H Neumann

Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding

Background  Double‐balloon enteroscopy (DBE) is a useful method for evaluation of obscure gastrointestinal bleeding (OGIB).

Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis

1. Kucik CJ, Martin GL, Sortor BV. Common intestinal parasites. Am Fam Physician 2004;69:1161-8. 2. Bungiro R, Capello M. Hookworm infection: new developments and prospects for control. Curr Opin Infect Dis 2004;17:421-6. 3. Fulmer HS, Huempfner HR. Intestinal helminthes in eastern Kentucky: a survey in three rural counties. Am J Trop Med Hyg 1965;14: 269-75. 4. Weller PF, Nutman TB. Intestinal nematodes. In: Braunwald E, Fauci AS, Kasper DL, editors. Harrison’s Principles of Internal Medicine. 15th ed. New York: McGraw-Hill Companies, Inc; 2001. p. 1235. 5. Salata RA, editors. Intestinal nematodes. Textbook of Internal Medicine. 3rd ed. Philadelphia: Lipincott-Raven Publishers Philadelphia: 1997. p. 1832-3. 6. Loukas A, Bethony J, Brooker S, et al. Hookworm vaccines: past, present, and future. Lancet Infect Dis 2006;6:733-41.

Dyspepsia and IBS Symptoms in Patients with NERD, ERD and Barrett’s Esophagus

Introduction: Irritable bowel syndrome (IBS) and functional dyspepsia (FD) are highly prevalent in the general population as does gastroesophageal reflux disease (GERD). Therefore, it is expected that these conditions may frequently overlap. Objective: We aimed at evaluating the presence ofFD and IBS symptoms in patients with erosive (ERD), non-erosive reflux disease (NERD) and Barrett’s esophagus (BE). Patients and Methods: 71 patients presenting at the reflux disease outpatient clinic were prospectively included in this study. 33 patients had NERD, 25 ERD and 13 BE according to the Montreal classification. All patients with ERD and NERD had typical reflux symptoms, as assessed by a validated GERD questionnaire (RDQ). The diagnosis of functional dyspepsia and IBS symptoms was assessed according to the Rome III criteria. Results: IBS symptoms (bloating, abdominal pain, constipation and diarrhea) were slightly more prevalent in NERD (54.6, 63.6, 21.20, 24.2%, respectively) than in ERD (48.0, 44.0, 12.0, 20.0%, respectively) and in BE (53.9, 23.10, 15,4, 23.1%, respectively), but none of these differences reached statistical significance. NERD patients had more FD symptoms than patients with ERD or BE, but again this difference did not reach statistical significance. Conclusion: Our data show that IBS and FD are common in the entire spectrum of GERD. The presence of these disorders might explain why many patients with GERD are deemed as treatment failures if they have no complete symptom relief with proton pump inhibitors.

Small bowel polyps and tumours: endoscopic detection and treatment by double‐balloon enteroscopy

Background  Double‐balloon enteroscopy has allowed us not only to inspect deeply the small bowel but also to carry out interventions for diseases of the small bowel.

Efficacy, Complications and Clinical Outcomes of Endoscopic Sclerotherapy with N-Butyl-2-Cyanoacrylate for Bleeding Gastric Varices

Background: Bleeding gastric varices (BGV) are a severe complication of portal hypertension. Although the obliteration of gastric varices using cyanoacrylate has been shown effective to eradicate gastric varices, there are still few data available on its effectiveness for acutely BGV, cyanoacrylate-related complications and follow-up. Aims: To report on the feasibility, efficacy and outcomes of N-buytl-2-cyanoacrylate sclerotherapy in patients with BGV. Methods: This is a retrospective cohort study of consecutive patients who were evaluated for BGV at University of Magdeburg Medical Center. Data abstracted for analysis from the prospectively collected database included patient’s demographics, etiology of gastric varices, Child-Pugh score, effectiveness of endoscopic treatment, clinical and endoscopic follow-up. Immediate hemostasis was defined as visible and clinical arrest of bleeding. The following were considered as potential complications of the procedure: aspiration, fever, worsening hemorrhage due to the sclerotherapy and systemic embolization of cyanoacrylate. Results: 33 patients (17 F, 16 M; mean age 54 years, range 18–81) with BGV (29 had active bleeding and 4 had stigmata of recent bleeding) underwent endoscopic injections of N-butyl-2-cyanoacrylate for hemostasis over a 5-year period. Mean follow-up: 9 months (range: 1 month to 5 years). Initial hemostasis was achieved in 88%. Treatment-related complications occurred in 5 (15.1%), the most common being deep ulcerations, which also resulted in recurrent bleeding. One patient presented with distal cyanoacrylate embolization. During long-term follow-up, 6 patients died, 5 as a consequence of the underlying liver disease and 1 as a consequence of complications due to systemic cyanoacrylate embolization. Conclusions: N-butyl-2-cyanoacrylate sclerotherapy is highly effective for the treatment of BGV, with rare complications occurring both acutely and in the long term.

