Gary May

Endoscopic cryotherapy for the management of gastric antral vascular ectasia.

BACKGROUND Gastric antral vascular ectasia (GAVE) is an uncommon but clinically significant cause of chronic GI bleeding. OBJECTIVE To assess the efficacy and safety of cryotherapy for endoscopic treatment of GAVE. DESIGN Patients received 3 sessions of endoscopic cryotherapy at 3-week to 6-week intervals and had a follow-up endoscopy 4 weeks thereafter. They were followed prospectively in terms of clinical and endoscopic response. SETTING Tertiary-care center, between October 2004 and April 2006. PATIENTS The patients were 43 to 89 years of age, with a diagnosis of GAVE and documented iron deficiency anemia. Eight patients had a history of overt GI bleeding. Eight patients (67%) had previously been treated with argon plasma coagulation (APC) (median 6 sessions, range 1-10 sessions) and failed to respond or had a recurrence. RESULTS Twelve patients were enrolled. Six patients (50%) had a complete response, and 6 patients had a partial response. The mean number of units of blood transfused in the period of 3 months before cryotherapy and during the period of follow-up of 3 months was 4.6 and 1.7 units, respectively. An increased mean Hb level, from 9.9 to 11.3 g/dL, was noted. The average duration of the cryotherapy was 5 minutes (range 1-15 minutes). In 32 of 36 cryotherapy treatment sessions performed (89%), it was technically possible to treat more than 90% of GAVE lesions. There were no immediate cryotherapy-related complications, and none of the patients required admission after the procedure. LIMITATIONS A pilot study from a single center. CONCLUSIONS Endoscopic cryotherapy is a safe and effective treatment for GAVE. It appears to be effective, even for GAVE refractory to APC therapy. Optimal cryogen, delivery device, and treatment protocols are yet to be determined.

Thalidomide for the treatment of chronic gastrointestinal bleeding from angiodysplasias: a case series

Background Mucosal angiodysplasias, either inherited or acquired, can cause gastrointestinal bleeding, sometimes refractory to treatment. From earlier case reports, thalidomide has been described to possess some benefits in this disease, but its benefits and risks nevertheless remain unclear. Objectives This pilot study assesses the efficacy, safety, and side-effect of thalidomide in the treatment of patients with chronic gastrointestinal bleeding from angiodysplasias. Methods Patients with chronic angiodysplasia bleeding and requiring ongoing transfusion were eligible for this open nonrandomized study. Thalidomide was started with 50 mg/day and then increased incrementally by 50 mg every week up to 200 mg/day, if tolerated, and continued for 6 months. Adverse events, hemoglobin, blood chemistry, and blood transfusion were monitored during the treatment and for 6-months posttreatment. Results Seven patients were recruited in this study. Four patients discontinued thalidomide within 3–8 weeks, because of fatigue (two patients), peripheral neuropathy (one patient), and skin rash (one patient). All side-effects resolved when thalidomide was discontinued. These four patients required the same volume of blood transfusions per month as pre-study. In contrast, the three patients who continued 100–200 mg/day of thalidomide for 6 months did not require any transfusions during the 6 months of medication. During 6-months posttreatment of these three patients, one maintained response without any transfusion for 2 months, then required 1 U of blood every 4 weeks, one patient required 2 U of blood every 3–4 weeks, and one patient died from diabetes complications. Conclusion Thalidomide should be considered as a therapeutic option in patients who are resistant to conventional therapy, but it has a high discontinuation rate because of its side-effects.

Double-Balloon Enteroscopy following Capsule Endoscopy in the Management of Obscure Gastrointestinal Bleeding: Outcome of a Combined Approach

