Eric M. Goldberg

Effect of gliadin on permeability of intestinal biopsy explants from celiac disease patients and patients with non-celiac gluten sensitivity.

Background: Intestinal exposure to gliadin leads to zonulin upregulation and consequent disassembly of intercellular tight junctions and increased intestinal permeability. We aimed to study response to gliadin exposure, in terms of barrier function and cytokine secretion, using intestinal biopsies obtained from four groups: celiac patients with active disease (ACD), celiac patients in remission (RCD), non-celiac patients with gluten sensitivity (GS) and non-celiac controls (NC). Methods: Ex-vivo human duodenal biopsies were mounted in microsnapwells and luminally incubated with either gliadin or media alone. Changes in transepithelial electrical resistance were monitored over 120 min. Media was subsequently collected and cytokines quantified. Results: Intestinal explants from all groups (ACD (n = 6), RCD (n = 6), GS (n = 6), and NC (n = 5)) demonstrated a greater increase in permeability when exposed to gliadin vs. media alone. The increase in permeability in the ACD group was greater than in the RCD and NC groups. There was a greater increase in permeability in the GS group compared to the RCD group. There was no difference in permeability between the ACD and GS groups, between the RCD and NC groups, or between the NC and GS groups. IL-10 was significantly greater in the media of the NC group compared to the RCD and GS groups. Conclusions: Increased intestinal permeability after gliadin exposure occurs in all individuals. Following gliadin exposure, both patients with gluten sensitivity and those with active celiac disease demonstrate a greater increase in intestinal permeability than celiacs in disease remission. A higher concentration of IL-10 was measured in the media exposed to control explants compared to celiac disease in remission or gluten sensitivity.

Detection of Lesions During Capsule Endoscopy: Physician Performance Is Disappointing

OBJECTIVES:Limited data guide capsule endoscopists on how to view the many images collected in each capsule. The objective of this study was to compare the detection rates of clinically significant findings in different capsule endoscopy reading modes and speeds.METHODS:Seventeen capsule endoscopists with experience from 23 to >1,000 total capsule procedures read 24 clips, 18 of which were abnormal. Clips were read in two different reading modes utilizing two speeds, including SingleView at 15 at frames per second (f.p.s.), SingleView 25 f.p.s., QuadView 20 f.p.s., and QuadView 30 f.p.s. The main outcome measurements were pathology detection rates correlated with reading mode, lesion type, reader experience, and timing order.RESULTS:SingleView 15, QuadView 20, and QuadView 30 had no significant difference in overall detection rate (45, 47, and 43%, respectively). SingleView 25 had a 26% detection rate, which was significantly lower than SingleView 15 (P=0.04) and QuadView 20 (P=0.002). The detection rates of angioectasias, ulcers/erosions, masses/polyps, and blood were 69, 38, 46, and 17%, respectively. Reader experience and timing of interpretation did not significantly impact detection rate. Limitations: Pathology was present on a few frames. Limited modes and speeds were assessed. Lesion types were not confirmed with surgical or deep enteroscopic methods. A relatively small number of readers provided interpretations.CONCLUSIONS:Overall, the detection rates in this study are lower than previously reported and not influenced by increasing experience. Detection rates are significantly higher when reading in SingleView 15 and QuadView 20 compared with reading in SingleView 25. Increasing viewing speed from QuadView 20 to QuadView 30 appears to have no significant effect on detection. Quality control measures to compare and improve lesion detection rates need further study.

