Maximino Correia Leitão

External validation of a classification for methylene blue magnification chromoendoscopy in premalignant gastric lesions

BACKGROUND Conventional endoscopy has low sensitivity, specificity, and interobserver agreement for the diagnosis of gastric atrophy, intestinal metaplasia, and dysplasia. Magnification chromoendoscopy (ME) may optimize the evaluation of premalignant gastric lesions. OBJECTIVE AND DESIGN As part of a multicenter trial, we aimed at validating a previously proposed classification for gastric methylene blue ME at a different center. SETTING, PATIENTS, AND INTERVENTIONS: A sample of patients (n = 42) with previously diagnosed chronic atrophic gastritis with or without intestinal metaplasia underwent ME (Pentax EG-3430Z) with 1% methylene blue by 2 endoscopists. MAIN OUTCOME MEASUREMENTS A simplified version of a previously published ME classification (group I, group II [further divided into subgroups IIE and IIF], and group III) was used for macroscopic lesions (n = 203) with Sydney-Houston and Vienna classifications being used for histologic analysis (n = 479 biopsy specimens). RESULTS AND LIMITATIONS Excellent reproducibility (wK = 0.92 [95% CI, 0.88-0.96]) was observed for classification in groups and substantial reproducibility (wK = 0.78 [95% CI, 0.72-0.84]) was found for classification in subgroups. Global validity was 82% (range 78%-86%), showing no false negatives (sensitivity of 100% [1/1 biopsy]) and a very low rate of false positives (specificity 99% [297/299 biopsies]) for dysplasia detection. CONCLUSIONS This classification for methylene blue ME was highly reproducible and valid for the diagnosis of premalignant gastric lesions when used in a center different from that involved in its conception. Despite requiring an unconventional endoscope and a longer procedure, these results could reinforce ME as a valuable technique in the surveillance of patients at risk for gastric cancer.

Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative

Background: The value of capsule endoscopy in the setting of inflammatory bowel disease type unclassified (IBDU) and indeterminate colitis (IC) remains obscure. The aim was to evaluate the clinical impact of capsule endoscopy on IBDU/IC patients with negative serology. Methods: Eighteen patients with long‐standing IBDU (n = 14) and IC (n = 4) were enrolled to undergo a capsule endoscopy and then followed prospectively. Lesions considered diagnostic of Crohns disease (CD) were 4 or more erosions/ulcers and/or a stricture. The median follow‐up time after capsule endoscopy was 32 ± 11 months (23–54 months). Results: Total enteroscopy was possible in all patients. In 2 patients the examination was normal (Group 1). In 9 patients subtle findings were observed (Group 2): focal villi denudation (n = 1) and fewer than 4 erosions/ulcers (n = 8). In 7 patients, 4 or more erosions/ulcers were detected (Group 3), leading to a diagnosis of CD. However, their treatment was not reassessed on the basis of the capsule findings. Until now, a definitive diagnosis has been achieved in 2 additional patients: 1 from Group 1 (ulcerative colitis) and another patient from Group 2 (CD), who began infliximab infusions. Nine patients remained indeterminate at follow‐up. Conclusions: Although capsule endoscopy enabled the diagnosis of CD in 7 patients, in none of them was the clinical management changed. Moreover, a change in therapy due to a diagnosis of CD was made for only 1 patient, who presented nonspecific findings. Our results suggest that capsule findings are not helpful in the work‐up of these patients. Inflamm Bowel Dis 2010

URGENT CAPSULE ENDOSCOPY IS USEFUL IN SEVERE OBSCURE-OVERT GASTROINTESTINAL BLEEDING

Aim:  With capsule endoscopy (CE) it is possible to examine the entire small bowel. The present study assessed the diagnostic yield of CE in severe obscure‐overt gastrointestinal bleeding (OOGIB).

Team approach to ERCP-directed single-brush cytology for the diagnosis of malignancy

OBJECTIVE To evaluate the clinical usefulness of single-brush cytology performed at ERCP as initial method for detecting pancreatobiliary malignancy, ensuring a very close relationship between endoscopists, cytotechnicians, and cytopathologists. STUDY DESIGN All 125 cytodiagnoses considered in this study correspond to the first brushing for each patient, collected by one of the three members of a fixed team of endoscopists in the presence of the same cytotechnician. Smears were fixed immediately with Merckofix spray, stained with Papanicolau, and analyzed by the same cytopathologist in a laboratory exclusively devoted to gastrointestinal cytopathology located at the endoscopy unit. RESULTS Of 125 cytological diagnoses 94 were considered benign, 4 suspicious, and 27 malignant. These findings were compared to the final diagnosis of 45 malignant and 80 benign lesions obtained either by surgical pathology or after at least one year of clinical follow-up. The comparison yielded 30 true positives, 78 true negatives, 1 false positive and 16 false negative results, which corresponds to a sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of 65.2, 98.7, 96.8, 83, and 86.4%, respectively. CONCLUSION Results seem to confirm the usefulness of an effective team approach to ERCP-directed brush cytology for the diagnosis of pancreatobiliary malignancy. However, sensitivity continues to be rather low.