BACKGROUND There is no consensus on the relative accuracy of capsule endoscopy (CE) versus double-balloon enteroscopy (DBE) to investigate obscure gastrointestinal bleeding (GIB). CE is less invasive, but DBE more directly examines the small bowel, and allows tissue sampling plus therapeutic intervention. OBJECTIVES To evaluate the yield and outcome of DBE following CE in patients with obscure GIB. METHODS After DBE became readily available at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (St Michaels Hospital, Toronto, Ontario), all patients with obscure GIB seen from December 2002 to June 2007 were evaluated identically, first with CE, then with DBE (some with further interventions). Findings, adverse outcomes and interventions are reported. RESULTS Fifty-one patients (25 women) with a mean (range) age of 64.1 years (34 to 83 years) are reported. Eight patients underwent DBE twice, for a total of 59 DBEs. Fourteen patients had overt GIB and the median (range) number of red blood cell unit transfusions was 10 (0 to 100). The positive findings for each type of lesion were compared in these 51 patients: angiodysplasia (CE 64.7% and DBE 61%, P=0.3), ulcers (CE 19.6% and DBE 18.6%, P=0.5), bleeding lesions (CE 43.1% and DBE 15.3%, P=0.0004) and mass (CE 10.2% and DBE 8.5%, P=0.5). DBE provided the advantage of therapeutic intervention: argon plasma coagulation (33 of 59 DBEs), clipping (two of 59), both argon plasma coagulation and clipping (three of 59), polypectomy (two of 59), tattooing (52 of 59) and biopsies (11 of 59). DBE detected lesions not seen by CE in 21 patients; lesions were treated in 18 patients. However, CE detected 31 lesions not seen by DBE. No major complications occurred with either examination. CONCLUSION Overall detection rates for both techniques are similar. Each technique detected lesions not seen by the other. These data suggest that CE and DBE are complementary and that both evaluate obscure GIB more fully than either modality alone.

Wire-guided cannulation versus contrast-guided cannulation in pediatric endoscopic retrograde cholangiopancreatography.

Background/Aim: Wire-guided cannulation (WGC) of the common bile duct may be associated with fewer complications and higher success rate compared with contrast-guided cannulation (CGC) in adults. Data in children are lacking. The aim of this study was to compare the successful cannulation and complication rate of WGC and CGC in pediatric endoscopic retrograde cholangiopancreatography (ERCP). Patients and Methods: We report a retrospective cohort study comparing WGC to CGC in a pediatric cohort. We reviewed the medical records of 167 children who underwent ERCP over a 10-year time period (CGC, 1999-2003, WGC, 2003-2009). Indications, findings, and success were analyzed. Results: A total of 93 patients (56%) underwent WGC and 74 (44%) CGC. Children in the WGC group were younger (9.5 ± 4.7 vs. 11.5 ± 4.6 years in CGC; P = 0.006) and underwent more therapeutic ERCP interventions (70% vs. 40% in CGC), whereas diagnostic ERCP was more common in the CGC group (60%; P < 0.005). The overall success (96%) and complication rate (8%) were identical in both groups but a trend toward a reduction in the complication rate over time was noted in the WGC group. Post-ERCP pancreatitis (PEP) was documented in one patient in the WGC group (1.1%) and three patients (4.2%) in the CGC group (P-NS). Conclusion: The success and complication rate in both CGC and WGC are comparable in children but considering the patient and procedure complexity and the trend toward lower PEP in the WGC group, WGC may be the preferable cannulation technique for ERCP in children.

4641 A new covered biliary wallstent: effectiveness in the palliation of malignant obstruction jaundice, results from a multicentre trial.

Background: Uncovered metal biliary stents have superior patency rates compared to plastic stents in the palliation of malignant biliary strictures. The rate of tumor ingrowth may be decreased by the use of a covered metal stent. This report describes a multicentre experience with a new covered Wallstent(Microvasive, Natick, USA)in 33 patients with malignant bile duct obstruction. The new design incorporates a silicone coating. This study was sponsored by Microvasive Endoscopy, Boston Scientific Corporation. Patients and Methods: 33 patients, 17 male, mean age 68 yr,(32 - 92)were included in the study. 21 (64%)patients had pancreatic carcinoma, 5 (15%) gastric carcinoma (3 BII gastrectomy), 3 (9%) cholangiocarcinoma, 1 (3%) ampullary carcinoma, 1 (3%) hepatoma,1 (3%) metastatic breast carcinoma and 1 unconfirmed. 25 (76%) had prior stent placement(1 metal). The length of obstruction ranged from 10 to 54 mm (mean 27 mm). Covered stents were placed in 8 pts transhepatically (San Francisco, Miami), in the remaining 25 pts endoscopic placement under fluoroscopic control (Toronto, Calgary). Results: Stent deployment was satisfactory in 31 out of 33 cases. Stent positioning was not optimal in 2 pts (1 transhepatic, 1 endoscopic) requiring immediate placement of additional uncovered Wallstents. Radial expansion ranged from 25 to 100%. Mean bilirubin level decreased from 150 μmol/L to 24 μmol/L at 1 month. Early complications included minor pain in 2 pts and acute cholecystitis in 1 pt requiring cholecystectomy. At 6 months, 15 pts had died, none with stent related complications. Among the 16 living pts, 3 developed obstructive jaundice (3-6 mos), 2 due to partial migration and one due to sludge. Overall 6 month complication rate was 19% (6/31). Conclusions:The new covered Wallstent remained patent until death or at 6 mos follow up in 28/31 pts. There was no evidence of ingrowth or overgrowth and in 2 cases obstruction at the proximal end of the stent could be attributed to partial migration. The design of this covered stent offers the potential of prolonged patency.

