classic” liver metastases are well established, and generally preoperative biopsy to plan a proper surgical strategy is not required. However, the radiological features of intrabiliary liver metastasis may not be distinctive, leading to possible misdiagnosis. We present the case of an 83-year-old woman who was referred to our unit because of jaundice. The medical history reported left hemicolectomy for cancer (pT3N0) 15 years earlier and hepatic segmentectomy for metastatic nodule 5 years earlier. Computed tomography and magnetic resonance imaging scans showed dilation of the common bile duct and intrahepatic bile ducts, with an intraductal nodule at the hepatic hilum (▶Fig. 1). Carcinoembryonic antigen and α-fetoprotein levels were normal. Endoscopic retrograde cholangiopancreatography showed a dilated biliary duct (14mm) with a “negative” image of about 20mm at the bifurcation. After sphincterotomy and papilloplasty up to 12mm, direct peroral cholangioscopy (POC) was performed using a slim scope (8.5mm diameter, EG 530FP; Fujifilm, Tokyo, Japan). A polypoid mass with irregular vascular pattern, highly suggestive of malignancy, was observed at the hepatic hilum (▶Fig. 2 a). Endoscopic resection of the lesion, under direct visualization, with a hot snare (15mm, Captivator II; Boston Scientific Corp., Marlborough, Massachusetts, USA) was performed, thus avoiding the need for biliary stent placement (▶Fig. 2b, ▶Video1). Histology revealed a metastasis of colorectal carcinoma (▶Fig. 3). The patient remained free of symptoms with normal bilirubin level for 12 months. To our knowledge this is the first case of an intrabiliary endoscopic resection performed under direct visualization. The POC is an advanced technique for intraluminal visual inspection and for therapeutic intervention of the biliary ducts [4], and shows potential as a promising approach in the diagnosis and treatment of a subgroup of patients with biliary obstruction secondary to intraductal masses.

Intrabiliary argon plasma coagulation hemostasis by direct cholangioscopy for a tricky post-ERCP bleeding

An 80-year-old man was admitted to the emergency department with fever, jaundice, and abdominal pain due to common bile duct (CBD) lithiasis. His past medical history revealed chronic renal failure and atrial fibrillation, which was treated with warfarin. Therapy with antibiotics and phytomenadione was promptly started, and international normalized ratio values returned to normal. Cholangiography showed the CBD dilated up to 18mm and multiple large stones. Sphincterotomy was performed, followed by papillary pneumatic dilation up to 15mm and stone extraction, with no residual filling defect at cholangiography. E-Videos

Using stents in the management of malignant bowel obstruction: the current situation and future progress

ABSTRACT Introduction: The use of self-expanding metal stents (SEMS) has been considered an effective and safe alternative to emergency surgery as bridge to surgery or for palliation in advanced colorectal cancer even though more recent data have raised concerns on both early and long-term outcomes when patients are treated with bridge to surgery indications. Areas covered: A comprehensive literature review of articles on endoscopic management of malignant bowel obstruction was performed. Indication, technique, outcomes, benefits and risks of these treatments in acute malignant colonic obstruction were reviewed. The clinical effectiveness and safety of SEMS in obstructive colorectal cancer, as bridge to surgery or for palliation compared to surgery, is discussed. Expert commentary: SEMS placement, when performed in tertiary level center with appropriate expertise in colorectal stenting, may have several advantages over surgery avoiding the potential for surgical morbidity in a typically frail group of patients even though these advantages are to be carefully balanced over the risk of life-threatening, stent-related complications.

Patients’ comorbidities reduce the clinical value of emergency colonoscopy: results of a retrospective cohort study

Background and study aims  Urgent endoscopy is often used to diagnose and sometimes treat acute upper gastrointestinal syndromes (hemorrhage, toxic ingestion, and occlusion). However, its suitability concerning the management of lower gastrointestinal conditions in emergency circumstances is controversial. Patients and methods  We studied the role of emergency colonoscopy in diagnosis and treatment of all consecutive patients presenting with acute lower gastrointestinal symptoms referred to our hospital on an emergency basis. All patients were first managed by physicians from the emergency room and/or the intensive care unit (ICU); the treatments included fluid resuscitation, blood transfusion, and antibiotic or cardiotonic as needed. Bowel cleansing was performed to purge the colon of clots, stool, and blood when clinically possible; alternatively, a bowel enema was used. Patients only underwent a computed tomography (CT) scan prior to the colonoscopy in clinically relevant situations. Colonoscopy was performed within 6 – 36 hours after hospitalization or the beginning of the clinical symptoms (hemorrhage, sepsis, colon distension) or occlusion, as assessed by abdominal CT scan. Results  From 2010 to 2015, 603 patients underwent urgent colonoscopy; among them, 214 (36 %) presented with lower GI bleeding, while 264 (44 %) had symptoms suggestive of intestinal ischemia; almost half (49 %, n = 295) of the patients were hospitalized in the ICU. Patients received therapies, such as clips (15 %), epinephrine injections (5 %), bipolar coagulation (7 %), or devolvulation (3 %) using colonoscopy or antibiotic therapy when needed. No perforation was observed after colonoscopy and only three cases of hemorrhage recurrence were documented as complications after the procedure. Overall, 192 patients died within 1 month after colonoscopy due to four independent risk situations, as follows: septic shock, heart transplantation, multiorgan failure, and ischemic colitis. Only 67 (35 %) underwent urgent intestinal surgery when ischemic colitis was identified, and this did not have a significant effect on the mortality rate. Conclusions  Urgent bedside colonoscopy is feasible and safe for routine use. The highest advantage was observed in patients with red blood hemorrhage, diarrhea, and colon distension when symptoms were not associated with multiorgane failure, heart transplantation, or septic shock. As revealed by colonoscopy and pathological features, ischemic colitis is associated with a bad prognosis, and patients experience a higher rate of early mortality regardless of whether they undergo urgent colon surgery.

Diagnostic Techniques in the Esophagus

Even in the pediatric age group many diseases can affect the esophageal tract. The only procedure that permits direct visualization of the esophageal mucosa is upper endoscopy. Upper gastrointestinal (GI) endoscopy is employed widely not only for diagnostic but also for therapeutic purposes. This technique allows biopsy collection, which permits confirmation of conditions such as inflammation or infection [1]. Moreover, it permits therapeutic interventions such as dilations, sclerotherapy, endoscopic band ligation, and extraction of foreign bodies.