Hermano Gouveia

External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions

BACKGROUND Conventional endoscopy has low sensitivity, specificity, and interobserver agreement for the diagnosis of gastric atrophy, intestinal metaplasia, and dysplasia. Magnification chromoendoscopy (ME) may optimize the evaluation of premalignant gastric lesions. OBJECTIVE AND DESIGN As part of a multicenter trial, we aimed at validating a previously proposed classification for gastric methylene blue ME at a different center. SETTING, PATIENTS, AND INTERVENTIONS: A sample of patients (n = 42) with previously diagnosed chronic atrophic gastritis with or without intestinal metaplasia underwent ME (Pentax EG-3430Z) with 1% methylene blue by 2 endoscopists. MAIN OUTCOME MEASUREMENTS A simplified version of a previously published ME classification (group I, group II [further divided into subgroups IIE and IIF], and group III) was used for macroscopic lesions (n = 203) with Sydney-Houston and Vienna classifications being used for histologic analysis (n = 479 biopsy specimens). RESULTS AND LIMITATIONS Excellent reproducibility (wK = 0.92 [95% CI, 0.88-0.96]) was observed for classification in groups and substantial reproducibility (wK = 0.78 [95% CI, 0.72-0.84]) was found for classification in subgroups. Global validity was 82% (range 78%-86%), showing no false negatives (sensitivity of 100% [1/1 biopsy]) and a very low rate of false positives (specificity 99% [297/299 biopsies]) for dysplasia detection. CONCLUSIONS This classification for methylene blue ME was highly reproducible and valid for the diagnosis of premalignant gastric lesions when used in a center different from that involved in its conception. Despite requiring an unconventional endoscope and a longer procedure, these results could reinforce ME as a valuable technique in the surveillance of patients at risk for gastric cancer.

Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative

Background: The value of capsule endoscopy in the setting of inflammatory bowel disease type unclassified (IBDU) and indeterminate colitis (IC) remains obscure. The aim was to evaluate the clinical impact of capsule endoscopy on IBDU/IC patients with negative serology. Methods: Eighteen patients with long‐standing IBDU (n = 14) and IC (n = 4) were enrolled to undergo a capsule endoscopy and then followed prospectively. Lesions considered diagnostic of Crohns disease (CD) were 4 or more erosions/ulcers and/or a stricture. The median follow‐up time after capsule endoscopy was 32 ± 11 months (23–54 months). Results: Total enteroscopy was possible in all patients. In 2 patients the examination was normal (Group 1). In 9 patients subtle findings were observed (Group 2): focal villi denudation (n = 1) and fewer than 4 erosions/ulcers (n = 8). In 7 patients, 4 or more erosions/ulcers were detected (Group 3), leading to a diagnosis of CD. However, their treatment was not reassessed on the basis of the capsule findings. Until now, a definitive diagnosis has been achieved in 2 additional patients: 1 from Group 1 (ulcerative colitis) and another patient from Group 2 (CD), who began infliximab infusions. Nine patients remained indeterminate at follow‐up. Conclusions: Although capsule endoscopy enabled the diagnosis of CD in 7 patients, in none of them was the clinical management changed. Moreover, a change in therapy due to a diagnosis of CD was made for only 1 patient, who presented nonspecific findings. Our results suggest that capsule findings are not helpful in the work‐up of these patients. Inflamm Bowel Dis 2010

Small-Bowel Capsule Endoscopy in Patients with Suspected Crohn's Disease—Diagnostic Value and Complications

Background. The aim of this work was to assess the value of capsule enteroscopy in the diagnosis of patients with suspected Crohns Disease (CD). Methods. This was a retrospective study in a single tertiary care centre involving patients undergoing capsule enteroscopy for suspected CD. Patients taking nonsteroidal anti inflammatory drugs during the thirty preceding days or with a follow-up period of less than six months were excluded. Results. Seventy eight patients were included. The endoscopic findings included mucosal breaks in 50%, ulcerated stenosis in 5%, and villous atrophy in 4%. The diagnosis of CD was established in 31 patients. The sensitivity, specificity, positive and negative predictive value of the endoscopic findings were 93%, 80%, 77%, and 94%, respectively. Capsule retention occurred in four patients (5%). The presence of ulcerated stenosis was significantly more frequent in patients with positive inflammatory markers. The diagnostic yield of capsule enteroscopy in patients with negative ileoscopy was 56%, with a diagnostic acuity of 93%. Conclusions. Small bowel capsule endoscopy is a safe and valid technique for assessing patients with suspected CD. Capsule retention is more frequent in patients with positive inflammatory markers. Patients with negative ileoscopy and suspected CD should be submitted to capsule enteroscopy.

