Christian M. Andrade

Safety of Gastrointestinal Endoscopy With Conscious Sedation in Patients With and Without Obstructive Sleep Apnea.

Background and Study Aims: Patients with obstructive sleep apnea (OSA) undergoing endoscopy with sedation are considered by practitioners to be at a higher risk for cardiopulmonary complications. The aim of the present study was to evaluate the safety of conscious sedation in patients with OSA undergoing gastrointestinal endoscopy. Patients and Methods: This is an IRB-approved prospective cohort study performed at the James A. Haley VA. A total of 248 patients with confirmed moderate or severe OSA by polysomnography and 252 patients without OSA were enrolled. Cardiopulmonary variables such as heart rate, blood pressure, and level of blood oxygen saturation were recorded at 3-minute intervals throughout the endoscopic procedure. Results: In total, 302 colonoscopies, 119 esophagogastroduodenoscopies, 6 flexible sigmoidoscopies, and 60 esophagogastroduodenoscopy/colonoscopies were performed. None of the patients in the study required endotracheal intubation, pharmacologic reversal, or experienced an adverse outcome as a result of changes in blood pressure, heart rate, or blood oxygen saturation. There were no significant differences in the rate of tachycardia (P=0.749), bradycardia (P=0.438), hypotension (systolic/diastolic, P=0.460; mean arterial pressure, P=0.571), or hypoxia (P=0.787) between groups. The average length of time spent in each procedure and the average dose of sedation administered also did not differ significantly between the groups. Conclusions: Despite the presumed increased risk of cardiopulmonary complications, patients with OSA who undergo endoscopy with conscious sedation have clinically insignificant variations in cardiopulmonary parameters that do not differ from those without OSA. Costly preventative measures in patients with OSA are not warranted.

Acute Putrescine Supplementation with Schwann Cell Implantation Improves Sensory and Serotonergic Axon Growth and Functional Recovery in Spinal Cord Injured Rats

Schwann cell (SC) transplantation exhibits significant potential for spinal cord injury (SCI) repair and its use as a therapeutic modality has now progressed to clinical trials for subacute and chronic human SCI. Although SC implants provide a receptive environment for axonal regrowth and support functional recovery in a number of experimental SCI models, axonal regeneration is largely limited to local systems and the behavioral improvements are modest without additional combinatory approaches. In the current study we investigated whether the concurrent delivery of the polyamine putrescine, started either 30 min or 1 week after SCI, could enhance the efficacy of SCs when implanted subacutely (1 week after injury) into the contused rat spinal cord. Polyamines are ubiquitous organic cations that play an important role in the regulation of the cell cycle, cell division, cytoskeletal organization, and cell differentiation. We show that the combination of putrescine with SCs provides a significant increase in implant size, an enhancement in axonal (sensory and serotonergic) sparing and/or growth, and improved open field locomotion after SCI, as compared to SC implantation alone. These findings demonstrate that polyamine supplementation can augment the effectiveness of SCs when used as a therapeutic approach for subacute SCI repair.

Carbon dioxide versus room air insufflation during balloon-assisted enteroscopy: A systematic review with meta-analysis

Background and study aims Carbon dioxide (CO2) insufflation has been suggested to be an ideal alternative to room air insufflation to reduce trapped air within the bowel lumen after balloon assisted enteroscopy (BAE). We performed a systematic review and meta-analysis to assess the safety and efficacy of utilizing CO2 insufflation as compared to room air during BAE. Patients and methods The primary outcome is mean change in visual analog scale (VAS; 10 cm) at 1, 3, and 6 hours to assess pain. Secondary outcomes include insertion depth (anterograde or retrograde), adverse events, total enteroscopy rate, diagnostic yield, mean anesthetic dosage, and PaCO2 at procedure completion. We searched MEDLINE and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception until May 2015. Multiple independent extractions were performed, the process was executed as per the standards of the Cochrane collaboration. Results Four randomized controlled trials (RCTs) were included in the meta-analysis. VAS at 6 hours favored CO2 over room air (MD 0.13; 95 % CI 0.01, 0.25; p = 0.03). Anterograde insertion depth (cm) was improved in the CO2 group (MD, 58.2; 95 % CI 17.17, 99.23; p = 0.005), with an improvement in total enteroscopy rate in the CO2 group (RR 1.91; 95 % CI 1.20, 3.06; p = 0.007). Mean dose of propofol (mg) favored CO2 compared to air (MD, – 70.53; 95 % CI – 115.07, – 25.98; P = 0.002). There were no differences in adverse events in either group. Conclusions Despite the ability of CO2 to improve insertion depth and decrease amount of anesthesia required, further randomized control trials are needed to determine the agent of choice for insufflation in balloon assisted enteroscopy.

Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

AIM To perform a systematic review and meta-analysis to assess the safety of conscious sedation in patients with obstructive sleep apnea (OSA). METHODS A comprehensive electronic search of MEDLINE and EMBASE was performed from inception until March 1, 2015. In an effort to include unpublished data, abstracts from prior gastroenterological society meetings as well as other reference sources were interrogated. After study selection, two authors utilizing a standardized data extraction form collected the data independently. Any disagreements between authors were resolved by consensus among four authors. The methodological quality was assessed using the Newcastle Ottawa tool for observational studies. The primary variables of interest included incidence of hypoxia, hypotension, tachycardia, and bradycardia. Continuous data were summarized as odds ratio (OR) and 95%CI and pooled using generic inverse variance under the random-effects model. Heterogeneity between pooled studies was assessed using the I2 statistic. RESULTS Initial search of MEDLINE and EMBASE identified 357 citations. A search of meeting abstracts did not yield any relevant citations. After systematic review and exclusion consensus meetings, seven studies met the a priori determined inclusion criteria. The overall methodological quality of included studies ranged from moderate to low. No significant differences between OSA patients and controls were identified among any of the study variables: Incidence of hypoxia (7 studies, 3005 patients; OR = 1.11; 95%CI: 0.73-1.11; P = 0.47; I2 = 0%), incidence of hypotension (4 studies, 2125 patients; OR = 1.10; 95%CI: 0.75-1.60; P = 0.63; I2 = 0%), incidence of tachycardia (3 studies, 2030 patients; OR = 0.94; 95%CI: 0.53-1.65; P = 0.28; I2 = 21%), and incidence of bradycardia (3 studies, 2030 patients; OR = 0.88; 95%CI: 0.63-1.22; P = 0.59; I2 = 0%). CONCLUSION OSA is not a significant risk factor for cardiopulmonary complications in patients undergoing endoscopic procedures with conscious sedation.

Metastatic leiomyosarcoma to the pancreas presenting as a massive upper gastrointestinal hemorrhage.

Leiomyosarcomas are rare, comprising only 0.1 % of all primary pancreatic malignancies [1]. They originate from smooth muscle and are most commonly found within the stomach and small intestine as well as in the large intestine, uterus, and retroperitoneum [2]. Leiomyosarcomas have a predilection for hematogenous spread with the liver and lungs being the most common sites of metastasis. Diagnosis requires immunohistochemical confirmation with positivity most commonly seen for smooth muscle actin (SMA), caldesmon, vimentin, and desmin. In a recent review, only 25 cases of solitary metastatic leiomyosarcomas were found in the literature [3]. In general, pancreatic metastatic lesions are rare, with the most commonly reported primary malignancies being of lung, renal, and gastric origin [4–6]. In a series of 4,955 adult autopsy cases, Adsay et al. found only 81 (1.6 %) cases of metastatic tumors to the pancreas [7]. At the time of diagnoses, most cases of metastatic pancreatic tumors are associated with multiorgan involvement [8, 9]. In this clinical context, literature regarding the treatment of such lesions is limited with respect to survival or quality of life but is generally regarded as poor. Here, we report a case of metastatic leiomyosarcoma to the pancreatic tail and lung. To our knowledge, it is the only known case of pancreatic metastasis presenting with life-threatening massive upper gastrointestinal hemorrhage resulting from a gastric variceal rupture.