Successful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

which there is little agreement on the best therapeutic option (1-5). A 47-years-old male, with alcoholic liver cirrhosis (Child-Pugh class C; MELD 29) and previous oesophageal varices bleeding, was admitted for profuse hematochezia. He was tachycardic, hypotensive and had haemoglobin 2,7 g/dl. Fluid and blood resuscitation, intravenous octreotide, ciprofloxacin and PPI were promptly started. Emergent upper gastrointestinal endoscopy (UGIE) revealed scarce fresh blood in the stomach and grade II oesophageal varices with red signs, which were thought to be the source of bleeding and treated with endoscopic banding. As hemodynamic instability and hematochezia persisted, UGIE was repeated with similar findings and no bleeding was identified on angiography. At 48 h from admission massive rebleeding occurred and a 3rd UGIE showed a fresh clot-over-varix located at 2nd to 3rd portions of duodenum (Fig. 1). Injection of the varix with 1 cc of lipiodol and cyanoacrylate 1:1 mixture was performed (Fig. 2), but spurting began soon after the procedure. Given the high surgical risk, yet another endoscopic approach was decided and successful 1ring banding was accomplished (Fig. 3). A 3rd-day UGIE showed a clean, shallow ulcer at the site of the varix (Fig. 4). No rebleeding episodes occurred. Several authors reported endoscopic banding for bleeding duodenal varices (1-4), sometimes followed by other therapies for rebleeding (3,4). Others used cyanoacrylate for emergent treatment of this condition (5), including after banding failure (3). This is, to our knowledge, the first report in which banding was apSuccessful endoscopic banding after cyanoacrylate failure for active bleeding duodenal varix

Meningitis in a patient with previously undiagnosed Crohn's disease

To the Editor: Crohn’s disease (CD) is a chronic inflammatory bowel disease with variable clinical presentation. An aggressive fistulizing pattern is possible and over one-third of CD patients will experience recurring fistulas during their disease course.1 Fistulization is a manifestation of the transmural nature of this disease,2 but fistulas to the epidural space are quite unusual.3 Herein we report a case of a male patient who presented to the medical emergency department with meningitis. Physical examination revealed multiple perianal and an abdominal fistula and subsequent complementary studies confirmed the presence of CD. A 26-year-old man was admitted to the emergency room because of high fever, severe headache, acute confusion, nausea, and vomiting. On admission his body temperature was 39°C, heart rate 120, respiratory rate 16, and blood pressure 103/55 mmHg. On physical examination the patient was confused, not oriented to person, place, or time. Kerning and Brudzinski signs were present but no Babinski or clonus. Ophthalmologic examination revealed papilloedema. There was no otitis, pharyngitis, or sinusitis and heart/lung examination was normal. Abdominal and pelvic examination revealed a large abdominal cutaneous fistula in the lower right quadrant and multiple perianal fistulas. Laboratory results upon admission showed leukocytosis (WBC of 23.2 G/L with 92% of PMN), thrombocytosis (689 G/L), and increased C-RP levels (20 mg/dL to a normal of 1 mg/dL). A head computed tomography (CT) scan revealed diffuse cerebral edema and lumbar punction was not performed initially. The patient was given, empirically, intravenous meropenem, vancomycin, and metronidazole. Two days later a lumbar puncture was unsuccessfully tried. Since the clinical symptoms and signs were highly suggestive of meningitis and the patient was recovering very well with antibiotic treatment the lumbar puncture was deemed dispensable. When the patient recovered he revealed that the perianal fistulas appeared 7 years ago and the abdominal fistula in the last 6 months but he hid this findings from his family and never sought medical help. A certain degree of mental impairment was obvious. After full recovery, a colonoscopy was performed and revealed severe inflammation of the rectum with a small orifice at the posterior wall corresponding, probably, to a fistulous tract. A similar process of severe inflammation was also present at the terminal ileum. Endoscopic and histologic findings were compatible with CD. Severe transmural

Prevalence and characteristics of Epstein–Barr virus-associated gastric carcinomas in Portugal

