Benjamin Tharian

Enteroscopy in small bowel Crohn's disease: A review.

Crohns disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohns. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trials in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.

Endoscopic ultrasound fine needle aspiration: Technique and applications in clinical practice

Since its initial report in 1992, endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) has now been incorporated into the diagnostic and staging algorithm for the evaluation of benign and malignant diseases of the gastrointestinal tract and of adjacent organs. Its introduction constitutes a major breakthrough in the endoscopic field and has gradually transformed EUS from a pure imaging modality into a more interventional procedure. In addition, the possibility of collecting samples, providing a definitive cytological and/or histological evidence of the presence of malignancy, has strongly contributed to changing EUS from a subjective, highly operator dependant procedure into a more objective one. This article will review the instrumentation, technique and the most important clinical applications of EUS-FNA.

Endoscopy in the Diagnosis and Management of Complications of Inflammatory Bowel Disease.

Abstract:The role of endoscopy in inflammatory bowel disease (IBD) has grown over the last decade in both diagnostic and therapeutic realms. It aids in the initial diagnosis of the disease and also in the assessment of the extent and severity of disease. IBD is associated with development of multiple complications such as strictures, fistulae, and colon cancers. Endoscopy plays a pivotal role in the diagnosis of colon cancer in patients with IBD through incorporation of chromoendoscopy for surveillance. In addition, endoscopic resection with surveillance is recommended in the management of polypoid dysplastic lesions without flat dysplasia. IBD-associated benign strictures with obstructive symptoms amenable to endoscopic intervention can be managed with endoscopic balloon dilation both in the colon and small intestine. In addition, endoscopy plays a major role in assessing the neoterminal ileum after surgery to risk-stratify patients after ileocolonic resection and assessment of a patient with ileoanal pouch anastomosis surgery and management of postsurgical complications. Our article summarizes the current evidence in the role of endoscopy in the diagnosis and management of complications of IBD.

Biomarkers in bile-complementing advanced endoscopic imaging in the diagnosis of indeterminate biliary strictures

Biliary strictures present a diagnostic challenge and a conundrum, particularly when an initial work up including abdominal imaging and endoscopic retrograde cholangiopancreatography based sampling are non-diagnostic. Advances in endoscopic imaging have helped us diagnose these strictures better. However, even with modern technology, some strictures remain a diagnostic challenge. The proximity of bile fluid to the bile duct epithelia makes it an attractive option to investigate for bio-markers, which might be representative of the functions/abnormal changes taking place in the biliary system. A number of biomarkers in bile have been discovered recently in approaching biliary strictures with their potential future diagnostic utility, further supported by the immunohistochemical analysis of the resected tissue specimens. Novel biliary biomarkers especially carcinoembryonic cell adhesion molecule 6 and neutrophil gelatinase-associated lipocalin seem promising in differentiating malignant from benign biliary strictures. Recent developments in lipidomic profiling of bile are also very promising. Biliary biomarkers appear to complement endoscopic imaging in diagnosing malignant etiologies of biliary stricture. Future studies addressing these biomarkers need to be incorporated to the current endoscopic techniques to determine the best approach in determining the etiology of biliary strictures.

What is the current role of endoscopy in primary sclerosing cholangitis

Endoscopy has important roles in the management of primary sclerosing cholangitis (PSC), ranging from narrowing down the differential diagnoses, screening for complications, determining prognosis and therapy. While the need for a diagnostic endoscopic retrograde cholangiopancreatography (ERCP) may be obviated by a positive magnetic resonance cholangiopancreatography (MRCP), a negative MRCP does not exclude PSC and may therefore necessitate an ERCP, which is traditionally regarded as the gold standard. In this editorial we have not covered the endoscopic management of inflammatory bowel disease in the context of PSC nor of endoscopic surveillance and treatment of portal hypertension complicating PSC.

