L. C. Fry

The spectrum of GI strongyloidiasis: an endoscopic-pathologic study.

BACKGROUND The aim of this study was a detailed endoscopic-pathologic assessment of patients with various forms of GI strongyloidiasis. METHODS Six patients with a diagnosis of GI strongyloidiasis who underwent endoscopic evaluation during a 3-year period (January 1998-January 2001) were included. Published information was reviewed in detail, focusing on the endoscopic features and the diagnostic approach to this parasitosis. OBSERVATIONS Strongyloidiasis has a broad range of endoscopic features. In the duodenum, the findings included edema, brown discoloration of the mucosa, erythematous spots, subepithelial hemorrhages, and megaduodenum. In the colon, the findings included loss of vascular pattern, edema, aphthous ulcers, erosions, serpiginous ulcerations, and xanthoma-like lesions, and, in the stomach, thickened folds and mucosal erosions. A histopathologic diagnosis of strongyloidiasis was made in all cases. CONCLUSIONS Strongyloidiasis can involve any segment of the GI tract. EGD with procurement of biopsy specimens from the duodenum was the most accurate method of diagnosis in this case series.

A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding.

Although the role of emergency esophagogastroduodenoscopy (EGD) and colonoscopy for upper and lower gastrointestinal bleeding (GIB) is well defined, there are no data on the concept of emergency double-balloon enteroscopy (DBE) for small-bowel bleeding. The aim of this study was to retrospectively evaluate the concept of emergency DBE in overt obscure GIB and assess its impact on patient management. A total of 17 emergency DBEs for overt obscure GIB were carried out in ten patients (six women, four men; mean age 68 years, range 35 - 83). The following diagnoses were made: actively bleeding Dieulafoy lesions of the small bowel, n = 2; bleeding tumors, n = 4 (carcinoids n = 2, adenocarcinoma n = 1, lipoma n = 1); bleeding angiodysplasias and/or large arteriovenous malformation (AVM), n = 2; multiple ulcers, n = 1; and no diagnosis, n = 1. Endoscopic therapies included argon plasma coagulation (n = 6), injection of epinephrine (n = 3), and use of fibrin glue (n = 1). It appears that emergency DBE is technically feasible, facilitates both diagnosis and therapy and enables management of patients with massive overt obscure GIB. This study is a first step in establishing the concept of emergency DBE for patients with suspected small-bowel bleeding.

Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series.

The Fujinon intelligent color enhancement (FICE) system is a new, virtual chromoendoscopy technique that enhances mucosal visibility. The aim of this study was to assess the utility of double-balloon enteroscopy (DBE) with FICE technology (EPX-4400 processor, Japan) for the characterization of various small-bowel diseases. Overall, a total of 574 endoscopic pictures were obtained and analyzed. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias. Its use for the characterization of celiac and Crohns disease appears to be limited. Overall, FICE may become a useful method that aids in characterization and provides new insights to small-bowel pathologies.

Diagnostic quality of polyps resected by snare polypectomy : Does the type of electrosurgical current used matter?

BACKGROUND:Traditionally, snare polypectomy is performed using blended, coagulation, or pure cutting electrical current (EC). The aim of this study was to assess and compare the diagnostic quality of polyps obtained by snare polypectomy using two different electrosurgical currents.METHODS:Consecutive patients undergoing colonoscopy underwent polypectomy using either blended EC with a conventional electrosurgical generator (ESG) or using an ESG with a microprocessor that automatically controls cutting and coagulation (Endocut). An experienced blinded gastrointestinal (GI) pathologist evaluated the specimens for diameter, cautery damage (amount and degree), margin evaluability, architecture, and general histologic diagnostic quality.RESULTS:One hundred sixteen patients (69% men, mean age 63.8 ± 15 yr) underwent 148 polypectomies (78 using blended current and 70 using Endocut). We found that the cautery degree was less with the Endocut than with the blended current (p < 0.02). Cautery amount was also higher in polyps resected using blended current (56%) than Endocut (51%) but this difference did not reach statistical significance (p = 0.1). Polyps resected using Endocut had better margin evaluability (75.7% to 60.3%, p = 0.046). The overall tissue architecture was similar in both groups. Polyps removed with blended current had less overall quality as compared to polyps removed by Endocut (p = 0.024).CONCLUSIONS:More extensive tissue damage occurred using blended EC with the conventional ESG than when using Endocut. The quality of the polypectomy specimens was overall better using Endocut. Finally, the ability to evaluate resected polyp margins and overall tissue histology was better with the microprocessor-controlled ESG than with the conventional ESG.

