Nikos Viazis

Large balloon dilation vs. mechanical lithotripsy for the management of large bile duct stones: a prospective randomized study.

OBJECTIVES:The removal of large bile duct stones (>12 mm) after endoscopic sphincterotomy (EST) remains a challenging issue in therapeutic endoscopy. The aim of this prospective, randomized, controlled trial was to compare the effectiveness and complications of EST followed by large balloon dilation (LBD) with that of EST followed by mechanical lithotripsy (ML) for the management of large bile duct stones.METHODS:A total of 90 patients with large bile duct stones (12–20 mm) were randomized to EST followed by LBD (n=45) or EST followed by ML (n=45). Success rate was determined with a final cholangiogram, whereas type and rate of post-procedure complications were assessed prospectively.RESULTS:Complete bile duct stone removal was accomplished in 97.7% of patients subjected to EST–LBD as compared with 91.1% of those subjected to EST–ML (P=0.36). Post-procedure complications were observed in two (4.4%) patients subjected to EST–LBD and in nine (20%) patients subjected to EST–ML (P=0.049). Rates of pancreatitis were similar between the two groups (one case in each), as was post-endoscopic retrograde cholangio pancreatography (ERCP) hemorrhage (one case in each group). None of the patients subjected to EST–LBD developed cholangitis, while this was seen in six patients subjected to EST–ML (0.0 vs. 13.3%, P=0.026). One patient subjected to EST–ML developed perforation, which was successfully managed conservatively. None of our patients with complications died.CONCLUSIONS:EST followed by LBD is equally effective as EST followed by ML for the removal of large bile duct stones, although it is associated with fewer complications.

Intestinal decontamination improves liver haemodynamics in patients with alcohol-related decompensated cirrhosis

Background  Endotoxaemia is commonly seen in cirrhotic patients with ascites and this may be associated with increased portal pressure.

Long-term administration of rifaximin improves the prognosis of patients with decompensated alcoholic cirrhosis

Cirrhotic patients are predisposed to intestinal bacterial overgrowth with translocation of bacterial products which may deteriorate liver hemodynamics. Having shown that short‐term administration of rifaximin improves liver hemodynamics in decompensated cirrhosis, we conducted this study to investigate the effect of intestinal decontamination with rifaximin on the long‐term prognosis of patients with alcohol‐related decompensated cirrhosis (Child‐Pugh > 7) and ascites.

Is there a role for second-look capsule endoscopy in patients with obscure GI bleeding after a nondiagnostic first test?

BACKGROUND Long-term follow-up data on patients with obscure GI bleeding subjected to capsule endoscopy (CE) are missing. OBJECTIVE Our purpose was to follow up patients with a nondiagnostic test and determine whether a second-look CE would be beneficial. PATIENTS We enrolled 293 subjects. CE studies were classified as diagnostic (positive findings) or nondiagnostic (findings of uncertain significance/no findings). Patients were followed up for a mean (SD) 24.8 (5.2) months. Outcome was defined as continued or complete resolution of bleeding. INTERVENTIONS Patients with a nondiagnostic test were subjected to a repeat CE if they manifested a new bleeding episode or a drop in hemoglobin >or=2 g/dL. RESULTS Positive findings, findings of uncertain significance, and no findings were identified in 41.6%, 16.0%, and 42.3% of our patients, respectively. Therapeutic intervention was possible in 72.1% of those with positive findings and in 30% of those with findings of uncertain significance. Complete resolution of bleeding occurred more often in patients with a diagnostic test (65.2%) compared with those with a nondiagnostic test (35.4%, P < .001). Second-look CE was performed in a subgroup of our patients (n = 76) and was diagnostic in those whose presentation changed from occult to overt or those whose hemoglobin dropped >or=4 g/dL. CONCLUSIONS In patients with obscure GI bleeding, a diagnostic CE leads to therapeutic interventions and a favorable outcome. Patients with a nondiagnostic test would definitely benefit from a second-look CE if the bleeding presentation changes from occult to overt or if the hemoglobin value drops >or=4 g/dL.

Does clinical response correlate with mucosal healing in patients with Crohn's disease of the small bowel? A prospective, case-series study using wireless capsule endoscopy.

