Joana Silva

What is the long-term outcome of a negative capsule endoscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND AND AIMSnThere are contradictory findings regarding long-term outcome in patients with obscure gastrointestinal bleeding and negative capsule endoscopy. Factors associated with rebleeding after a negative videocapsule are not entirely known.nnnOBJECTIVEnThe aim of this study was to compare the rebleeding rate between negative and positive capsule endoscopy patients and to identify predictive factors for rebleeding in patients with negative findings.nnnMATERIAL AND METHODSnConsecutive patients with obscure gastrointestinal bleeding referred to a single center over a period of 5 years were identified. After exclusion of patients with a follow time < 6 months, 173 patients were included. Clinical information was retrospectively collected from medical records. Rebleeding was defined as evidence of melena/hematochezia, a drop in hemoglobin of ≥ 2 g/dL, or the need for transfusion 30 days after the index episode.nnnRESULTSnThe mean age was 61.7 years and 60% were female. The median follow up time was 27 months. Most patients were referred for occult gastrointestinal bleeding (67.1%) while 32.9% were referred for overt bleeding. More than 50% of the patients had negative capsule endoscopy. The rebleeding rate in negative capsule endoscopy is 16%, with a mean follow-up time of 25.8 months and is significantly lower than positive capsule endoscopy (16% vs. 30.2%, p = 0.02). Rebleeding after negative capsule endoscopy is higher in patients who need more transfusions of packet red blood cells before capsule endoscopy (3.0 vs. 0.9, p = 0.024) and have overt bleeding (46% vs. 13.9%, p = 0.03). In 53% of these patients, rebleeding occurs > 12 months after a negative capsule endoscopy.nnnCONCLUSIONSnPatients with obscure gastrointestinal bleeding and a negative capsule endoscopy had a significantly lower rebleeding rate and can be safely followed. However, a higher transfusion of red blood cells previous to capsule endoscopy and an overt bleeding are associated with a higher rebleeding. So, it is reasonable to consider that these patients may benefit of at least one year of follow-up.

The Importance of Alternative Diagnostic Modalities in the Diagnosis of Small Bowel Tumors After a Negative Capsule Endoscopy

Capsule endoscopy is widely accepted as the preferred diagnostic test in the evaluation of small bowel diseases, especially in the setting of obscure gastrointestinal bleeding. It has revolutionized small bowel examination and has improved the detection of small bowel tumors. However, small bowel tumors are sometimes missed by capsule endoscopy. Furthermore, there are several recent reports comparing capsule endoscopy with other diagnostic modalities, such as double balloon enteroscopy and CT/RM enterography, that challenge the reportedly high negative predictive value of capsule endoscopy in detecting small bowel tumors. We report the case of a patient with overt obscure gastrointestinal bleeding due to a gastrointestinal stromal tumor diagnosed by CT enterography after two negatives capsule endoscopies. This case shows that capsule endoscopy may overlook significant life threatening lesions and highlights the importance of using other diagnostic modalities after a negative capsule endoscopy, especially in patients with a high index of suspicion for small bowel tumoral pathology or persistent/recurrent bleeding.

Risk factors for polyp retrieval failure in colonoscopy

Introduction Colonoscopy is able to diagnose, resect and retrieve colonic polyps. Although retrieval of resected polyps is still globally advised, it is not always successful. We aimed to define the risk factors for polyp retrieval failure in colonoscopy. Methods A single-center, retrospective study assessed 3507 consecutive and non-urgent colonoscopies, performed between September 2011 and December 2012. Colonoscopies were included in our analysis if the diagnosis of at least one polyp was established, and one or more snare polypectomies were performed. Demographic and technical data were collected according to the patient’s endoscopy report. Results A total of 1109 polyps were analyzed, corresponding to 496 colonoscopies from 483 different patients. We found that 53 (4.8%) of the resected polyps were not retrieved. In a univariate analysis, the factors associated with polyp retrieval failure were: age, polyp size, resection technique, bowel preparation, location and the presence of a previous colorectal surgery (pu2009<u20090.05). In the multivariate analysis, a previous colorectal surgery, resection by cold snare, location in the right colon, inadequate bowel preparation and a polyp size up to 5u2009mm were independently associated with higher polyp retrieval failure (pu2009<u20090.05). Discussion Different and well-defined factors were associated with polyp retrieval failure. Because bowel preparation was the only modifiable factor identified, a special focus should be given to this topic.