Splenic Avulsion Following PEG Tube Placement: A Rare but Serious Complication

Placement of a percutaneous endoscopic gastrostomy (PEG) tube is a common procedure to allow for enteral nutrition in patients with multiple indications. PEG tube placement is a safe procedure with minor complications such as site infection and irritation. One of the more severe complications is splenic laceration, which may result in intra-peritoneal bleeding and manifest as an acute abdomen. We present a rare case of intra-abdominal bleeding secondary to catastrophic splenic injury 12 hours after PEG tube placement resulting in hemodynamic compromise. The patient underwent splenectomy and had an uneventful recovery.

Hepatobiliary and pancreatic: Hepatic focal fatty infiltration mimicking hepatocellular carcinoma: Education and imaging

A 61 year old male attended the Emergency Department at our hospital because of an acute episode of abdominal pain. His past medical history was significant for hypertension, type 2 diabetes and documented cirrhosis because of hepatitis C (genotype 1) and prior alcohol abuse. A computerized tomography (CT) scan of the abdomen was performed. He had a lesion of decreased attenuation in the right lobe of the liver as well as other changes consistent with cirrhosis (Figure 1).Hepatocellular carcinoma was thought to be the most likely diagnosis. However, his liver function tests were normal and his alpha-fetoprotein was only mildly elevated at 5.5 U/ml. The patient was referred for a CTguided biopsy of the lesion. Histological findings included a large area of scarring, ductular reaction and a focus of atypical glandular proliferation. A subsequent positron emission tomography scan was negative, including the absence of any hypermetabolic activity in the liver. A second CT-guided liver biopsy showed micronodular cirrhosis associated with mild chronic hepatitis and moderate steatosis. Upper gastrointestinal endoscopy and colonoscopy were negative. He was advised to lose weight and improve his glycemic control. Over the following twelve months, his weight decreased from 190 kg to 173 kg with an improvement in glycemic control as assessed by HbA1c. A repeat CT scan showed no evidence of the lesion in the right lobe of the liver (Figure 2). The radiological abnormality on the initial CT scan was attributed to focal fatty infiltration. Imaging techniques to support the diagnosis of non-alcoholic fatty liver disease include an upper abdominal ultrasound study, a non-contrast CT scan and a magnetic resonance imaging scan. The latter has the best resolution of fat and has been reported as being 100% sensitive and 92% specific for steatosis. While some patients have a diffuse abnormality throughout the liver, the majority have at least some heterogeneity with a geographic, focal, subcapsular, multifocal or perivascular appearance on imaging studies. For example, focal fatty infiltration has a predilection for the regions of the porta hepatis, gallbladder fossa and along the falciform ligament. Clearly-defined focal fatty infiltrates in the right lobe of the liver appear to be uncommon. In the above case, weight reduction and improvement in glycemic control were associated with resolution of the lesion. These measures are helpful for most patients with diffuse steatosis but whether they are helpful in the majority with focal steatosis is less clear.

Hepatobiliary and pancreatic: Hepatic focal fatty infiltration mimicking hepatocellular carcinoma

A 61 year old male attended the Emergency Department at our hospital because of an acute episode of abdominal pain. His past medical history was significant for hypertension, type 2 diabetes and documented cirrhosis because of hepatitis C (genotype 1) and prior alcohol abuse. A computerized tomography (CT) scan of the abdomen was performed. He had a lesion of decreased attenuation in the right lobe of the liver as well as other changes consistent with cirrhosis (Figure 1).Hepatocellular carcinoma was thought to be the most likely diagnosis. However, his liver function tests were normal and his alpha-fetoprotein was only mildly elevated at 5.5 U/ml. The patient was referred for a CTguided biopsy of the lesion. Histological findings included a large area of scarring, ductular reaction and a focus of atypical glandular proliferation. A subsequent positron emission tomography scan was negative, including the absence of any hypermetabolic activity in the liver. A second CT-guided liver biopsy showed micronodular cirrhosis associated with mild chronic hepatitis and moderate steatosis. Upper gastrointestinal endoscopy and colonoscopy were negative. He was advised to lose weight and improve his glycemic control. Over the following twelve months, his weight decreased from 190 kg to 173 kg with an improvement in glycemic control as assessed by HbA1c. A repeat CT scan showed no evidence of the lesion in the right lobe of the liver (Figure 2). The radiological abnormality on the initial CT scan was attributed to focal fatty infiltration. Imaging techniques to support the diagnosis of non-alcoholic fatty liver disease include an upper abdominal ultrasound study, a non-contrast CT scan and a magnetic resonance imaging scan. The latter has the best resolution of fat and has been reported as being 100% sensitive and 92% specific for steatosis. While some patients have a diffuse abnormality throughout the liver, the majority have at least some heterogeneity with a geographic, focal, subcapsular, multifocal or perivascular appearance on imaging studies. For example, focal fatty infiltration has a predilection for the regions of the porta hepatis, gallbladder fossa and along the falciform ligament. Clearly-defined focal fatty infiltrates in the right lobe of the liver appear to be uncommon. In the above case, weight reduction and improvement in glycemic control were associated with resolution of the lesion. These measures are helpful for most patients with diffuse steatosis but whether they are helpful in the majority with focal steatosis is less clear.

