Duowu Zou

Assessment of morbidity and mortality associated with EUS-guided FNA: a systematic review

BACKGROUND EUS-guided FNA (EUS-FNA) permits both morphologic and cytologic analysis of lesions within or adjacent to the GI tract. Although previous studies have evaluated the accuracy of EUS-FNA, little is known about the complications of EUS-FNA. Moreover, the frequency and severity of complications may vary from center to center and may be related to differences in individual experience. OBJECTIVE To systematically review the morbidity and mortality associated with EUS-FNA. DESIGN MEDLINE and EMBASE were searched to identify relevant English-language articles. MAIN OUTCOME MEASUREMENTS EUS-FNA-specific morbidity and mortality rates. RESULTS We identified 51 articles with a total of 10,941 patients who met our inclusion and exclusion criteria; the overall rate of EUS-FNA-specific morbidity was 0.98% (107/10,941). In the small proportion of patients with complications of any kind, the rates of pancreatitis (36/8246; 0.44%) and postprocedure pain (37/10,941; 0.34%) were 33.64% (36/107) and 34.58% (37/107), respectively. The mortality rate attributable to EUS-FNA-specific morbidity was 0.02% (2/10,941). Subgroup analysis showed that the morbidity rate was 2.44% in prospective studies compared with 0.35% in retrospective studies for pancreatic mass lesions (P=.000), whereas it was 2.33% versus 5.07% for pancreatic cysts (P=.036). LIMITATIONS Few articles reported well-designed, prospective studies and few focused on overall complications after EUS-FNA. CONCLUSIONS EUS-FNA-related morbidity and mortality rates are relatively low, and most associated events are mild to moderate in severity.

Epidemiology of Peptic Ulcer Disease: Endoscopic Results of the Systematic Investigation of Gastrointestinal Disease in China

OBJECTIVES:Complications of peptic ulcer disease (PUD) are common in China. Population-based estimates of the prevalence of PUD are needed to quantify and characterize the population at risk of these complications.METHODS:As part of a large epidemiological study, 3,600 randomly selected residents of Shanghai (aged 18–80 years) were asked to undergo endoscopy and to provide blood samples for Helicobacter pylori serology. All participants also completed a general information questionnaire and Chinese versions of the reflux disease questionnaire (RDQ) and Rome II questionnaire. Associations between PUD and other factors were analyzed using a multiple logistic regression model.RESULTS:In total, 3,153 individuals (87.6%) completed the survey. All underwent blood tests, and 1,030 patients (32.7%) agreed to undergo endoscopy. Results from 1,022 patients were suitable for analysis. In all, 176 participants (17.2%) had PUD (62 with gastric ulcer; 136 with duodenal ulcer). The prevalence of H. pylori infection was 73.3% in the total population and 92.6% among those with PUD. H. pylori infection was associated with the presence of PUD (odds ratio (OR), 6.77; 95% confidence interval (CI), 2.85–16.10). The majority (72.2%) of individuals with PUD had none of the upper gastrointestinal symptoms assessed by the RDQ. PUD was not significantly associated with symptom-defined gastroesophageal reflux disease (GERD) (OR, 0.80; 95% CI, 0.32–2.03), reflux esophagitis (OR, 1.46; 95% CI, 0.76–2.79) or dyspepsia (OR, 1.69; 95% CI, 0.94–3.04).CONCLUSIONS:The prevalence of endoscopically confirmed PUD in this Shanghai population (17.2%) is substantially higher than in Western populations (4.1%). The majority of individuals with PUD were asymptomatic.

Prucalopride in the treatment of chronic constipation in patients from the Asia-Pacific region: a randomized, double-blind, placebo-controlled study.

Background  The study evaluated efficacy and safety of the 2 mg dose of prucalopride compared to placebo in patients with chronic constipation (CC) from the Asia‐Pacific region.

Epidemiology of symptom-defined gastroesophageal reflux disease and reflux esophagitis: the systematic investigation of gastrointestinal diseases in China (SILC).

