Fergal Donnellan

Self-expandable metal stents for obstructing colonic and extracolonic cancer: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). This Guideline was also reviewed and endorsed by the Governing Board of the American Society for Gastrointestinal Endoscopy (ASGE). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. ESGE guidelines represent a consensus of best practice based on the available evidence at the time of preparation. They may not apply in all situations and should be interpreted in the light of specific clinical situations and resource availability. Further controlled clinical studies may be needed to clarify aspects of these statements, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations. ESGE guidelines are intended to be an educational device to provide information that may assist endoscopists in providing care to patients. They are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment

Prevention of Post-ERCP Pancreatitis

Pancreatitis is the most common complication of ERCP. It can be associated with substantial morbidity. Hence, the minimization of both the incidence and severity of post-ERCP pancreatitis is paramount. Considerable efforts have been made to identify factors that may be associated with an increased risk of this complication. In addition, both procedure- and pharmacological-related interventions have been proposed that may prevent this complication. This paper outlines these interventions and presents the evidence to support their use in the prevention of post-ERCP pancreatitis.

Response to endoscopic therapy for biliary anastomotic strictures in deceased versus living donor liver transplantation

BACKGROUND Endoscopic therapy has been successful in the management of biliary complications after both deceased donor liver transplantation (DDLT) and living donor liver transplantation (LDLT). LDLT is thought to be associated with higher rates of biliary complications, but there are few studies comparing the success of endoscopic management of anastomotic strictures between the two groups. This study aims to compare our experience in the endoscopic management of anastomotic strictures in DDLT versus LDLT. METHODS This is a retrospective database review of all liver transplant patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) after liver transplantation. The frequency of anastomotic stricture and the time to develop and to resolve anastomotic stricture were compared between DDLT and LDLT. The response of anastomotic stricture to endoscopic therapy was also analyzed. RESULTS A total of 362 patients underwent liver transplantation between 2003 and 2011, with 125 requiring ERCP to manage biliary complications. Thirty-three (9.9%) cases of DDLT and 8 (27.6%) of LDLT (P=0.01) were found to have anastomotic stricture. When comparing DDLT and LDLT, there was no difference in the mean time to the development of anastomotic strictures (98+/-17 vs 172+/-65 days, P=0.11), likelihood of response to ERCP [22 (66.7%) vs 6 (75.0%), P=0.69], mean time to the resolution of anastomotic strictures (268+/-77 vs 125+/-37 days, P=0.34), and the number of ERCPs required to achieve resolution (3.9+/-0.4 vs 4.7+/-0.9, P=0.38). CONCLUSIONS Endoscopic therapy is effective in the majority of biliary complications relating to liver transplantation. Anastomotic strictures occur more frequently in LDLT compared with DDLT, with equivalent endoscopic treatment response and outcomes for both groups.

JNK mitogen-activated protein kinase limits calcium-dependent chloride secretion across colonic epithelial cells

Neuroimmune agonists induce epithelial Cl(-) secretion through elevations in intracellular Ca2+ or cAMP. Previously, we demonstrated that epidermal growth factor receptor (EGFR) transactivation and subsequent ERK MAPK activation limits secretory responses to Ca2+-dependent, but not cAMP-dependent, agonists. Although JNK MAPKs are also expressed in epithelial cells, their role in regulating transport function is unknown. Here, we investigated the potential role for JNK in regulating Cl(-) secretion in T(84) colonic epithelial cells. Western blot analysis revealed that a prototypical Ca2+-dependent secretagogue, carbachol (CCh; 100 microM), induced phosphorylation of both the 46-kDa and 54-kDa isoforms of JNK. This effect was mimicked by thapsigargin (TG), which specifically elevates intracellular Ca2+, but not by forskolin (FSK; 10 microM), which elevates cAMP. CCh-induced JNK phosphorylation was attenuated by the EGFR inhibitor, tyrphostin-AG1478 (1 microM). Pretreatment of voltage-clamped T(84) cells with SP600125 (2 microM), a specific JNK inhibitor, potentiated secretory responses to both CCh and TG but not to FSK. The effects of SP600125 on CCh-induced secretion were not additive with those of the ERK inhibitor, PD98059. Finally, in apically permeabilized T(84) cell monolayers, SP600125 potentiated CCh-induced K+ conductances but not Na+/K+ATPase activity. These data demonstrate a novel role for JNK MAPK in regulating Ca2+ but not cAMP-dependent epithelial Cl(-) secretion. JNK activation is mediated by EGFR transactivation and exerts its antisecretory effects through inhibition of basolateral K+ channels. These data further our understanding of mechanisms regulating epithelial secretion and underscore the potential for exploitation of MAPK-dependent signaling in treatment of intestinal transport disorders.

