Mariano Marcolongo

Prevalence, clinical spectrum and atypical symptoms of gastro‐oesophageal reflux in Argentina: a nationwide population‐based study

Background:  Population‐based data on gastro‐oesophageal reflux in Latin America are lacking.

Long-term outcome of argon plasma ablation therapy for bleeding in 100 consecutive patients with colonic angiodysplasia.

PurposeAngiodysplasia is a frequent cause of colonic bleeding. Argon plasma coagulation was reported to be useful in endoscopic hemostasis. However, the long-term outcomes have been poorly evaluated. This study was designed to assess the long-term outcomes of bleeding patients with colonic angiodysplasia treated by argon plasma coagulation.MethodsA cohort of 100 patients with gastrointestinal bleeding caused by colonic angiodysplasia was studied prospectively. The endoscopic intervention was considered successful if there was no further overt bleeding and hemoglobin concentration was stabilized (primary end point). Secondary end points were the requirement of blood transfusions, the need for surgery, bleeding-related mortality, and overall mortality.ResultsOvert bleeding resolved and hemoglobin levels were stabilized without transfusions or iron therapy in 85 of 100 patients (85 percent) after a median follow-up of 20 (range, 6-62) months. Transfusion requirements ceased in 90 percent of patients and only one required surgery. No patient died because of hemorrhage. In the subgroup of patients with anemia, mean hemoglobin levels increased from 9.3 (range, 5.5–12.2) g/dl before treatment to 12.6 (range, 7.4–16.7) g/dl after treatment (P < 0.01). The probability of remaining free of rebleeding at one and two year follow-up was 98 percent (95 percent confidence interval, 96–100) and 90 percent (95 percent confidence interval, 83–97), respectively. Among 118 procedures, only two complications were observed (1.7 percent).ConclusionsEndoscopic argon plasma ablation therapy is useful in the management of bleeding from colonic angiodysplasia.

Argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias.

BACKGROUND Angiodysplasia is a frequent cause of GI bleeding. Argon plasma coagulation has been shown to arrest bleeding, but its efficacy for prevention of recurrent bleeding has not been thoroughly evaluated. This study assessed the effectiveness and the safety of argon plasma coagulation for prevention of recurrent bleeding from GI angiodysplasias. METHODS A total of 60 patients with GI bleeding caused by angiodysplasia were included. The endoscopic intervention was considered successful if there was no further overt bleeding and if the Hb level stabilized. Recurrent bleeding was defined as any detectable bleeding episode (hematemesis, melena, or hematochezia) or a decrease in Hb level. RESULTS Overt bleeding was resolved, and the Hb level stabilized without transfusion or supplemental iron therapy in 50 of the 60 patients (83%) at a median follow-up of 18 months (range 6-38 months). In the subgroup of patients with anemia, mean Hb level increased from 8.6 g/dL (range 5.1-12.2 g/dL) to 12 g/dL (range 8.0-15.2 g/dL) ( p < 0.01). The estimated probability of remaining free of recurrent bleeding at 1- and 2-year follow-up was 86%: 95% CI [73%, 93%] and 80%: 95% CI [64%, 89%], respectively. Among 72 procedures, only two were associated with a complication (2.8%). CONCLUSIONS Endoscopic argon plasma coagulation is both effective and safe for prevention of recurrent bleeding from GI angiodysplasia.

Endoscopic management of biliary complications after adult living-donor versus deceased-donor liver transplantation.