Abstract Objective. Gastroesophageal reflux disease (GERD) is thought to be less prevalent in China than in Western countries. However, essential population-based endoscopy data are lacking for this country. Material and methods. As part of a wider study, 3600 individuals selected randomly from the Shanghai region were asked to undergo endoscopy. Participants completed a general information questionnaire and a Chinese version of the Reflux Disease Questionnaire. When sufficient numbers were available, associations were assessed using multiple logistic regression or the Wilcoxon rank-sum test. Results. Of 3153 (87.6%) individuals who completed the survey, 1030 (32.7%) agreed to endoscopy and 1029 endoscopies were suitable for analysis. Symptom-defined GERD was more prevalent in the endoscopy group (4.7%) than in the non-endoscopy group (1.7%). Prevalence estimates were 6.4% for reflux esophagitis, 1.8% for endoscopically suspected esophageal metaplasia and 0.7% for hiatus hernia. Reflux esophagitis was more prevalent in patients with symptom-defined GERD than in those without (12.5% [6/48] vs. 6.1% [60/981]), and was significantly associated with reflux symptoms of any frequency or severity (OR = 2.10, 95% CI 1.13–3.89) and with negative Helicobacter pylori infection (OR = 0.44, 95% CI 0.25–0.80). Only 28.8% of participants with reflux esophagitis had heartburn and/or regurgitation symptoms. Epigastric burning was significantly more severe and frequent in participants with reflux esophagitis than in those without (p = 0.05). Conclusions. Reflux esophagitis is less prevalent in China than reported in Western countries. Further work is needed to establish why reflux esophagitis appears less symptomatic in China than in Western countries.

A population-based survey of the epidemiology of symptom-defined gastroesophageal reflux disease: the Systematic Investigation of Gastrointestinal Diseases in China

BackgroundThe epidemiology of gastroesophageal reflux disease (GERD) has yet to be investigated using the symptomatic threshold criteria recommended by the Montreal Definition. This study aimed to determine the prevalence of symptom-defined GERD across five regions of China, and to investigate variables associated with GERD.MethodsA representative sample of 18 000 adults (aged 18-80 years) were selected equally from rural and urban areas in each region (n = 1800). According to the Montreal Definition, GERD is present when mild symptoms of heartburn and/or regurgitation occur on ≥2 days a week, or moderate-to-severe symptoms of heartburn and/or regurgitation occur on ≥1 day a week.ResultsIn total, 16 091 participants completed the survey (response rate: 89.4%) and 16 078 responses were suitable for analysis. Applying the Montreal criteria, the prevalence of symptom-defined GERD was 3.1% and varied significantly (p < 0.001) among the five regions (from 1.7% in Guangzhou to 5.1% in Wuhan) and between rural and urban populations (3.8% vs 2.4%). Factors significantly associated with GERD included living in a rural area and a family history of gastrointestinal diseases.ConclusionsThis population-based survey found that the prevalence of symptom-defined GERD in China was 3.1%, which is lower than that found in Western countries.

Alarm features and age for predicting upper gastrointestinal malignancy in Chinese patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper gastrointestinal malignancy: an endoscopic database review of 102 665 patients from 1996 to 2006

Objective Patients with dyspepsia with alarm features are suspected of having upper gastrointestinal (GI) malignancy; however, the true value of alarm features in predicting an underlying malignancy for patients with dyspepsia with high background prevalence of Helicobacter pylori infection and upper GI malignancy is uncertain. The aim of the present study was to determine the diagnostic accuracy of alarm features in predicting upper GI malignancy by reviewing an endoscopic database consisting of >100 000 Chinese patients. Methods A retrospective analysis of prospectively collected data was conducted in a single tertiary medical centre. Consecutive patients who underwent oesophagogastroduodenoscopy (OGD) for dyspepsia in 1996–2006 were enrolled. The data including gender, age, symptoms, and endoscopic and pathological findings were analysed. The main outcome measure was the diagnostic accuracy of individual alarm feature. Results 102 665 patients were included in the final analysis. Among all the 4362 patients with malignancy, 52% (2258/4362) had alarm features. Among 15 235 patients who had alarm features, 2258 (14.8%) were found to have upper GI malignancy. The pooled sensitivity and specificity of the alarm features were 13.4% and 96.6%, respectively. Only the feature of dysphagia in patients between 36 and 74 years old had a positive likelihood ratio (PLR) >10 for malignancy prediction, while all other alarm features in other age groups had a PLR <10. Conclusions For uninvestigated Chinese patients with dyspepsia with high background prevalence of H pylori infection and upper GI malignancy, alarm features and age, except for dysphagia in patients between 36 and 74 years old, had limited predictive value for a potential malignancy; therefore, prompt endoscopy may be recommended for these patients. However, less invasive, inexpensive screening methods with high diagnostic yield are still needed to reduce unnecessary endoscopy workload.

