Angeliki Theodoropoulou

A Prospective, Randomized Comparison of Adrenaline Injection in Combination with Detachable Snare Versus Adrenaline Injection Alone in the Prevention of Postpolypectomy Bleeding in Large Colonic Polyps

OBJECTIVES:Our study sought to compare the efficacy of adrenaline injection in combination with detachable snare versus adrenaline injection alone in the prevention of postpolypectomy bleeding in large colonic polyps.METHODS:At the time of colonoscopy, patients with at least one colonic polyp ≥2 cm were randomized to receive treatment either by the injection of a 1:10.000 solution of adrenaline and the position of a detachable snare followed by a conventional snare polypectomy (group A) or injection of adrenaline followed by a conventional snare polypectomy (group B). A total of 159 consecutive patients were randomly assigned to one of the above groups. Out of them, 84 patients (47 men, 37 women, mean age 61 yr) were assigned to group A and 75 (37 men, 38 women, mean age 64 yr) to group B. Early (<24 h) and late (>24 h–30 days) bleeding complications were assessed.RESULTS:Overall bleeding complications occurred in 10/159 (6.2%) of the patients. There were two cases of bleeding in group A (2.3%), and eight in group B (10.6%) (P = 0.04). The number of early bleeding episodes was significantly reduced in group A patients (1 case) compared to that of group B (7 cases) (P = 0.02). In contrast, there was no significant difference between group A and B as far as late bleeding is concerned.CONCLUSIONS:Our data suggest that the use of adrenaline injection in combination with detachable snare may significantly decrease the number of early postpolypectomy bleeding episodes in patients with large colonic polyps.

Endoscopic sedation in Greece: Results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition

BACKGROUND AND STUDY AIMS Recent surveys regarding practices in sedation during endoscopic procedures are limited, particularly in Greece where they are nonexistent. This survey was designed to provide national data on sedation practices in Greece. METHODS A 27-item survey regarding practices of endoscopy and sedation was mailed nationwide to 502 members of the Hellenic Society of Gastroenterology. RESULTS A total of 201 questionnaires were returned (40%). Survey respondents performed an average of 48 oesophagogastroduodenoscopies (EGD) and 35 colonoscopies per month. 50 of the respondents, who perform endoscopic retrograde cholangiopancreatography (ERCP), conducted an average of 10 ERCP per month. 15 of the respondents, who perform endoscopic ultrasound (EUS), conducted an average of 6 EUS per month. Respondents administered sedation intravenously in 64% of EGD, 78% of colonoscopies, 100% of ERCP and 100% of EUS. 125 of the respondents (62.1%) reported the use of synergistic sedation (benzodiazepines plus opioids), 71 of the respondents (35.3%) reported the use of benzodiazepines alone and 68 of the respondents (33.8%) reported the use of propofol based sedation in selected cases (more than one response was permitted). In most cases, propofol administration was directed by an anaesthesiologist. The majority of the respondents monitored vital signs and pulse oximetry (90% and 96%, respectively). CONCLUSION The use of sedation and physiologic monitoring in Greece is now standard practice during endoscopy. Benzodiazepines, either alone or combined with an opioid, are used by the majority of endoscopists, while propofol is used in selected cases, mainly in the presence of an anaesthesiologist.

Association between enhanced soluble CD40 ligand and prothrombotic state in inflammatory bowel disease.

Background Inflammatory bowel disease is associated with an increased incidence of thromboembolic complications. The aim of this study was to investigate the role of the soluble CD40 ligand (sCD40L), which displays prothrombotic properties, in patients with ulcerative colitis (UC) and Crohns disease (CD) in comparison with inflammatory and healthy controls. Methods Plasma levels of sCD40L, prothrombin fragment 1+2 (F1+2), thrombin–antithrombin (TAT) complex and soluble P-selectin were measured in 104 inflammatory bowel disease patients (54 ulcerative colitis and 50 Crohns disease), in 18 cases with other causes of intestinal inflammation and in 80 healthy controls using commercially available enzyme-linked immunosorbent assays. Plasma levels of sCD40L were correlated with disease activity, type, localization and treatment as well as with the measured thrombophilic parameters. Results CD patients had significantly higher sCD40L levels than both groups of controls (CD vs HC P < 0.001; CD vs non-IBD P < 0.05). UC patients had higher but not significantly different sCD40L levels compared with the controls. Both UC and CD patients with active disease had significantly higher sCD40L levels in comparison with patients with inactive disease. Plasma levels of sCD40L were correlated with platelet count (r = 0.27, P = 0.001). They also showed a correlation with prothrombin F1+2 (r = 0.16, r = 0.03) and TAT (r = 0.15, r = 0.04) as well as with P-selectin (r = 0.19, P = 0.01). Conclusions The increased sCD40L plasma levels may represent, at least in some degree, a molecular link between inflammatory bowel disease and the procoagualant state.

