Ervin Toth

Small-bowel neoplasms in patients undergoing video capsule endoscopy : a multicenter European study

BACKGROUND AND STUDY AIMnSmall-bowel tumors account for 1% - 3% of all gastrointestinal neoplasms. Recent studies with video capsule endoscopy (VCE) suggest that the frequency of these tumors may be substantially higher than previously reported. The aim of the study was to evaluate the frequency, clinical presentation, diagnostic/therapeutic work-up, and endoscopic appearance of small-bowel tumors in a large population of patients undergoing VCE.nnnPATIENTS AND METHODSnIdentification by a questionnaire of patients with VCE findings suggesting small-bowel tumors and histological confirmation of the neoplasm seen in 29 centers of 10 European Countries.nnnRESULTSnOf 5129 patients undergoing VCE, 124 (2.4%) had small-bowel tumors (112 primary, 12 metastatic). Among these patients, indications for VCE were: obscure gastrointestinal bleeding (108 patients), abdominal pain (9), search for primary neoplasm (6), diarrhea with malabsorption (1). The main primary small-bowel tumor type was gastrointestinal stromal tumor (GIST) (32%) followed by adenocarcinoma (20%) and carcinoid (15%); 66% of secondary small-bowel tumors were melanomas. Of the tumors, 80.6% were identified solely on the basis of VCE findings. 55 patients underwent VCE as the third procedure after negative bidirectional endoscopy. The lesions were single in 89.5% of cases, and multiple in 10.5%. Retention of the capsule occurred in 9.8% of patients with small-bowel tumors. After VCE, 54/124 patients underwent 57 other examinations before treatment; in these patients enteroscopy, when performed, showed a high diagnostic yield. Treatment was surgery in 95% of cases.nnnCONCLUSIONSnOur data suggest that VCE detects small-bowel tumors in a small proportion of patients undergoing this examination, but the early use of this tool can shorten the diagnostic work-up and influence the subsequent management of these patients.

Colon capsule endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

PillCam colon capsule endoscopy (CCE) is an innovative noninvasive, and painless ingestible capsule technique that allows exploration of the colon without the need for sedation and gas insufflation. Although it is already available in European and other countries, the clinical indications for CCE as well as the reporting and work-up of detected findings have not yet been standardized. The aim of this evidence-based and consensus-based guideline, commissioned by the European Society of Gastrointestinal Endoscopy (ESGE) is to furnish healthcare providers with a comprehensive framework for potential implementation of this technique in a clinical setting.

Use of patency capsule in patients with established Crohn’s disease

BACKGROUND AND STUDY AIMSnVideo capsule endoscopy (VCE) is invaluable in the diagnosis of small-bowel pathology. Capsule retention is a major concern in patients with Crohns disease. The patency capsule was designed to evaluate small-bowel patency before VCE. However, the actual benefit of the patency capsule test in Crohns disease remains unclear. The aim of this study was to evaluate the clinical impact of patency capsule use on the risk of video capsule retention in patients with established Crohns disease.nnnPATIENTS AND METHODSnThis was a retrospective, multicenter study of patients with established Crohns disease who underwent VCE for clinical need. The utilization strategy for the patency capsule was classified as selective (only in patients with obstructive symptoms, history of intestinal obstruction or surgery, or per treating physicians request) or nonselective (all patients with Crohns disease). The main outcome was video capsule retention in the entire cohort and within each utilization strategy.nnnRESULTSnA total of 406 patients who were referred for VCE were included in the study. VCE was performed in 132u200a/406 patients (32.5u200a%) without a prior patency capsule test. The patency capsule test was performed in 274u200a/406 patients (67.5u200a%) and was negative in 193 patients. Overall, VCE was performed in 343 patients and was retained in the small bowel in 8 (2.3u200a%). In this cohort, the risk of video capsule retention in the small bowel was 1.5u200a% without use of a prior patency capsule and 2.1u200a% after a negative patency test (Pu200a=u200a0.9). A total of 18 patients underwent VCE after a positive patency capsule test, with a retention rate of 11.1u200a% (Pu200a=u200a0.01). Patency capsule administration strategy (selective vs. nonselective) was not associated with the risk of video capsule retention.nnnCONCLUSIONSnCapsule retention is a rare event in patients with established Crohns disease undergoing VCE. The risk of video capsule retention was not reduced by the nonselective use of the patency capsule. Furthermore, VCE after a positive patency capsule test in patients with Crohns disease was associated with a high risk of video capsule retention.