Education and Imaging. Hepatobiliary and pancreatic: hepatic focal fatty infiltration mimicking hepatocellular carcinoma.

A 61 year old male attended the Emergency Department at our hospital because of an acute episode of abdominal pain. His past medical history was significant for hypertension, type 2 diabetes and documented cirrhosis because of hepatitis C (genotype 1) and prior alcohol abuse. A computerized tomography (CT) scan of the abdomen was performed. He had a lesion of decreased attenuation in the right lobe of the liver as well as other changes consistent with cirrhosis (Figure 1).Hepatocellular carcinoma was thought to be the most likely diagnosis. However, his liver function tests were normal and his alpha-fetoprotein was only mildly elevated at 5.5 U/ml. The patient was referred for a CTguided biopsy of the lesion. Histological findings included a large area of scarring, ductular reaction and a focus of atypical glandular proliferation. A subsequent positron emission tomography scan was negative, including the absence of any hypermetabolic activity in the liver. A second CT-guided liver biopsy showed micronodular cirrhosis associated with mild chronic hepatitis and moderate steatosis. Upper gastrointestinal endoscopy and colonoscopy were negative. He was advised to lose weight and improve his glycemic control. Over the following twelve months, his weight decreased from 190 kg to 173 kg with an improvement in glycemic control as assessed by HbA1c. A repeat CT scan showed no evidence of the lesion in the right lobe of the liver (Figure 2). The radiological abnormality on the initial CT scan was attributed to focal fatty infiltration. Imaging techniques to support the diagnosis of non-alcoholic fatty liver disease include an upper abdominal ultrasound study, a non-contrast CT scan and a magnetic resonance imaging scan. The latter has the best resolution of fat and has been reported as being 100% sensitive and 92% specific for steatosis. While some patients have a diffuse abnormality throughout the liver, the majority have at least some heterogeneity with a geographic, focal, subcapsular, multifocal or perivascular appearance on imaging studies. For example, focal fatty infiltration has a predilection for the regions of the porta hepatis, gallbladder fossa and along the falciform ligament. Clearly-defined focal fatty infiltrates in the right lobe of the liver appear to be uncommon. In the above case, weight reduction and improvement in glycemic control were associated with resolution of the lesion. These measures are helpful for most patients with diffuse steatosis but whether they are helpful in the majority with focal steatosis is less clear.

Unusual Finding of an Intact Moth During Routine Colonoscopy.

Case Report There is scant literature describing inadvertent ingestion of insects visualized during endoscopy.1,2 Previously described insects include ants, wasps, bees, yellow jackets, and cockroaches. We present a case of a 55-year-old male with a normal colonoscopy except for the discovery of a lifeless winged insect between folds of the transverse colon (Figure 1). In the image, the insect is ventral side up on the colon lining. Two compound eyes and abdomen are visible, but the thorax and portions of the wings are overexposed. Six legs can be discerned, and the insect had roughly a 6-mm craniocaudal length and a 12-mm wingspan. The image was later identified by an entomologist as a moth belonging to order Lepidoptera. Moths typically have scales covering the body and wings, but these scales are easily removed when exposed to an acidic environment. A loss of these scales explains the whitish coloration of the moth, as most of the pigmentation is found on the scales. Although these ingestions are of little consequence to the patient, they are quite rare and may even be startling to the endoscopist. To our knowledge, this is the first case of a moth described within the gastrointestinal tract.