Ralf Kiesslich

Advanced endoscopy imaging in inflammatory bowel diseases

BACKGROUND AND AIMSnRapid assessment of mucosal inflammation is of crucial importance for the initial diagnosis and the assessment of mucosal healing in inflammatory bowel disease (IBD). Moreover, the identification of intraepithelial neoplasias in IBD is of key relevance for clinical management. Here, we systematically analyzed the utility of advanced endoscopic imaging techniques for optimized diagnosis in IBD.nnnMETHODSnPubMed/Medline, Web of Knowledge, and Cochrane library were searched twice for diagnostic studies on advanced endoscopic imaging in IBD. Clinical and technical information was retrieved and subsequently analyzed. Main outcome parameters consisted of the quality of the results, adverse events, and diagnostic yield.nnnRESULTSnFifty-six clinical studies with a total of 3296 patients were selected for final analysis. Filter technologies permitted a more detailed analysis of mucosal inflammation in IBD. In spite of substantial heterogeneity across studies, dye-based chromoendoscopy with targeted biopsy sampling yielded higher detection rates of intraepithelial neoplasias in ulcerative colitis as compared with white-light endoscopy with random biopsy sampling. Moreover, endocytoscopy and endomicroscopy allowed subsurface imaging of inflamed or neoplastic mucosa in IBD at subcellular resolution. Finally, endomicroscopy-aided molecular imaging enabled the identification of membrane-bound tumor necrosis factor on mucosal cells as a potential driver of disease activity in Crohns disease. No relevant adverse events were reported.nnnCONCLUSIONSnAdvanced endoscopic imaging technologies are feasible, safe, and partially effective tools for detailed diagnosis of mucosal inflammation and detection of neoplasias in IBD. Results obtained from these advanced techniques may provide a rational basis for individualized, optimized therapy for IBD patients.

G-EYE advanced colonoscopy for improved polyp detection rates – a randomized tandem pilot study with different endoscopists

BACKGROUND AND AIMSnu2002The most commonly missed polyps inxa0colonoscopy are those located behind haustral folds. The G-EYE system is a standard colonoscope consisting of re-processable balloon at its distal tip.u200aThe G-EYE balloon improves the detection of polyps by straightening the haustral folds. In our back-to-back tandem study, we aimed to determine whether and to what extent the G-EYE system could reduce adenoma miss rates in screening colonoscopy.nnnMETHODSnu2002Patients referred to colonoscopy were randomized into 2 groups. Group A underwent a standard colonoscopy (SC) followed by balloon colonoscopy (BC), and Group B underwent BC followed by SC. In this randomized tandem study, the investigators level of training and the endoscopists themselves were changed after each withdrawal. Each endoscopist was blinded to the results of the first withdrawal.nnnRESULTSnu2002Fifty-eight patients were enrolled and randomized into 2 groups with similar baseline characteristics. Nine patients were excluded from the study. Twenty-five patients underwent SC followed by BC while 24 underwent BC followed by SC. The adenoma miss rate for SC was 41u200a%, with an additional detection rate of 69u200a% for BC (ratio 1.69). The overall miss rate for polyps was 60u200a% for SC, with an additional detection rate of 150u200a% for BC (ratio 2.5). Experienced investigators who used BC were able to identify an additional 7 polyps while inexperienced investigators.nnnCONCLUSIONSnu2002Although our results could not clearly confirm that BC improves adenoma detection, the investigators experience appears to be a major determinant of the adenoma detection rate.

Endoscopic and angiographic management of lower gastrointestinal bleeding: Review of the published literature:

Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.

Endoscopic Bleeding Control

Gastrointestinal bleeding (GIB) can occur at different locations and different intensities throughout the intestine. Gastrointestinal bleeding is subdivided based on the location (upper, lower, middle GIB). The upper GI tract comprises the esophagus, stomach, and duodenum (up to the papilla of Vateri). Middle GIB relates to that part of the GI tract located below the papilla Vateri up to the terminal ileum. Lower GIB is defined as a bleeding within the colon and rectum.

Neue Einblicke mit der gastrointestinalen Endoskopie

Auf der europäischen Gastroenterologenwoche (United European Gastroenterology Week, UEGW) in Barcelona waren die Weiterentwicklung der Gerätetechnik und die wissenschaftlichen Erkenntnisse im Bereich der gastrointestinalen Endoskopie führende Themen. In einer Serie von Artikeln werden in GASTRO NEWS von Referenten des UEGW-Updates die Inhalte der wichtigsten Vorträge und Abstracts präsentiert.