A Long-Term Follow-Up Study on Endoscopic Management of Children and Adolescents With Chronic Pancreatitis

OBJECTIVES:Data on therapeutic endoscopic retrograde cholangiopancreatography (ERCP) for chronic pancreatitis (CP) in children and adolescents, especially with long-term follow-up of consequences, are rarely reported. The aim of this study was to determine the long-term follow-up results of therapeutic ERCP for CP in children and adolescents.METHODS:All patients with CP who received therapeutic ERCP at Changhai Hospital from January 1997 to May 2009, with the age at first onset of pain being less than 18.0 years, were included. Attempts were made to contact all adolescents and follow-up data were recorded. Clinical data were assessed before and after every ERCP.RESULTS:Follow-up information was available in 42 (91.3%) of the 46 patients who received therapeutic ERCP. There were 20 boys and 22 girls, with the age at first onset being 11.8±4.5 years. A total of 110 therapeutic ERCP sessions were performed in the 42 patients. The post-ERCP complication rate was 17.3%, including mild and moderate pancreatitis (n=17) and mild cholangitis (n=2). The mean follow-up period of time was 61.4 (range: 24–132) months. Five patients underwent subsequent surgery because of refractory abdominal pain after endotherapy. Of the remaining 37 patients who received therapeutic ERCP alone, abdominal pain improved in 30 (81.1%) patients, and was completely relieved in 24 (64.9%) patients during the period of follow-up.CONCLUSIONS:Therapeutic ERCP may offer long-term improvement in pain in children and adolescents with CP.

EUS-guided celiac ganglion irradiation with iodine-125 seeds for pain control in pancreatic carcinoma: a prospective pilot study

BACKGROUND Celiac plexus neurolysis for the palliative reduction of pain in unresectable pancreatic carcinoma (PC) is safe but provides limited relief. In a previous study, we found that EUS-guided implantation of iodine-125 ((125)I) around the celiac ganglia is a safe procedure and can induce apoptosis of local neurons in a porcine model. OBJECTIVE To evaluate the safety and efficacy of direct celiac ganglion irradiation with (125)I seeds for the relief of moderate to severe pain secondary to unresectable PC. DESIGN Prospective study. SETTING Single, tertiary care referral center. PATIENTS This study enrolled consecutive patients who had moderate to severe pain resulting from biopsy-proven unresectable PC. INTERVENTION All patients underwent EUS-guided direct celiac ganglion irradiation with (125)I seeds. Follow-up was conducted at least once weekly until death. MAIN OUTCOME MEASUREMENTS Blood parameters, Visual Analog Scale (VAS) score, mean analgesic (MS Contin [morphine sulfate]) consumption, and complications were evaluated during follow-up. RESULTS Twenty-three patients with unresectable PC underwent the procedure. The mean number of seeds implanted in the celiac ganglion per patient was 4 (range 2-6). Immediately after the procedure, pain relief and analgesic consumption showed no significant changes compared with preoperative values. Six patients (26%) reported pain exacerbation. Two weeks later, the VAS score and mean analgesic consumption were significantly less than preoperative values. No procedure-related deaths or major complications occurred. LIMITATIONS Uncontrolled study. CONCLUSIONS EUS-guided direct celiac ganglion irradiation with (125)I seeds can reduce the VAS score and analgesic drug consumption in patients with unresectable PC.