Underwater endoscopic mucosal resection of large colorectal lesions

In this prospective study, 11 consecutive patients with neoplastic colorectal lesions (median size 20u200amm, range 15u200a-u200a25u200amm) underwent endoscopic polyp removal by underwater endoscopic mucosal resection (EMR). Six lesions were removed en bloc and five lesions were removed by piecemeal resection. Pathological examination revealed seven R0 resections, and in four cases the pathology could not be determined. Two cases of procedure-related bleeding occurred but these were easily managed using hemostatic forceps and clip application. No perforations or delayed bleedings were observed. Underwater EMR is a relatively simple, safe, and useful method for the removal of large colorectal lesions.

Treatment of a benign colorectal anastomotic stricture with a biodegradable stent.

the treatment of malign obstructions in the lower gastrointestinal tract [1]. However, metal stents are not suitable for benign conditions. Recently, treatment with biodegradable stentshasbeen implemented for non-malignantdiseases in theupper gastrointestinal tract [2,3], but there is no case in the literature reporting on the use of biodegradable stents for benign conditions in the lower gastrointestinal tract. Here we describe a case with a benign stricture in a colorectal anastomosis, treatedwith a biodegradable stent. A 68-year-old man underwent sigmoid stoma reversal after Hartmann’s procedure (for perforated diverticulitis). The patient developed a symptomatic stricture in the colorectal anastomosis (● Fig. 1), and biopsies were benign. Despite three endoscopic dilations, the patient suffered from repeated symptomatic stricture recurrence. Due to significant co-morbidity, the patient was not suitable for surgical treatment. As an alternative approach, a self-expanding biodegradable esophageal stent (SX-Ella stent; ELLA-CS, Hradec Kralove, Czech Republic) was chosen. The lumen of the stricture was less than 5mm and was dilated up to 12mm. The biodegradable stent was deployed in the middle of the stricture using a guide wire (● Fig. 2). The position of the stent was Treatment of a benign colorectal anastomotic stricture with a biodegradable stent

Clinical validity of flexible spectral imaging color enhancement (FICE) in small-bowel capsule endoscopy: a systematic review and meta-analysis

Patients and methodsu2003A comprehensive literature search was conducted. We measured pooled rate of lesion visualization improvement and improvement in lesion detection comparing FICE settings 1u200a-u200a3 and WLE, for angioectasias and ulcers/erosions. Pooled results were derived using the random-effects model because of high heterogeneity as measured by I2. Repeated-measures analysis of variance (ANOVA) was used to measure differences in lesion detection between WLE and the three FICE modes. Resultsu200313 studies were analyzed. All studies used the PillCam SB 1 and/or SB 2 devices. Most used experienced readers. Improvement in delineation had been investigated in 4 studies; in the 3 studies entered into the meta-analysis, using FICE setting 1, 89u200a% of angioectasias and 45u200a% of ulcer/erosions were considered to show improved delineation. For FICE settings 2 and 3, small proportions of images showed improved delineation. Heterogeneity of studies was high with I2u200a>u200a90u200a% in 4/6 analyses. Lesion detection had been investigated in 10 studies; meta-analysis included 5 studies. Lesion detection did not differ significantly between any of the FICE modes and WLE. Conclusionsu2003Overall, the use of the three FICE modes did not significantly improve delineation or detection rate in SBCE. In pigmented lesions, FICE setting 1 performed better in lesion delineation and detection.