Impact of Histological and Endoscopic Remissions on Clinical Recurrence and Recurrence-free Time in Ulcerative Colitis

Background: Clinical and endoscopic remissions constitute the therapeutic goals in ulcerative colitis (UC). Histological healing is currently not a target in UC. This study aims to determine the impact of the definition of endoscopic remission (Mayo endoscopic subscore [MSe] 0–1) and histological activity in the recurrence of UC and recurrence-free survival time. Methods: Patients with UC in clinical remission (partial Mayo score ⩽ 1) and endoscopic remission (MSe ⩽ 1) who underwent colonoscopy with biopsies between March 2010 and December 2013 were included. The validated Nancy score was used to evaluate histological activity, which considers inactivity if 0 to 1 and activity if 2 to 4. The recurrence-free time was evaluated and recurrence was defined as partial Mayo score ≥ 2, therapy to induce remission, hospitalization, or colectomy. Predictive factors associated with recurrence and time to recurrence were determined. Results: Sixty patients were included; 58.3% (n = 35) were women, with a mean age of 52.7 years. MSe = 1 was observed in 46.7% (n = 28) and histological activity in 38.3% (n = 23). Clinical recurrence occurred in 31.7% (n = 19) of patients, with a cumulative risk of 17.1%/24.5%/26.7%/40.1% at 12/24/36/48 months, respectively. MSe = 1 (P = 0.02) and histological activity (P = 0.007) were significantly associated with recurrence. Of these, only histological activity (P = 0.03) was an independent predictive factor of recurrence. Patients with MSe = 1 (P = 0.02) and with histological activity (P = 0.01) had a significantly shorter recurrence-free time in univariate analysis. In multivariate analysis, only histological activity (P = 0.02) was an independent predictive factor of lower recurrence-free time. Conclusion: The presence of histological activity represents an independent predictive factor of recurrence and time to recurrence, which was not verified with MSe 0 to 1.

Balloon overtube-assisted stenting in difficult upper and lower gastrointestinal locations using a modified over-the-wire technique.

In this series of four patients, some modifications of the standard over-the-wire (OTW) technique for stent deployment using the balloon overtube normally used in single-balloon enteroscopy are presented. This modified technique allowed the use of OTW stents in patients where there were difficulties that meant the standard technique was unsuccessful. For each patient, the authors describe different small novel adaptations of this modified technique that enabled self-expanding metal stents (SEMSs) and biodegradable stents to be successfully deployed in different gastrointestinal locations. Moreover, in one patient the stent was placed without fluoroscopic guidance.

Resection of a large ileal lipoma exhibiting ball-valve prolapse into the cecum with a "grasp-to-retract, ligate, unroof, and let-go" technique.

A 51-year-old woman was referred to our department for endoscopic resection of a symptomatic ileal lipoma, which had been detected during a previous colonoscopy performed to investigate a 6-month historyof intermittent episodes of abdominal pain and diarrhea. Colonoscopy revealed a large, yellowish, pseudo-pedunculated ileal lesion with normal overlying mucosa that was prolapsed through the ileocecal valve into the cecum (● Fig.1). Because of retraction of the lipoma into the terminal ileum with manipulation (● Fig.2,● Video 1), a two-channel therapeutic colonoscope (CF-2T160I; Olympus America, Center Valley, Pennsylvania, USA) was used. The lipoma was pulled toward the ascending colon with a grasping forceps while an endoloop (MAJ-254; Olympus), previously placed over the forceps, was positioned and tightened around its base (● Fig.3,● Video 1). Endoloop ligation resulted in congestion of the mucosa and the extrusion of fat – the “naked fat” sign (● Fig.4,● Video 1). Subsequently, unroofing was accomplished by snare resection of the top of the tumor (● Fig.5,● Video 1), histopathologic examination of which confirmed the clinical diagnosis. At follow-up colonoscopy 2 months later, the patient was asymptomatic, and a scar with no residual lesion was found (● Fig. 6). Lipomas account for 21.4% of all benign small-bowel tumors and are located Fig.3 Endoscopic image depicting the use of a grasping forceps to pull the lipoma toward the ascending colon, allowing placement of the endoloop. Fig.1 Endoscopic image of an ileal submucosal lesion with a normal overlying mucosa. The lesion has prolapsed through the ileocecal valve into the cecum. Fig.2 Endoscopic image showing retraction of the lipoma into the terminal ileum.