Background. Although data about the incidence and management of biliary complications after deceased-donor liver transplantation (DDLT) are well defined, those pertaining to adult living-donor liver transplantation (LDLT) are conflicting. Methods. We retrospectively compared endoscopic retrograde cholangio-pancreatography (ERCP) findings in 30 LDLT vs. 357 DDLT consecutive adult recipients with duct-to-duct biliary reconstruction. LDLT and DDLT recipients were followed up for median durations of 30.5 and 36.0 months after the last ERCP, respectively. Results. Postoperative biliary complications were more frequently identified at ERCP after LDLT versus DDLT (10/30 [33.3%] vs. 34/357 [9.5%]; P<0.001). Complications mainly consisted of anastomotic biliary strictures (10/30 [33.3%] vs. 27/357 [7.6%]; LDLT vs. DDLT recipients, respectively; P<0.001) and biliary leaks (4/30 [13.3%] vs. 6/357 [1.7%]; LDLT vs. DDLT recipients, respectively; P=0.005; some patients had both complications). Stricture dilation was successful in 4/10 (40%) LDLT vs. 27/27 (100%) DDLT recipients (P<0.001), and bile ducts remained patent up to the end of follow-up without further intervention in 2/10 (20.0%) vs. 21/27 (77.8%) patients, respectively (P=0.002). Endoscopic treatment of bile leaks was successful in 3/4 (75.0%) vs. 5/6 (83.3%) LDLT versus DDLT recipients, respectively (NS). Conclusions. Biliary complications were more frequent after LDLT compared with DDLT. Endoscopic treatment of anastomotic biliary strictures was successful in a minority of patients after LDLT, in contrast with DDLT. Most biliary leaks were successfully treated at endoscopy after LDLT or DDLT.

Grasp or brush for biliary sampling at endoscopic retrograde cholangiography? A blinded randomized controlled trial.

OBJECTIVES Brushing, the standard sampling method at endoscopic retrograde cholangiography (ERC), lacks sensitivity for cancer detection. We assessed a novel sampling method using a grasping basket.METHODS Fifty-six patients with a suspected malignant biliary stricture were randomized to biliary sampling at ERC using a basket (basket group, N = 30) or a brush (brush group, N = 26), followed by the alternate device. When deemed necessary, strictures were dilated (using 6-mm balloons exclusively). The primary end point was sensitivity for cancer detection at cytopathological examination of the first sample collected in each patient; the cytopathologist was blinded to clinical details and sampling method. All analyses followed an intention-to-treat principle.RESULTS All 56 patients had successful sampling with both techniques; 50 (89%) had a final diagnosis of malignant stricture. Sensitivity for cancer detection with the first sample collected in each patient was significantly higher in the basket compared to brush group (20/25 [80%] vs 12/25 [48%], respectively, P = 0.018, OR 4.33, 95% CI 1.24–15.21). Seventeen (34%) of the 50 sample pairs collected from malignant cases showed discordant cytopathological results: 15 patients had a positive basket and a negative brush result while two had the inverse association (P = 0.002, OR 7.5, 95% CI 1.65–47.44). Basketting more frequently yielded positive samples from malignant strictures in case of presampling balloon dilation (27/32 [84%] vs 10/18 [56%], respectively, P = 0.043, OR 4.32, 95% CI 1.14–16.37). Specificity was 100% (both methods).CONCLUSION Biliary sampling at ERC using a dedicated basket provided a significantly higher sensitivity for cancer detection than brushing; presampling stricture dilation significantly increased sensitivity.

Uninvestigated Dyspepsia in Latin America: A Population-Based Study

We sought to assess the prevalence, severity of symptoms, and risk factors of uninvestigated dyspepsia in a population-based study in Argentina. Eight hundred thirty-nine valid questionnaires were evaluated. Dyspepsia was present in 367 subjects (43.2%; 95% confidence interval [CI], 39.8–46.6); 110 (13.6%) had overlap with gastroesophageal reflux disease (GERD). The group with dyspepsia without GERD consisted of 257 subjects (29.6%; 95% CI, 26.5–32.7), 183 (71.1%) had ulcer-like dyspepsia, and 74 (28.9%) had dysmotility-like dyspepsia. Symptoms were considered very severe in 1.9%, severe in 14.0%, moderate in 59.5%, and mild in 24.5% of the subjects. Dyspepsia was associated with a score >14 on the psychosomatic symptom scale (PSC) (OR, 2.52; 95% CI, 1.75–3.61), a family history of diseases of the esophagus or stomach (OR, 1.73; 95% CI, 1.19–2.52) and an educational level >12 years (OR, 1.55; 95% CI, 1.05–2.29). Dyspepsia is especially prevalent in Argentina. In a significant proportion of dyspeptic subjects, the severity of symptoms interferes with daily activities. A higher PSC, positive family history, and a higher educational level are risk factors for dyspepsia.

