John David Horwhat

A Randomized Comparison of Methylene Blue-Directed Biopsy Versus Conventional Four-Quadrant Biopsy for the Detection of Intestinal Metaplasia and Dysplasia in Patients With Long-Segment Barrett's Esophagus

OBJECTIVES:Methylene blue (MB) selectively stains specialized intestinal metaplasia (SIM) and may assist in surveying a columnar-lined esophagus for Barretts esophagus associated dysplasia.METHODS:This is a prospective, randomized crossover study comparing 4-quadrant random biopsies (4QB) versus MB-directed biopsies for the detection of SIM and dysplasia in 48 patients with long segment Barretts esophagus (LSBE). Patients randomly underwent two endoscopies over a 4-wk time period with either 4QB or MB-directed biopsies as their first or second exam. Our aim was to correlate stain intensity with histology.RESULTS:The sensitivity of MB for SIM and dysplasia was 75.2% and 83.1%, respectively. The yield of 4QB for identifying nondysplasia SIM was 57.6% (523/917) and for dysplasia was 12% (111/917). Dark staining was significantly associated with histologic grade (P < 0.007). The final diagnosis was correct in 43 (90%) patients using MB and in 45 (94%) using 4QB. The 4QB technique missed dysplasia in 3 of 21 patients while MB biopsies missed dysplasia in 5 of 21 patients. The discordance between the two techniques was not significant (P = 0.727, McNemars test). The mean number of biopsies taken during 4QB was 18.92 ± 6.36 and with MB was 9.23 ± 2.89 (P < 0.001).CONCLUSION:MB requires significantly fewer biopsies than 4QB to evaluate for SIM and dysplasia. Dark staining correlates more with HGD than LGD in our experience. While MB is not more accurate than 4QB, MB may help to define areas to target for biopsy during surveillance endoscopy in patients with LSBE.

Broken pancreas, broken heart.

Fulminant (peri)myocarditis is a very infrequent EIM of IBD and oft en presents with sudden-onset severe congestive heart failure (4,5) . Clinical presentation is variable, but in the 2 – 4 weeks before presentation, patients oft en have fl u-like (e.g., fevers, arthalgias and malaise) and gastrointestinal symptoms. Laboratory fi ndings may include leukocytosis, eosinophilia, and elevated levels of ESR, cardiac troponin, and C-reactive protein. Myocarditis in these patients appears not to correlate with disease activity (2,3) . Early recognition of myo(peri)carditis is crucial and needs prompt treatment. Treatment of fulminant disease includes aggressive inotropic support possibly accompanied by the placement of an intra-aortic balloon pump and / or a ventricular assist device. In conclusion, this case report demonstrates the occurrence of lymphocytic myocarditis in a patient with previously undiagnosed Crohn ’ s disease. It cannot be fully excluded that the myocarditis found in this patient was unrelated to his Crohn ’ s disease. However, the reported occurrence of perimyocarditis in Crohn ’ s disease in the absence of another explanation for the myocarditis strongly suggests that the two are related. Awareness of the possibility of this rare and potentially life-threatening EIM of IBD is therefore important.

Barrett's esophagus: surveillance and reversal.

The following on surveillance and reversal of Barretts esophagus (BE) includes commentaries on criteria for surveillance even when squamous epithelium stains normally with a variety of biomarkers; the long‐term follow‐up of surgery versus endoscopic ablation of BE; the recommended surveillance intervals in patients without dysplasia; the sampling problems related to anatomic changes following fundoplication; the value of tissue spectroscopy and optical coherence tomography; the cost‐effectiveness of biopsy protocols for surveillance; the quality of life of Barretts patients; and risk stratification and surveillance strategies.

M1105 Do All Patients With Barrett's Esophagus Require Twice Daily Proton Pump Inhibitor Therapy?

Predicting High-Grade Dysplasia (HGD) and Esophageal Adenocarcinoma (EAC) in Patients With Non-Dysplastic Barretts Esophagus (BE): Results From a Large, Multicenter Cohort Study Srinivas Gaddam, Patrick E. Young, Amy Wang, Ajay Bansal, Neil Gupta, Sachin B. Wani, Mandeep Singh, Vikas Singh, Keng-Yu Chuang, Vikram Boolchand, Hemanth Gavini, Priti Sud, John Kuczynski, April D. Higbee, Amit Rastogi, Sharad C. Mathur, Brooks D. Cash, Gary W. Falk, Richard E. Sampliner, Prateek Sharma

3506 COMPARISON OF CONTROLLED RADIAL EXPANSION BALLOON DILATORS TO CONVENTIONAL BALLOON DILATORS IN PATIENTS WITH BENIGN ESOPHAGEAL STRICTURES.

BACKGROUND: The current treatment of benign esophageal strictures often relies on the use of successively larger reusable Savary dilators or disposable balloon catheters. Recently, a new balloon catheter has been designed in which the balloon material has been preprogrammed to reach three successively larger sizes, depending upon the inflation pressure. This allows one balloon to provide dilatation to three different diameters (CRE TM balloon, Microvasive). AIM: To provide a prospective, multi-center, randomized comparison of the CRE TM balloon to a standard balloon dilator with regards to ease of use, complications, and effectiveness in patients with benign esophageal strictures. METHODS: A total of 60 patients were studied. Forty men and 20 women, mean age of 67 (range 24-87), with benign esophageal strictures were randomized based on stricture severity. At the time of entry, the two groups were comparable with regards to age, gender, history of previous dilatation, presence of esophagitis, use of antireflux medication, severity of dysphagia, and stricture severity. The mean lumen diameter prior to dilatation was 12.3 mm in the CRE TM group and the standard group was 12.7 mm. RESULTS: In comparing the effectiveness of the two groups, the dysphagia score within the first day was reduced by 3.5 in the CRE TM group vs. 2.6 in the standard group, p=0.07. Maximum dilatation obtained was 17.3 mm in the CRE TM group versus 17.1 mm in the standard group. Dilatation time was comparable, although the CRE TM balloon deflated more quickly than the standard, 6 versus 28 seconds. A slightly smaller number of CRE TM balloons were used per case than standard dilators, 1.2 versus 1.4. There was a trend in favor of the CRE TM balloon in regards to effectiveness at one month with an improvement in dysphagia score of 2.8 vs. 1.9 (p=0.07). CONCLUSIONS: The CRE TM balloon works at least as well as the standard balloon in dilatation of benign esophageal strictures. The CRE TM balloon allows dilatation to progressively larger diameters using a single catheter. There is a trend that suggests the CRE TM balloon might allow more effective dilatation with an increase in lumen size and reduction of symptoms. These trends should be explored in the context of a larger-scale randomized trial.