Martin Grauer

Assessment of Crohn's disease activity by confocal laser endomicroscopy

Background: Confocal laser endomicroscopy (CLE) allows microscopic imaging within the mucosal layer of the gut during ongoing endoscopy. Different studies have addressed the potential of CLE for in vivo diagnosis of ulcerative colitis and microscopic colitis. However, there are no data on the utility of CLE for in vivo diagnosis of Crohns disease (CD). The aim was to assess the clinical utility of CLE in patients with CD and to determine whether disease activity can be graded using CLE. Methods: Consecutive patients with and without CD were enrolled. The colonic mucosa was examined by standard white‐light endoscopy followed by CLE. The features seen on CLE were compared between CD patients and controls. Results: In all, 76 patients with CD were screened, of whom 54 patients were included in the present study. Eighteen patients without inflammatory bowel disease (IBD) served as controls. A significantly higher proportion of patients with active CD had increased colonic crypt tortuosity, enlarged crypt lumen, microerosions, augmented vascularization, and increased cellular infiltrates within the lamina propria. In quiescent CD, a significant increase in crypt and goblet cell number was detected compared with controls. Based on our findings, we propose a Crohns Disease Endomicroscopic Activity Score (CDEAS) for assessing CD activity in vivo. Conclusions: CLE has the potential to significantly improve diagnosis of CD compared with standard endoscopy. These findings should be evaluated in future prospective trials to assess the value of this newly developed CLE score for prediction of disease course and therapeutic responses. (Inflamm Bowel Dis 2012;)

Virtual chromoendoscopy for prediction of severity and disease extent in patients with inflammatory bowel disease: a randomized controlled study.

Background:Increased vascular permeability and angiogenesis play a crucial role in the pathogenesis of inflammatory bowel disease (IBD). Aim was to determine whether computed virtual chromoendoscopy has the potential to enhance assessment of disease severity and extent in patients with mild or inactive IBD in comparison to high-definition white-light endoscopy. Methods:Consecutive patients with IBD were randomly assigned at a 1:1 ratio to undergo colonoscopy with high-definition white light (group A) or computed virtual chromoendoscopy (group B). The mucosal vascular pattern and any mucosal abnormalities were recorded. Subsequent to endoscopic characterization targeted, biopsies were obtained from every segment for subsequent histopathological analysis of disease activity. Results:Overall, 100 patients were screened to participate in this study of whom 78 patients (high-definition white light, n = 39; computed virtual chromoendoscopy, n = 39) completed the study protocol thereby matching the previously calculated sample size. Average duration of the examination was 18 minutes in group A and 20.5 minutes in group B that was not statistically significant. When comparing the endoscopic prediction of inflammatory extent and activity with the histological results, an overall agreement of 48.71% and 53.85% (group A) and 92.31% and 89.74% (group B) was found, respectively. These differences were statistically significant (P = 0.0009 and P = 0.066). Conclusions:This study indicates that computed virtual chromoendoscopy significantly improves the diagnosis of the severity and extent of mucosal inflammation in patients with IBD. This newly developed imaging technique may therefore have important implications for therapeutic interventions in patients with IBD.

Seeing the sodium in a patient with hypernatremia

A 34-year-old patient with diabetes insipidus after removal of a hypothalamic tumor, developed difficulties with his treatment and presented with hypernatremia. On admission his blood pressure was normal, he was confused, had polyuria and secondary hyperaldosteronism, and his serum [Na+] was 162 mmol/l. We lowered the serum [Na+] with free water and desmopressin so that after 13 days his serum [Na+] was 141 mmol/l and his symptoms were improved. We reviewed the patients charts and discovered that his body weight was 79.0 kg with hypernatremia, and 78.5 kg after correction of his serum [Na+] and aldosterone.

Confocal Laser Endomicroscopy for In Vivo Diagnosis of Clostridium difficile Associated Colitis — A Pilot Study

Background Clostridium difficile infection (CDI) is one of the most dreaded causes of hospital-acquired diarrhea. Main objective was to investigate whether confocal laser endomicroscopy (CLE) has the capability for in vivo diagnosis of C. difficile associated histological changes. Second objective was to prove the presence of intramucosal bacteria using CLE. Methods 80 patients were prospectively included, 10 patients were diagnosed with CDI based on toxigenic culture. To validate the presence of intramucosal bacteria ex vivo, CLE was performed in pure C. difficile culture; additionally fluorescence in situ hybridization (FISH) was performed. Finally, CLE with fluorescence labelled oligonucleotide probe specific for C. difficile was performed ex vivo in order to prove the presence of bacteria. Results CLE identified CDI-associated histological changes in vivo (sensitivity and accuracy of 88.9% and 96.3%). In addition, intramucosal bacteria were visualized. The presence of these bacteria could be proven by CLE with labeled, specific molecular C. difficile probe and FISH-technique. Based on comparison between CLE and FISH analyses, sensitivity and specificity for the presence of intramucosal bacteria were 100%. Conclusion CLE has the potential for in vivo diagnosis of CDI associated colitis. In addition, CLE allowed the detection of intramucosal bacteria in vivo.