Spectrum of biliary parasites affecting the biliary tree (Fasciola hepatica, Echinococcus granulosus, and Ascaris lumbricoides)

Parasites are common worldwide and may involve any part of the gastrointestinal tract. Despite the high prevalence, reports of biliary involvement and its endoscopic treatment are scarce. Hereby we present a spectrum of biliary tree parasitosis (▶Video1). Case 1 was an 18-year-old woman who presented to our institution with jaundice and pruritus. An abdominal ultrasound revealed mobile lamellae in the gallbladder and common bile duct. An endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy was performed. Multiple adult vital flatworms (Fasciola hepatica) were retrieved with a Dormia basket (▶Fig. 1). Intraductal instillation of 2.5% iodopovidone was performed, and we allowed it to act for 5 minutes by occluding the distal bile duct with a balloon [1]. Medical treatment with triclabendazole was then completed and the patient had an excellent clinical outcome. The second case was a 27-year-old man who was admitted with acute cholangitis. An abdominal computed tomography (CT) scan was performed. The common bile duct was dilated and a subhepatic cystic cavity was observed. We decided to perform an ERCP, during which an extrinsic compression of the duodenum was first observed. The cholangiography showed dilatation of the intraand extrahepatic bile ducts with heterogeneous distribution and filling of the contrast into the bile duct. The subhepatic cavity was also rapidly filled with contrast, so we assumed that it was in communication with the biliary tree (▶Fig. 2). A sphincterotomy was performed and we extracted multiple membranes, mucinous contents, and purulent bile with an extractor balloon. Subsequent medical treatment with albendazole was given with a good clinical response being achieved. Case 3 was a 72-year-old woman who presented with acute cholangitis. An abdominal computed tomography (CT) scan was performed. Multiple thin-walled cysts were observed in the liver with dilatation of the biliary tree. An ERCP with sphincterotomy was performed. The cholangiogram showed extrahepatic bile duct dilatation. The intrahepatic bile ducts of the right hepatic lobe seemed “displaced” by the presence of an occupying mass. Multiple hydatid membranes (Echinococcus granulosus) were extracted with a Dormia basket Video 1 Case 1 shows multiple adult vital flatworms (Fasciola hepatica) being retrieved with a Dormia basket. Case 2 shows the extraction of multiple membranes, mucinous contents, and purulent bile with an extractor balloon in a patient with a hydatid cyst and how the cyst is cleared at the end of the procedure. Case 3 shows the extraction of multiple membranes with a Dormia basket. Case 4 shows a large Ascaris lumbricoides being extracted with a stone retrieval basket.

787 Risk of Death and Thromboembolism in Patients That Do Not Resume Anticoagulation After an Episode of Peptic Ulcer Bleeding