IgG4-related disease and lymphocyte-variant hypereosinophilic syndrome: A comparative case series

To compare the clinical and laboratory features of IgG4‐related disease (IgG4‐RD) and lymphocyte‐variant hypereosinophilic syndrome (L‐HES), two rare diseases that often present with lymphadenopathy, gastrointestinal symptoms, eosinophilia, and elevated immunoglobulins/IgE.

A Novel Two-Step Approach for Retrieval of an Impacted Biliary Extraction Basket

Biliary extraction baskets are a commonly used instrument for the removal of choledocholithiasis in endoscopic retrograde cholangiopancreatography (ERCP). Impaction of the extraction basket is a recognized complication of ERCP, and is usually the result of discrepancy between the size of bile duct stone and the diameter of the distal bile duct. Whilst mechanical lithotriptors can be used to crush the stone or break the wires of the basket to allow its release, failure of the lithotriptor device can occur. We describe the case of a 59-year-old gentleman who had an ERCP performed for choledocholithiasis. Basket impaction was encountered, and the mechanical lithotriptor failed to dislodge the stone/basket complex. A two-step technique involving balloon dilatation and forceps manipulation of the basket was applied to successfully dislodge the impacted basket. We believe this simple and safe technique should be adopted to rescue impacted biliary extraction baskets to avoid the need for potential surgical removal.

Low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate, and clear liquid diet alone prior to small bowel capsule endoscopy

AIM To compare low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate and clear liquid diet alone as bowel preparation prior to small bowel capsule endoscopy (CE). METHODS We retrospectively collected all CE studies done from December 2011 to July 2013 at a single institution. CE studies were reviewed only if low volume polyethylene glycol with ascorbic acid, sodium picosulfate-magnesium citrate or clear liquid diet alone used as the bowel preparation. The studies were then reviewed by the CE readers who were blinded to the preparation type. Cleanliness and bubble burden were graded independently within the proximal, middle and distal small bowel using a four-point scale according to the percentage of small bowel mucosa free of debris/bubbles: grade 1 = over 90%, grade 2 = between 90%-75%, grade 3 = between 50%-75%, grade 4 = less than 50%. Data are expressed as mean ± SEM. ANOVA and Fishers exact test were used where appropriate. P values < 0.05 were considered statistically significant. RESULTS A of total of 123 CE studies were reviewed. Twenty-six studies were excluded from analysis because of incomplete small bowel examination. In the remaining studies, 39 patients took low volume polyethylene glycol with ascorbic acid, 31 took sodium picosulfate-magnesium citrate and 27 took a clear liquid diet alone after lunch on the day before CE, followed by overnight fasting in all groups. There was no significant difference in small bowel cleanliness (1.98 ± 0.09 vs 1.84 ± 0.08 vs 1.76 ± 0.08) or small bowel transit time (213 ± 13 vs 248 ± 14 ± 225 ± 19 min) for clear liquid diet alone, MoviPrep and Pico-Salax respectively. The bubble burden in the mid small bowel was significantly higher in the MoviPrep group (1.6 ± 0.1 vs 1.9 ± 0.1 vs 1.6 ± 0.1, P < 0.05). However this did not result in a significant difference in diagnosis of pathology. CONCLUSION There was no significant difference in small bowel cleanliness or diagnostic yield of small bowel CE between the three preparations regimens used in this study.