Utility of double-balloon enteroscopy for the evaluation of malabsorption.

Introduction: Occasionally, patients with malabsorption represent a diagnostic challenge. Double-balloon enteroscopy (DBE) allows deep and detailed examination of the small bowel. Aim: To determine the diagnostic value of DBE in patients with malabsorption of unclear origin. Methods: DBE was performed in a total of 12 patients with clinical malabsorption. Biopsy specimens were taken from macroscopic lesions or from examined small bowel at three different levels of scope insertion depth. Tissue specimens were evaluated with standard hematoxylin and eosin, the modified Marsh classification and, when indicated, special stains for amyloidosis. Results: Fifteen DBEs were successfully performed in 12 patients without complications. DBE with small bowel biopsies yielded a diagnosis in 8 patients (67%). A new diagnosis was reached in 4 patients (33%). The new diagnoses included: Crohn’s disease, primary intestinal lymphangiectasia and jejunal amyloidosis. In none of these 4 patients did the duodenal biopsies yield a diagnosis. Also, DBE excluded enteropathy-associated T-cell lymphoma (EATL) and/or ulcerative jejunitis in symptomatic celiac disease patients. Conclusions: DBE had a diagnostic value of 42% in patients with malabsorption of unclear origin. In addition, DBE was useful to rule out complications of long-standing celiac disease such as ulcerative jejunitis or EATL. DBE should be reserved for patients with unexplained malabsorption. DBE with jejunal and ileal biopsies appears to have a diagnostic value in patients with malabsorption, even when duodenal biopsies are histologically normal.

Polypectomy Techniques for Difficult Colon Polyps

A difficult polyp is any flat or raised colonic mucosal lesion that given its size, shape or location makes it difficult for the colonoscopist to remove. Although many ‘difficult polyps’ will be an easy target for the advanced endoscopist, polyps that are >15 mm, have a large pedicle, are flat and extended, are difficult to see or are located in the cecum or any angulated portion of the colon should be always considered difficult. Post-polypectomy complications are more common in the presence of difficult polyps. This review describes several useful tips and tricks to deal with such polyps.

Glatiramer acetate induced acute exacerbation of autoimmune hepatitis in a patient with multiple sclerosis.