In vivo diagnosis of lymphocytic colitis by confocal laser endomicroscopy

We read with interest the paper by Moussata et al and the GI snapshot by Neufert et al , published in recent issues of Gut .1 ,2 The authors described in these outstanding articles the potential of confocal laser endomicroscopy (CLE) to either image intramucosal bacteria in vivo in patients with inflammatory bowel diseases and also to visualise disease specific findings (‘foamy macrophages’) in a patient with Mycobacterium avium intracellulare infection. CLE was recently introduced as a new emerging endoscopic imaging modality which due to its inherent capability of providing in vivo images of microscopic tissue changes at 1000-fold …

Digital Chromoendoscopy With i-Scan for In Vivo Prediction of Advanced Colorectal Neoplasia: A Multicenter Study.

Background: Recent studies have analyzed the potential of advanced endoscopic imaging techniques for differentiating hyperplastic and adenomatous colorectal lesions. Latest endoscopic resection techniques now also allow for treatment of more advanced staged lesions including treatment of early cancerous lesions. Aims: To assess the potential of the i-scan technology to differentiate between adenomatous polyps and advanced staged neoplasia. Methods: Consecutive patients undergoing colonoscopy at a tertiary referral center were included. After a dedicated training, participating endoscopists underwent a review of 298 unknown images of colonic lesions to assess colorectal lesion histology. Results: Overall accuracy for prediction of advanced staged neoplasia was 92.2% (sensitivity: 94.2%, specificity 90.9%). The positive and negative predictive values were calculated as 87.5% and 95.9%, respectively. The &kgr;-value for differentiating adenomatous polyps and advanced staged neoplasia was 0.8193 (0.7894 to 0.8492). Intraobserver agreement was calculated with a &kgr;-value of 0.9301 (0.8875 to 0.9727). Conclusions: Accurate interpretation of i-scan images for prediction of advanced colorectal neoplasia can successfully be performed even by nonexpert endoscopists with a high overall accuracy and excellent interobserver agreements.

PTH-026 Water infusion enteroscopy – description of a new technique with first clinical results

Introduction Device assisted enteroscopy is the standard technique to explore the deep small bowel. However, continuous insufflation of air often significantly distends the small intestine and hampers subsequent advancement of the enteroscope, resulting in distension related abdominal discomfort that can compromise the completion of the procedure and its diagnostic and therapeutic yield. We aimed at developing a novel water infusion technique to reduce small bowel distension and to facilitate enteroscopic procedures. Method We have performed enteroscopies with water infusion in patients who underwent prior wireless capsule enteroscopy that yielded pathologic findings which required further evaluation and/or treatment. Once the enteroscope was passed through the pylorus CO2insufflation was switched off. Subsequent advancement of the scope was performed with water infusion whenever necessary to visualise the intestinal lumen. Push-and-pull enteroscopy was performed as per the standard technique. The primary study end points were: system preparation time, rates of successful deep small bowel enteroscopy, procedure duration, diagnostic and therapeutic yield, rate of adverse events. The secondary endpoints included subjective evaluations by the patients concerning the discomfort associated with the procedure and by the endoscopist concerning the ease of performing the procedure. Results Water infusion enteroscopies were performed in 4 patients. The median age of the patients included in the study was 62 (range 36–72). Median time to prepare the system was 2 min (Range 2–3). Enteroscopy was performed successfully in all cases. The estimated median small bowel intubation depth – past the ligament of Treitz- was 160 cm (Range 145–220 cm). Median time of the procedure was 14 min (Range 14–16). All the procedures provided diagnostic elements or enabled treatment. No complications occurred during or after the procedure. Endoscopic findings and treatments are described in the table. Patients reported no significant discomfort during and after the procedure, and endoscopists were able to complete the procedure with ease in all patients. Endoscopic findings and treatmentsAbstract PTH-026 Table 1 Patient ID Endoscopic findings Treatment 1 Atrophy of intestinal mucosa Biopsy 2 NSAID enteropathy Biopsy 3 Multiple bleeding angiodysplasias APC coagulation 4 Yellow plaques Biopsy Conclusion The newly introduced water infusion technique allows for deep small bowel enteroscopy within a relatively short period of time. This procedure is relatively safe and well tolerated. Further studies are needed to assess the efficacy and safety of Disclosure of interest None Declared.