Kanishka Bhattacharya

Large-diameter biliary orifice balloon dilation to aid in endoscopic bile duct stone removal: a multicenter series

BACKGROUND The utility and safety of endoscopic biliary orifice balloon dilation (EBD) for bile duct stone removal (with use of large-diameter balloons) after biliary endoscopic sphincterotomy (BES) is currently not well established. OBJECTIVE Our purpose was to evaluate the efficacy and complications of BES followed by > or = 12 mm diameter EBD for bile duct stone removal. DESIGN Retrospective, multicenter series. SETTING Five ERCP referral centers in the United States. PATIENTS AND INTERVENTIONS Patients who underwent attempted removal of bile duct stones by BES followed by EBD with > or = 12 mm diameter dilating balloons were identified by searching the prospectively recorded endoscopic databases from 1999 to 2007. Clinical parameters, endoscopic data, and outcomes were collected and analyzed. RESULTS One hundred three patients, mean age 70 +/- 17 years (range 23-98 years), with 56 (54%) women, underwent 107 procedures. Eleven patients (11%) had a prior history of acute pancreatitis. Pancreatogram was performed in 15 (14%) patients. Median stone size and median balloon diameter used was 13 mm. Complete stone removal in the first session of EBD was accomplished in 102 (95%) procedures, and mechanical lithotripsy was required in 29 (27%). Six patients (5.4%) had documented procedure-related complications including one patient with severe bleeding and one with severe cystic duct perforation. No acute pancreatitis occurred. CONCLUSION EBD with a large-diameter balloon in conjunction with BES for bile duct stone removal is effective and relatively safe. This technique appears to be a reasonable alternative option when standard BES and basket or balloon sweep are inadequate to remove bile duct stones.

A multicenter randomized comparison of the Endocapsule and the Pillcam SB

BACKGROUND Video capsule endoscopy has been shown to be the single most effective endoscopic procedure for identifying the source of obscure GI bleeding (OGIB). OBJECTIVE Our purpose was to report on the Food and Drug Administration pivotal trial in which the Endocapsule (EC) (Olympus America, Allentown, Pa) was compared with the Pillcam SB (PSB) (Given Imaging, Yoqneam, Israel) in patients with OGIB. DESIGN A novel trial design was used in which the EC and the PSB were swallowed by the same patient 40 minutes apart, in randomized order. SETTING Four academic medical centers. PATIENTS Patients with OGIB aged 18 to 85 years who had either been transfused or who had a hematocrit of <31% in males or <28% in females. INTERVENTIONS Both video capsules were swallowed in random order. Videos from the PSB were read locally for patient management. All videos were then read by at least 2 independent readers for normal versus abnormal categorization, a diagnosis, capsule transit time, reading time, and a subjective assessment of image quality. MAIN OUTCOME MEASUREMENT Categorization of videos as either normal or abnormal. RESULTS Data from 51 of 63 enrolled patients were analyzed. Nine patients were excluded for technical reasons and 3 for protocol violations. Twenty-four videos were read as normal and 14 as abnormal from both capsules. Disagreement occurred in 13. No adverse events were reported for either capsule. Overall agreement was 38 of 51 (74.5%) with a kappa of 0.48, P = .008. LIMITATIONS Although ingestion order was randomized, the videos could not be read blind owing to a different shape of the image margin. CONCLUSIONS (1) Both devices were safe and had a comparable diagnostic yield within the range previously reported. (2) There was a subjective difference in image quality favoring the EC. (3) This study design provided unique information about capsule movement in the small intestine and the lack of electromechanical interference between 2 different capsules.