Pylephlebitis After Colonic Polypectomy Causing Fever and Abdominal Pain

Pylephlebitis is a rare condition with a high mortality risk if not recognized and treated early. The most common symptoms include fever and abdominal pain, with the majority of cases manifesting with a polymicrobial bacteremia. We report an elderly woman with pylephlebitis presenting with fever, abdominal pain, diarrhea, and vomiting, likely secondary to a polypectomy 6 weeks prior. Abdominal CT revealed portal vein thrombus and blood cultures grew Streptococcus milleri and Haemophilus parainfluenza type V. Pylephlebitis should be considered when symptoms and signs of infection develop following endoscopic procedures, particularly in patients with an underlying hypercoaguable disease.

Deflating the Lure of Double-Balloon Enteroscopy.

To the Editor: Prudent physicians favor diagnostic certainty, appreciating that clinicians are more often criticized for what was not done than for what was. It is therefore not surprising that there has been an exponential increase in the number of requests for double-balloon enteroscopy (DBE), the most commonly performed method of deep enteroscopy, to explain occult obscure bleeding. Part of this is fear of missing neoplasia, and part is the hope that treating lesions which are found will relieve the patient of the need for iron supplementation. We have no argument with proceeding to video capsule endoscopy (VCE) or radiologic imaging such as computed tomographic enterography or magnetic resonance enterography in these patients but we wonder if the role of DBE is being overemphasized. First, even in expert hands the complication rate approaches a clinically significant number: from a safety point of view DBE is not just the small bowel equivalent of colonoscopy. Major complications have been reported in approximately 1% of all diagnostic DBE, rising to 5% for therapeutic procedures.1 The rate of these complications is meaningful: 0.2% to 0.3% pancreatitis-related, 0.2% to 0.8% bleeding-related, 0.1% to 2.9% perforations-related, 0.5% sedation-related complications.2–4 Recently, Lara and colleagues reported that the risk of hypoxemia was much higher than previously described. Among 432 overtubeassisted enteroscopies, significant hypoxemia developed in 15 (3.4%). On the basis of the frequency of adverse events, they changed their practice to have all antegrade DBE cases done with general anesthesia including endotracheal intubation.5 Second, the likelihood of DBE changing long-term outcome—a more relevant measurement than diagnostic yield—is disappointingly low even when therapeutic endoscopic techniques are used. A recent meta-analysis has demonstrated that while endoscopic therapy for isolated small bowel angiodysplasias showed efficacy as initial therapy, recurrence rate was significant—45% of patients over a mean (±SD) of 22±13 months.6 In addition, Rahmi et al’s7 prospective multicenter study found that despite endoscopic treatment for patients with obscure gastrointestinal bleeding and angiodysplasia on VCE, about one third had rebleeding at 1 year. Consensus statements from gastroenterology associations reasonably offer DBE recommendations that are more general than specific. For example, the American College of Gastroenterology guidelines state that “Total deep enteroscopy should be attempted if there is a strong suspicion of a small bowel lesion based on clinical presentation (strong recommendation).”8 We agree with this advice, but unfortunately the accuracy of clinical presentation is poor in predicting small bowel lesions, so this guideline can readily interpreted as encouragement for DBE. In our view, the American College of Gastroenterology guidelines are best interpreted as favoring DBE for patients with a strong suspicion of a small bowel lesion and who have a reasonable chance of changing outcome from this procedure. To date this subgroup seems to be characterized by anemia with no responsible abnormalities seen at gastroscopy, push enteroscopy, colonoscopy plus either (1) active melena or hematochezia or (2) computed tomographic enterography, magnetic resonance enterography, or VCE suggesting either a malignancy or a lesion amenable to endoscopic therapy, and (3) iron deficiency anemia not responding to oral iron supplementation requiring transfusions or parenteral iron. A generation ago, the editor of the New England Journal of Medicine pleaded to physicians to resist the allure of our innate stubborn quest for diagnostic certainty, arguing that this not only risks complications from the tests and increases costs, but also can lead to finding abnormalities that require further work-up even when these are thought not to be of clinical relevance.9 DBE is often an example of such diagnostic aggressiveness. Just because we can does not mean we should.