Endoscopic mucosal resection of esophageal squamous papillomatosis

A 62-year-old woman was referred for investigation of heartburn. She did not have any other significant medical history and denied any other symptoms including weight loss, dysphagia, odynophagia, regurgitation and hematemesis. Her only medication was pantoprazole 40 mg daily for her gastroesophageal reflux disease. Endoscopy was performed with a GIF-Q180 gastroscope (Olympus Optical, Japan), which demonstrated multiple flesh-coloured pedunculated papules at the gastroesophageal junction (Figure 1). Biopsies demonstrating atypical epithelial proliferation confirmed the diagnosis of esophageal squamous papillomatosis, without the presence of dysplasia or carcinoma. A polymerase chain reaction study was negative for herpes simplex virus. Following discussion with the patient, an extensive endoscopic mucosal resection (EMR) incorporating all of the lesions was performed using a band mucosectomy device (Duette, Cook Medical, Ireland) (Figures 2 and ​and3).3). Histology from the EMR specimens was similar to the original mucosal biopsy results. No immediate or delayed complications occurred. Figure 1) Squamous papillomatosis Figure 2) Endoscopic mucosal resection Figure 3) Post-resection

Economic impact of prescreening on gastroenterology outpatient clinic practice.

Background Outpatient clinic activity represents a major workload for clinicians. Unnecessary outpatient visits place a strain on service provision, resulting in unnecessary delays for more urgent cases. Goals We sought to determine both the impact and economic benefit of employing phone follow-up and physician assistant (PA) triage systems on attendances at a gastroenterology outpatient department. Study We performed a retrospective chart review of all patients attending a gastroenterology outpatient clinic over a 2-week period. Patients were categorized into new or follow-up attendees and the follow-up patients were further subcategorized into 1 of 4 groups: (1) those attending to receive results of investigations requiring no further treatment (group A); (2) those attending to receive results of investigations requiring further treatment (group B); (3) those attending with a chronic gastrointestinal disease requiring no active change in management (group C); (4) those attending with a chronic gastrointestinal disease requiring active change in management (group D). It was assumed that patients in group A could be managed by phone follow-up in place of clinic attendance and patients in group C could be triaged to see a PA. Results Out of a total of 329 outpatient attendees, 40 (12%) required no active intervention (group A) and would have been suitable for phone follow-up. A further 58 (18%) had stable disease, requiring no change in management and hence, could have been triaged to see a PA. Implementation of phone follow-up and patient review by PA could reduce salary expenses of outpatient practice by 17%. Conclusions Our findings support routine prescreening of outpatient attendees to enhance the efficiency of gastroenterology outpatient practice.

Evaluation of the small bowel in inflammatory bowel disease

Crohn’s disease is a chronic inflammatory bowel disease (IBD) that can affect the entire GI tract, and adequate visualization of the small bowel is imperative for both diagnosis and management. Magnetic resonance and computed tomography enterography have gradually replaced barium-based studies. Magnetic resonance enterography has the distinct advantage of avoiding ionizing radiation to which many patients with IBD are overexposed. Endoscopy-based techniques, including capsule endoscopy and device-assisted enteroscopy, allow direct visualization of the small bowel mucosa. Deep enteroscopy has the additional benefit of allowing sampling of the mucosa for histological analysis. Small intestine contrast ultrasound is rapidly gaining credence as an excellent, radiation-free imaging technique, but is not available in all countries. Other imaging modalities, such as positron emission tomography and leucocyte scintigraphy, continue to be studied and may have a role in specific circumstances. This review summarizes the evidence for the various techniques for evaluating the small bowel in IBD.