Frederick H. Weber

Analysis of a grading system to assess the quality of small-bowel preparation for capsule endoscopy: in search of the Holy Grail.

Background: The diagnostic yield of capsule endoscopy is vulnerable to inadequate visualization related to residual bile or chyme remaining in the lumen despite intestinal lavage. It has been challenging to determine the optimal lavage preparation of the bowel and patient diet before capsule endoscopy, as well as the timing of the procedure, because no well-accepted, validated grading system for assessing the quality of intestinal lavage before capsule endoscopy is available. There remains no consensus on the reliability of qualitative, quantitative, or computer-derived assessments of the quality of preparation for capsule endoscopy. This study evaluates intra-observer and interobserver agreement for a previously validated scale. Materials and methods: The digital images of 34 patients who underwent capsule endoscopy were independently reviewed by two blinded physicians according to a previously validated grading scale. One of the physicians reviewed and graded the patients a second time. The quality of the bowel luminal preparation was assessed with a qualitative parameter (fluid transparency) and a more quantitative parameter (mucosal invisibility) for each of three small-intestinal segments, and an overall small-bowel score for each parameter was assigned as well. A weighted kappa coefficient was used to calculate intra-observer (observer 1A and 1B) and interobserver (observer 1A and observer 2) agreement. A kappa value of 0.60 or more suggests strong agreement, 0.40 to 0.60 moderate agreement, and less than 0.40 poor agreement. Results: The intra-observer weighted kappa index for both fluid transparency and mucosal visibility was 0.52, which is consistent with moderate agreement. The interobserver weighted kappa indices for fluid transparency and mucosal invisibility were 0.29 and 0.42, respectively, demonstrating suboptimal interobserver agreement. The individual segment interobserver kappa indices were better for mucosal visibility (0.52, 0.39, and 0.47 for small-bowel segments 1, 2, and 3, respectively) than for fluid transparency (0.18, 0.38, and 0.31). Conclusions: The proposed grading scale for assessing the quality of preparation for capsule endoscopy has inadequate interobserver and intra-observer agreement. Capsule endoscopy preparation grading scales that focus more on quantitative than on qualitative assessment may demonstrate more reliable performance characteristics. Optimizing the quality of preparation and diagnostic yield of capsule endoscopy will first require the development of a well-validated grading scale.

Early Implementation of Video Capsule Enteroscopy in Patients with Left Ventricular Assist Devices and Obscure Gastrointestinal Bleeding.

Gastrointestinal bleeding (GIB) is a frequent challenge encountered in patients implanted with a left ventricular assist device (LVAD), affecting approximately 25% of this population. Many patients have no identifiable source of bleeding after routine esophagogastroduodenoscopy and colonoscopy and are labeled as obscure GIB (OGIB). Significant costs and invasive procedures are required to investigate and stop the source of bleeding in these patients. We performed a retrospective analysis at a single tertiary referral center to investigate the diagnostic yield and overall effectiveness of video capsule enteroscopy (VCE) in this population. Eight patients with LVADs underwent nine VCE studies for OGIB. The diagnostic yield was 100%, with intraluminal blood the most common finding. The jejunum was the most common location for pathology detected on VCE. Sixty-seven percent of the studies directly guided further endoscopy with successful cessation of bleeding in 100% of these patients. Finally, after an average follow-up of 46 weeks, the total number of endoscopic procedures and total units of transfused packed red blood cells (pRBC) were significantly less after the patient underwent the VCE study compared with before. Video capsule enteroscopy is a safe and high-yield investigative procedure in this population and should be implemented earlier to improve patient outcomes and reduce costs of care.

A new meaning to butterflies in the stomach.

Question: A 68-year-old woman with rheumatoid arthritis maintained on methotrexate presented with a 4-year history of intermittent episodes of abdominal pain and nausea that gradually progressed to emesis and increasing abdominal girth. The symptoms usually lasted for 48-72 hours with resolution of symptoms with food avoidance. Her symptoms initially began after starting methotrexate, which she took orally for 3 years followed by 1 year as a subcutaneous injection. The symptoms were exacerbated after each subsequent weekly dose. Her vital signs, laboratory studies, and physical examination were normal except for mild diffuse abdominal tenderness, hyperactive bowel sounds, and bulging flanks. An upper gastrointestinal series with small bowel follow through showed signs of partial small bowel obstruction. Abdominal CT revealed loculated abdominal and pelvic ascites with an associated peripheral rim enhancement (Figure A, arrow at peripheral rim enhancement). Paracentesis with analysis of peritoneal fluid revealed a transudative process. She subsequently underwent diagnostic laparotomy for persistent symptoms of suspected small bowel obstruction unresponsive to conservative measures. An unusual white encasing material around the peritoneum and small bowel wall without any strangulation or overt obstruction (Figure B, C) was noted. Peritoneal biopsy obtained at the time of the surgery contained acellular white clotted material with no findings of malignancy. What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Clinical Predictors for Repeat Hospitalizations in Left Ventricular Assist Device (LVAD) Patients With Gastrointestinal Bleeding

