Gregory Albers

Aspiration of a capsule endoscope and description of a unique retrieval technique

The capsule endoscope has revolutionized small-bowel inspection, which before was limited to indirect studies, such as barium radiography, scintigraphy, and angiography, or to direct but invasive push enteroscopy. It provides a direct, yet minimally invasive, visualization of the small bowel. Capsule endoscopy is approved by the FDA for detection of small-bowel mucosal abnormalities. To date its major application has been evaluation of occult gastrointestinal (GI) bleeding. The device has been used in 340,000 patients worldwide, with 105,000 procedures in the US within the last year. As its applications increase to include evaluation of conditions such as Crohn’s disease, small-bowel polyps, and abnormal small-bowel radiographic studies, its utilization will increase (sales increased by 18% over the last year), and clinicians should be aware of its complications. Three cases of capsule endoscope aspiration have been reported in gastroenterology literature to date. This is the first report in otolaryngology literature. Although rare, this complication is potentially fatal and should be considered an emergency. A 67-year-old man with history of anemia was referred for capsule endoscopy to evaluate for occult GI hemorrhage. Due to a past medical history of hypertension, diabetes mellitus, cerebrovascular accident, and intermittent dysphagia, endoscopic placement of a capsule endoscope (M2A, Given Imaging, Ltd, Duluth, GA) was recommended. However, the patient declined and chose to swallow the capsule, immediately after which he began to cough and exhibit dysphonia, which resolved. There was no respiratory distress, but he developed a persistent cough. Within 3 minutes the patient became tachypneic and tachycardic, but his oxygen saturation remained above 95%. There were ronchi, but no stridor. The physician recognized the possibility of interrogating the capsule endoscope to determine its location. Images from the capsule endoscope were downloaded and analyzed within 5 minutes and definitively revealed that the device was aspirated promptly after it was swallowed (Fig 1). This process took less time than obtaining plain radiographs. The patient was taken to the operating room for retrieval

Acute small bowel perforation after wireless capsule endoscopy in a patient with Crohn's disease: a case report

IntroductionWireless capsule endoscopy is an important tool for minimally invasive evaluation of the small bowel, allowing improved diagnostic yield with low complication rates relative to traditional modalities. Recently however, reports on small bowel perforation after wireless capsule endoscopy have surfaced. Here we present the first case of acute small bowel perforation in a middle-aged male in the United States.Case presentationA 58-year-old male with a presumed quiescent history of Crohns Disease presented to the Emergency Department in a septic state 48 hours after a wireless capsule endoscopy procedure complaining of abdominal pain, distension, and frequent emesis. A computed tomography scan of the abdomen was suggestive of small bowel perforation and ischemic enteritis. The patient was adequately resuscitated and taken to the operating room for an ileocecectomy and extensive resection of the small bowel. Pathology of the resected specimen revealed an ileal stricture and associated necrotizing ileitis, and a perforation just proximal to the stricture.ConclusionWireless capsule endoscopy remains the preferred endoscopic imaging method of the small bowel. This case illustrates the importance of appropriate patient selection and evaluation of functional patency of the small bowel prior to wireless capsule endoscopy, especially with the growing role of this procedure in the evaluation of inflammatory bowel disease.

EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain. OBJECTIVE Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions. DESIGN Prospective, paired design. SETTING Six academic endoscopy centers. PATIENTS This study involved patients with upper abdominal pain referred for endoscopy. INTERVENTION All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion. FOLLOW-UP telephone interviews and chart reviews. MAIN OUTCOME MEASUREMENTS Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions. RESULTS A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies. LIMITATIONS No cost analysis. CONCLUSION The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Abstract A21: A Phase IIa trial of metformin for colorectal cancer risk reduction among patients with a history of colorectal adenomas and elevated body mass index

