Chien-Yuan Hung

Benign esophageal lesions: Endoscopic and pathologic features

Benign esophageal lesions have a wide spectrum of clinical and pathologic features. Understanding the endoscopic and pathologic features of esophageal lesions is essential for their detection, differential diagnosis, and management. The purpose of this review is to provide updated features that may help physicians to appropriately manage these esophageal lesions. The endoscopic features of 2997 patients are reviewed. In epithelial lesions, the frequency of occurrence was in the following order: glycogenic acanthosis, heterotopic gastric mucosa, squamous papilloma, hyperplastic polyp, ectopic sebaceous gland and xanthoma. In subepithelial lesions, the order was as follows: hemangioma, leiomyoma, dysphagia aortica and granular cell tumor. Most benign esophageal lesions can be diagnosed according to their endoscopic appearance and findings on routine biopsy, and submucosal lesions, by endoscopic resection. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. We suggest endoscopic resection of all granular cell tumors and squamous papillomas because, while rare, these lesions have malignant potential. Dysphagia aortica should be considered in the differential diagnosis of dysphagia in the elderly.

Effect of Physician-Delivered Patient Education on the Quality of Bowel Preparation for Screening Colonoscopy

Background. Inadequate bowel preparation is common in outpatients undergoing screening colonoscopy because of unawareness and poor adherence to instruction. Methods. Herein, 105 consecutive outpatients referred for screening colonoscopy were enrolled in this prospective, colonoscopist-blinded study. The patients were assigned to an intensive-education group, with 10 minutes of physician-delivered education, or to standard care. At the time of colonoscopy, the quality of bowel preparation was assessed using the Boston Bowel Preparation Scale (BBPS). The primary outcome was a BBPS score ≥5. The secondary outcomes were the mean BBPS score, insertion time, adenoma detection rate, and number of adenomas detected. Results. We analyzed 39 patients who received intensive education and 60 controls. The percentage of adequate bowel preparations with a BBPS score ≥5 was higher in the intensive-education group than in the control group (97.4% versus 80.0%; P = 0.01). The adjusted odds ratio for having a BBPS score ≥5 in the intensive-education group was 10.2 (95% confidence interval = 1.23–84.3; P = 0.03). Other secondary outcomes were similar in the 2 groups. Conclusions. Physician-delivered education consisting of a brief counseling session in addition to written instructions improves the quality of bowel preparation in outpatients undergoing screening colonoscopy.

The add-on N-acetylcysteine is more effective than dimethicone alone to eliminate mucus during narrow-band imaging endoscopy: a double-blind, randomized controlled trial.

Abstract Objective. Recent studies have shown that pronase can improve mucosal visibility, but this agent is not uniformly available for human use worldwide. This study aimed to assess the efficacy of N-acetylcysteine (NAC), a mucolytic agent, in improving mucus elimination as measured by decreased endoscopic water flushes during narrow-band imaging (NBI) endoscopy. Material and methods. A consecutive series of patients scheduled for upper gastrointestinal endoscopy at outpatient clinics were enrolled in this double-blind, randomized controlled trial. The control group drank a preparation of 100 mg dimethicone (5 ml at 20 mg/ml) plus water up to 100 ml, and the NAC group drank 300 mg NAC plus 100 mg dimethicone and water up to 100 ml. During the endoscopy, the endoscopist used as many flushes of water as deemed necessary to produce a satisfactory NBI view of the entire gastric mucosa. Results. In all, 177 patients with a mean age of 51 years were evaluated in this study. Significantly lesser water was used for flushing during NBI endoscopy for the NAC group than the control group; 40 ml (30–70, 0–120) versus 50 ml (30–100, 0–150) (median (interquartile range, range), p = 0.0095). Conclusions. Considering the safety profile of NAC, decreasing the number of water flushes for optimal vision and unavailability of pronase in some areas, the authors suggest the use of add-on NAC to eliminate mucus during NBI endoscopy.