BackgroundGastric cancer (GC) is one of the most common malignant tumors of the digestive tract and is the third leading cause of cancer death worldwide. Epstein–Barr virus (EBV) has been associated with approximately 10% of the total cases of gastric carcinomas. No previous study has analyzed the prevalence of EBV infection in gastric cancer of the Portuguese population.MethodsIn the present study, we have analyzed 82 gastric carcinoma cases and 33 healthy individuals (control group) from Coimbra region for the presence of EBV by polymerase chain reaction (PCR) and by in situ hybridization (ISH) for EBV-encoded small RNAs (EBERs). The status of H. pylori infection was assessed by serology and by PCR.ResultsEBV was detected by PCR in 90.2% of stomach cancer cases, whereas EBERs were detected in 11%. In our series, EBV-associated gastric carcinoma (EBVaGC) were significantly associated with gender and the majority of them presented lymph node metastasis. These cases were generally graded in more advanced pTNM stages and, non-surprisingly, showed worse survival. H. pylori infection was detected in 62.2% of the gastric cancers and 64.7% of these patients were CagA+. On the other hand, the H. pylori prevalence was higher in the EBV-negative gastric carcinomas (64.4%) than in those carcinoma cases with EBV+ (44.4%).ConclusionsThe present study shows that prevalence of EBVaGC among Portuguese population is in accordance with the worldwide prevalence. EBV infection seems to be associated to poorer prognostic and no relation to H. pylori infection has been found. Conversely, the presence of H. pylori seems to have a favourable impact on patient’s survival. Our results emphasize that geographic variation can contribute with new epidemiological data on the association of EBV with gastric cancer.

Primary leiomyoma of the liver: accurate preoperative diagnosis on liver biopsy

Primary leiomyoma of the liver is an exceptionally rare tumour in non-immunocompromised patients. Preoperative diagnosis of the lesion is difficult as complete imaging of this type of lesion is scarcely defined and preoperative biopsy was not the practice in previously reported cases. We report a voluminous primary leiomyoma of the liver occurring in a healthy middle-aged woman where a preoperative diagnosis was accurately achieved on biopsy. Because of its size, surgery was undertaken for exclusion of malignancy. A 16-month uneventful follow-up has been completed. We discuss the advantage of a preoperative diagnosis and propose that an imaging-guided liver biopsy should be undertaken, provided malignancy features are absent. This could prevent liver surgery merely for diagnostic purposes. Finally, we report imaging features that have not been previously described, namely on magnetic resonance imaging, which may provide an insight about the nature of this particular lesion and, advantageously, contribute toward a non-invasive diagnosis.

SMALL BOWEL PSEUDOMELANOSIS AND ORAL IRON THERAPY

Small bowel pseudomelanosis is a rarely reported clinical entity characterized by brown pigmentation of small bowel mucosa. The authors describe two cases, both with iron deficiency anemia, one of an 81‐year‐old female patient submitted for capsule endoscopy that revealed a brown pigmentation of all small bowel mucosa and another of an 81‐year‐old male whose retrograde double‐balloon enteroscopy revealed a diffuse brown pattern of small bowel mucosa. Ileal biopsies confirmed intense iron deposition in the macrophages of the lamina propria. Both patients were on oral iron therapy and the second one had a previous double‐balloon enteroscopy, 2 years earlier, which revealed only ileal angiodysplasias. These two cases demonstrate the importance of two new endoscopic methods for diagnosis of small bowel pseudomelanosis, the rarity of such an entity and its close relation with oral iron therapy.

4579 Eus doppler-guided manometry of esophageal varices.

`Background and Aims: Variceal size and the presence of red signs on esophageal varices (EV) are considered to be the most important endoscopic factors to predict the risk of variceal rupture. However, endoscopic parameters alone cannot reliably anticipate the eminence of variceal bleeding. Variceal pressure (VP) is a major determinant of the risk of variceal bleeding and has been assessed by direct needle puncture of EV. This method, however, is invasive and may cause bleeding requiring immediate sclerotherapy. Reliability of non-invasive techniques to assess VP remains controversial. The endoscopic balloon technique is strongly observer-dependent: the ideal time for pressure reading is often difficult to decide, resulting in inter- and intra-observer variances. In this study we assessed the feasibility and accuracy of a new method based on EUS power doppler for monitoring EV blood flow during balloon manometry. Methods: Experimental assessment of this technique was performed with an in vitro model consisting of a plastic tube containing artificial latex varices, perfused with water and connected to a manometer. A linear array echoendoscope featuring power doppler was used to assess flow within the varices.A specially designed balloon for EV manometry was attached to the tip of the echoendoscope. Insufflation of this balloon resulted in compression of the varices until flow ceased on EUS power doppler. At this time, pressure readings were made. This procedure was then performed in 12 patients with portal hypertension and EV. Patients were sedated with midazolam and esophageal peristalsis was minimized with iv hyoscine butylbromide. Results: In vitro studies showed a good correlation between the measured pressure and the actual pressure (r=0.92). Determination of VP was technically successful in all patients. VP was 26.2 ± 6.8 mm Hg. Conclusions: Our preliminary results indicate that EUS dopplerguided manometry of EV is feasible and accurate. This technique may become a more reliable method for VP measurement and warrants further investigation. This research was funded in part by the Portuguese Health Ministry Committee for Investigation in Health Care.