Background: There are no studies assessing mucosal healing of the small bowel in patients with Crohns disease (CD). Our aim was to assess the correlation between clinical response and mucosal healing of the small bowel using wireless capsule endoscopy (WCE). Methods: This was a prospective, multicenter, case‐series study. Forty patients with known or suspected CD were included, recruited in 4 tertiary referral centers of Athens. They all had an acute flare‐up of their disease (CD Activity Index [CDAI] >150), involvement of the small bowel, and the nonstricturing, nonpenetrating type of the disease. All patients underwent WCE prior to the initiation of any treatment. Treatment varied according to the treating physician. For the evaluation of mucosal healing, 3 endoscopic variables were collected: number of apthous ulcers, number of large ulcers, and period of time that any endoscopic lesion was visible (erythema, edema, ulcers). When patients achieved clinical response (after at least a month of treatment) they underwent a second WCE, with evaluation of the same parameters. Results: The number of large ulcers was the only endoscopic variable that showed a significant improvement. The numbers of large ulcers before and after treatment were 8.3 ± 1.4 and 5 ± 0.8, respectively (mean ± SEM) (mean difference 3.3 ± 1.2, 95% confidence interval [CI] 0.8–5.9, P = 0.01). The other 2 variables did not improve significantly. Conclusions: Since only 1 out of 3 endoscopic variables improved significantly with treatment, we can conclude that clinical response does not seem to correlate with mucosal healing in patients with CD of the small bowel.

Selective Serotonin Reuptake Inhibitors for the Treatment of Hypersensitive Esophagus: A Randomized, Double-Blind, Placebo-Controlled Study

OBJECTIVES:Ambulatory 24-h pH–impedance monitoring can be used to assess the relationship of persistent symptoms and reflux episodes, despite proton pump inhibitor (PPI) therapy. Using this technique, we aimed to identify patients with hypersensitive esophagus and evaluate the effect of selective serotonin reuptake inhibitors (SSRIs) on their symptoms.METHODS:Patients with normal endoscopy and typical reflux symptoms (heartburn, chest pain, and regurgitation), despite PPI therapy twice daily, underwent 24-h pH–impedance monitoring. Distal esophageal acid exposure (% time pH <4) was measured and reflux episodes were classified into acid or non-acid. A positive symptom index (SI) was declared if at least half of the symptom events were preceded by reflux episodes. Patients with a normal distal esophageal acid exposure time, but with a positive SI were classified as having hypersensitive esophagus and were randomized to receive citalopram 20 mg or placebo once daily for 6 months.RESULTS:A total of 252 patients (150 females (59.5%); mean age 55 (range 18–75) years) underwent 24-h pH–impedance monitoring. Two hundred and nineteen patients (86.9%) recorded symptoms during the study day, while 105 (47.9%) of those had a positive SI (22 (20.95%) with acid, 5 (4.76%) with both acid and non-acid, and 78 (74.29%) with non-acid reflux). Among those 105 patients, 75 (71.4%) had normal distal esophageal acid exposure time and were randomized to receive citalopram 20 mg (group A, n=39) or placebo (group B, n=36). At the end of the follow-up period, 15 out of the 39 patients of group A (38.5%) and 24 out of the 36 patients of group B (66.7%) continue to report reflux symptoms (P=0.021).CONCLUSIONS:Treatment with SSRIs is effective in a select group of patients with hypersensitive esophagus.

Sedation in digestive endoscopy: the Athens international position statements

Aliment Pharmacol Ther 2010; 32: 425–442

Colon capsule endoscopy is feasible to perform after incomplete colonoscopy and guides further workup in clinical practice.

