Christopher W. Teshima

Double balloon enteroscopy and capsule endoscopy for obscure gastrointestinal bleeding: An updated meta-analysis

Background and Aim:u2002 Uncertainty remains about the best test to evaluate patients with obscure gastrointestinal bleeding (OGIB). Previous meta‐analyses demonstrated similar diagnostic yields with capsule endoscopy (CE) and double balloon enteroscopy (DBE) but relied primarily on data from abstracts and were not limited to bleeding patients. Many studies have since been published. Therefore, we performed a new meta‐analysis comparing CE and DBE focused specifically on OGIB.

Abnormal intestinal permeability in Crohn's disease pathogenesis

Increased small intestinal permeability is a longstanding observation in both Crohns disease patients and in their healthy, asymptomatic first‐degree relatives. However, the significance of this compromised gut barrier function and its place in the pathogenesis of the disease remains poorly understood. The association between abnormal small intestinal permeability and a specific mutation in the NOD2 gene, which functions to modulate both innate and adaptive immune responses to intestinal bacteria, suggests a common, genetically determined pathway by which an abnormal gut barrier could result in chronic intestinal inflammation. Furthermore, rodent colitis models show that gut barrier defects precede the development of inflammatory changes. However, it remains possible that abnormal permeability is simply a consequence of mucosal inflammation. Further insight into whether abnormal barrier function is the cause or consequence of chronic intestinal inflammation will be crucial to understanding the role of intestinal permeability in the pathogenesis of Crohns disease.

Long-term response rates to infliximab therapy for Crohn’s disease in an outpatient cohort

BACKGROUNDnInfliximabs efficacy in the induction and maintenance of remission in luminal Crohns disease has been confirmed by randomized, controlled trials. Less clearly described are long-term outcomes in the clinical practice setting since the establishment of regularly scheduled, every eight-week maintenance infliximab infusions. Existing reports describing clinical practice outcomes are limited by short durations of follow-up or by the use of episodic dosing, or focus on safety data rather than clinical outcomes.nnnOBJECTIVEnTo examine induction and maintenance responses to infliximab in an outpatient inflammatory bowel disease clinic.nnnMETHODSnA retrospective chart review was performed. Clinical outcomes were infliximab induction and maintenance responses, defined as the ability to stop and remain off corticosteroids while not requiring additional therapy for active disease.nnnRESULTSnOne hundred thirty-three patients were identified with records sufficiently detailed to be analyzed. Of these, 117 patients (88%) demonstrated a clinical response to induction; 104 of 117 (89%) were on concomitant immunosuppressive therapy; 80 of 104 on azathioprine/6-mercaptopurine (77%); and 24 of 104 on methotrexate (23%). The mean duration of clinical response was 94 weeks (95% CI 78.8 to 109.2). The proportion of patients who maintained response at 30 weeks was 83.2%, at 54 weeks was 63.6% and at 108 weeks was 44.9%. Adverse events occurred for 15 of 117 patients (12.8%), consisting of nine infusion reactions, four serum sickness-like reactions, one rash and one infection.nnnCONCLUSIONnPatients treated with infliximab therapy for luminal Crohns disease in our outpatient clinic achieved excellent induction and maintenance of response rates, confirming the real-life efficacy of maintenance infliximab established in clinical trials.

Canadian Digestive Health Foundation Public Impact Series 5: Pancreatitis in Canada. Incidence, prevalence, and direct and indirect economic impact

The Canadian Digestive Health Foundation initiated a scientific program to assess the incidence, prevalence, mortality and economic impact of digestive disorders across Canada in 2009. The current article presents the updated findings from the study concerning pancreatitis.

