Michael Bellutti

Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding

Background  Double‐balloon enteroscopy (DBE) is a useful method for evaluation of obscure gastrointestinal bleeding (OGIB).

Therapeutic ERCP with the double-balloon enteroscope in patients with Roux-en-Y anastomosis

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Detection of Neuroendocrine Tumors of the Small Bowel by Double Balloon Enteroscopy

Background Neuroendocrine tumors (NET) account for one-third of all small bowel neoplasms. The search for the primary tumor in NET is important, even though it is difficult to localize, as its surgical excision leads to a better prognosis, even in metastasized stages of the disease. The objective of this study was to evaluate the use of double balloon enteroscopy (DBE) for the detection of the primary tumor in patients with NET. Methods Twelve consecutive patients (eight women, four men) with suspected carcinoid syndrome, either metastatic to the liver (n = 5), symptoms of a neuroendocrine tumor with elevated tumor markers (n = 5), or obscure gastrointestinal bleeding (n = 2) underwent DBE for the search of the primary tumor or the source of bleeding. All patients underwent abdominal sonography and a computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), ileocolonoscopy, and octreotide scintigraphy prior to DBE. Capsule endoscopy was performed in four patients. Results A total of 17 DBE were performed in the 12 patients. The CT scan and sonography of the abdomen as well as EGD and ileocolonoscopy were unable to detect the primary tumor in any patient. A submucosal tumor of the ileum or the jejunum could be detected by DBE was detected in seven patients (58%) (anal route, n = 4; oral route, n = 3). In four of these patients (33%) this finding could be confirmed by the surgical resection of a NET. In two patients (17%) with a submucosal ileum protrusion suspicious for NET, laparotomy and intraoperative endoscopy did not confirm the tumor. Conclusions In this study, the diagnostic yield of DBE for primary tumor search in patients with metastatic or suspected NET was 33%. Although endoscopic small bowel investigation by DBE seems to enrich the diagnostic possibilities for the diagnosis of small bowel-NET, at the present time DBE should only be performed in selected cases, possibly based on a positive previous work-up.

Small bowel polyps and tumours: endoscopic detection and treatment by double‐balloon enteroscopy

Background  Double‐balloon enteroscopy has allowed us not only to inspect deeply the small bowel but also to carry out interventions for diseases of the small bowel.

Utility of double-balloon enteroscopy for the evaluation of malabsorption.

Introduction: Occasionally, patients with malabsorption represent a diagnostic challenge. Double-balloon enteroscopy (DBE) allows deep and detailed examination of the small bowel. Aim: To determine the diagnostic value of DBE in patients with malabsorption of unclear origin. Methods: DBE was performed in a total of 12 patients with clinical malabsorption. Biopsy specimens were taken from macroscopic lesions or from examined small bowel at three different levels of scope insertion depth. Tissue specimens were evaluated with standard hematoxylin and eosin, the modified Marsh classification and, when indicated, special stains for amyloidosis. Results: Fifteen DBEs were successfully performed in 12 patients without complications. DBE with small bowel biopsies yielded a diagnosis in 8 patients (67%). A new diagnosis was reached in 4 patients (33%). The new diagnoses included: Crohn’s disease, primary intestinal lymphangiectasia and jejunal amyloidosis. In none of these 4 patients did the duodenal biopsies yield a diagnosis. Also, DBE excluded enteropathy-associated T-cell lymphoma (EATL) and/or ulcerative jejunitis in symptomatic celiac disease patients. Conclusions: DBE had a diagnostic value of 42% in patients with malabsorption of unclear origin. In addition, DBE was useful to rule out complications of long-standing celiac disease such as ulcerative jejunitis or EATL. DBE should be reserved for patients with unexplained malabsorption. DBE with jejunal and ileal biopsies appears to have a diagnostic value in patients with malabsorption, even when duodenal biopsies are histologically normal.

Double-balloon enteroscopy in the diagnosis of suspected isolated Crohn's disease of the small bowel

Diagnosis of Crohns disease (CD) with isolated involvement of the small bowel remains a major challenge. Diagnostic procedures allowing direct insight into the midgut have become available with the introduction of double‐balloon enteroscopy (DBE) and video‐capsule endoscopy (VCE). The aim of the present study was to evaluate the role of DBE in the diagnosis of isolated CD of the small bowel.