A Faculty Development Program to Train Tutors to Be Discussion Leaders Rather Than Facilitators

Purpose During 2003, 2004, and 2005, the role of 70 tutors was changed from that of facilitator to discussion leader, in a preclinical PBL learning course, Gastrointestinal Pathophysiology, by use of three key business school teaching strategies: questions, summaries, and schematics. The purpose of this study was to learn what difference this new approach made. Method During each of the three study years, 171 (2003), 167 (2004), and 170 (2005) students were given Likert-scale attitudinal questionnaires to rate whether their tutors encouraged student direction of the tutorials and whether the summaries and closure schematics benefited their learning. Students’ overall course evaluations and mean USMLE scores were quantitatively analyzed, pre- and postintervention. A variety of statistical tests were used to assess the statistical significance of means at the confidence level of .05. Results In the third year of the program, student ratings indicated that their tutors were significantly better at encouraging student direction of the tutorials than in the first year (P < .05). The students reported that the tutorial made a more important contribution to their learning (P < .05), and the course objectives were better stated (P = .038) and better met (P = .007). Overall satisfaction with the course also improved significantly (P = .006). Part I gastrointestinal system mean scores of the USMLE showed a statistically significant increase in 2005 compared with 2001 or 2002. Conclusions The tutor as a discussion leader who questions, summarizes, and uses schematics to illustrate concepts had a significant and positive impact on learning in tutorials, achieving course objectives, improving overall course satisfaction, and increasing a standardized national exam’s mean score.

Performance characteristics of retrograde single-balloon endoscopy: A single center experience.

AIM To evaluate the technical success, diagnostic yield (DY) and therapeutic potential of retrograde single balloon enteroscopy (rSBE). METHODS A retrospective review of 136 rSBE procedures performed at a tertiary academic referral center from January 2006 and September 2013 was completed. Patient characteristics including age, gender and inpatient status were collected. The indication for the procedure was categorized into one of three groups: Obscure gastrointestinal bleeding (GIB), evaluation for Crohns disease and abnormal imaging. Procedural characteristics including insertion depth (ID), procedure time, concordance with pre-procedural imaging and complications were also recorded. Lastly, DY, defined as the percentage of cases producing either a definitive diagnosis or findings that could explain clinical symptoms and therapeutic yield (TY), defined as the percentage of cases in which a definitive intervention was performed, were determined. Mucosal tattooing and biopsy alone were not included in the TY. RESULTS A total of 136 rSBE procedures were identified. Mean patient age was 57.5 (± 16.2) years, 67 (49.2%) were male, and 110 (80.9%) procedures were performed on an outpatient basis. Indications for rSBE included GIB in 55 (40.4%), evaluation of inflammatory bowel disease (IBD) in 29 (21.3%), and imaging suggestive of pathology other than GIB or IBD in 43 (31.6%). Nine (6.6%) rSBEs were performed for other indications. Mean ID was 68.3 (± 39.3) cm proximal to the ileocecal valve and mean time to completion was 41.7 (± 15.5) min. Overall, 73 (53.7%) cases were diagnostic and 25 (18.4%) cases were therapeutic in which interventions (argon plasma coagulation, stricture dilatation, polypectomy, etc.) were performed. Pre-procedural imaging was performed in 88 (64.7%) patients. Endoscopic concordance of positive imaging findings was seen in 31 (35.2%) cases. Follow up data was available in 93 (68.4%) patients; 2 (2.2%) reported post-procedural abdominal pain within 30 d following rSBE. There were no other reported complications. CONCLUSION rSBE exhibits an acceptable diagnostic and TY, rendering it a safe and effective procedure for the evaluation and treatment of small bowel diseases.

Hamartomatous small intestinal polyp from tuberous sclerosis.

An abdominal computed tomography scan and esophagogastroduodenoscopy were unremarkable. Colonoscopy revealed 2 diminutive rectal polyps. Pathology revealed smooth muscle proliferation consistent with hamartomatous polyps. Capsule endoscopy revealed a large pedunculated multilobular polyp in the midjejunum (Fig. 1). A single-balloon enteroscopy identified a 3-cm pedunculated polyp (Figs. 2 and 3) in the jejunum, which was removed with a hot snare. Pathology revealed smooth muscle and vascular proliferation. Stains for angiomyolipoma (HMB-45) were negative and the polyp was determined to be a hamartoma (Fig. 4). The patient has remained asymptomatic postpolypectomy.

