Darius Sorbi

Management and long-term prognosis of Dieulafoy lesion

BACKGROUND The Dieulafoy lesion is an important cause of gastrointestinal (GI) hemorrhage. Optimal treatment and long-term outcome are unknown. This study aimed to characterize the presentation of the Dieulafoy lesion and to summarize the results and report the long-term outcome of endoscopic therapy. METHODS Data regarding diagnosis, treatment and outcomes were derived from our GI Bleed Team database, patient records and follow-up correspondence. RESULTS Ninety Dieulafoy lesions were identified in 89 patients after a mean of 1.9 endoscopies. Their mean age was 72 years. Thirty-four percent of lesions were extragastric. Median transfusion requirement was 5 units. Two patients exsanguinated and 3 required surgery; all others were initially successfully treated endoscopically (with or without epinephrine injection): heat probe (71 patients), band ligation (3), hemoclip (1), laser (2), bipolar probe (4), sclerotherapy (2) and epinephrine alone (2). Gastric perforation occurred in 1 patient following sclerotherapy. Thirty-day mortality was 13%, 4 related to hemorrhage and 5 related to comorbidity. During median follow-up of 17 months, 34 patients (42%) died. One patient had recurrent bleeding 6 years after operation. CONCLUSIONS Dieulafoy lesion is relatively common and often extragastric. Endoscopic therapy is safe and effective. Long-term recurrence was not evident following endoscopic ablation. Follow-up after ablative therapy appears unnecessary.

Postpolypectomy lower gastrointestinal bleeding: Potential role of aspirin

INTRODUCTION:Limited data exist on the role of aspirin in increasing the risk of clinically significant postpolypectomy bleeding (PPB), which is defined as lower gastrointestinal (GI) hemorrhage following colonoscopic polyp removal requiring transfusion, hospitalization, endoscopic intervention, angiography, or surgery.OBJECTIVES:To determine if aspirin use prior to colonoscopy increases the risk of clinically significant PPB.METHODS:A case-control study of patients with clinically significant PPB at Mayo Clinic Scottsdale and Rochester was performed. Information collected included age, gender, recent use of aspirin or NSAIDs (within three days of colonoscopy), polyp characteristics, and polypectomy technique. The control group consisted of patients matched for age (±3 yr), gender, and cardiovascular morbidity who had undergone polypectomy without any complications. The populations were compared to determine the odds ratio (OR) of PPB with aspirin use.RESULTS:During the study period, 20,636 patients underwent colonoscopy with polypectomy at the two institutions and 101 patients presented with clinically significant PPB. Twenty patients were excluded from analysis because of prior anticoagulant use. The remaining 81 patients were matched to 81 patients who had undergone colonoscopy without complications. The two groups were comparable in terms of polyp size (97%≤ 10 mm, bleeding group; 95%≤ 10 mm, control group). Aspirin use prior to polypectomy was 40% in the bleeding group and 33% in the control group (OR 1.41; 95% C.I. 0.68 to 3.04).CONCLUSION:Postpolypectomy bleeding is an uncommon but important complication of endoscopic polypectomy. There was no statistically relevant difference in prior aspirin use before polypectomy in the bleeding group and the matched controls.

An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities

An assessment of the role of liver biopsies in asymptomatic patients with chronic liver test abnormalities

Unsedated small-caliber esophagogastroduodenoscopy (EGD) versus conventional EGD : A comparative study

BACKGROUND & AIMS Significant portions of the cost and complications of esophagogastroduodenoscopy (EGD) are related to sedation. This study aimed to assess the feasibility, acceptability, and accuracy of unsedated small-caliber transoral EGD (sc-EGD). METHODS A 4-phase study was performed in healthy volunteers and patients. Phases 1 and 2 involved assessment of the technical feasibility of sedated sc-EGD and the tolerability of unsedated sc-EGD, respectively, in volunteers. Subsequently, the technical feasibility, tolerability, and diagnostic accuracy of sedated and unsedated sc-EGD were determined by having each patient undergo sc-EGD (Pentax EG-1840) with (phase 3) and without (phase 4) sedation, followed by sedated conventional EGD (c-EGD) (Olympus GIF-100 or GIF-Q140) by a staff endoscopist blinded to the findings of the sc-EGD. The t test for paired samples was used for statistical analysis. A P value of <0.05 was considered significant. RESULTS Sedated and unsedated sc-EGD were technically feasible and tolerable in all volunteers. In patients, compared with sedated c-EGD, sedated and unsedated sc-EGD were 96% and 97% accurate, respectively. The overall acceptability of unsedated sc-EGD was only slightly worse than that of sedated c-EGD (median, 2 vs. 1 on a scale of 1-10). After unsedated sc-EGD, 98% of patients expressed willingness to undergo the procedure again. No complications were observed during any phase of the study. CONCLUSIONS Unsedated sc-EGD is technically feasible, tolerable, and accurate. It can potentially decrease the costs and complications of sedated conventional EGD.

