Andrew Brock

Is Endoscopic Therapy Effective for Angioectasia in Obscure Gastrointestinal Bleeding?: A Systematic Review of the Literature.

Goal: We aimed to summarize pooled rebleeding rates of angioectasia after therapeutic endoscopy, and compare these to historical control (no intervention) rates. Background: Obscure gastrointestinal bleeding continues to be challenging to diagnose and treat; in America, small bowel angioectasias are the most common cause. Technology advances led to higher diagnostic yield for these lesions; however, therapeutic impact of endoscopy remains unclear. Study: A PubMed search (June 1, 2006 to September 19, 2013) with 2 independent reviews sought articles reporting rebleeding rates of symptomatic angioectasia without therapy (natural history) and after endoscopic treatment. This study list was added to studies in the 2007 American Gastroenterological Association systematic review. Data on number of patients who underwent endoscopic therapy, type of therapy used, number of patients who experienced rebleeding, and follow-up time were extracted. Rebleeding data were pooled and weighted averages were reported with 95% confidence intervals (CI). Results: Twenty-four articles (n=490 patients) with data on endoscopic therapy for angioectasia and 6 natural history cohorts (n=130) receiving no therapy for angioectasia were eligible. Of the endoscopic therapy patients, 121 at push enteroscopy and 427 at balloon-assisted enteroscopy; 209/490 (42.7%; 95% CI, 38%-47%) rebled. Of the control (no therapy) patients, 64/130 (49.2%; 95% CI, 40%-58%) rebled. Number needed to treat is estimated at 15 to 16. Conclusions: Rebleeding rate after endoscopic therapy for symptomatic small bowel angioectasia may be comparable to that expected without therapy. Endoscopic therapy may be ineffective; if effective, the needed to treat is estimated to be high. Controlled studies, with intervention-stratified and etiology-stratified outcomes are needed.

Endoscope storage time: assessment of microbial colonization up to 21 days after reprocessing

BACKGROUND Insufficient data exist for how long endoscopes can be stored after reprocessing. Concern about possible microbial colonization has led to various recommendations for reprocessing intervals among institutions, with many as short as 5 days. A significant cost savings could be realized if it can be demonstrated that endoscopes may be stored for as long as 21 days without risk of clinically significant contamination. OBJECTIVE To demonstrate whether flexible endoscopes may be stored for as long as 21 days after reprocessing without colonization by pathogenic microbes. DESIGN Prospective, observational study. SETTING Tertiary care center. ENDOSCOPES Four duodenoscopes, 4 colonoscopes, and 2 gastroscopes. INTERVENTION Microbial testing of endoscope channels. MAIN OUTCOME MEASUREMENTS Culture results at days 0, 7, 14, and 21. RESULTS There were 33 positive cultures from 28 of the 96 sites tested (29.2% overall contamination rate). Twenty-nine of 33 isolates were typical skin or environmental contaminants, thus clinically insignificant. Four potential pathogens were cultured, including Enterococcus, Candida parapsilosis, α-hemolytic Streptococcus, and Aureobasidium pullulans; all were likely clinically insignificant as each was only recovered at 1 time point at 1 site, and all grew in low concentrations. There were no definite pathogenic isolates. LIMITATIONS Single center. CONCLUSION Endoscopes can be stored for as long as 21 days after standard reprocessing with a low risk of pathogenic microbial colonization. Extension of reprocessing protocols to 21 days could effect significant cost savings.

Over-the-scope clip for endoscopic closure of gastrogastric fistulae

BACKGROUND Gastrogastric fistulae (GGF) are a well-known complication of Roux-en-Y gastric bypass (RYGB). Endoscopic approaches for closure of GGF have gained popularity, but with limited data and efficacy. OBJECTIVES The primary arm of the study was to evaluate the safety and efficacy of the endoscopic closure of GGF using the over-the-scope clip (OTSC) device. SETTING University hospital, United States METHODS: This is a retrospective review of consecutive patients at a single academic center from September 2013 to December 2014 who underwent upper endoscopy with attempted OTSC placement for closure of GGF related to RYGB. Preprocedural, procedural, and postprocedural data were collected. Outcome measures included technical success, primary success, and long-term success. RESULTS A total of 14 patients underwent attempted GGF closure using OTSC. Twelve of the 14 patients (85.7%) had technical success. Four patients were lost to follow-up. Primary success was achieved in 5 of the 10 patients (50%) in which it was assessed, either by upper gastrointestinal series or endoscopy. One of the 5 patients who had primary success was then lost to follow-up. Of the 4 patients in whom primary success was achieved and had long-term follow up, 75% (n = 3) achieved long-term success at a mean follow-up of 6.6 months from initial OTSC placement (range, 3-9), making for a long-term success rate of 33% (3/9). There were no reported complications. CONCLUSION OTSC closure of small GGF is feasible, safe, and offers a reasonable alternative to surgical revision. Large GGF may undergo attempted endoscopic closure, acknowledging a high failure rate.