Background Patients implanted with left ventricular assist devices (LVAD) carry an increased risk of gastrointestinal bleeding (GIB), estimated at 25% in most studies. Significant efforts are employed in localizing and stopping the source of bleeding, but the rates of repeat hospitalization for GIB remain surprisingly high. Given the increasing incidence of LVAD-dependent end-stage heart failure and the excessive costs associated with repetitive endoscopic investigations, risk factors associated with re-bleeding need to be determined. The aim of our study was to investigate clinical predictors associated with repeat hospitalizations for GIB in patients implanted with a LVAD. Methods We conducted a retrospective cohort using the prospectively assembled ventricular assist device database at the University of Alabama at Birmingham. We identified all end-stage heart failure patients who were implanted with a continuous-flow (CF) LVAD between Jan 1, 2009 and Dec 31, 2013. We excluded pulsatile devices, biventricular assist devices (BiVADs), right ventricular assist devices (RVADs), and patients under 19 years of age. Results There were 102 patients implanted with a CF-LVAD within the specified time period. With an average follow-up of 127 weeks, 32 (31.4%) patients developed GIB requiring 79 separate hospitalizations. Average time from LVAD implantation to first bleed was 343 days. The re-bleeding rate requiring readmission was 56.3% in those admitted with GIB, with eight (25%) of the patients necessitating multiple readmissions. The average hospital stay for a primary diagnosis of GIB was 9.45 days. Totally, 68 (86%) patients required endoscopic evaluation during their hospitalization, with 35 (44%) necessitating multiple procedures during the same admission. The average time to first endoscopy was 2.5 days with a median of 2 days. Patients receiving early endoscopy (< 48 h from admission) were 57% less likely to require future readmission for GIB compared to patients undergoing late endoscopy (> 48 h) (OR: 0.43, CI: 0.19 - 0.9). Other factors associated with repeat admissions for GIB included indication for LVAD (bridge to transplant had OR: 0.07, CI: 0.02 - 0.27), male gender (OR: 10.4, CI: 1.8 - 59), length of initial hospital stay (OR: 0.83, CI: 0.71 - 0.97), and INR on admission (OR: 3.6, CI: 1.46 - 8.8). Although not statistically significant, patients undergoing subsequent endoscopies during a single admission were 84% less likely to develop re-bleeding in the future (OR: 0.158, CI: 0.025 - 1.02). Conclusions GIB in LVAD patients is a significant problem with high rates of readmission despite extensive endoscopic investigations and anticoagulant adjustments. Our experience revealed that early endoscopy, longer initial hospital stay, and better INR control were all associated with decreased rates of readmission for GIB in this population. These modifiable factors should be emphasized and addressed in the future to reduce the burdens associated with repeated hospitalizations.

Flexible endoscopic management of Zenker’s diverticulum

re 1. A, Barium esophagram revealing ZD and a prominent CP. B, Landmark triad of ZD to the left, a prominent cricopharyngeus (CP bar) in the le, and the esophagus with nasogastric tube to the right. C, Needle-knife used to initially incise through prominent cricopharyngeus.D,Muscle fibers icopharyngeus visible after incision with the needle-knife. E, Ceramic ball insulated tip knife, which allows more controlled cutting, in use. rough-the-scope clips applied at base of diverticulum after cricopharyngeal incision to close any potential defects. G, Barium esophagram after omy revealing a small residual ZD. Intubation was also notably easier after myotomy. ZD, Zenker’s diverticulum; CP, cricopharyngeal muscle.

An Unusual Familial, Recurrent Neoplasm

The University of Alabama of Birmingham, Internal Medicine Residency Training Program, Alabama; and Digestive Health Center, Kirklin Clinic Birmingham, Alabama 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 Question: A 76-year-old Caucasian woman presented with 3 episodes of melena over the preceding month and significant weight loss of 6 dress sizes over the preceding year. She had a melenic GI bleed 40 years prior, at which time a small bowel neoplasm was resected. She remained well without recurrence or rebleeding until the recent presentation. Physical examination was entirely unremarkable and laboratory studies were normal. Her family history was notable for a daughter who died at age 42 from a perforated small bowel neoplasm that had demonstrated hepatic metastases upon presentation. A paternal uncle had 30 inches of small or large bowel resected for a neoplasm. Esophagogastroduodenoscopy revealed multiple gastric submucosal masses with the largest being 5 cm in diameter (Figure A, B). Colonoscopy was nondiagnostic and computed tomographic enterography revealed numerous neoplasms in the distal esophagus (Figure C), stomach (Figure D), and small bowel (Figure E). What is the diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. 111 112 113 114 115