URGENT CAPSULE ENDOSCOPY IS USEFUL IN SEVERE OBSCURE-OVERT GASTROINTESTINAL BLEEDING

Aim:  With capsule endoscopy (CE) it is possible to examine the entire small bowel. The present study assessed the diagnostic yield of CE in severe obscure‐overt gastrointestinal bleeding (OOGIB).

Virtual chromoendoscopy can be a useful software tool in capsule endoscopy

BACKGROUND capsule endoscopy (CE) has revolutionized the study of small bowel. One major drawback of this technique is that we cannot interfere with image acquisition process. Therefore, the development of new software tools that could modify the images and increase both detection and diagnosis of small-bowel lesions would be very useful. The Flexible Spectral Imaging Color Enhancement (FICE) that allows for virtual chromoendoscopy is one of these software tools. AIMS to evaluate the reproducibility and diagnostic accuracy of the FICE system in CE. METHODS this prospective study involved 20 patients. First, four physicians interpreted 150 static FICE images and the overall agreement between them was determined using the Fleiss Kappa Test. Second, two experienced gastroenterologists, blinded to each other results, analyzed the complete 20 video streams. One interpreted conventional capsule videos and the other, the CE-FICE videos at setting 2. All findings were reported, regardless of their clinical value. Non-concordant findings between both interpretations were analyzed by a consensus panel of four gastroenterologists who reached a final result (positive or negative finding). RESULTS in the first arm of the study the overall concordance between the four gastroenterologists was substantial (0.650). In the second arm, the conventional mode identified 75 findings and the CE-FICE mode 95. The CE-FICE mode did not miss any lesions identified by the conventional mode and allowed the identification of a higher number of angiodysplasias (35 vs 32), and erosions (41 vs. 24). CONCLUSIONS there is reproducibility for the interpretation of CE-FICE images between different observers experienced in conventional CE. The use of virtual chromoendoscopy in CE seems to increase its diagnostic accuracy by highlighting small bowel erosions and angiodysplasias that weren´t identified by the conventional mode.

Capsule endoscopy assisted by traditional upper endoscopy

BACKGROUND AND AIMS Capsule endoscopy (CE) can be prevented by difficulties in swallowing the device and/or its gastric retention. In such cases, endoscopic delivery of the capsule to duodenum is very useful. We describe the indications and outcomes of cases in which traditional endoscopic techniques allowed placement of the capsule in duodenum. PATIENTS AND METHODS This is a retrospective, descriptive case series. All patients in the above conditions were identified and indications for CE, endoscopic-placement technique, complications and completeness of small bowel imaging were registered. RESULTS Endoscopic-assisted delivery of the capsule was necessary in 13 patients (2.1% of all CE; 7 males; mean age--47.9 +/- 24.9 years, range 13 to 79 years). Indications for endoscopic delivery included: inability to swallow the capsule (7), gastric retention in previous exams (3), abnormal upper gastrointestinal anatomy (3). In eight patients, the capsule was introduced in GI tract with: foreign body retrieval net alone (3), retrieval net and a translucent cap (2), prototype delivery device (2) or a polypectomy snare (1). Five patients ingested the capsule that was then placed in duodenum with a polypectomy snare (3) or a retrieval net (2). No major complications occurred. Complete small bowel examination was possible in 10 patients (77%). CONCLUSIONS Endoscopic placement of capsule endoscope in the duodenum is rarely needed. However it may be safely performed by different techniques avoiding some limitations of CE. The best methods for endoscopic delivery of the capsule in the duodenum seem to be retrieval net with a translucent cap when the patient is unable to swallow the device or a retrieval net only to capture the capsule in the stomach when the patients swallows it easily.

Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding

BACKGROUND in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. AIMS evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. RESULTS with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. CONCLUSIONS intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

Successful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

which there is little agreement on the best therapeutic option (1-5). A 47-years-old male, with alcoholic liver cirrhosis (Child-Pugh class C; MELD 29) and previous oesophageal varices bleeding, was admitted for profuse hematochezia. He was tachycardic, hypotensive and had haemoglobin 2,7 g/dl. Fluid and blood resuscitation, intravenous octreotide, ciprofloxacin and PPI were promptly started. Emergent upper gastrointestinal endoscopy (UGIE) revealed scarce fresh blood in the stomach and grade II oesophageal varices with red signs, which were thought to be the source of bleeding and treated with endoscopic banding. As hemodynamic instability and hematochezia persisted, UGIE was repeated with similar findings and no bleeding was identified on angiography. At 48 h from admission massive rebleeding occurred and a 3rd UGIE showed a fresh clot-over-varix located at 2nd to 3rd portions of duodenum (Fig. 1). Injection of the varix with 1 cc of lipiodol and cyanoacrylate 1:1 mixture was performed (Fig. 2), but spurting began soon after the procedure. Given the high surgical risk, yet another endoscopic approach was decided and successful 1ring banding was accomplished (Fig. 3). A 3rd-day UGIE showed a clean, shallow ulcer at the site of the varix (Fig. 4). No rebleeding episodes occurred. Several authors reported endoscopic banding for bleeding duodenal varices (1-4), sometimes followed by other therapies for rebleeding (3,4). Others used cyanoacrylate for emergent treatment of this condition (5), including after banding failure (3). This is, to our knowledge, the first report in which banding was apSuccessful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

Meningitis in a patient with previously undiagnosed Crohn's disease

To the Editor: Crohn’s disease (CD) is a chronic inflammatory bowel disease with variable clinical presentation. An aggressive fistulizing pattern is possible and over one-third of CD patients will experience recurring fistulas during their disease course.1 Fistulization is a manifestation of the transmural nature of this disease,2 but fistulas to the epidural space are quite unusual.3 Herein we report a case of a male patient who presented to the medical emergency department with meningitis. Physical examination revealed multiple perianal and an abdominal fistula and subsequent complementary studies confirmed the presence of CD. A 26-year-old man was admitted to the emergency room because of high fever, severe headache, acute confusion, nausea, and vomiting. On admission his body temperature was 39°C, heart rate 120, respiratory rate 16, and blood pressure 103/55 mmHg. On physical examination the patient was confused, not oriented to person, place, or time. Kerning and Brudzinski signs were present but no Babinski or clonus. Ophthalmologic examination revealed papilloedema. There was no otitis, pharyngitis, or sinusitis and heart/lung examination was normal. Abdominal and pelvic examination revealed a large abdominal cutaneous fistula in the lower right quadrant and multiple perianal fistulas. Laboratory results upon admission showed leukocytosis (WBC of 23.2 G/L with 92% of PMN), thrombocytosis (689 G/L), and increased C-RP levels (20 mg/dL to a normal of 1 mg/dL). A head computed tomography (CT) scan revealed diffuse cerebral edema and lumbar punction was not performed initially. The patient was given, empirically, intravenous meropenem, vancomycin, and metronidazole. Two days later a lumbar puncture was unsuccessfully tried. Since the clinical symptoms and signs were highly suggestive of meningitis and the patient was recovering very well with antibiotic treatment the lumbar puncture was deemed dispensable. When the patient recovered he revealed that the perianal fistulas appeared 7 years ago and the abdominal fistula in the last 6 months but he hid this findings from his family and never sought medical help. A certain degree of mental impairment was obvious. After full recovery, a colonoscopy was performed and revealed severe inflammation of the rectum with a small orifice at the posterior wall corresponding, probably, to a fistulous tract. A similar process of severe inflammation was also present at the terminal ileum. Endoscopic and histologic findings were compatible with CD. Severe transmural

An Unusual Endoscopic Image of a Submucosal Angiodysplasia

Obscure gastrointestinal bleeding is responsible for 2–10% of the cases of digestive bleeding. Angiodysplasia is the most common cause. The authors report a case of a 70-year-old female patient admitted to our Gastrointestinal Intensive Care Unit with a significant digestive bleeding. Standard upper and lower endoscopy showed no abnormalities, and we decided to perform a capsule enteroscopy that revealed a submucosal nodule with active bleeding in the jejunum. An intraoperative enteroscopy confirmed the presence of a small submucosal lesion with a central ulceration, and subsequently a segmental enterectomy was performed. Surprisingly, the histopathological diagnosis was angiodysplasia. The patient remains well after a two-year period of follow-up. We present this case of obscure/overt gastrointestinal bleeding to emphasize the role of capsule and intraoperative enteroscopy in the evaluation of these situations, and because of the unusual endoscopic appearance of the angiodysplasia responsible for the hemorrhage.