Complications of colonoscopy in a large public county hospital in Greece. A 10-year study

BACKGROUND AND STUDY AIMS Information about the complications of colonoscopy in Southern Europe is limited, particularly in Greece where it is non-existent. Our study sought to determine the complications of colonoscopy in a large public county hospital in Greece over a 10-year period. PATIENTS AND METHODS All colonoscopy procedures from 1996 to 2006 were entered into a database. Data were analysed by both univariate and multivariate methods. RESULTS Nine thousand six hundred forty-eight colonoscopies were entered into a database. The procedures were diagnostic in 79% and therapeutic in 21%. Overall bleeding complications occurred in 83 out of the 9648 patients (0.8%: 95% confidence interval [0.7%, 0.9%]). Perforation occurred in four female patients (0.04%: 95% confidence interval [0.01%, 0.07%]) in the sigmoid colon. Multivariate stepwise logistic regression analysis in the therapeutic colonoscopies revealed that presence of significant polyps (odds ratio 4.7, confidence interval [2.9-7.6]), the male sex (odds ratio 2, 95% confidence interval [1.2-3.3]) and the time period of the procedure (the first 5 years) (odds ratio 1.7, 95% confidence interval [1.01-3]), are significant predictors of a post-colonoscopy bleeding episode. CONCLUSION This historical cohort study, the first in Greece on this subject, shows that colonoscopy is a rather safe procedure and that the rate of complications in this study was low.

Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial.

BACKGROUND AND STUDY AIMS We sought to determine whether bispectral index (BIS) monitoring is a useful adjunct to the administration of propofol titrated to deep sedation, as measured by reductions of doses of propofol administered during endoscopic retrograde cholangiopancreatography (ERCP). PATIENTS AND METHODS 90 consecutive patients undergoing ERCP were randomized to receive propofol titrated to deep sedation, with the BIS value either visible (BIS group, n = 46) or invisible (control group, n = 44) to the anesthesiologist. In the BIS group, the anesthesiologist was instructed to use the BIS value as the primary end point for titration of sedation, and to target BIS values between 40 and 60. For the control group, the anesthesiologist was instructed to titrate propofol according to routine practice in the unit using the modified Observers Assessment of Alertness/Sedation (MOAA/S) Scale (MOAA/S score 0). RESULTS The mean (SD) propofol doses (mg/min per kg weight) were 0.139 (0.02) and 0.193 (0.02) for the BIS and control groups, respectively (P < 0.001). Mean (SD) BIS values throughout the procedure were 61.68 (7.5) and 56.93 (4.77) for the BIS and control groups, respectively (P = 0.001). During the maintenance phase of sedation (MOAA/S score 0), the mean (SD) BIS values were 53.73 (8.67) and 45.65 (4.39) for the BIS and control groups, respectively (P < 0.001). CONCLUSIONS Our data suggest that BIS monitoring led to a reduction in the mean propofol dose when the BIS value was used as the primary target for sedation in ERCP procedures.

Plasma thrombin-activatable fibrinolysis inhibitor and plasminogen activator inhibitor-1 levels in inflammatory bowel disease.