Background: The existing literature regarding smoking and alcohol consumption and risk of gastrointestinal bleeding (GIB) is sparse and conflicting. In an attempt to study modifiable risk factors of GIB, we assessed the risk of GIB associated with smoking and alcohol consumption in a large prospective cohort of men. Methods: We studied 51,529 men in the Health Professional follow-up Study (HPFS) who were aged 40-75 years at baseline in 1986. We identified men with GIB requiring hospitalization and/or blood transfusion based on their responses to biennial questionnaires from 2006-2012 and reviewed medical records to validate self-report. Information about smoking and alcohol consumption was updated every two and four years, respectively. We used Cox proportional hazards regression to calculate the relative risks (RR) and 95% confidence intervals (CI) adjusting for age, study year, body mass index, physical activity, regular aspirin and nonsteroidal anti-inflammatory drug use, and alcohol/smoking. Results: We documented 311 episodes of GIB during a 26-year follow up period. After adjustments for other potential risk factors, individuals who consumed >15 g/day of alcohol had a multivariate RR of 1.65 (95% CI, 1.10-2.47; p for linear trend 0.004) when compared with men who did not consume alcohol. Intake of > 15 g/day of alcohol appeared to be primarily related to upper GIB (multivariable RR 1.74; 95% CI, 0.98-3.08; p for linear trend 0.007). Risk of GIB increased linearly with amount of liquor consumed (p for linear trend 15 g/day of alcohol was significantly associated with peptic ulcer disease (multivariable RR 1.85; 95% CI, 0.97-3.54; p for linear trend 0.02), but not esophagitis/gastritis/duodentitis, or diverticular bleeding. There were few cases of bleeding due to portal hypertension (n=4). Current and past smokers did not appear to have increased risk of GIB when compared to those who never smoked (multivariable RR 0.89; 95% CI, 0.45-1.76 and 1.12, 95% CI 0.88-1.41, respectively). We also did not find a significant association between pack years of smoking and risk of GIB (multivariable RR 1.01; 95% CI, 0.63-1.62 when comparing men with at least 45 pack-years of exposure to never smokers). Conclusions: In this large prospective study, alcohol consumption, but not smoking, was associated with an increased risk of GIB. Associations were most notable for upper GI bleeding associated with intake of liquor.

Su1247 Postcolonoscopy Colorectal Cancer (PCCRC) in a Population of a Closed System of Health Care Provision

BACKGROUND: Previous studies have demonstrated that patients post cholecystectomy have had no definitive association with colorectal adenomatous polyps. It is thought that chronic inflammation from bile acids may lead to increase development of colorectal polyps. Post cholecystectomy chronic diarrhea is likely from bile acid exposure. Additionally chronic constipation is thought to be an risk factor for colorectal cancer. The purpose of this study is to investigate for an increased risk for colorectal adenomas in post cholecystectomy patients and to look for the association of polyps with chronic diarrhea in these patients. METHODS: We performed a retrospective chart review of the patients who underwent cholecystectomy between 01/200112/2012 who also had a colonoscopy following surgery. Patients without a personal history of IBD, colorectal polyps and/or family history of colorectal cancer were included in the study. Patients were further divided into two groups, those with and without chronic diarrhea. Polyps were further classified based on histology and location. RESULTS: A total of 395 patients were included in the study (63% female, with a mean age of 50 y). The average number of years between the cholecystectomy and a colonoscopy was 2.6 years. An increased risk for colorectal polyps 151(38%) (95% confidence interval (CI)-0.33-0.43) was found among these patients when compared to an average risk in general population aged 50 y (20%). A total of 28% patients in the study were found to have proximal colon polyps (0.28, 95% CI 0.21 to 0.36) and no significant difference was found when compared to the average risk population (13-37%). In contrast an increased risk of polyps in distal colon 48% (0.48, 95% CI: 0.40 to 0.56) was found when compared to the average risk population (25-40%). Twenty five percent of patients had polyps in both proximal and distal colon 37/151 (0.25; 95% CI 0.18 to 0.32), statistics were not compared to the general population. Hyper plastic polyps were found in 37% (0.37, 95%CI: 0.29 to 0.45) patients, which were not found to be at increased risk when compared to average risk (20-40%). Adenomas, 55% (0.55, 95% CI: 0.46 to 0.63), were found to be at increased risk when compared to average risk (25-30%). Additionally an increased risk was found for serrated polyps, 9% (0.09, 95% CI 0.05 to 0.15), when compared to average risk (1-7%). In patients with chronic diarrhea the proportion of polyps was 0.26 compared to 0.43 in those without chronic diarrhea. (Odds ratio=0.47, 95% CI 0.29-0.75, P=0.002), revealing a negative association of polyps with chronic diarrhea in this set of patients. CONCLUSIONS: Cholecystectomy was found to increase the risk for distal colorectal adenomas/polyps. Chronic diarrhea was found to be negatively associated with colorectal polyps in this set of patients.