Pierluigi Consolo

Depression, Anxiety and Anger in Subtypes of Irritable Bowel Syndrome Patients

The present study aimed to elucidate the differences in depression, anxiety, anger, and quality of life in a sample of non-psychiatric IBS patients, starting from the hypothesis that IBS subtypes may have different symptomatic expressions of negative emotions with different outcomes on quality of life measures. Forty-two constipation-predominant IBS (C-IBS) subjects and 44 diarrhea-predominant IBS (D-IBS) subjects, after an examination by a gastroenterologist and a total colonoscopy, underwent a clinical interview and psychometric examination for the assessment of depression, anxiety, anger and quality of life. IBS subtypes showed different symptomatic profiles in depression, anxiety and anger, with C-IBS patients more psychologically distressed than D-IBS subjects. Affective and emotional symptoms should be considered as specific and integral to the syndrome, and recognizing the differences between IBS subtypes may have relevant implications for treatment options and clinical outcome.

Through-the-scope large diameter self-expanding metal stent placement as a safe and effective technique for palliation of malignant colorectal obstruction: A single center experience with a long-term follow-up

Abstract Objective. The aim of this study was to evaluate the outcomes of through-the-scope (TTS) large diameter self-expanding metal stent (SEMS) placement for palliation of malignant colorectal obstruction. Material and methods. Between January 2005 and December 2009, all patients who underwent endoscopic SEMS placement for palliation of malignant colorectal obstruction were prospectively enrolled. Results. Thirty-nine patients (17M and 22F; mean age 75.9 ± 10.6 years, range 50–91) were enrolled. The most frequent location was the sigmoid colon (13 cases). The causes of obstruction were colorectal malignancy in 32 patients and extracolonic malignancy in 7. Technical success was achieved in 36/39 patients (92.3%) and clinical success in 35/39 patients (89.7%). Technical failure was related to female sex (p = 0.04) and the extracolonic etiology of the stricture (p < 0.001). There were three early complications: two procedure-related perforations successfully managed conservatively and one hemorrhage treated with APC. Early complications were related to the location of strictures at the recto-sigmoid junction (p < 0.001). Late complications occurred in 10 patients: 8 of these patients experienced occlusive symptoms (attributable to tumor ingrowth in 5 cases and stool impaction in 3 cases); the remaining 2 were one case of tumor ingrowth with sub-occlusive symptoms and hemorrhage, and one case of distal migration. There was no procedure-related mortality and all complications were managed without surgical intervention. SEMS patency duration was 236 ± 128 days (range 31–497) and mean survival of the patients was 259 ± 121 days (range, 32–511). Conclusions. In our experience, TTS large-diameter SEMS placement is a safe and effective treatment for palliation of malignant colorectal obstruction.

An endoscopic approach to the management of surgical bile duct injuries: nine years’ experience

BACKGROUND The evaluation of the endoscopic treatment of surgical bile duct injuries, especially in the management of post-operative strictures, remains controversial. AIM The aim of this study was to evaluate the feasibility of using endoscopic management from a study of the clinical reports of two of the main endoscopy units in Sicily. PATIENTS AND METHODS A total of 137 consecutive patients were selected. There were 85 simple biliary fistulas: 64 from the cystic duct stump; 19 from the gall bladder bed; and two from intra-hepatic bile ducts. There were 52 biliary lesions: 15 complete transections; 12 incomplete lesions of the common bile duct with six associated strictures; five complete or incomplete sections of the right antero-medial duct; and 20 incomplete strictures (without leak). RESULTS The success rate was 96.3% for simple biliary fistulas. Endoscopic therapy was feasible only in 40.6% of lesions of the common bile duct or the right antero-medial duct (13/32), but with 100% success. In the case of strictures (with or without associated leak), there was a good outcome in 88.2% of patients who completed the therapeutic procedure. CONCLUSIONS Endoscopic management of simple biliary fistulas and incomplete lesions of the common bile duct is the preferred approach. If continued for 12-24 months, with the placement of three or more 10F stents, the management of stenoses is guaranteed to yield good results.

A comparison of uncovered metal stents for the palliation of patients with malignant biliary obstruction: nitinol vs. stainless steel.

BACKGROUND Various types of self-expandable metal stents have been introduced for the palliation of malignant biliary obstruction. AIMS To compare the outcomes of WallFlex™ and Wallstent™ uncovered biliary self-expandable metal stents (SEMSs) for the palliation of patients with malignant biliary obstruction. METHODS Between October 2008 and December 2009, all SEMSs placed for malignant biliary obstruction were WallFlex™: all patients palliated were included in the study. Before October 2008, all the SEMSs placed for malignant biliary obstruction were Wallstent™, and the patients palliated from July 2007 to September 2008 were the comparative group. RESULTS A total of 58 WallFlex™ and 54 Wallstent™ SEMSs were placed, and efficacious biliary decompression was achieved in all patients. Early complications occurred in 5 patients in the WallFlex™ group and in 3 in the Wallstent™ group (p=ns). Late complications occurred in 6 patients in the WallFlex™ group and in 16 in the Wallstent™ group (p<0.01). The overall patency of the self-expandable metal stent in the WallFlex™ and the Wallstent™ groups was similar (227 days vs. 215 days, p=ns). Mean patient survival was 242 days in the WallFlex™ group and 257 days in the Wallstent™ group (p=ns). CONCLUSIONS We found no difference in terms of overall patency between the two types of SEMSs, but there was an increased rate of late adverse events in the Wallstent™ group.