Bile Leak from the Duct of Luschka

A 64-year-old diabetic man underwent an open cholecystectomy for acute necrotizing cholecystitis. Post-operatively he developed a biloma which was drained percutaneously. A bile leak was suspected and he underwent an ERCP. Initial cholangiography was normal, but upon continued injection of contrast agent, a bile leak originating from a branch of the right hepatic duct or duct of Luschka became evident. A sphincterotomy was performed and a plastic stent was placed into the common bile duct. The leak resolved and the plastic stent was removed 6 weeks later.

The spectrum of gastrointestinal strongyloidiasis: an endoscopic-pathologic study

Purpose: Although the literature on strongyloidiasis is extensive, there is a remarkable paucity of information about the endoscopic findings of gastrointestinal (GI) strongyloidiasis, with most information coming from sporadic case reports. The aim of this study was to present a detailed endoscopic-pathologic study of patients with various forms of GI strongyloidiasis.

Safe technique for direct percutaneous endoscopic jejunostomy tube placement using single-balloon enteroscopy with fluoroscopy

Direct percutaneous endoscopic jejunostomy (DPEJ) is a useful method for the delivery of nutrition in patients with a variety of gastrointestinal (GI) problems [1–3]. However, DPEJ using standard colonoscopes or the push technique remains a technically challenging procedure, with success rates of about 68% in expert hands [2]. Herein, we present the key steps to conducting a successful DPEJ using a single-balloon enteroscopy technique. A 62-year-old woman presented with severe necrotizing pancreatitis mandating intensive care therapy. The pancreas necrosis progressed into a huge collection, resulting in partial gastric outlet obstruction (▶Fig. 1 a). Despite endoscopic drainage, the patient remained nauseated and was unable to tolerate oral feeding. We were consulted to place a direct percutaneous jejunostomy (PEG) tube. The patient was placed in the supine position, and the therapeutic double-balloon enteroscope was used in single-balloon mode (i. e. no balloon was attached to the tip of the scope) (▶Video1). The scope and overtube were then advanced to about 80 cm distal to the pylorus. A jejunal loop was then carefully located using both endoscopic and fluoroscopic guidance (▶Video1). PEG tube placement was performed using the Ponsky method (pull-type technique using a 20 Fr PEG-kit; Cook Medical, Bloomington, Indiana, USA) (▶Video1). Once the string had been endoscopically grasped by the snare, the scope and string were pulled back out through the overtube (▶Fig. 1b, c, ▶Video1). A key element of the technique is the overtube, which is left in situ. The string was attached to the PEG tube and, as the string was pulled back out through the skin incision, the PEG tube was pulled through (i. e. inside) the overtube (▶Video1). The scope was advanced into the overtube and was used to help push the PEG button, and subsequently to inspect the jejunum for correctness of PEG tube placement (▶Fig. 1d, ▶Video1). An enteral diet was started 12 hours later. This new method of PEG tube placement focuses on three key components: 1) use of a balloon-assisted overtube, which provides endoscopic stabilization during the procedure; 2) use of fluoroscopy, leading to increased success of finding an adequate jejunal loop for puncture; 3) leaving the overtube in place during the entire procedure (and also for PEG tube removal), which decreases the risk of GI luminal damage during pulling of the PEG tube and during scope manipulation, as the overtube “shields” the inside of the GI tract. The combination of all these aspects may increase the safety and success of this technique.