Background Patients with inflammatory bowel disease (IBD) have an increased risk of thromboembolic events. Imbalance of fibrinolysis has been suggested as one of the possible pathogenetic mechanisms. As plasminogen activator inhibitor-1 (PAI-1) and thrombin-activatable fibrinolysis inhibitor (TAFI) are inhibitors of fibrinolysis, we studied TAFI as well as PAI-1 plasma levels in IBD patients compared with healthy controls. Methods A total of 132 IBD patients [68 ulcerative colitis (UC) and 64 Crohns disease (CD)] and 50 healthy controls were enrolled. PAI-1 and TAFI plasma levels were assessed by commercially available enzyme-linked immunosorbent assay kits. Their relationship with clinical parameters of UC and CD was assessed. Results Mean plasma PAI-1 levels were significantly higher in both UC patients (3.9±1.3 IU/ml) and CD patients (4.0±1.5 IU/ml) compared with healthy controls (3.1±1.1 IU/ml) (P=0.01). On the other hand, mean plasma TAFI levels were significantly lower in both UC patients (14.7±3.1 μg/ml) and CD patients (13.3±3.4 μg/ml) compared with healthy controls (17.4±3.0 μg/ml) (P<0.0001). Patients with active disease had significantly higher PAI-1 levels compared with patients with inactive disease for both diseases (P=0.03 and P=0.01, respectively). No significant association between plasma TAFI levels and disease activity was also found. Plasma TAFI levels were significantly lower in patients with ileal CD compared with patients with colonic CD. Conclusion PAI-1 plasma levels are increased whereas TAFI levels are decreased in IBD patients. These results suggest an imbalance of fibrinolysis in IBD.

Association between thrombocytosis and iron deficiency anemia in inflammatory bowel disease.

Background Thrombocytosis and iron deficiency anemia are frequent complications of inflammatory bowel disease (IBD). The aim of this study was to investigate the correlation between iron deficiency anemia and thrombocytosis in IBD patients. Methods A total of 198 consecutive IBD patients and 102 healthy controls participated in the study. The parameters investigated were: platelets (PLT), mean platelet volume, platelet distribution width, plateletcrit, hematocrit (HCT) levels, hemoglobulin (Hb) levels, mean corpuscular volume (MCV), red cell distribution width (RDW), ferritin levels, soluble transferrin receptor (sTfR) levels, the sTfR-F index (sTfR-F=sTfR/log10 ferritin), and vitamin B12 and folate levels. Thrombocytosis was defined as an absolute number of PLT greater than 400k/&mgr;l. Disease activity indices (Crohn’s Disease Activity Index for Crohn’s disease and Simple Clinical Colitis Activity Index for ulcerative colitis) as well as C-reactive protein (CRP) were also correlated with the study parameters. Results The IBD patients demonstrated decreased HCT levels, Hb levels, MCV, mean platelet volume, and ferritin levels and an increased absolute PLT count, RDW, platelet distribution width, plateletcrit, sTfR and sTfR-F index (P<0.0001) compared with healthy controls. Twenty-seven patients exhibited thrombocytosis (13.6%). The median value for PLT (interquartile range) was 289 (228–355)k/&mgr;l, for Hb levels was 13.4 (12.0–14.7) g/dl, for ferritin levels was 36.6 (19.7–80.7) ng/ml, and for sTfR-F was 0.82 (0.61–1.37) mg/l. The PLT in IBD patients correlated with HCT levels, Hb levels, MCV, RDW, Fe levels, ferritin levels, sTfR, sTfR-F, CRP levels, Simple Clinical Colitis Activity Index, and Crohn’s Disease Activity Index (Spearman’s &rgr; correlation). In the multivariate analysis, only Hb levels, RDW, CRP levels, ferritin levels, and sTfR-F remained significant (P<0.05). None of the aforementioned was observed in the control group. Conclusion The absolute PLT count seems to correlate with iron deficiency anemia parameters and disease activity in IBD patients. Controlling the inflammation and managing iron deficiency could lead to reversal of thrombocytosis in IBD patients.