Endoscopic resection as a treatment for duodenal gangliocytic paraganglioma

An 80-year-old man was referred to our department due to a duodenal mass found on upper endoscopy, performed for evaluation of ferropenic iron anemia. History taking revealed no particular issues other than antihypertensive medication. He had no abdominal pain, weight or blood loses and his physical examination was uneventful. Laboratory blood tests revealed a hemoglobin of 9.3 g/dl, serum iron of 21 g/dl, ferritin of 12.3 ng/ml and transferrine of 9.1%. In our department, endoscopic re-evaluation showed, immediately proximal to the ampulla, a 3 cm pedunculated and ulcerated subepithelial lesion (Fig. 1). Endoscopic ultrasound (EUS) revealed a well-circumscribed, homogeneous and hypoechoic mass with origin in the submucosal layer, with no lymph nodes (Fig. 2). No lymph node or other organ affection was found on abdominal and pelvic CT. After a multidisciplinary discussion an endoscopic approach was decided. A snare polypectomy was performed (Fig. 3) and the histopathological and immunochemical evaluation revealed a gangliocytic paraganglioma (GP). No evidence of endoscopic and histological recurrence was observed on follow-up EGD after one year. No iron deficiency was present at this time. GP is a rare submucosal tumor that occurs most frequently in the second portion of the duodenum, near the ampulla of Vater. The most common clinical manifestation is gastrointestinal bleeding (45.1%), followed by abdominal pain (42.8%) and anemia (14.5%).1 There are no endoscopic or echoendoscopic pathognomonic findings of GP. The most common endoscopic features of GPs, such as ulcerations and the presence of a peduncle are also present in other types of submucosal tumors of the duodenum.2 In endoscopic ultrasound (EUS),

Reevaluation of Self-Expanding Metal Stents as a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction: Six Years Experience

Introduction Self-expanding metal stents (SEMS) as a bridge to surgery have been used as an alternative for acute malignant left-sided colonic obstruction. However, the benefits are uncertain. The European Society of Gastrointestinal Endoscopy no longer recommends their use in patients with low surgical risk because of the risk of tumor recurrence. Methods Patients admitted for acute malignant left-sided colonic obstruction who underwent SEMS as a bridge to elective surgery or urgent surgery were retrospectively evaluated. Postoperative morbidity/mortality, stent complications and survival were recorded. Our aim was to compare the outcome between preoperative SEMS and direct emergent surgery in acute left-sided malignant colonic obstruction. Results 42 patients were included (SEMS group: 27 and surgery group: 15). There were no differences between groups in relation to age, ASA classification and tumor stage. The technical success of SEMS was 88.9% and the clinical success was 85.2%. There were three SEMS related perforations. In the surgery group, the stoma rate was higher (86.7% vs 25.9%, p < 0.001) and there was a trend for a lower length of hospital stay (18.9 days vs 26.3 days, p = 0.051). SEMS verses surgery group: There were no differences in the rate of temporary stoma (57.1% vs 61.5%, p = 0.84), definitive stoma (42.8% vs 38.5%, p = 0.84), success of primary anastomosis (86.7% vs 66.7%, p = 0.22) and Clavien–Dindo classification (≥III: 36% vs 58.2% p = 0.24). Overall survival at 1/5 years was identical in the two groups 100%/56% in the SEMS group vs 93%/43% in the surgery group, p = 0.14), as well as tumor recurrence at 3/5 years (24%/50% vs 20%/36% respectively, p = 0.68). Conclusions SEMS are associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival and recurrence between the groups.

