Joseph W. Leung

Urgent Colonoscopy for Evaluation and Management of Acute Lower Gastrointestinal Hemorrhage: A Randomized Controlled Trial

OBJECTIVES:We hypothesized that early intervention in patients with lower gastrointestinal bleeding (LGIB) would improve outcomes and therefore conducted a prospective randomized study comparing urgent colonoscopy to standard care.METHODS:Consecutive patients presenting with LGIB without upper or anorectal bleeding sources were randomized to urgent purge preparation followed immediately by colonoscopy or a standard care algorithm based on angiographic intervention and expectant colonoscopy.RESULTS:A total of 50 patients were randomized to each group. A definite source of bleeding was found more often in urgent colonoscopy patients (diverticula, 13; angioectasia, 4; colitis, 4) than in the standard care group (diverticula, 8; colitis, 3) (the odds ratio for the difference among the groups was 2.6; 95% CI 1.1–6.2). In the urgent colonoscopy group, 17 patients received endoscopic therapy; in the standard care group, 10 patients had angiographic hemostasis. There was no difference in outcomes among the two groups—including: mortality 2% versus 4%, hospital stay 5.8 versus 6.6 days, ICU stay 1.8 versus 2.4 days, transfusion requirements 4.2 versus 5 units, early rebleeding 22% versus 30%, surgery 14%versus 12%, or late rebleeding 16% versus 14% (mean follow-up of 62 and 58 months).CONCLUSION:Although urgent colonoscopy identified a definite source of LGIB more often than a standard care algorithm based on angiography and expectant colonoscopy, the approaches are not significantly different with regard to important outcomes. Thus, decisions concerning care for patients with acute LGIB should be based on individual experience and local expertise.

A proof-of-principle, prospective, randomized, controlled trial demonstrating improved outcomes in scheduled unsedated colonoscopy by the water method

BACKGROUNDnAn observational study in veterans showed that a novel water method (water infusion in lieu of air insufflation) enhanced cecal intubation and willingness to undergo a repeat scheduled unsedated colonoscopy.nnnOBJECTIVEnTo confirm these beneficial effects and significant attenuation of discomfort in a randomized, controlled trial (RCT).nnnDESIGNnProspective RCT, intent-to-treat analysis.nnnSETTINGnVeterans Affairs ambulatory care facility.nnnPATIENTSnVeterans undergoing scheduled unsedated colonoscopy.nnnINTERVENTIONSnDuring insertion, the water and traditional air methods were compared.nnnMAIN OUTCOME MEASUREMENTSnDiscomfort and procedure-related outcomes.nnnRESULTSnEighty-two veterans were randomized to the air (n = 40) or water (n = 42) method. Cecal intubation (78% vs 98%) and willingness to repeat (78% vs 93%) were significantly better with the water method (P < .05; Fisher exact test). The mean (standard deviation) of maximum discomfort (0 = none, 10 = most severe) during colonoscopy was 5.5 (3.0) versus 3.6 (2.1) P = .002 (Student t test), and the median overall discomfort after colonoscopy was 3 versus 2, P = .052 (Mann-Whitney U test), respectively. The method, but not patient characteristics, was a predictor of discomfort (t = -1.998, P = .049, R(2) = 0.074). The odds ratio for failed cecal intubation was 2.09 (95% CI, 1.49-2.93) for the air group. Fair/poor previous experience increased the risk of failed cecal intubation in the air group only. The water method numerically increased adenoma yield.nnnLIMITATIONSnSingle site, small number of elderly men, unblinded examiner, possibility of unblinded subjects, restricted generalizability.nnnCONCLUSIONSnThe RCT data confirmed that the water method significantly enhanced cecal intubation and willingness to undergo a repeat colonoscopy. The decrease in maximum discomfort was significant; the decrease in overall discomfort approached significance. The method, but not patient characteristics, was a predictor of discomfort. (Clinical trial registration number NCT00747084).

Proximal migration of biliary stents: Attempted endoscopic retrieval in forty-one patients

BACKGROUNDnProximal migration of a biliary stent is an uncommon event, but its management can present a technical challenge to the therapeutic endoscopist.nnnMETHODSnWe reviewed the methods that have been used for retrieval of proximally migrated biliary stents in a referral endoscopy center.nnnRESULTSnForty-four cases were identified; 38 stents (86%) were extracted successfully. Half of the stents were retrieved after first passing a guide wire through the stent lumen. Various accessories were then used to withdraw the stents, the Soehendra device being the most popular. Nearly one third were retrieved by grasping the stents directly, usually with a wire basket or forceps. The remainder were recovered after using a stone retrieval balloon alongside the stents to provide traction indirectly. Interventional radiology techniques were needed in two cases, and surgery in one.nnnCONCLUSIONSnCannulating the stent lumen with a wire is often the best approach in patients with a biliary stricture or a nondilated duct. An over-the-wire accessory can then be used to secure the stent. In patients with a dilated duct, indirect traction with a balloon or direct grasping of the stent with a wire basket, snare, or forceps is usually successful. Using these techniques, most proximally migrated biliary stents can be retrieved endoscopically.