Timing of video capsule endoscopy relative to overt obscure GI bleeding: implications from a retrospective study

BACKGROUND Diagnostic yield of video capsule endoscopy (VCE) may be higher if it is performed closer to the time of overt obscure GI bleeding (OOGIB). OBJECTIVE To evaluate the diagnostic yield of VCE and rate of therapeutic intervention for OOGIB for inpatients and outpatients with respect to timing of the intervention. DESIGN Retrospective cohort study. SETTING Tertiary academic center. PATIENTS Patients who had VCE for OOGIB between August 2008 and August 2010. INTERVENTIONS VCE for inpatients versus outpatients. MAIN OUTCOME MEASURES Diagnostic yield and rate of therapeutic intervention for inpatients versus outpatients. RESULTS One hundred forty-four inpatients (65 women) and 116 outpatients (49 women) were included. Diagnostic yield was 65.9% for inpatients versus 53.4% for outpatients (P = .054). Inpatients were divided into those who had VCE within 3 days (<3 days; n = 90) of admission versus after 3 days (>3 days; n = 54). Active bleeding and/or an angioectasia was found in 44.4% of the <3-day group compared with 27.8% of the >3-day group (P = .046) versus 25.8% of the outpatients. Therapeutic intervention was performed in 18.9% of the <3-day group versus 7.4% of the >3-day group (P = .046) versus 10.3% of outpatients. Diagnostic yield and therapeutic intervention rate between the >3-day group and outpatients were not significantly different. Length of stay (days) was less in the <3-day cohort, at 6.1 versus 10.3 in the >3-day cohort (P < .0001). LIMITATIONS Long-term outcomes were not studied. This was a retrospective study. CONCLUSIONS Early deployment of VCE within 3 days of admission results in a higher diagnostic yield and therapeutic intervention rate and an associated reduction of length of stay.

Does trainee participation during colonoscopy affect adenoma detection rates

INTRODUCTION: Training future endoscopists is essential to meeting the increasing demands for colonoscopy. It remains unknown whether adenoma detection rates are adversely affected by trainee participation. METHODS: This is a single-center, prospective study. The primary aim of this study was to investigate whether adenoma detection rates differed between procedures with or without trainee involvement. A total of 368 consecutive patients entered the analysis (181 with trainee participation and 187 without). RESULTS: Adenomas were detected in 19.3% of experienced physician-only procedures and in 14.9% of procedures with trainee participation. Advanced adenomas were detected in 8.6% of experienced physicians’ procedures vs. 4.9% of trainee procedures. Polyp detection was nearly identical in both groups (32% for experienced physicians; 33% for trainees). Trainee participation delayed the procedure by a mean of seven minutes. CONCLUSION: Adenoma detection rates did not differ significantly, whether there was trainee involvement or not. A trend toward finding more adenomas or advanced adenomas in the absence of a trainee was observed, but it was lower than previously reported interobserver variability among experienced physicians. The small difference in adenoma detection was not observed for polyp detection, which may be explained by the more frequent removal of hyperplastic polyps by trainees.

Preliminary colonoscopy facilitates retrograde double-balloon enteroscopy.

Background and study aims: Retrograde double-balloon enteroscopy (RDBE) has a high failure rate due to difficulty intubating the ileo-cecal (IC) valve. We examined the utility of a pre-RDBE colonoscopy using a pediatric colonoscope to clean the cecum and perform an initial intubation of the IC valve. Patients and methods: This study is a retrospective review of RDBE procedures for 45 patients at a single tertiary-care center to examine the success of IC intubation, maximal depth of enteroscope insertion, and duration of the procedure. Results: The IC intubation success rate among patients who underwent RDBE using this novel method was 100 % as compared to 72.7 % using the traditional method (P < 0.003). Conclusions: RDBE preceded by colonoscopy had a significantly higher IC intubation success rate, compared to RDBEs performed using the traditional method. Results support the use of this novel method when IC valve intubation using standard methods is difficult, and it may limit the need for repeat procedures or the use of other modalities for examining the small bowel.