Mechanical Hemostasis Techniques in Nonvariceal Upper Gastrointestinal Bleeding

One of the most important advances in gastroenterology has been the use of endoscopic hemostasis techniques to control nonvariceal upper gastrointestinal bleeding, particularly when high-risk stigmata are present. Several options are available, including injection therapy, sprays/topical agents, electrocautery, and mechanical methods. The method chosen depends on the nature of the lesion and experience of the endoscopist. This article reviews the available mechanical hemostatic modalities.

A Not-So-Obscure Cause of Gastrointestinal Bleeding

A 66-year-old man was admitted to the hospital with a 2-day history of fatigue, dizziness on standing, and bright red blood from the rectum that transitioned to black, tarry stools. He reported no abdominal pain, nausea, vomiting, or weight loss. He had a history of several myocardial infarctions and subsequent ischemic cardiomyopathy (ejection fraction, approximately 20%); a HeartMate II left ventricular assist device (LVAD) had been placed 2.5 months earlier as destination therapy (i.e., permanent therapy for a patient who is not a candidate for heart transplantation). He also had chronic atrial fibrillation. Medications included warfarin (target international normalized ratio [INR], 2.0 to 3.0), low-dose aspirin, amiodarone, and metoprolol. On physical examination, the patient’s skin and conjunctiva were pale. The heart rate and blood pressure (measured by automated sphygmomanometry) were 74 beats per minute and 117/99 mm Hg, respectively. A continuous hum from the LVAD was heard in the precordial region. The abdomen was soft, with normoactive bowel sounds. Melena was noted in the patient’s bed. There were no stigmata of chronic liver disease.

Patients' short-term knowledge of personal polyp history inadequate despite systematic notification of results after polypectomy.

Objectives Patients’ memories of personal polyp characteristics have been shown to be inadequate when compared with the medical record. An accurate polyp history is necessary to adhere to guidelines. We sought to determine whether systematically informing patients of the results of their colonoscopy and pathology in a multifaceted manner could increase their knowledge of their personal polyp history. Methods We conducted a prospective pilot study of 240 consecutive patients undergoing screening colonoscopy with polypectomy by a single endoscopist (B.J.H.) at a tertiary care center. All of the patients were provided with a verbal report of findings immediately after the procedure, an endoscopy report specifying polyp size and number, and a mailed letter specifying the pathology results of their polyps. Telephone contact was attempted for all of the patients. Patients were asked to recall the size, number, and histology of their polyps. Results One hundred (42%) of the patients completed the telephone survey. Forty patients remembered the polyp number; five remembered their polyp histology, and one recalled the polyp size. None of the patients recalled all three factors, although patients who recalled telling a family member the results of the colonoscopy were more likely to recall at least one polyp descriptor (relative risk 2.62 [95% confidence interval 1.01–6.83]). No other variables were associated with polyp recall. Conclusions Patients’ knowledge of personal polyp characteristics, even after systematic notification, does not seem adequate for determining the best guideline-based colonoscopy surveillance interval. Discussing results with family members may help.

Cap-assisted retrograde single-balloon enteroscopy results in high terminal ileal intubation rate

Background and study aims: Retrograde single-balloon enteroscopy (RSBE) facilitates evaluation of the distal small bowel and provision of appropriate therapy when necessary. Intubation of the terminal ileum (TI) is a major rate-limiting step, with failure rates as high as 30 %. Cap-assisted endoscopy has proven beneficial in other aspects of endoscopy. We have noticed that it similarly aids in TI intubation during RSBE by facilitating opening of the ileocecal valve (ICV). The primary aim of this study was to measure the TI intubation rate using cap-assisted RSBE. Other procedural details and outcomes were also measured. Patients and methods: A total of 36 consecutive RSBEs performed between July 2011 and May 2014 at the Medical University of South Carolina were retrospectively reviewed. All procedures were performed or supervised by our center’s small bowel endoscopist (ASB). Outcomes measured included TI intubation rate, procedure time, depth of maximal insertion (DMI), diagnostic yield (DY), therapeutic yield (TY), and complications. Results: The TI intubation rate was 97 % (35 /36). The one failure was due to stool completely obscuring the cecum. Median procedure time was 54 minutes, with a mean DMI of 68 cm beyond the ICV. The technical success rate was 86 %, whereas DY and TY were 61 % and 25 %, respectively. There were no complications. The study was limited in that it involved a single endoscopist at a single center. Conclusions: Cap-assisted RSBE results in a high TI intubation rate, without compromise to safety or procedural yield.