Prevalence and Characteristics of Extra-intestinal Manifestations in a Large Cohort of Greek Patients with Inflammatory Bowel Disease

BACKGROUND AND AIMS Extraintestinal manifestations [EIMs] are common in inflammatory bowel disease [IBD]. Data on epidemiology and risk factors of EIMs in IBD patients are limited. The aim of this study was to investigate the prevalence of EIMs in a large cohort of Greek IBD patients and identify risk factors for their development. METHODS The study population consisted of IBD patients, who were followed in eight tertiary Greek hospitals. Demographic and clinical characteristics of patients were analysed. The diagnosis of EIMs was based on standard criteria and on specialist consultation. RESULTS In total, 1860 IBD patients (1001 with Crohns disease [CD], 859 with ulcerative colitis [UC]) were registered. Among them 615 [33.1%] exhibited at least one EIM; 238 patients [38.6%] developed an EIM before IBD diagnosis. An association between active IBD and presence of an EIM was established in 61.1% of the patients. Arthritic [peripheral arthritis], mucocutaneous [erythema nodosum], and ocular [episcleritis] were the most common manifestations. EIMs were more prevalent in females, patients with CD, smokers [for all p <0.0001], patients with extensive UC [p = 0.007], and patients with a previous appendectomy [p < 0.0001] or a major IBD-related surgery [p = 0.012]. CONCLUSIONS About one-third of Greek IBD patients developed at least one EIM. Of those, more than one-third had their EIM diagnosed before IBD, and in about two-thirds it was related to disease activity. EIMs were more frequently present in females and patients with extensive UC in multivariate analysis.

Sixty- versus thirty-seconds papillary balloon dilation after sphincterotomy for the treatment of large bile duct stones: A randomized controlled trial

BACKGROUND Endoscopic biliary sphincterotomy followed by endoscopic papillary balloon dilation is a promising method for large stones. However, there are no data on the optimal duration of papillary balloon dilation after a biliary sphincterotomy. AIMS To compare the effectiveness and complications of the endoscopic papillary balloon dilation for 60s versus 30s after endoscopic biliary sphincterotomy. METHODS A total of 124 patients with bile duct stones, submitted for endoscopic biliary sphincterotomy plus endoscopic papillary balloon dilation, were prospectively randomized to either the 60-s dilation group (G60, n = 60) or the 30-s dilation group (G30, n = 64). RESULTS The complete removal of bile duct stones was similar: group G30, 55/64 (86%) versus group G60, 51/60 (85%); p = 0.9. The rates of post-endoscopic retrograde cholangio-pancreatography pancreatitis were also similar: 2 (3.1%) in group G30 versus 2 (3.3%) in group G60, p = 0.9. Post-procedural bleeding occurred in 2 cases (3.1%) in group G30 versus 4 (6.6%) in group G60, (p = 0.17). Two perforations of moderate severity were observed, one in each group. CONCLUSIONS 30-s papillary balloon dilation, performed after endoscopic biliary sphincterotomy for the management of bile duct stones, was equally effective to the 60-s papillary balloon dilation.

Genetic Risk Factors in Young Patients With Ischemic Colitis

BACKGROUND & AIMS Although ischemic colitis (IC) usually occurs in old people with concomitant illnesses, an increasing frequency of this disease among young people has been reported. Inherited risk factors have been suggested to play an important role in the pathogenesis of IC. The aim of this study was to investigate the prevalence and possible role of mutations associated with cardiovascular morbidity in young patients with IC. METHODS Patients younger than 55 years old with nonocclusive colon ischemia who were conservatively treated were included in the study. The diagnosis of definite IC was based on established clinical, endoscopic, and histologic criteria. Twelve polymorphisms of thrombophilic and vasoactive genes were evaluated in a group of 19 young patients with IC compared with 52 matched healthy controls (HC) by using commercially available kit. RESULTS The frequency of the 506 Q allele of the factor V (FV) 506 RQ (Leiden) mutation was significantly higher in patients with IC than in HC (P = .005). The allele frequency of the mutant 4G allele of plasminogen activator inhibitor (PAI) polymorphism was significantly higher in patients with IC compared with HC (P = .006). The frequencies of the genotypes and mutant alleles of the other 10 polymorphisms were not statistically different in the 2 groups (P > .05). CONCLUSIONS Our results suggest that FV R506Q and PAI-1 gene polymorphisms might be associated with the development of IC in young patients without other serious illness. Genetic predisposition might play an important role in the pathogenesis of IC in young patients.