Background: Despite advances in colorectal cancer (CRC) screening, early detection, and treatment, CRC remains the 2nd most common cancer cause of death in the U.S.. Obesity is increasing in incidence in the U.S., and has been implicated in colorectal adenoma (CRA) risk, risk of CRA recurrence, and risk of CRC. Obese patients with history of CRA are a high-risk group that may benefit from novel CRC prevention strategies. There is early evidence for reduced cancer mortality among metformin users. The signaling pathway activated by metformin (LKB1/AMPK/mTOR) is implicated in tumor suppression in ApcMin/+ mice, as evidenced by metformin-induced reduction in polyp burden, increased ratio of pAMPK/AMPk, decreased ratio of pmTOR/mTOR, and decreased ratio of pS6Ser235/S6Ser235 in polyp specimens. We hypothesized that metformin would affect colorectal tissue S6Ser235 similarly in humans, targeting obese patients with recent history of CRAs as a high-risk group. Methods: A phase IIa clinical biomarker trial was conducted across 3 clinical sites via the NCI-funded Southern California Chemoprevention Program. Eligible participants included non-diabetic, obese patients (BMI >30) with history of colorectal adenoma within the past 3 years, age ≥ 35 years and ≤ 80 years. All patients received an upward titration of metformin over 3 weeks to 1000mg po bid, which was continued until the end-of-study (EOS) at 12 weeks. Rectal mucosa biopsies were obtained at baseline (BL) and at time of EOS endoscopy. Tissue S6Ser235 immunostaining was analyzed in a blinded fashion by the study pathologist using Histo Score (HScore) analysis. A paired t-test was used to examine the effect of metformin on activated S6serine235 (i.e., the ratio of pS6serine235/ S6serine235). Results: 45 patients were consented to achieve 32 eligible subjects. 4 subjects were removed from study due to Adverse Events (1 SAE, unrelated). In order of frequency, the most common AEs were diarrhea, cramping, flatulence, nausea, stomach pain; 80% of participants had Grade 1 AE, 27% had grade 2 AE. Mean (SD) weight and body mass index at BL were 105.2 (17.42) kg and 34.9 (5.57) respectively. Weight did not significantly differ over the course of the study. Glucose levels at EOS did not significantly differ from BL. Vitamin B12 levels were significantly reduced at EOS vs. BL (-46.7 pg/mL, 95% CI -73.2 to -20.2). Comparing EOS to BL tissue S6Ser235 by IHC HScore analysis, no significant differences were observed. Mean (SD) Hscore at BL was 1.1 (0.57) and 1.1 (0.51) at EOS. Median HScore change was 0.032 (p=0.77). Conclusions: Among obese CRA patients, 12 weeks of oral metformin 1000mg twice daily does not reduce pS6 levels in the rectal mucosa. Other potential mechanisms of action have not yet been analyzed. Data from this clinical trial indicate that metformin can be used safely in a non-diabetic population. Further research is needed to determine what effects, if any, metformin has on the target tissue of origin (colorectum) relevant to colorectal carcinogenesis if metformin is to be pursued as a CRC chemopreventive agent. Citation Format: Jason A. Zell, Christine E. McLaren, Timothy R. Morgan, Michael J. Lawson, Sherif Rezk, Gregory C. Albers, Wen-Pin Chen, Joseph C. Carmichael, Luz Rodriguez, Eva Szabo, Leslie Ford, Michael Pollak, Frank L. Meyskens. A Phase IIa trial of metformin for colorectal cancer risk reduction among patients with a history of colorectal adenomas and elevated body mass index. [abstract]. In: Proceedings of the Thirteenth Annual AACR International Conference on Frontiers in Cancer Prevention Research; 2014 Sep 27-Oct 1; New Orleans, LA. Philadelphia (PA): AACR; Can Prev Res 2015;8(10 Suppl): Abstract nr A21.

Mucosal associated lymphoid tissue (MALT) lymphoma involving cervical heterotopic gastric mucosa (inlet patch) in a patient with gastric malt lymphoma

Mucosal associated lymphoid tissue (MALT) lymphoma involving cervical heterotopic gastric mucosa (inlet patch) in a patient with gastric malt lymphoma

An unusual case of papillary stenosis from Strongyloides stercoralis in a patient with HTLV-1

An unusual case of papillary stenosis from Strongyloides stercoralis in a patient with HTLV-1