Variceal Bleeding: Prophylaxis, Treatment, and Prevention

Variceal bleeding leads to significant morbidity and mortality in patients with portal hypertension. Mortality can be greater than 50% with the initial bleed and many patients develop recurrent bleeding with equal or greater mortality. Currently cirrhosis is the leading cause of portal hypertension, which is defined as a hepatic vein-portal vein gradient greater than 5 mmHg. Portal hypertension may arise from increased splanchnic blood flow due to systemic vasodilation that occurs in the hyperdynamic circulation of cirrhosis or from increased vascular resistance in intrahepatic and/or portocollateral vessels; by decreasing splanchnic blood flow, portal inflow decreases and so does portal pressure. Pharmacologic therapy consisting of nonselective β-blockers, vasopressin, and octreotide act by decreasing splanchnic blood flow, and long-acting nitrates may cause direct vasodilation of portocollateral vessels and/or decreased splanchnic blood flow. Nonselective β-blockers are the cornerstone of treatment for primary prophylaxis of bleeding, whereas vasopressin and octreotide are used for acute hemorrhaging. Two endoscopic modalities are available for control of acute bleeding and prevention of recurrent bleeding: sclerotherapy and endoscopic variceal ligation. After standard airway control and adequate fluid resuscitation, endoscopy helps localize the area of bleeding, and often in conjunction with vasopressin or octreotide can help control bleeding. Empiric antibiotics (fluoroquinolones or third-generation cephalosporins) should be started prior to endoscopy and early in the course of treatment. Sclerotherapy and band ligation along with nonselective β-blockers can help prevent recurrences of bleeding. For patients with bleeding gastric varices or uncontrollably bleeding esophageal varices, interventional radiologic procedures such as the transjugular intrahepatic portosystemic shunt (TIPS) can be used, and depending on the clinical condition and Childs classification of the patient, a surgically created portosystemic shunt may be appropriate treatment. Hopefully with emerging, new techniques and more widespread, prudent use of prophylactic drugs and endoscopy, the mortality and morbidity of variceal bleeding can be reduced.

Tu1447 A Long Term Retrospective Analysis of Large Polypectomies Using Standard Injection and Lift Techniques

characteristics, lesion location and histology. Statistical analyses were performed using SPSS 19 (SPSS Inc., Chicago, IL, USA). Results: EMR was performed in 1109 lesions 20mm (910 colon, 82%; 199 rectum, 18%). 37 patients did not have EMR and were excluded from analysis (22 cancer suspected; 15 technical difficulties). Significant differences exist in key patient and lesion characteristics, and procedural success rates (Table 1). Rectal lesions had a significantly higher risk of CRC than colonic lesions (11.5% v 6.0%, P 0.007). The odds of CRC in the rectum was 1.6 times greater than in the colon on multiple logistic regression analysis, however was not an independent predictor of CRC (95% CI 0.9-3.0, P 0.138). Independent predictors of CRC were Paris classification and morphology, presence of Kudo pit pattern 5 and lesion size (all P 0.05). The most common subgroup (0-IIa/b G lesions) had the same low risk for CRC in the colon and rectum (2.3% v 2.4%, P 1.000) (Table 2). A Is component in a G lesion magnified the risk of CRC in the colon, which was further increased in the rectum (5.9% v 9.6%, RR 1.63, P 0.196). The same applied to 0-IIa/b lesions with NG morphology in the colon compared to the rectum (7.7% v 22.2%, RR 2.87, P 0.171). NG lesions with a Is component in the rectum had the highest relative risk of CRC (7.1% v 30.8%, P 0.017, RR 4.31, 95% CI for RR 1.2-15.0). Conclusion: Specific subtypes of rectal AMNs have a greater relative risk of CRC compared to colonic AMNs, particularly NG lesions with a Is component. Endoscopic morphology determines the endoscopic therapeutic approach. Independent of site, granular flat lesions can be removed by multi-piece excision, as the risk of CRC is low. However, lesions with a Is component and NG morphology need to be assessed on a case by case basis to determine the correct strategy and should be considered for en bloc resection, particularly when found in the rectum.

Isolated intestinal angioedema due to angiotensin-converting enzyme inhibitor use: a case report and review of the literature

Isolated intestinal angioedema due to angiotensin-converting enzyme inhibitor use: a case report and review of the literature