Endoscopic Tattooing of Gastrointestinal and Pancreatic Lesions

The intraoperative identification of the lesions found at endoscopic examination is often difficult, especially during laparoscopic surgery. At present, the most used technique for the intraoperative detection of pathological lesions is endoscopic tattooing. The large majority of studies carried out concern colorectal lesions; however, endoscopic tattooing has also been described for esophageal, gastric, small bowel and, more recently, pancreatic lesions. In this review, the authors evaluated indications, substances used, injection techniques, accuracy, safety and, finally, the risk of complications related to this procedure.

Is pregnancy a predisposing factor for Dieulafoy's duodenal lesion or only a coincidence?

Dieulafoy’s lesion (DL) is a rare vascular abnormality of a submucosal artery, associated with a minute mucosal defect, that can be the cause of a massive, potentially lifethreatening, gastrointestinal (GI) hemorrhage [1]. Although such lesions may develop anywhere throughout the entire GI tract, they most often develop in the proximal stomach [1]. Safety and efficacy of endoscopic management for DLs have been widely recognized. Various endoscopic techniques, including injection therapy, thermal probes, laser therapy, endoscopic band ligation and hemoclipping have been used with high rates of successful hemostasis [2]. To date, no cases of bleeding DL in pregnant woman have been described in literature. We describe a case of a 35-years-old, ninth week pregnant woman referred to our Emergency Department because of melena in the previous 2 days, sickness and syncopal episode. Blood examination showed red blood cells 2.9 × 106/ L (normal range: 4.0—5.2); hemoglobin 7.1 g/dL (normal range: 12.0—16.0); mean cell volume 75.9 fL (normal range: 80.0—100.0). Heart rate was 130 bpm; blood pressure 100/70 mmHg; SatO2 100%. No blood was encountered after nose-gastric tube placement. We started red blood cells transfusion, while performed ultrasonography showed intra-uterine normal gestational sac, with a living fetus, crown rump length 24.8 mm, corresponding to predicted gestational age. The performed esophagogastroduodenoscopy under deep sedation showed blood in the second duodenal portion but no hemorrhagic lesion was observed. We decided to change the gastroscope with the colonoscope reaching the third duodenal portion where a Dieulafoy’s spurting lesion was observed (Fig. 1) and the bleeding was stopped with four metallic clips placement (Fig. 2). Patient was submitted to a second look upper GI endoscopy 2 days later showing the clips correctly placed and no evidence of rebleeding. At 1 month followup, patient still does not have any sign of GI bleeding, and pregnancy is physiologically going on. Figure 2 Placement of four metallic clips on the bleeding lesion.

Negative Emotions in Irritable Bowel Sindrome: which differences among IBS Subtypes?

There are conflicting data on peculiar negative emotional patterns in Irritable Bowel Syndrome subtypes. Our study was aimed to determine possible differences in depression, anxiety and anger in patients suffering from Irritable Bowel Syndrome constipation, diarrhoea and mixed subtypes. The sample underwent a psychometric examination for the assessment of depression (Hamilton Rating Scale Depression), anxiety (Hamilton Rating Scale Anxiety), and anger (State-Trait Anger Expression Scale 2). Differences among groups were assessed using the Analysis of variance with Bonferroni post hoc comparisons, or the χ²-test if requested. 111 subjects ( diarrhoea subtype =37; constipation subtype =34; mixed subtype =40) were included in the study. The severity of depressive symptoms was “moderate” in patients with constipation subtype and “mild” in patients with diarrhoea and mixed subtypes (17.15±6.7 vs 14.24±6.6 vs 12.50±4.9); no statistically significant differences were documented among subtypes. Severity of anxiety symptoms was “mild to moderate” in patients with constipation subtype (mean = 18.53 ± 7.7), and mild in patients with diarrhoea (mean = 13.35 ± 7.1) and mixed subtypes (mean = 13.25 ± 4.7); statistically significant differences among subgroups were found (Constipation vs D iarrhoea : p=0.004; Constipation vs Mixed : p=0.003). Regarding anger, significant differences among subgroups emerged at State Anger Feeling Angry and Anger In variables, both higher in constipation subtype group than in mixed subtype group (State Anger Feeling Angry: p=0.002; Anger In: p=0.001). P atients with constipation subtype constitute a subgroup characterized by a discrete burden of negative emotions, mainly anxiety and anger.