Hyperamylasemia and pancreatitis following spiral enteroscopy

BACKGROUNDnAcute pancreatitis is a significant potential complication with double-balloon enteroscopy. Hyperamylasemia is frequently observed after both double-balloon enteroscopy and single-balloon enteroscopy but often without associated pancreatitis. Whether the same phenomenon occurs with spiral enteroscopy is currently unknown.nnnAIMSnTo determine the incidence of pancreatitis and hyperamylasemia following spiral enteroscopy.nnnMETHODSnA prospective cohort study of consecutive patients undergoing proximal spiral enteroscopy was conducted. Serum amylase levels were measured immediately before and following the procedure, combined with observation for clinical signs of pancreatitis.nnnRESULTSnA total of 32 patients underwent proximal spiral enteroscopy, with a mean total procedure time of 51 min (range 30 min to 100 min) and mean depth of insertion of 240 cm (range 50 cm to 350 cm). The diagnostic yield was 50%, with 31% of all procedures being therapeutic. While no patients exhibited signs that raised suspicion of pancreatitis, hyperamylasemia was common (20%). Hyperamylasemia was not significantly associated with procedure duration or depth of insertion but was linked to patients with Peutz-Jeghers syndrome and with the use of propofol sedation, suggesting that it may be more common in difficult cases.nnnCONCLUSIONSnPostprocedural hyperamylasemia occurred frequently with proximal spiral enteroscopy, while no associated pancreatitis was observed. This finding suggests that hyperamylasemia may not necessarily reflect pancreatic injury nor portend a risk for pancreatitis.

Small Bowel Enteroscopy

Over the past decade, the advent of capsule endoscopy and balloon-assisted enteroscopy has revolutionized the approach to small intestinal diseases. The small bowel is no longer out of reach, and has fallen within the diagnostic and therapeutic realm of the gastrointestinal endoscopist. Double-balloon enteroscopy was the first type of balloon-assisted endoscopy and is the method for which there are the most data. Single-balloon enteroscopy has since been introduced as an alternative balloon-assisted method, followed more recently by the development of spiral overtube-assisted enteroscopy. The purpose of the present article is to review these methods of small bowel enteroscopy and to discuss the latest developments. While the investigation of small bowel diseases cannot be addressed without considering the central role of capsule endoscopy, a detailed assessment is beyond the scope of the present article, and capsule endoscopy will only be discussed as it pertains to enteroscopy.

Small-bowel endoscopy

Capsule endoscopy and double-balloon enteroscopy (DBE) have similar diagnostic yields for the evaluation of small-bowel diseases [2]. Some of the unique advantages of capsule endoscopy, such as its less invasive nature, superior tolerability and, in theory, complete visualization of the small-bowel mucosa, dictates that capsule endoscopy is the preferred first-line investigation in patients with suspected small-bowel pathology [3]. However, capsule endoscopy is limited by the inability to perform real-time assessments and biopsy sampling or therapeutic interventions on detected lesions, for which small-bowel enteroscopy is needed. Thus, DBE or single-balloon enteroscopy (SBE) often needs to be performed after capsule endoscopy, guided by the capsule results. In the majority of patients a combination of oral and anal DBE procedures are used to achieve complete small-bowel visualization. However, it is important to choose the initial insertion route most likely to reach the suspected pathology for reasons of efficiency, patient comfort, and prevention of possible complications. Previous studies have used the relative location of abnormal findings seen on capsule endoscopy to select an initial oral or anal DBE route [4]. In a similar fashion, the study by Li et al. [1] prospectively evaluated a system of using the relative position of lesions identified by capsule endoscopy within the small bowel to calculate a location index that would then determine the primary route of DBE insertion. The index of lesion location was defined as the time from the pylorus to the lesion as a percentage of the time from the pylorus to the ileocecal valve. The cut-off for the lesion location index used to select the insertion route for DBE was determined from previously collected data from 16 patients. Based on these retrospective data, a location index of ≤ 0.6 was adopted to select an initial oral approach and > 0.6 for an initial anal approach; this was then prospectively applied to patients with suspected small-bowel diseases who underwent capsule endoscopy (complete to the cecum) followed by DBE. A total of 82 patients were enrolled in the study. Six (7.3%) were excluded because lesions seen on capsule endoscopy (all of which were suspected submucosal tumors) could not be confirmed on bi-directional DBE. Another 16 patients (19.5%) were excluded because the capsule did not reach the cecum by the end of the capsule recording time, so no index could be calculated. Thus, 60 patients remained for comparison of complete capsule endoscopy and DBE findings. In patients who underwent both oral and anal DBE procedures, confirmation of capsule endoscopy findings was defined according to the first DBE procedure performed. The indications for small-bowel investigation were obscure gastrointestinal bleeding (OGIB; n = 40 [67%]), suspected Crohn’s disease (n = 8 [13%]), suspicion of small-bowel tumor (n = 5 [8%]), and unexplained abdominal pain or diarrhea (n = 7 [12%]). A total of 60 DBE procedures were performed – 41 oral and 19 anal, all of which reached the lesions identified on capsule endoscopy. A large number of patients were found to have small-bowel tumors compared with the number with angiodysplasia, 20 (33%) and 10 (17%), respectively, a result not in keeping with findings from OGIB studies that have been performed in Europe and North America but not that surprising given that this study was conducted in East Asia. The diagnosis from DBE was confirmed by subsequent surgery in 42 patients (70%), with the estimated distance from the pylorus to the lesion of interest differing between DBE and surgery by an average of only 18 cm (range 0–50 cm). The mean capsule transit time from the pylorus to the lesion was 125 minutes (± 75) and 276 minutes (± 95), for the oral and