Diagnostic utility of K-ras mutational analysis on bile obtained by endoscopic retrograde cholangiopancreatography

BACKGROUNDnBecause K-ras oncogene mutations are present in more than 90% of pancreaticobiliary tumors, we tested prospectively whether K-ras mutational analysis of bile samples obtained during ERCP was superior to conventional bile cytology for diagnosis of malignancy.nnnMETHODSnBile samples from 20 patients undergoing ERCP for evaluation of jaundice were examined by both cytologic study and the polymerase chain reaction for the presence of K-ras oncogene mutations.nnnRESULTSnPolymerase chain reaction products were amplified from the bile of 8 of 12 patients with malignancy and 3 of 8 with benign disease; K-ras oncogene mutations were present in 4 of 8 polymerase chain reaction products from malignant samples but absent in all 3 from benign samples. No cytologic results were positive for malignancy.nnnCONCLUSIONSnBile obtained during ERCP can yield positive results in K-ras mutational analysis, even when results of conventional bile cytology are negative. In this study, K-ras mutational analysis had a sensitivity of 33% (4 of 12), a specificity of 100%, and a positive predictive value of 100% for diagnosis of malignancy.

Advanced Digestive Endoscopy: ERCP

This book, edited by Peter Cotton and Joseph Leung, is the latest comprehensive review of ERCP techniques and their applications. Apart from the two editors, whose expertise in this area is universally acknowledged, many other worldwide specialists have contributed to it. The idea of having a print version as well as an ‘e-book’ version reflects the acceleration of our world, with the need for continuous updating. The necessity for such a review is underlined by the growing demands concerning ERCP training and acquiring competence in this area. As a gastroenterologist being trained in ERCP myself, I perceived this book from that viewpoint.

An in vitro, randomized, prospective study to maximize cellular yield during bile duct brush cytology.

Endoscopic retrograde brush cytology is useful for the evaluation of biliary strictures. Access across a stricture can be maintained by removing the cytology brush while leaving the sheath in the bile duct. We examined the potential for loss of diagnostic cellular material in this setting using the canine biliary system. Twenty consecutive samples were randomly collected by (1) pushing the brush from the end of the sheath or (2) pulling the brush through the length of the sheath. Slides prepared from cell suspensions were scored by a cytopathologist blinded to the collection method. Pulling the brush resulted in a significant loss of cellular material (p < 0.001). In a second phase, 23 consecutive samples were randomly obtained in the same fashion. Combining salvage cytology of material from the sheath with cytology of the pulled-brush specimens produced cellular yields similar to those of specimens obtained by pushing the brush from the sheath. If the brush is pulled from the sheath during bile duct brush cytology, we suggest that salvage cytology be performed in order to maximize the diagnostic sensitivity.

Acute Cardiovascular Complications of Endoscopy: Prevalence and Clinical Characteristics

We sought to determine the prevalence of acute cardiovascular complications of endoscopy and to describe the clinical features associated with such events. Acute cardiovascular complications were identified from a computerized database of all endoscopies performed at our institution, and their clinical histories were abstracted from the medical records. Of 21,946 endoscopic procedures performed between August 1, 1988, and December 31, 1992, 9 women and 22 men (0.14%) developed acute cardiovascular complications including vasovagal reaction (24), supraventricular tachycardia (4), myocardial infarction (2) and congestive heart failure (1). Fourteen patients had underlying coronary artery disease and 4 others exertional angina; 20 of 25 electrocardiograms available before the endoscopy were abnormal. Twenty patients required treatment during endoscopy, but only 3 needed continued therapy. One patient died of a periprocedural acute myocardial infarction. Seven (23%) patients experienced additional cardiac events during the follow-up period of 21.8 +/- 15.8 months. In conclusion, acute cardiovascular complications of endoscopy are infrequent and usually self-limited; serious complications occurred exclusively in the setting of known underlying heart disease.

Involvement of Luminal Bacteria, Heat Shock Protein 60, Macrophages and γδ T Cells in Dextran Sulfate Sodium-Induced Colitis in Rats

The in vivo immunological events in dextran sulfate sodium (DSS) -induced colitis were evaluated. Rats were fed water (control) or 5% DSS. Colonic sections were assessed by light microscopy, Gram stain, immunohistochemistry, and electron microscopy. A progressive decline in number and increase in fragmentation of bacteria in the colonic lumen was observed over time. Luminal bacteria were the first to show heat shock protein 60 (HSP60) staining (day 3). Macrophages in close proximity to these bacteria were next to show such staining (day 6), and finally the damaged epithelial cells when colitis became severe (day 15). Ultrastructural assessment showed cell–cell contact interactions between macrophages and dendritic γδ T cells. An increase in the number of γδ T cells and ED1-positive macrophages in the affected colonic tissue over time was documented. These results suggest colonic bacteria, host macrophages, and γδ T cells play specific roles in the immunological reactions in DSS-induced colitis, possibly via an HSP60-mediated mechanism.

Case report: Annular pancreas divisum—a report of two cases and review of the literature

Annular pancreas divisum is a rare congenital variant of pancreatic anatomy which may cause symptoms of gastric outlet obstruction and recurrent pancreatitis. It is diagnosed by endoscopic retrograde pancreatography. We present two cases of this condition and review the literature.

Case of the month: "Air-in a view"

A 57-year-old female was referred to Duke University Medical Center (DUMC) for investigation of recurrent pancreatitis. Her first episode of pancreatitis, which had occurred 3 years earlier, manifested as epigastric pain and a markedly elevated serum amylase level which necessitated hospital admission for 9 days. Her history was negative for relevant pancreatic risk factors including alcohol abuse, medications, family history and hyperlipidaemia. Ultrasound (US) of the gallbladder showed no gallstones. CT of the abdomen showed a swollen head of pancreas with peri-pancreatic inflammatory change and fluid, consistent with pancreatitis. The biliary tree was not dilated. She made a complete recovery and was well until 8 months later when she had recurrent epigastric pain of a similar character with elevation of the serum amylase. She was admitted to hospital for 3 days. A repeat US scan showed no cholelithiasis. Following resolution of her symptoms, she underwent endoscopic retrograde cholangiopancreatography...