Die mittlere gastrointestinale Blutung und der Einsatz der Notfallendoskopie mit dem Doppel-Ballon Enteroskop (DBE)

Einleitung: Der Einsatz der OGD und Koloskopie zur Notfallbehandlung akuter GI-Blutungen (GIB) ist gut definiert. Die DBE stellt eine etablierte Methode zur Diagnostik und Therapie von Dunndarmerkrankungen dar. Bisher wurde jedoch der Einsatz der DBE in der Notfalltherapie akuter unklarer GIB noch nicht untersucht. Ziele: Evaluierung der DBE in der Notfalltherapie akuter unklarer GIB. Methodik: Retrospektiv wurden die uber den Zeitraum von 4 Jahren erhobenen Daten aller Pat., die aufgrund einer unklaren GIB eine DBE in unserer Klinik erhalten hatten, ausgewertet. Die unklare GIB wurde dabei nach den Leitlinien der AGA definiert. Eine Notfall-DBE wurde definiert als Untersuchung, die innerhalb von 24 Stunden nach Auftreten einer klinischen Symptomatik durchgefuhrt wurde. Alle Untersuchungen wurden dabei mit dem therapeutischen DBE (Fujinon, Japan) durchgefuhrt. Ergebnis: Insgesamt wurden 152 DBE-Untersuchungen bei 114 Pat. durchgefuhrt. In 87 Fallen lag eine „obscure overt“, in 27 Fallen eine „obscure occult“ Blutung vor. 15 Notfall-DBE wurden bei 9 Pat. (6 F, 3M; Altersmedian 68 Jahre, range 48–83 Jahre; ASA 2/3) aufgrund einer „obscure overt“ Blutung durchgefuhrt. Alle Pat. zeigten initial peranalen Blutabgang oder Teerstuhl. Vor der DBE wurde bei allen Pat. sowohl eine OGD als auch eine Koloskopie durchgefuhrt. Folgende Diagnosen konnten gestellt werden (1 Patient hatte mehrere Blutungsursachen): aktive Blutung aus einer Dieulafoy-Lasion des Dunndarms (n=2); blutender Dunndarmtumor (Karzinoid n=2; Adenokarzinom n=1; Lipom n=1); blutende Angiodysplasie und/oder grose arteriovenose Malformation (n=2); multiple Ulzera (n=1); Jejunitis (n=1). Die folgenden endoskopischen Therapien wurden durchgefuhrt: APC n=6; Adrenalinunterspritzung n=3; Fibrinkleber n=1. Bei einem Patienten mit rezidivierender Blutung aus einer Dieulafoy-Lasion mussten zeitversetzt 3 DBE durchgefuhrt werden um schlieslich die Blutung zu stillen. Die Patienten mit den Dunndarmtumoren erhielten eine elektive Laparotomie mit Dunndarmteilresektion. Schlussfolgerung: Die Notfallendoskopie mit dem DBE ist technisch praktikabel und sicher fur den Pat. Sie ermoglicht eine rasche und wenig invasive Diagnostik und Therapie und hat damit das Potential das Outcome der Pat. zu verbessern.

Katheterfreie pH-Metrie mittels Bravo-Kapsel versus Standard-pH-Metrie bei Patienten mit nicht erosiver Refluxkrankheit (NERD)

BACKGROUND: pH-monitoring is considered the gold standard for the detection of acid reflux in patients with non-erosive reflux disease (NERD). Preliminary pH studies performed over periods longer than 24 hours have shown that in up to one-third of subjects abnormal pH exposure is detected only on the second day of monitoring. Therefore, pH-monitoring during 48 hours may yield more information about pathological acid reflux in patients being investigated for NERD. AIM: Thea im of this study was to compare conventional 24-hour pH-monitoring with the new wireless 48-hour Bravo pH-monitoring in patients with NERD. PATIENTS AND METHODS: Patients with typical reflux symptoms, a positive reflux disease questionnaire and negative endoscopy (NERD) and without any form of acid suppressive therapy were included in this prospective study. The patients were divided into two groups: group A for conventional 24-hour pH-monitoring and group B for wireless 48-h Bravo pH-monitoring. RESULTS: 76 patients with a diagnosis of NERD based on a positive RDQ questionnaire and negative endoscopy were included. (47 woman, 29 men, median age: 49 years). 54 underwent conventional pH-monitoring and 22 underwent 48-h pH-monitoring with the new wireless BRAVO system. The overall incidence of acid reflux was 55 % in patients with NERD. Acid reflux was detected less frequently when using Bravo as compared to conventional pH-monitoring. In addition, the Bravo pH-metry showed a large day-to-day variability. CONCLUSIONS: Prolonged pH-monitoring over a period longer than 24 hours did not improve the detection of acid reflux in patients with NERD. Thus, it appears that the Bravo pH-metry does not offer an advantage over standard pH-metry in the daily clinical practice.