Missed lesion with conventional endoscopy discovered by double-balloon enteroscopy : endoscopist or instrument? -authors' reply

enteroscopy: endoscopist or instrument? – authors’ reply SIRS, We appreciate the interest of Drs Manes and Bianchi Porro in our work. In their long experience using double balloon enteroscopy (DBE) in patients with obscure gastrointestinal bleeding (OGIB), they also observed that a significant proportion of patients (11%) have lesions missed by conventional endoscopy. While performing DBE, Dr Manes and Dr Bianchi Porro made astute observations and added two other important explanations for missed lesions by conventional endoscopy. First, endoscopist inexperience appears to be a factor hindering an adequate evaluation of patients with OGIB. Thus, it is imperative that guidelines for management of OGIB be modified to add that an experienced endoscopist performs or supervises the procedures in these patients. Even if this proposal sounds ‘logical’, ours and their experience suggests that many GI lesions are missed because of endoscopist inexperience. 2 Their second observation is also of clinical importance: the thin and flexible enteroscope allows for improved visualization of lesions in difficult or ‘hidden’ positions, such as behind folds, the duodenal bend or the ileococeal valve. This important technical aspect should be kept in mind when investigating patients with OGIB or other suspected small bowel diseases, such as tumours. Further to improving the visibility in the locations mentioned by Manes and Bianchi Porro, we would like to add that due to its flexibility, length and balloon-assisted technique, DBE is also very useful for performing ileo-colonoscopy in patients with previously incomplete colonoscopy or ERCP in patients with complex upper GI anatomy. 5

W1393 Is Tumor M2-Pyruvate Kinase (PK) a Potential Marker for the Discrimination Between Chronic Pancreatitis and Pancreatic Cancer?

were determined. MIA PaCa-2 pancreatic cancer cell lines with functional mitochondria (rho+) and the same lines without functional mitochondria (rhoo) (J. Biol. Chem. 281:37416, 2006), were treated with ascorbate and clonogenic survival determined. The oxygen electrode method was used to determine H2O2 production. MIA PaCa-2 tumor cells (2 x 106) were delivered subcutaneously into the flank region of nude mice and allowed to grow until they reached 3 mm in greatest dimension at which time they were randomized to receive either ascorbate (4g/kg) or osmotically equivalent i.p. saline as a control (1 M) given to mice i.p. every day for two weeks. Results: There was a time and dose-dependent increase in measured H2O2 productionwith increased concentrations of ascorbate. Ascorbate decreased clonogenic survival and viability in pancreatic cancer cell lines in a dose-dependent manner. Ascorbate had no effect on the H6c7 cell line, but decreased viability in the H6c7 cell lines that express K-ras oncogene. Ascorbate (5 and 10 mM) decreased viability in all human pancreatic cancer cell lines tested. In rho+ cells, ascorbate resulted in a dose-dependent decrease in clonogenic survival, but no cytotoxicity in the rhoo cells. The group of animals that received ascorbate had significantly slower tumor growth when compared to the controls receiving osmotically equivalent saline (P < 0.0001, n = 5-8/group). On day 15 of treatment, there was a 3.5fold decrease in tumor growth in animals receiving ascorbate when compared to controls. Conclusions: Pharmacological doses of ascorbate, achievable in humans when given intravenously, may have potential for therapy in pancreatic cancer. The ascorbate-induced cytotoxicity in pancreatic cancer cells may be mediated by a mitochondrial mechanism.

T1964 Dilation of Intercellular Spaces in Esophageal Epithelium in Non-Erosive and Erosive Reflux Disease Patients and Appropriate Controls

and pH recordings. c) sleep stages using standardized EEG, EOG and EMG recording. Results: A total of 96 EPR were recorded only three of which occurred during sleep, therefore, data regarding the remaining 93 episodes were pooled. Of these refluxates, 10 were fluid, 78 were gas and 5 were mixed. UES and esophageal pressure behavior for refluxates of different physical properties were similar and this data was pooled. Two types of UES pressures were identified during pharyngeal reflux. The UES nadir pressure for complete UES relaxation (cUES-R) averaged -2.1±3.0 mmHg. UES nadir pressure for partial relaxation (pUES-R) averaged 9.4±4.0 mmHg. Complete relaxation occurred in 26/93 (28%) of EPR while incomplete relaxation occurred in 67/93(72%). Pharyngeal reflux events occurred within 1-2 seconds of or as late as 10s after GE reflux (GER) (table). Reflux-induced CC pressure was either equal to or significantly greater than UES residual pressure (p<0.01, table). This was also true for the three pharyngeal reflux events during sleep. GER events not associated with EPR had an average CC pressure of 7.5±3.7 mmHg and a UES pressure of 54±27 mmHg. Conclusions: 1) EPR during sleep is rare. 2) EPR is accompanied by either complete or partial relaxation of UES. 3) Reflux-induced CC pressure equals or exceeds UES nadir pressure.