An assessment of the management of acute bleeding varices: a multicenter prospective member-based study

OBJECTIVE:Bleeding from esophagogastric varices is a major complication of portal hypertension. Despite recent practice guidelines for the management of bleeding esophageal or gastric varices, the widespread application of these measures by gastroenterologists has not been evaluated. The purpose of this study was to continue the concept of membership-based research within diverse practice settings by expanding the American College of Gastroenterology (ACG) GI Bleeding Registry to assess the management and outcome of acute variceal bleeding.METHODS:All ACG members (domestic and foreign) were invited to participate during the 1997 Annual Fall meeting and by mail. Data were collected over 12 months. Information obtained included physician training, practice demographics, patient demographics, disease etiology and severity, clinical presentation, medications, transfusion needs, therapy, complications, and rebleeding within 2 wk.RESULTS:A total of 93 physicians/centers (79.6% domestic, 26.9% university and affiliated, 3.2% Veterans Affairs) participated. Complete demographic data were available for 725 of the 741 patients enrolled with index bleeding. The median age of these 725 patients was 52 yr and 73.3% were male. The most common single etiology for portal hypertension was cirrhosis (94.3%). The most common causes of cirrhosis were alcohol (56.7%), hepatitis C virus (30.3%), and hepatitis B virus (10.0%). Hemodynamic instability was noted in 60.7% of the patients (22.3% tachycardic, 9.7% orthostatic, 28.7% hypotensive). Index interventions included banding (40.8%; median five bands), sclerotherapy (36.3%), combination banding/sclerotherapy (6.2%), octreotide (52.6%; median 3 days), balloon tamponade (5.5%), transjugular intrahepatic portosystemic shunt (TIPS) (6.6%), liver transplantation (1.1%), surgical shunt (0.7%), and embolization (0.1%). Transfusion of packed red blood cells, fresh frozen plasma, and platelets was given in 83.4%, 44.7%, and 24.6% of the patients with index bleeding, respectively. Median transfusion was four units of packed red blood cells, three units of fresh frozen plasma, and 1.5 units of platelets. Rebleeding occurred in 92 of the 741 patients (12.6%) at a median of 7 days (mean 11 days) and was treated by banding (18.5%; median six bands), sclerotherapy (30.4%), octreotide (63%; median 2 days), balloon tamponade (17.4%), TIPS (15.2%), and surgical shunt (3.3%). Complications from the index bleeding and rebleeding within 2 wk included ulceration (2.6%, 2.2%), aspiration (2.4%, 3.3%), medication side effects (0.8%, 0%), dysphagia (2.3%, 0%), odynophagia (2.2%,0%), encephalopathy (13%,17.4%), and hepatorenal syndrome (2.4%, 2.2%), respectively. After the index bleeding, 46.2% of patients were treated with β-blockers and 8.2% with nitrates. The majority of patients with index bleeding had Childs B cirrhosis (61.5%). Patients presenting with recurrent bleeding had mostly Childs B (46.7%) or Childs C cirrhosis (44.6%). The overall short-term mortality after index bleeding was 12.9%.CONCLUSIONS:Acute variceal hemorrhage occurs more often in patients with Childs B and C cirrhosis. Endoscopic banding is the most common single endoscopic intervention. Adjunctive pharmacotherapy is prevalent acutely and after stabilization. Both morbidity and mortality may be lower than reported in previous studies.

Comparative performance in the porcine esophagus of different solutions used for submucosal injection

BACKGROUND Before endoscopic mucosal resection and polypectomy of sessile lesions, injection of fluid into the submucosa cushions and isolates the tissue and thereby reduces thermal injury and the risk for perforation and hemorrhage. This study investigated the performance of 5 different solutions when used to form submucosal fluid cushions in the porcine esophagus. METHODS Five groups of 5 pigs were studied. In each pig, 6 separate submucosal injections of 5 mL of a single test solution were performed within the distal third of the esophagus. The time required for the submucosal bleb to flatten completely was recorded after each injection. The solutions used were as follows: normal saline solution, normal saline plus epinephrine solution, 50% dextrose, 10% glycerine/5% fructose in normal saline solution, and 1% rooster comb hyaluronic acid. RESULTS The normal saline solution and normal saline plus epinephrine solutions had the shortest disappearance times (respectively, median 2.4 and 3.0 minutes), which were significantly shorter compared with the other test solutions. The mean disappearance times for 50% dextrose and 10% glycerine were, respectively, 4.7 and 4.2 minutes. The mean disappearance time for hyaluronic acid was 22.1 minutes. CONCLUSIONS A solution of hyaluronic acid appears to be ideal for producing a lasting submucosal cushion for prolonged procedures. Dextrose 50% is superior to normal saline solution and may serve as an alternative to hyaluronic acid in terms of availability and cost.