Investigation of cytotoxic T-lymphocyte-associated protein 4 gene polymorphisms in symptomatic gallstone disease

Gallstone disease (GSD), which is increasingly prevalent in Taiwan, develops through a complex process involving genetic, environmental, and immune factors. Cytotoxic T-lymphocyte-associated protein 4 (CTLA4) limits T-cell proliferation. The present study looked for associations between symptomatic GSD and polymorphisms of the CTLA4 gene. For this case-control cross-sectional study among Taiwanese, 275 patients with symptomatic GSD and 852 controls were enrolled. Genotyping of CTLA4-318 C/T, +49 A/G, and CT60 A/G single nucleotide polymorphisms (SNPs) was performed by polymerase chain reaction-restriction fragment length polymorphism. The genotype, allele, carrier, and haplotype frequencies were calculated by direct counting or with Haploview 4.1 software. Genotype, allele, carrier, and haplotype frequencies of the CTLA4 SNPs studied were equally distributed in symptomatic GSD patients and controls. No significant associations between symptomatic GSD and these 3 SNPs were observed. Our data suggest that CTLA4-318 C/T, +49 A/G, and CT60 A/G SNPs do not confer increased susceptibility to symptomatic GSD.

The Feasibility of Using Simulated Targets in the Stomachs of Live Pigs for Full Endoscopic Submucosal Dissection Training

Background/Aims In endoscopic submucosal dissection (ESD) training, only a flat target lesion can usually be simulated in the normal mucosa. This study aimed to evaluate the feasibility of simulated targets in the stomachs of live pigs for complete training. Methods Six trained endoscopists with hands-on experience with ex vivo, isolated pig stomachs were enrolled in this pilot study. An endoscopic banding device was used to create a polyp that was snared, leaving an ulcerated lesion. This simulated target model was used to perform ESD in pigs. The en bloc resection rate, procedure time, complications, quality of resection, and participants’ opinions on the simulated targets were compared with the conventional model. Results En bloc resections were achieved in all six simulated targets and six conventional models. The mean size of the resected specimens was 32.2 mm (range, 20 to 39 mm) in the simulated target group and 23.5 mm (range, 11 to 40 mm) in the conventional group. The target model had a high quality of resection and had a high satisfaction rate for margin identification and correct peripheral marking. Conclusions Good identification of the lesion and ease of periphery marking in the target model may improve resection quality.

Clinical endoscopic management and outcome of post-endoscopic sphincterotomy bleeding

Post-endoscopic sphincterotomy bleeding is a common complication of biliary sphincterotomy, and the incidence varies from 1% to 48%. It can be challenging to localize the bleeder or to administer various interventions through a side-viewing endoscope. This study aimed to evaluate the risk factors of post-endoscopic sphincterotomy bleeding and the outcome of endoscopic intervention therapies. We retrospectively reviewed the records of 513 patients who underwent biliary sphincterotomy in Mackay Memorial Hospital between 2011 and 2016. The blood biochemistry, comorbidities, indication for sphincterotomy, severity of bleeding, endoscopic features of bleeder, and type of endoscopic therapy were analyzed. Post-endoscopic sphincterotomy bleeding occurred in 65 (12.6%) patients. Forty-five patients had immediate bleeding and 20 patients had delayed bleeding. The multivariate analysis of risk factors associated with post-endoscopic sphincterotomy bleeding were liver cirrhosis (P = 0.029), end-stage renal disease (P = 0.038), previous antiplatelet drug use (P<0.001), and duodenal ulcer (P = 0.023). The complications of pancreatitis and cholangitis were higher in the bleeding group, with statistical significance. Delayed bleeding occurred within 1 to 7 days (mean, 2.5 days), and 60% (12/20) of the patients received endoscopic evaluation. In the delayed bleeding group, the successful hemostasis rate was 71.4% (5/7), and 65% (13/20) of the patients had ceased bleeding without endoscopic hemostasis therapy. Comparison of different therapeutic modalities showed that cholangitis was higher in patients who received epinephrine spray (P = 0.042) and pancreatitis was higher in patients who received epinephrine injection and electrocoagulation (P = 0.041 and P = 0.039 respectively). Clinically, post-endoscopic sphincterotomy bleeding and further endoscopic hemostasis therapy increase the complication rate of pancreatitis and cholangitis. Realizing the effectiveness of each therapeutic modalities and appropriate management of different levels bleeding are important.

Gender-specific association of the interleukin 18 gene with symptomatic gallstone disease.

Symptomatic gallstone disease (SGSD) induced several inflammatory responses and affected extrahepatic bile ducts. Although the pathology and environmental risk factors of gallstone disease are well documented, immune or inflammatory responses in SGSD development are still inconclusive. Interleukin 18 (IL18) is a pro‐inflammatory cytokine that plays an important role in immune, infectious, and inflammatory diseases because of the induction of interferon‐γ. In this study, we investigated whether polymorphisms of the IL18 gene were associated with SGSD susceptibility.