Nitinol versus steel partially covered self-expandable metal stent for malignant distal biliary obstruction: A randomized trial

BACKGROUND AND STUDY AIMSnCovered nitinol alloy self-expandable metal stents (SEMSs) have been developed to overcome the shortcomings of steel SEMS in patients with malignant biliary obstruction. In a randomized, multicenter trial, we compared stent patency, patient survival, and adverse events in patients with partly covered stents made from steel or nitinol.nnnPATIENTS AND METHODSnA total of 400 patients with unresectable distal malignant biliary obstruction were randomized at endoscopic retrograde cholangiopancreatography (ERCP) to insertion of a steel or nitinol partially covered SEMS, with 200 patients in each group.u200aThe primary outcome was confirmed stent failure during 300 days of follow-up.u200annnRESULTSnAt 300 days, the proportion of patients with patent stents was 77 % in the steel group, compared with 89 % in the nitinol group (P = 0.01). Confirmed stent failure occurred more often in the steel SEMS group compared with the nitinol SEMS group, in 30 versus 14 patients (P = 0.02). Stent migration occurred in 13 patients in the steel group and in 3 patients in the nitinol group (P = 0.01). Median patient survival (secondary outcome) was 137 days and 120 days in the steel SEMS and nitinol SEMS groups, respectively (P = 0.59).nnnCONCLUSIONSnThe nitinol SEMS showed longer patency time, and the nitinol group had fewer patients with stent failure, compared with the steel SEMS group. We could not detect any differences between the two groups regarding survival time, and regarding adverse event rate.Clinical trial registration : NCT 00980889.

Primary gastroduodenal amyloidosis.

position of insoluble fibrillar proteins in various organs [1]. In humans, more than 23 different and unrelated proteins are known to form amyloid fibrils [2]. Amyloidosis is divided into primary (i. e. idiopathic) and secondary amyloidosis (i. e. associated with chronic inflammatory conditions, and infectious and neoplastic disorders) [1]. Primary amyloidosis is extremely rare in the gastrointestinal tract. Fewer than 1% of patients with primary amyloidosis in the gastrointestinal tract have any symptoms [3]. We report a case of primary gastroduodenal amyloidosis in which endoscopic ultrasound (EUS) was instrumental in the work-up. A 76-year-old man presented with a history of fatigue, dyspepsia, and anemia. An upper-gastrointestinal endoscopy revealed prominent gastric folds and gastropathy (● Fig. 1a). Gastric biopsies showed only signs of unspecific inflammation. The patient developed diarrhea andweight loss. Abdominal computed tomography (CT) showed unspecific gastric wall thickening. The initial suspicion was a malignant disease such as scirrhous carcinoma, which led to an EUS referral. EUS revealed gastric wall thickening (● Fig. 1b) and a complete lack of normal sonographic layers in the stomach wall, suggestive of an infiltrative disease (● Fig. 1b), but no sign of malignancy. Another upper-gastrointestinal endoscopy was undertaken with new biopsies from the stomach and bulbus duodeni. Congo red staining revealed amorphous eosinophilic infiltrates (● Fig. 2a) and green birefringence under polarized light (● Fig. 2b), which is diagnostic for amyloidosis [1]. It may be suggested that tissue deposition of insoluble proteins causes the sonographic disappearance of normal gastric wall layers in amyloidosis. This patient had no systemic disease such as a chronic immune disease or neoplastic disorder, which are the most common causes of secondary amyloidosis. Thus this patient had a primary amyloidosis in the gastroduodenum. In conclusion, this case highlights the use of EUS in the work-up of patients with suspected amyloidosis in the stomach and duodenum. Endoscopy_UCTN_Code_CCL_1AB_2AD_3AD

Endoscopic diagnosis and treatment of a giant duodenal lipoma presenting with gastrointestinal bleeding