Glyceryl trinitrate for prevention of pancreatitis after endoscopic retrograde cholangiopancreatography: a meta-analysis of randomized, double-blind, placebo-controlled trials

BACKGROUND AND STUDY AIMS Although trials evaluating the preventive effect of glyceryl trinitrate (GTN; nitroglycerin) on pancreatitis occurring after endoscopic retrograde cholangiopancreatography (ERCP) have been reported, there is no agreement as to whether prophylactic GTN treatment can in fact reduce the incidence of post-ERCP pancreatitis. We performed a meta-analysis to compare the effects of prophylactic GTN with placebo on post-ERCP pancreatitis. STUDY DESIGN Databases including PubMed, EMBASE, the Cochrane Library, and the Science Citation Index were searched to find relevant randomized controlled trials (RCTs). Two reviewers independently identified relevant trials evaluating the prophylactic effect of GTN on the occurrence of post-ERCP pancreatitis. The outcome measure was the incidence of post-ERCP pancreatitis. RESULTS Eight trials involving 1920 patients were analyzed. Meta-analysis showed that the incidence of post-ERCP pancreatitis was significantly reduced by GTN treatment (GTN group 5.9 %, placebo group 9.8 %, P = 0.002), with a relative risk of 0.61 (95 % confidence interval 0.44 - 0.84). Patients who received GTN were 39 % less likely to develop pancreatitis. Subgroup analyses suggested that GTN administered by the sublingual or transdermal route may be useful. CONCLUSIONS Prophylactic GTN is useful for prevention of post-ERCP pancreatitis, but the optimal dosage and the optimal route and timing of administration need further clarification before this treatment can come into routine clinical use.

Quantitative assessment and characterization of visceral hyperalgesia evoked by esophageal balloon distention and acid perfusion in patients with functional heartburn, nonerosive reflux disease, and erosive esophagitis.

Background and ObjectivesThe role of esophageal hypersensitivity in functional heartburn (FH) with negative pH test, negative symptom index, and the proton pump inhibitor (PPI) failure has not been established. The aim of this study was to investigate the characterization of visceral hyperalgesia evoked by esophageal balloon distention and acid perfusion in patients with FH, nonerosive reflux disease, and erosive esophagitis and further characterize the pathophysiologic mechanism of FH. MethodsA total of 21 FH patients (with esophageal acid exposure <3.1% and a symptom index<50% and nonresponse to a therapeutic trial with proton pump inhibitors, 25 Nonerosive reflux disease (NERD) patients (with esophageal acid exposure>4%), 23 erosive esophagitis (EE) patients (LA grade B to D), and 18 healthy controls were recruited in the study. Mechanosensitivity including the initial perception threshold (IPT) and pain threshold (PT) was evaluated by using a Barostat with a double-random staircase distension protocol. Chemosensitivity was graded along a visual analog scale after perfusion of saline and 0.1 N HCl. ResultsThe baseline IPTs and PTs were all lower in patients with FH, NERD, and EE than in the controls (all P<0.01). In addition, the baseline PT in FH patients was significantly lower than those in NERD (P=0.015) and EE patients (P<0.001). After acid perfusion, the mean symptom intensity scores were significantly greater in patients with FH, NERD, and EE than those in the controls (all P<0.001). The postacid perfusion IPTs in patients with FH, NERD, and EE were all significantly lower than the corresponding baseline values (all P<0.01). The PTs in FH (P=0.026) and EE patients (P<0.001) were significantly lower than the corresponding baseline values. Moreover, the postacid perfusion PT was significantly lower in FH patients than in NERD patients (P<0.001). ConclusionsFH patients are more sensitive to mechanical or chemical stimuli than NERD patients. Sensitization of esophageal acid-sensitive chemoreceptors may exert a significant influence on the pressure-sensitive mechanoreceptors, and there is the cooperative interaction in the process of esophageal visceral hyperalgesia.