Argon plasma coagulation of a bleeding angioectasia in a jejunal diverticulum by single-balloon enteroscopy.

An 86-year-old woman with a history of cardiac and chronic renal failure was referred to our gastroenterology outpatient clinic because of an iron deficiency anemia and intermittent, self-limited hematochezia episodes. Colonoscopy and upper endoscopy revealed no alterations. A capsule endoscopy showed a nonbleeding angioectasia in the proximal ileum. Single-balloon enteroscopy was proposed to treat the angioectasia. During the procedure, a large jejunal diverticulum with a bulky clot was seen in the proximal jejunum (● Fig.1). The clot was removed afterwater irrigation, andanoozingbleeding was found from an angioectasia located in the fundus of the diverticulum (● Fig.2). Distal tattooing was performed. Bleeding was then controlled with combination therapy: first a submucosal epinephrine injection (● Fig.3) followed by argon plasma coagulation (APC) of the angioectasia (● Fig.4). No immediate or delayed complications were recorded, and there was no recurrence of bleeding during 1 year of follow-up. Small-bowel diverticula are a rare condition usually characterized by mucosal and submucosal herniation through the muscular layer on the mesenteric border [1]. Although they are usually asymptomatic, malabsorption, abdominal discomfort, obstruction, bloating, bleeding, or perforation may occur [2]. Currently, capsule enteroscopy and device-assisted enteroscopy are the mainstays for diagnosis [3]. Small-bowel angioectasias are a common cause of obscure gastrointestinal bleeding, mostly in the elderly. APC by device-assisted enteroscopy has been shown to be effective and safe in the management of small-bowel angioectasias [4]. Identification of a bleeding angioectasia in a jejunal diverticulum is an exceptional finding. The risk of diverticular perforation after APC may be increased. To the best of our knowledge, this is the first case report of APC by single-balloon enteroscopy in a bleeding angioectasia located in a jejunal diverticulum.

Grasp-to-retract modification of the tulip-bundle technique in forward and retroflexed position for difficult hemostatic therapy in the sigmoid colon

A 60-year-old woman with no relevant medical history underwent endoscopic mucosal resection (EMR) of a 7-cm 0-Is lesion in the distal sigmoid colon. A solution of saline, indigo carmine, and 1/100 000 adrenaline was injected into the submucosa, and piecemeal snare resection was performed (● Fig.1). Persistent oozing occurred during EMR and was partially controlled by subsequent submucosal injections and resections. After complete resection, a 4×4cm mucosal defect over a colonic fold could be seen, with diffuse oozing but no visible vessels. The defect was closed using hemostatic clips, but diffuse oozing persisted between the clips (● Fig.2). Attempts to place a detachable snare (MAJ-254; Olympus, Tokyo, Japan) underneath the clips, in order to perform the tulip-bundle technique, were unsuccessful because of the large diameter of the defect with clips and its position over the fold (● Fig.3, ● Video 1). Therefore, a double-channel colonoscope (GIF 2T160I; Olympus) was used, and a grasping forceps was used to retract the defect while the detachable snare was positioned underneath the clips, resulting in immediate hemostasis (● Fig.4,● Video 2). Despite initial hemostasis, the patient presented with hematochezia 4 hours later. Recurrent oozing from the proximal border of the mucosal defect, which had not been entrapped by the detachable snare, was observed and could not be Fig.3 Attempts to place a detachable snare underneath the clips, in order to perform the tulip-bundle technique, were unsuccessful because of the large diameter of the defect with clips and its position over the colonic fold. Fig.2 After complete resection, a 4×4cm mucosal defect over a colonic fold was apparent, with diffuse oozing but no visible vessels. The defect was closed using hemostatic clips, but diffuse oozing persisted between the clips. Fig.1 Endoscopic mucosal resection of a 7-cm, type 0-Is lesion in the distal sigmoid colon.