A 66-year-old man presented with fatigue and acute upper gastrointestinal bleeding (hemoglobin 92g/L). He had melena but no signs of hematemesis. Upper gastrointestinal endoscopy revealed a 35×15-mm large polypoid lesion with multiple ulcerations in the second part of the duodenum (● Fig.1). No biopsy samples were taken due to the risk of bleeding. The diagnosis was unclear and the patient underwent endoscopic ultrasound, which demonstrated a hyperechoic lesion measuring 11×19mm in diameter in the submucosa in the duodenal wall with intact muscularis propria (● Fig.2), suggestive of a lipoma. A subsequent capsule endoscopy excluded distal causes of bleeding in the small intestine. Next, the lesion was removed endoscopically using an endoloop and snare without any complication (● Fig.3). The resected lesion exhibited multiple ulcerated areas (● Fig.4). Histological examination demonstrated a duodenal lipoma with large blood vessels in contact with these ulcerated areas (● Fig.5). Duodenal lipomas are extremely rare and constitute only one in 600 benign tumors of the gastrointestinal tract [1]. Duodenal lipomas are usually asymptomatic but larger ones can, in rare cases, cause abdominal pain, intestinal obstruction, or hemorrhage [2,3]. Symptomatic duodenal lipomas should be removed. The current recommendation is endoscopic excision, unless this is technically difficult and warrants surgical excision. Nonetheless, this unusual case with a duodenal lipoma causing upper gastrointestinal bleeding underlines the clinical importance of endoscopic ultrasound in the workup of patients with unclear submucosal lesions in the gastrointestinal tract. Endoscopy_UCTN_Code_CCL_1AB_2AZ

Acute pancreatitis evoked by small-cell lung carcinoma metastases and detected by endoscopic ultrasound

Small-cell lung cancer (SCLC) is an aggressive disease that has a poor prognosis and tends to metastasize early [1]. The most frequent intra-abdominal sites of SCLC metastases include the adrenal glands and liver [2]. The pancreas is a rare site of SCLC metastasis. We report a case of acute pancreatitis triggered by SCLC metastasis in the pancreas. A 52-year old woman with SCLC presented with vomiting and epigastric pain radiating to her back. Blood tests revealed increased alkaline phosphatase (ALP, 4.3μkat/L), gamma-glutamyl transferase (GT, 4.7μkat/L), and amylase (5.2μkat/L), while bilirubin was normal. The patient had acute pancreatitis but no history of gallstone disease or excessive alcohol intake. A subsequent workup with transabdominal ultrasound showed no signs of disease in the liver, gallbladder, or pancreas, but a magnetic resonance cholangiopancreatography revealed dilatation of the extrahepatic bile duct (9.5mm) and three unclear lesions in the pancreas, which raised suspicions of malignancy and led to a referral for endoscopic ultrasound (EUS). EUS demonstrated three hypoechoic processes (two in the head and one in the body of the pancreas) with regular borders (● Fig.1). The two processes (22 and 32mm) in the pancreatic head were compressing the pancreatic duct causing proximal dilatation of the duct (4.5mm). Fine-needle aspiration (21-gauge needle) of one of the processes in the head of the pancreas followed by cytological examination revealed small-cell carcinoma cells (● Fig.2a) staining positively for thyroid transcription factor-1 (● Fig.2b), which is a highly specific marker for primary lung adenocarcinomas. The patient received a plastic biliary stent due to progressive cholestasis and continued abdominal pain. After recovery, the patient received palliative chemotherapy. In conclusion, we report an unusual case in which acute pancreatitis was induced by SCLC metastases. We point the focus on using EUS in the work-up of patients with acutepancreatitis of unknownaetiology. Fig.2 Cytological examination following fine-needle aspiration of one of the processes in the pancreatic head revealed: a small cell carcinoma cells (single and loose clusters of small cells with a high nucleocytoplasmic ratio); b positive immunocytological expression of thyroid transcription factor-1. Fig.1 Endoscopic ultrasound (EUS) image of the pancreas showing two hypoechoic processes with regular well-demarked borders in the head of the pancreas. UCTN – Unusual cases and technical notes E45