A Most Unusual Passage Per Rectum

Question: A 60-year-old man with acute myelogenous leukemia (AML) in remission relapsed and was admitted for salvage chemotherapy. He received induction with methotrexate, epirubicin and cisplatin. During the course of treatment, he became hypotensive and tachycardic, prompting transfer to the intensive care unit. Septic shock was empirically treated with broad-spectrum antibiotics. His course was further complicated by persistent pancytopenia, atrial fibrillation with rapid ventricular response, disseminated intravascular coagulation and respiratory failure requiring mechanical ventilation. He developed abdominal distension, proximal small bowel dilation, and mesenteric edema by computed tomography without pneumoperitoneum. Subsequent radiographic studies over several days revealed no interval changes; conservative therapy with nasogastric tube suction and methylnaltrexone was given. Five days later, he had an episode of melena accompanied by passage rectally of a 15-cm tubular structure (Figure A). Within hours of this event, he developed multisystem organ failure and hypotension followed by asystolic cardiac

Capsule endoscopy for acute upper gastrointestinal bleeding: is the cherry ripe yet?

We read with interest the prospective cohort study by Gralnek et al. [1], which used the PillCam ESO 2 (Given Imaging Ltd., Yoqneam, Israel) in the emergency department for patients presenting with acute upper gastrointestinal bleeding. This represents part of a limited emerging literature on the subject [2–4]. Although the feasibility and safety of video capsule endoscopy (VCE) in this clinical setting appear clear, there remain a number of obstacles to be overcome before VCE can become an integral part of the initial emergency department assessment of upper gastrointestinal bleeding. The first issue is the overall accuracy of VCE as a triage tool to stratify patients with regard to timing of endoscopy, use of intravenous medications (proton pump inhibitors, octreotide, terlipressin), appropriate level of inpatient monitoring and care, or stratifying to outpatient management. The crux of this issue lies in the ability of VCE to detect luminal blood and mucosal lesions and, most importantly, in the sensitivity of VCE for the detection of lesions with high risk stigmata. The finding of 83.3% sensitivity for luminal blood compared quite favorably with the 33.3% sensitivity of nasogastric aspirate. Most of this difference can be explained by blood in the duodenal lumen detected by VCE but missed by nasogastric aspirate. However, nasogastric aspiration has been known to have a low sensitivity and specificity for acute upper gastrointestinal hemorrhage [5], so this is a rather low bar to hurdle. Although the authors found no significant difference in the identification of peptic or inflammatory lesions between VCE (67.5%) and esophagogastroduodenoscopy (87.5%), the possibility of a type II error is quite plausible given the small numbers of patients completing both studies (n=41). Most significantly, it will be critical to assess the sensitivity of VCE for the detection of lesions with high risk stigmata, as this would be an independent triage tool to determine the suitability of outpatient management. Failure to detect any high risk lesion could have major clinical consequences with regard to inappropriate outpatient management stratification. We also wonder whether the use of intravenous erythromycin in this setting could have skewed the evidence of gross blood findings affecting the results for nasogastric tube aspiration. The second issue regards who is most appropriate and available to interpret VCE in the emergency room situation? There are some preliminary data showing that emergency room physicians and gastroenterologists demonstrate excellent agreement and interpretation of VCE in this setting [3]. Alternatively, video images could be interpreted by an off-site gastroenterologist for real-time decision making. The third issue is cost-effectiveness of VCE in this setting. The mean length of stay for patients discharged from the hospital with a diagnosis of gastrointestinal hemorrhage is 4.5 days and the mean hospital charges are US

A Single-Center Randomized Controlled Trial Evaluating Timing of Preparation for Capsule Enteroscopy

26210 per admission [6]. The physician Medicare national average fee in the USA for PillCam ESO 2 is US

Optimizing colonic preparation: the solution is becoming clearer and clearer.

755 including the technical and professional fees. VCEmust demonstrate considerable diagnostic sensitivity and specificity for triage so that significant inpatient cost savings can be realized or hospitalizations safely avoided, otherwise it will simply add another costly test to the evaluation of upper gastrointestinal hemorrhage. The further question of whether VCE can replace a traditional esophagogastroduodenoscopy or buy time until one can be done will only be realized in further studies. In conclusion, we commend the investigators for evaluating this interesting and novel strategy of using VCE in the setting of acute upper gastrointestinal bleeding; however, we await more data for its effective implementation in an algorithmic through-the-door approach.