Sirs: Glatiramer acetate (Copaxone ) is a synthetic random copolymer of four amino acids and is antigenically similar to myelin basic protein [1]. It represents an established second-line therapy for relapsing-remitting type of multiple sclerosis (MS). Recently, glatiramer acetate was suggested to induce autoimmune diseases [2, 3]. We report here a case of a 71year-old man who had suffered from MS since 1992, and was treated with interferon beta-1b between 1994 and 2004. In 1999, a weak positive test result for antinuclear antibodies (ANA) with a titre of 80 (normal <80) was detected in his serum. Liver blood tests were normal. In January 2004, the interferon therapy was interrupted because of elevated (<3· ULN) serum liver enzyme activities. EDSS was performed giving a result of 3.5. Two months later, glatiramer acetate in a dose of 20 mg once a day was initiated because of increasing disability of the patient (EDSS 4.5). In May 2004, he presented first in our clinic with malaise and jaundice which was associated with elevated serum liver enzyme activities (Table 1). There was no evidence of any metabolic, viral (hepatitis A, B C and E, HSV, VZV, EBV, CMV) or alcoholic diseases or bile duct obstruction. The patient had no medical history that might have predisposed him for developing AIH (e.g. nitrofurantoin and minocycline). His physical examination showed only a slightly enlarged liver without stigmata of chronic liver disease. Blood tests showed elevated serum alanine aminotransferase and bilirubin levels (Table). Immunological studies revealed a significantly elevated titre of 1,280 of ANA, while serum IgG and total immunoglobulin levels remained normal. Further serological markers of AIH including autoantibodies against F-Actin, SLA, LC, LKM and c-ANCA, p-ANCA, SMA, and AMA were all negative. Liver histology suggested a drug-induced liver-injury without fibrotic changes of the liver. The treatment with Copaxone was stopped. The liver tests returned to normal in four weeks. Any medication was stopped over the next 15 months after first episode of acute hepatitis. The liver serum tests were controlled monthly and remained within the normal range. The MS showed, however, an unfavourable course giving an EDSS score of 6.5. In November 2005, our patient re-presented with fever, uncharacteristic abdominal symptoms, and elevated serum liver enzyme activities (Table 1). There was no evidence of viral hepatitis or obstruction of bile ducts. At this stage, the diagnosis of autoimmune hepatitis (AIH) was made. Our patient was commenced on budesonide (Budenofalk Caps) 3 mg tid. The therapy led to a significant improvement of liver function tests. Subsequently, he was put on mycophenolate mofetil (CellCept ). Glatiramer acetate is reported to be well tolerated. Most commonly reported adverse events include local reactions on the injection site and transient postinjection systemic reactions. In the context with the treatment with glatiramer acetate, autoimmune diseases such as myasthenia gravis [2] and autoimmune thyreoiditis [3] have been reported. Significant liver complications including the development of AIH have not been previously published. In our case, the optimal response to immunosuppressive treatment, the presence of high-titre autoantibodies, the second exacerbation of hepatitis, and the association of AIH with MS, especially in males, [4, 5] argues against a drug-induced liver disease. Glatiramer acetate can induce T helper type 2 cells that cross-react with myelin basic protein [6]. These cells release cytokines like IL-4, IL-6, and IL-10 which therefore may enhance the production of autoantibodies [7] and lead to induction of autoimmune diseases in genetically predisposed patients. The commercial formulation of Copaxone contains mannitol that was recently identified as an immunoactive hapten capable of provoking anaphylaxis [8]. Mannitol may play a distinct role in the H. Neumann (&) Æ A. Csepregi P. Malfertheiner Dept. of Gastroenterology, Hepatology, and Infectious Diseases Otto-von-Guericke University Leipziger St. 44 39120 Magdeburg, Germany E-Mail: Helmut.Neumann@Medizin.UniMagdeburg.de

A ‘Double-Balloon Enteroscopy Worth the Money’: Endoscopic Removal of a Coin Lodged in the Small Bowel

Double-balloon enteroscopy (DBE) has become the standard endoscopic method to diagnose and treat disorders of the small bowel. The most common therapeutic applications of DBE are hemostasis, polypectomy and stricture dilation. DBE has also been used to place stents in the small bowel and to retrieve foreign bodies such as retained capsule endoscopes. In this report, we describe the removal of a coin that had remained lodged in the jejunum for 8 days.

Endoscopic examination of the small bowel: from standard white light to confocal endomicroscopy.

thorough endoscopic visualization of the small bowel mucosa is essential for reaching an accurate diagnosis and to btain targeted biopsies. Standard white light endoscopes perit gross examination of the small bowel mucosa (Figure A). hus, major defects such as erosions, ulcers, lymphangiectasias, r abnormal duodenal folds are easily recognized. The water mmersion technique increases our ability to inspect the small owel villi1 (Figure B). This technique can be very helpful when nvestigating conditions such as celiac disease or certain malbsorption syndromes.1 The introduction of magnification or oom endoscopy increased our ability to further analyze the ucosal details. Although initially used for the evaluation of arrett‘s esophagus and colonic polyps, this technique has also ound its way into the evaluation of small bowel diseases2 Figure C). By applying dyes and magnifying the mucosa (magification chromoendoscopy), further architectural detail of the ucosa can be elucidated.3 New dyeless or virtual chromoenoscopy techniques such as narrow band imaging (NBI) and ujinon intelligent color enhancement (FICE) have further enanced our optical capabilities for the evaluation of gut mucoal lesions.4 The use of filters inside of the endoscope (NBI) or ophisticated computer programs that manipulate the waveengths of the light of the captured image (FICE) results in irtual chromoendoscopic methods (dyeless chromoendoscopy) hat allow us to study the mucosal villi in great detail. By using he combination of magnification and virtual chromoendosopy, the structure and the microcapillary system of the villi can e nicely delineated (Figure D, NBI; Figure E, FICE). Recently, onfocal endomicroscopy was used to study the esophageal, tomach, and colon mucosa.5 The targeted structure is magnied in such a way that a virtual histology image of the mucosa in vivo histology) is achieved. We believe that in the near uture, confocal endomicroscopy might further help characterze and diagnose diseases affecting the small bowel such as eliac disease, Crohn’s disease, infections, vasculitis, mesenteric schemia, and angiodysplasias, among others.