Mankanwal S. Sachdev

Capsule endoscopy: a review.

Capsule endoscopy (CE) is a novel technology that allows direct noninvasive visualization of the entire small intestine. CE permits a detailed examination in the ambulatory setting, allowing identification of clinically relevant lesions, and it is appealing to both patients and providers. There are two types of capsules that are currently commercially available: one specifically designed to view the small bowel and the other for the esophagus. Common indications for small bowel CE include obscure gastrointestinal bleeding, initial diagnosis of suspected Crohns disease, and other small bowel pathology. The esophageal capsule is currently used to evaluate Barrett esophagus and esophageal varices. It is a well-tolerated procedure with relatively few complications. Although CE performance may be superior to existing technologies, its impact on clinical decision-making and patient outcomes are of even greater importance. Herein lies a review of the latest information on CE, its indications, complications, future utilities, and developing technology.

Sedation for upper endoscopy: Comparison of midazolam versus fentanyl plus midazolam

Background: The benefit of using one or two drugs for conscious sedation in upper endoscopy remains unproven. This study evaluates the adequacy of conscious sedation during upper endoscopy using midazolam alone compared with midazolam plus fentanyl. Methods: Patients older than 18 years of age who underwent elective, outpatient upper endoscopy were included. They were randomized to receive either a combination of midazolam/fentanyl or midazolam alone. The adequacy of sedation obtained was assessed using a questionnaire answered by the physician at the end of the procedure, and by the patient 24 to 72 hours after endoscopy. Results: From the endoscopists perspective, following an intention-to-treat analysis, patients had better tolerance in the combination group (78.3% excellent/good tolerance M/F group versus 55.8% M group) (P = 0.043) (Table 2). Per patients assessment excellent/good tolerance was found in 93% of M group and 94% in F/M group (P = 1.0). No difference in duration of the procedure was found between the two groups. No complications during endoscopies were reported. Table 2. Tolerance: midazolam versus midazolam plus fentanyl Conclusions: In diagnostic upper endoscopy, an adequate level of sedation can be obtained safely either by midazolam or midazolam plus fentanyl. From an endoscopists perspective, the combination is significantly better.

Nonalcoholic Fatty Liver Disease of Obesity

Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are part of the same continuum. They are a major, under-recognized cause of chronic liver disease. Good medical treatment options do not exist to date. The mainstay of treatment is weight loss. Bariatric surgery offers weight loss and improvement of NAFLD and NASH.

Pancreatic necrosectomy using an automated mechanical endoscopic tissue extraction device

A 66-year-old man with uncontrolled diabetes mellitus and prior cholecystectomy presented to an outside hospital with symptoms of intractable abdominal pain, nausea, and vomiting. He received a diagnosis of acute pancreatitis and was treated conservatively and eventually discharged. He continued to have persistent symptoms and was admitted again. An abdominal CT scan revealed a pancreatic fluid collec-

Sigmoid colon polyp EMR with novel endoscopic morcellator

A 65-year-old woman underwent screening colonoscopy and was found to have a 60-mm polyp that was removed in piecemeal fashion by another gastroenterologist. The initial pathologic examination noted tubular adenoma with high-grade dysplasia. Repeated surveillance colonoscopy 3 months later noted a 20-mm area of residual focus that was draping over a fold. Examination of repeated biopsy specimens taken at that time noted tubular adenoma without high-grade dysplasia or malignancy (Fig. 1A). Owing to risk factors, such as prior high-grade dysplasia and the location and character-