BACKGROUND Colon capsule endoscopy (CCE) could be an option to examine the colon after incomplete colonoscopy. OBJECTIVE To investigate the extent that CCE complements incomplete colonoscopy and guides further workup. DESIGN Prospective, follow-up study. SETTING Three tertiary-care centers. PATIENTS Consecutive outpatients after colonoscopy failure; 1-year study period. INTERVENTION Patients underwent CCE either immediately after colonoscopy or were rescheduled. Further investigations were guided by the results of CCE. Patients were followed as long as 2 years. RESULTS We studied 75 outpatients; 39 had a screening colonoscopy. One third of the patients underwent CCE immediately after colonoscopy. Overall, CCE reached or went beyond the colon segment at which colonoscopy stopped in 68 patients (91%). CCE technically complemented difficult colonoscopy independently of whether same-day CCE was performed (24 [96%]) or was not performed (44 [88%]). CCE detected additional significant findings in 36% of the same-day CCE cases and in 48% of the rescheduled ones. Two patients in the same-day group and 13 in the rescheduled CCE group underwent further colon examination that revealed additional significant findings in 3 of them. Ten percent of the patients reported mild adverse events (AE). If needed, 63 participants (84%) were willing to repeat CCE. Follow-up has not identified symptomatic missed colon cancers. LIMITATIONS Selected patient population, first-generation colon capsule, old preparation scheme. CONCLUSION CCE performed immediately or at a scheduled date after colonoscopy failure is feasible and safe. CCE after incomplete colonoscopy appears to yield significant findings, guide further workup, and has high patient acceptance.

Course of inflammatory bowel disease in patients infected with human immunodeficiency virus.

Background: Human immunodeficiency virus (HIV) infection depletes CD4+ lymphocytes, which may benefit patients with inflammatory bowel disease (IBD). The aim was to compare the course of IBD in HIV patients with a matched group of IBD seronegative patients. Methods: A total of 20 IBD (14 Crohns disease, 6 ulcerative colitis) HIV infected patients and 40 matched control seronegative IBD patients (2 controls per case) were compared regarding relapse of their disease. The CD4+ count was followed every 6 months and a value of ≤500 cells/&mgr;L was used to define patients with immunosuppression. Relapse rates per year of follow‐up were compared among the 2 groups and survival curves for cumulative remission rates were compared with a log‐rank test. Multivariate analysis was used to discriminate among the impact of different variables on the risk of IBD relapse. Results: The median duration of follow‐up was 8.4 years (range 0.6–18 years). The mean relapse rate for the HIV+IBD group was 0.016/year of follow‐up as compared to 0.053/year of follow‐up for the IBD‐matched control group (P = 0.032). Regarding the HIV‐positive/IBD group, 14 patients were immunosuppressed at any given time during the follow‐up period. None of these patients experienced an IBD relapse, whereas 3 out of the 6 without immunosuppression relapsed (P = 0.017). According to the multivariate analysis, HIV status was the only risk factor independently associated with a lower probability of IBD relapse. Conclusions: HIV infection reduces the relapse rates in IBD patients and this may be attributed to the lower CD4+ counts seen in these patients. (Inflamm Bowel Dis 2010;)

Long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis

BACKGROUND-AIM The aim of this study is to identify the long term benefit of one year infliximab administration for the treatment of chronic refractory pouchitis following ileo-pouch anal anastomosis (IPAA) for ulcerative colitis (UC). METHODS Seven patients with chronic refractory pouchitis diagnosed by clinical, endoscopic and histological criteria received infliximab 5 mg/kg at 0, 2, and 6 weeks and thereafter every 2 months for 1 year. Three patients had fistulae (1 pouch-bladder, 2 perianal) and 4 extraintestinal manifestations (2 erythema nodosum, 2 arthralgiae). All patients were refractory to antibiotics and 3 to azathioprine. Crohns disease was excluded after re-evaluation of the history and small bowel examination with enteroclysis or capsule endoscopy. Clinical response was classified as complete, partial and no response. Fistulae closure was classified as complete, partial and no closure. The pouchitis disease activity index (PDAI) was used as an outcome measure. All patients were followed up for 3 years after discontinuation of infliximab therapy. RESULTS After 1 year of infliximab administration 5 patients had complete clinical response, 1 partial clinical response and 1 no response, while 2 out of the 3 patients with fistulae had a complete closure. The median PDAI dropped from 11 (baseline) (range, 10-14) to 5 (range, 3-8). Extraintestinal manifestations were in complete remission too. Three years after completion of therapy, all patients with complete clinical response at one year remained in remission. CONCLUSIONS One year infliximab administration is associated with a long term benefit in patients with chronic refractory pouchitis following IPAA for UC.