Contrast does not affect cholangioscope image quality.

BACKGROUND/AIMS Peroral cholangioscopy is a rapidly evolving technique that allows direct examination of the bile duct. We sought to determine if there was a difference in image quality with the cholangioscope immersed in normal saline compared with radiologic contrast or a mixture of contrast and normal saline. METHODS Images were captured using the SpyGlass® cholangioscope system (Boston Scientific Corp.) immersed in solutions ranging from 0 to 100% contrast. The images were then reviewed in a blinded fashion by a panel of 9 endoscopists with experience using the SpyGlass® system. The reviewers scored the quality of each image based on a scale of 0 (extremely poor) to 10 (excellent). RESULTS With the cholangioscope immersed in saline and 100% contrast, the mean image quality scores were 7.6 (95% confi dence interval [CI], 6.7-8.5) and 6.9 (95% CI, 5.8-8.0), respectively. The highest mean image quality score was 7.8 (95% CI, 6.7-8.9), obtained in 70% contrast. No signifi cant difference was noted in mean image quality scores using a one way analysis of variance technique (p=0.414). CONCLUSIONS Although there are limitations to ex vivo studies, we encourage endoscopists to use intraductal contrast prior to peroral cholangioscopy, if needed for lesion localization.

Large solitary rectal ulcer as a complication of prostate brachytherapy

the intestine. Indeed, in 1 patient, a mesocaval shunt was noted by the patient to pass into her ileostomy bag 18 years after colectomy and ileostomy. The present case serves as a reminder that it is important to take a complete history and that if one can imagine a complication as occurring, it is likely that at some point it will. The word duodenum derives from the Latin duodeni, meaning 12 and referring to the 12-finger-width length of this segment of intestine. The 10 fingers of a talented surgeon, followed by the 10 fingers of a talented endoscopist were required to render the patient asymptomatic; inflation is seen in all aspects of life today. Lawrence J. Brandt, MD Associate Editor for Focal Points At the Focal Point

Effect of live oral attenuated Typhoid vaccine, Ty21a, on systemic and terminal ileum mucosal CD4+ T memory responses in humans

Mucosal CD4+ T memory responses after typhoid immunization

The Endoscopic Management of Biliary and Pancreatic Injury

Pancreaticobiliary injuries are frequently encountered by interventional endoscopists and are a common cause of morbidity and even mortality. They are seen postoperatively after cholecystectomy, liver transplantation, pancreatectomy, and splenectomy. They may also result from blunt and penetrating trauma, and may even be related to gastrointestinal interventions like ERCP or liver biopsy. Early recognition and a multidisciplinary approach to treatment are crucial to limit systemic effects of the injury and prevent associated morbidity. Principles of therapy are often similar whether the injury is iatrogenic or traumatic. This chapter focuses on the endoscopic management of these biliary and pancreatic injuries rather than stone disease or neoplastic processes.

Systemic air embolism complicating upper gastrointestinal endoscopy: a case report with post-mortem CT scan findings and review of literature

ABSTRACT Endoscopy of the gastrointestinal and biliary tract is a common procedure and is routinely performed for therapeutic and diagnostic purposes. Perforation, bleeding and infection are some of the more common reported side effects. Air embolism on the other hand, is a rare complication of gastrointestinal endoscopy. We report a 77-year-old African-American female with a history of pancreatic cancer, which was resected with a Whipple procedure. As part of diagnostic and therapeutic procedure, an endoscopic retrograde cholangiopancreatography was planned several months after the surgery. The patients heart rate suddenly slowed to 40 bpm during the procedure and she became cyanotic and difficult to oxygenate after the endoscope was introduced and CO2 gas was insufflated. A forensic autopsy was performed with post-mortem computed tomography (PMCT) and revealed extensive systemic air embolism. The detailed PMCT and autopsy findings are presented and current literature is reviewed.