An autosomal dominant form of non-cirrhotic portal hypertension

To the Editor: The familial aggregation idiopathic non-cirrhotic portal hypertension (INCPH) has been previously described, however, there have been no reports of Mendelian inheritance [1–5]. We describe the first case of autosomal dominant inheritance of INCPH in a single family. Fig. 1 demonstrates the autosomal dominant inheritance pattern, including male-to-male transmission. I.6 suffered a fatal variceal haemorrhage and may have also been affected. In this patient however, secondary causes of portal hypertension could not be excluded given the lack of a comprehensive medical record. INCPH was diagnosed in all cases in accordance with criteria proposed by Schouten [6], excluding II.1 who died prior to liver biopsy being performed. The siblings and children of affected family members have been screened with upper gastrointestinal endoscopies, hepatosplenic ultrasound and full blood examination.

Digital cholangioscopy–directed removal of a surgical staple from a strictured bile duct

A 69-year-old man with dual liver and kidney transplantation 3 years earlier underwent ERCP for evaluation of an anastomotic biliary stricture. An ERCP revealed a tight anastomotic stricture. After standard biliary sphincterotomy and stricture dilation, a cholangiogram was suggestive of a small linear foreign body at the stricture site. Direct endoscopic evaluation of the stricture with the new digital SpyGlass cholangioscopy system (Boston Scientific Corp, Natick, Mass) identified a staple protruding through the biliary mucosa at the stricture site. The staple was removed by using SpyBite biopsy forceps (Boston Scientific, Marlborough, Mass) (Fig. 1A and B; Video 1, available online at www.giejournal.org), and three 7F 10 cm stents were placed sequentially across the stricture site. The new digital SpyGlass cholangioscope provided excellent visualization and allowed direct targeting to remove the foreign body, which could have been a nidus for stricture formation. SpyGlass DS is a single use, direct visualization system with an integrated digital sensor that

Utility of endoscopic ultrasound and endoscopy in diagnosis and management of hepatocellular carcinoma and its complications: What does endoscopic ultrasonography offer above and beyond conventional cross-sectional imaging?

Hepatocellular carcinoma constitutes over 90% of the primary liver tumors, the rest being cholangiocarcinoma. It has an insidious presentation, which is responsible for the delayed presentation. Hence, the management strategy relies on screening to diagnose it an early stage for curative resection and/or treatment with local ablative techniques or chemotherapy. However, even with different screening programs, more than 60% of tumors are still detected at an advanced stage, leading to an unchanged mortality rate, thereby implying a room for improvement in the screening and diagnostic process. In the last few years, there has been evolution of utility of endoscopy, specifically endoscopic ultrasonography along with Fine needle aspiration, for this purpose, which we comprehensively review in this article.

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Ectopic Hepatocellular Carcinoma within a Choledochal Cyst Diagnosed Using Single-Operator Digital Cholangioscopy

Verrucous carcinoma of the esophagus—remains a diagnostic enigma

with no prominent cytological atypia and typical vascular invasion are shown in Fig. 3 (hematoxylin and eosin, magnification ×20 and ×40, respectively). The polyp stalk was free of tumor infiltration. A strict endoscopic and radiological surveillance program was undertaken, based on upper endoscopy and contrast-enhanced CT scan performed at month 3 and 6 after polypectomy. No evidence of recurrent HCC was reported after one year, including also a positive emission computed tomography. Fatigue and anemia progressively improved after endoscopic polyp resection, with return to normal hemoglobin levels within six months. HCC extension to small bowel is considered anecdotal and generally restricted to patients with diffuse neoplastic involvement of the liver [1, 2]. To our knowledge, only one case has been described of a single duodenal isolated recurrence of HCC [2]. However, this patient was not a liver transplant recipient and had fibrolamellar HCC. HCC recurrence nowadays is reported at a rate lower than 20% after liver transplantation, according to a retrospective radiologic study involving 119 patients [3]. Notably, in the latter study extra-hepatic recurrence of HCC without liver involvement was not a rare event, being observed in 4 of 16 recurrent cases. To our knowledge, this is the first report of a duodenal recurrence of a solitary HCC after liver transplantation. Although this unusual site of extrahepatic tumor recurrence is probably rare, this possibility, together with other more frequent classical sites, such as lymph nodes, lung and adrenal glands, should be taken into consideration in the long-term surveillance of patients liver-transplanted for HCC.