Magnetic imaging-assisted colonoscopy vs conventional colonoscopy: A randomized controlled trial

AIMnTo compare magnetic imaging-assisted colonoscopy (MIC) with conventional colonoscopy (CC).nnnMETHODSnMagnetic imaging technology provides a computer-generated image of the shape and position of the colonoscope onto a monitor to give visual guidance to the endoscopist. It is designed to improve colonoscopy performance and tolerability for patients by enabling visualization of loop formation and endoscope position. Recently, a new version of MIC technology was developed for which there are limited data.To evaluate this latest generation of MIC among experienced rather than inexperienced or trainee endoscopists, a prospective randomized trial was performed using only gastroenterologists with therapeutic endoscopy training. Consecutive patients undergoing elective outpatient colonoscopy were randomized to MIC or CC, with patients blinded to their group assignment. Endoscopic procedural metrics and quantities of conscious sedation medications were recorded during the procedures. The procedure was classified as usual or difficult by the endoscopist at the conclusion of each case based on the need for adjunctive maneuvers to facilitate endoscope advancement. After more than one hour post-procedure, patients completed a 10 cm visual analogue pain scale to reflect the degree of discomfort experienced during their colonoscopy. The primary outcome was patient comfort expressed by the visual analogue pain score. Secondary outcomes consisted of endoscopic procedural metrics as well as a sedation score derived from standardized dose increments of the conscious sedation medications.nnnRESULTSnTwo hundred fifty-three patients were randomized and underwent MIC or CC between September 2011 and October 2012. The groups were similar in terms of the indications for colonoscopy and patient characteristics. There were no differences in cecal intubation rates (100% vs 99%), insertion distance-to-cecum (82 cm vs 83 cm), time-to-cecum (6.5 min vs 7.2 min), or polyp detection rate (47% vs 52%) between the MIC and CC groups. The primary outcome of mean pain score (1.0 vs 0.9 out of 10, P = 0.41) did not differ between MIC and CC groups, nor did the mean sedation score (8.2 vs 8.5, P = 0.34). Within the subgroup of cases considered more challenging or difficult, time-to-cecum was significantly faster with MIC compared to CC, 10.1 min vs 13.4 min respectively (P = 0.01). Sensitivity analyses confirmed a similar pattern of overall findings when each endoscopist was considered separately, demonstrating that the mean results for the entire group were not unduly influenced by outlier results from any one endoscopist.nnnCONCLUSIONnAlthough the latest version of MIC resulted in faster times-to-cecum within a subgroup of more challenging cases, overall it was no better than CC in terms of patient comfort, sedation requirements and endoscopic procedural metrics, when performed in experienced hands.

Refractory Bleeding from a Malignant Duodenal Ulcer Treated with Placement of a Fully-Covered Gastroduodenal Stent

The placement of gastroduodenal self-expanding metal stents (SEMS) is an established treatment for malignant duodenal obstruction [1]. Fully-covered stents are designed to prevent tumor in-growth [2]. The following case demonstrates the novel and successful management of intractable bleeding from a malignant duodenal ulcer by the placement of a fully-covered SEMS. We believe the covered stent was instrumental in providing a tamponade effect on the malignant lesion leading to hemostasis.