Gastric Mucosal Calcinosis: A Rare Cause of Bleeding

A52-year-old man with end-stage renal disease on hemodialysis presented with coffee-ground emesis and black stools. The physical examination revealed pale conjunctivae but was otherwise unremarkable. The laboratory analysis was significant for hemoglobin 4.4 g/dL, creatinine 7.8 mg/dL, and normal calcium and phosphorus (8.7 mg/dL and 2.5 mg/dL, respectively). The esophagogastroduodenoscopy revealed multiple smooth, nonbleeding nodules measuring 3–5 mm in diameter, extending radially in linear rows throughout the antrumwith an overlying clot (Figure A). Two similar lesions were noted in the second portion of the duodenum (Figure B). Biopsies showed benign gastric and small bowel mucosa with calcinosis (Figure C). The bone scan demonstrated radiotracer within the region of the stomach, also compatible with calcinosis. The computed tomography scan was significant for mitral annular calcification and scattered pancreatic parenchymal calcifications. The patient did not have any risk factors for chronic pancreatitis. A review of laboratory studies over the past year revealed a persistently elevated parathyroid hormone as well as frequent hyperphosphatemia with occasional hypercalcemia. Two sessions of argon plasma coagulation, 14 days apart, were performed on the gastric lesions. No other endoscopic therapy was undertaken. After 8 months of follow-up, the patient did not have further bleeding. Gastric mucosal calcinosis (GMC) is a rare disorder typically encountered incidentally on routine biopsy or at autopsy. Metastatic calcification is the most common cause of GMC and occurs in the setting of abnormal calcium-phosphate metabolism. Hypercalcemia and/or hyperphosphatemia cause the deposition of calcium salts

Sporadic Fundic Gland Polyps and Gastric Acid Suppression Level

Background: Fundic gland polyps (FGPs) are a common endoscopic finding and are known to be associated with proton pump inhibitors (PPIs) use. It is not known if their prevalence is affected by gastric acidity levels. This study aimed to assess whether there is a correlation between FGPs and gastric acidity levels as identified on 24‐hour ambulatory impedance‐pH studies in patients on PPI therapy. Methods: We performed a review of 402 consecutive patients who take at least once daily PPI and underwent esophagogastroduodenoscopy with combined impedance‐pH studies in the same setting (time and place) between January 2010 and December 2014. Patients were classified into 2 groups based on the presence or absence of biopsy‐confirmed FGPs during endoscopy. Results: Of the 402 patients, 30 (7%) had FGPs. One of these polyps was found with low‐grade dysplasia. There was no significant difference of the distributions of the [H+] in the FGPs versus the nonpolyp groups (P = 0.741). There was no significant difference between the 2 groups regarding PPI dose frequency regimens (once and twice) (P = 0.074). However, we found weak ordinal association with PPI duration (P = 0.01) (Spearman = 0.1). Conclusions: FGPs are common endoscopic lesions. Incidence of dysplasia in FGPs is not only rare, but also of unknown clinical significance. Although they seem to be associated with PPIs, the mechanism remains unclear, as we found no correlation between the presence of FGPs and gastric acid control or PPI dose. Future studies would be useful to elucidate an alternate mechanism.

Success of Percutaneous Endoscopic Gastrostomy by Single Balloon Enteroscopy in Patients Who Have Undergone Roux-en-Y Gastric Bypass

Data is limited regarding the success and safety of percutaneous endoscopic gastrostomy (PEG) placements by single balloon enteroscopy (SBE) in patients with Roux-en-Y gastric bypass (RNY-GB) anatomy. We report on 23 cases of PEG placements by SBE with overall technical success of reaching the excluded stomach 70% and with PEG placement success rate of 69%. No intra-procedural adverse events occurred. This technique seems safe when feasible for PEG placement in patients with RNY-GB anatomy.