Endoscopic surveillance and ablative therapy for periampullary adenomas

Abstract OBJECTIVES: Periampullary adenomas are an increasingly recognized condition, both in those with familial adenomatous polyposis syndromes (FAP) as well as sporadic cases. Endoscopic management has been advocated for these lesions without differentiating between these two patient groups regarding aim of therapy. The aims of this study were to determine the safety and effectiveness of endoscopic surveillance and ablative therapy of periampullary adenomas in patients with both sporadic and FAP-associated lesions. METHODS: Retrospective analysis of 59 patients with FAP and 32 with sporadic lesions who were all enrolled in a program of endoscopic surveillance and ablative therapy. Median follow-up was 24 months (range, 1–134 months). RESULTS: Ampullary ablative therapy has resulted in return to normal histology in 44 and 34% of sporadic and FAP-associated lesions, respectively. Complications of endoscopic therapy were mild in 12 patients and severe in 3 patients: the latter category involved one occurrence of asymptomatic duodenal stenosis and one occurrence of postcoagulation syndrome—both after Nd-YAG laser therapy—and necrotizing pancreatitis after ampullary biopsy in one patient. Thirteen patients have been referred for surgical intervention. There has been no mortality and no cases of advanced malignancy missed by endoscopy. CONCLUSIONS: Endoscopic surveillance and ablative therapy of periampullary lesions is safe and can be effective, although eradication of ampullary tissue requires multiple ablative sessions.

Endoscopic identification and quantification of aberrant crypt foci in the human colon

BACKGROUND Aberrant crypt foci may be precancerous lesions in the human colon. The occurrence of aberrant crypt foci was compared in patients with an endoscopically normal colon, known adenomatous polyps, and known colorectal cancer. METHODS In 90 patients (30 colonoscopically normal, 30 with adenomatous polyps, 30 with colorectal cancers) magnification chromoscopy was performed to identify aberrant crypt foci in the distal 10 cm of the rectum. Representative biopsy specimens were obtained for histopathologic assessment. RESULTS Aberrant crypt foci were readily identified. Median and (mean) numbers of aberrant crypt foci were as follows: endoscopically normal colon, 3.5 (5.0); adenomatous polyp(s), 4.0 (6.9); and colorectal cancer, 7.5 (9.9). The number of aberrant crypt foci detected was significantly associated (p = 0.02) with an increased odds that a patient would be in the group with known colorectal cancer (odds ratio = 1.11; 95% CI [1.02, 1.21]), but not in any other group. CONCLUSIONS Despite a stepwise increase in the number of aberrant crypt foci across the 3 groups, aberrant crypt foci was significantly associated only with comorbid colorectal cancer. Aberrant crypt foci was not associated with adenomatous polyp(s) or normal colon. Additional studies are needed to further elucidate the role of aberrant crypt foci in the development of colorectal neoplasia in humans.

Strategies to address increased demand for colonoscopy: guidelines in an open endoscopy practice

BACKGROUND AND AIMS Since Medicare approval for reimbursement of screening colonoscopies, the number of colonoscopy requests has increased. Physician resources have often been inadequate to meet the demand. We sought to reduce the demand for colonoscopy in an open endoscopy system by using a guideline-based triage system to eliminate inappropriate procedures and to align the timing of surveillance colonoscopies with recommendations made by national organizations. METHODS This was a cohort study with primary care outpatients. From October 2002 to February 2003, 498 consecutive patients on a waiting list of 2400 awaiting colonoscopy for all indications were triaged and are the focus of the study. Selection of patients for appropriate colonoscopy was based on consensus guidelines developed for institutional use by using established published guidelines for appropriate colonoscopy indications. RESULTS Of the 498 consecutive patients triaged, 139 (28%) were deemed inappropriate. The most common reason was inappropriate referral for surveillance of colorectal polyps. The percentage of inappropriate referrals by the 3 largest referring specialties (internal medicine, family medicine, and gastroenterology) combined was also 28% with no statistically significant differences between specialties. CONCLUSIONS Most referrals for colonoscopy in an open-access endoscopy system were appropriate, although about 1 in 4 were not. Use of triage and further education of physicians regarding colonoscopy may optimize colonoscopy utilization.

Clinical application of a new disposable lithotripter: a prospective multicenter study

BACKGROUND Mechanical lithotripsy has become a well-accepted method of bile duct stone fragmentation and removal. The Olympus lithotripter (Olympus American, Melville, NY) is the standard reusable lithotripter at the institutions that participated in this study. A disposable device with a preassembled pistol grip may perform equally well and facilitate operation. METHODS Twenty patients with bile duct stones were evaluated as part of a multicenter prospective study. Data were obtained regarding stone size and number, bile duct diameter, and configuration, ease of cannulation, basket function, stone capture and crushing success, and complications. RESULTS The maximum stone size averaged 16.5 +/- 1.2 mm (range 10 to 30 mm). Sixteen patients had multiple stones (median 5, range 2 to 12). The mean bile duct diameter was 20.5 +/- 1.5 mm (range 12 to 38 mm). Cannulation was successful in all within 5 attempts. Basket deployment failed in 1 patient because of stone size and the basket was misshapen in 14. Bile duct clearance was complete in 16 subjects (80%), incomplete in 2 patients, and failed in 2 patients. Abnormal duct configuration (sigmoid, stricture) was noted in 2 of 4 patients with failed capture and 7 of 16 patients with successful clearance. No statistically significant difference was observed between the bile duct diameter, maximum stone size, number of stones, and successful clearance. CONCLUSION The disposable lithotripter is easy to use and, compared with the published results for the reusable lithotripter, performs almost as well.