Molecular imaging within the lower gastrointestinal tract: From feasibility to future

Molecular imaging is based on the labelling of defined molecular targets through the utilization of fluorescently linked probes and their subsequent detection with high‐resolution endoscopic devices, thereby enabling visualization of single molecules including receptors. Whereas early studies have used molecular imaging for improved visualization and detection of early dysplasia and cancer as well as for assessing intestinal inflammation and inflammation‐associated cancer within the gastrointestinal (GI) tract, more recent studies have impressively demonstrated that molecular imaging can also be used to characterize and visualize the molecular fingerprint of cancer and inflammation in vivo and in real time. With this, molecular imaging can be used to guide expression‐tailored individualized therapy. With the rapid expansion and diversification of the repertoire of biological agents utilized in inflammatory bowel disease and cancer, this approach is gaining increasing attention. Within this review, we first summarize the technical components commonly used for molecular imaging and then review preclinical and clinical studies and evolving clinical applications on molecular imaging within the lower GI tract. Molecular imaging has the potential to significantly change endoscopic diagnosis and subsequent targeted therapy of gastrointestinal cancer and chronic gastrointestinal diseases.

Intervallkarzinom des Dickdarms oder seltene Differenzialdiagnose

Vier Monate nach einer unauffälligen Nachsorgekoloskopie klagt eine 78-jährige Patientin über zunehmende Bauchschmerzen. Eine Ultraschalluntersuchung des Bauchraums zeigt eine Tumorformation im Bereich des Cöcalpols. Erst bei der Wiederholung der Koloskopie ergibt sich der Nachweise für die richtige Diagnose.

Welche Ursache hat die idiopathische, rezidivierende Pankreatitis?

Nach der Diagnose einer chronischen Pankreatistis ungeklärter Genese vor mehr als zehn Jahren klagt ein 46-jähriger Patient aktuell über chronische abdominelle Schmerzen und Fieber. Eine Endosonografie ergibt keine klaren Zeichen der chronischen Pankreatitis und keine Choledocholithiasis. Erst eine Magnetresonanztomografie mit selektiver Darstellung der Gallen- und Pankreasgänge zeigte die Ursache.

Efficacy and safety of PICOPREP tailored dosing compared with PICOPREP day-before dosing for colon cleansing: a multi-centric randomised study

Background and study aimsu2002The success of any colonoscopy procedure depends upon the quality of bowel preparation. We evaluated the efficacy and safety of a new tailored dosing (TD) regimen compared with the approved PICOPREP day-before dosing regimen (DBD) in the European Union. Patient and methodsu2002Patients (≥u200a18 years) undergoing colonoscopy were randomised (2:1) to TD (Dose 1, 10u200a–u200a18 hours; Dose 2, 4u200a–u200a6 hours before colonoscopy) or DBD (Dose 1 before 8:00AM on the day before colonoscopy; Dose 2, 6u200a–u200a8 hours after Dose 1). The primary endpoint of overall colon cleansing efficacy was based on total Ottawa Scale (OS) scores (0u200a–u200a14, excellent-worst). The key secondary endpoint was a binary endpoint based on the ascending colon OS (success 0 or 1, failure [≥u200a2]). Convenience and satisfaction were evaluated similar to the primary and key secondary endpoints. Safety and tolerability were also evaluated. Resultsu2002Use of the PICOPREP TD regimen resulted in a statistically significant reduction in the mean total Ottawa Scale score compared to the PICOPREP DBD regimen (–3.93, 95u200a% confidence intervals [CI]:u200a–u200a4.99,u200a–u200a2.97; Pu200a<u200a0.0001) in the intent-to-treat analysis set. The PICOPREP TD regimen also resulted in a statistically significant increase in the odds of achieving an ascending colon OS scoreu200a≤u200a1, compared to the PICOPREP DBD regimen (estimated odds ratio 9.18, 95u200a% CI: 4.36, 19.32; Pu200a<u200a0.0001). There was no statistically significant difference in the overall rate of treatment-emergent adverse events (12u200a% (TD) and 5.7u200a% (DBD), respectively, Pu200a=u200a0.2988). The convenience and satisfaction were comparable in the two groups. Conclusionu2002The TD regimen was superior to the DBD regimen for overall and ascending colon cleansing efficacy. ClinicalTrials.gov Identifier: NCT02239692

The Near Future of Endoscopic Screening in IBD

Patients with long-standing extensive chronic inflammatory bowel disease (IBD) have an increased risk of developing intraepithelial neoplasia and colitis-associated cancer (CAC) compared to the average risk population. In 2003, the first randomized, controlled trial was published evaluating lesions in the colon according to a modified Pit-Pattern classification after pan-chromoendoscopy with methylene blue (0.1 %). Chromoendoscopy enabled unmasking dysplastic lesions and clarifying the borders between neoplastic and normal tissue. This has led to the “smart biopsy” concept, where more targeted biopsies become possible after enhanced endoscopy (chromoendoscopy). In addition, confocal laser endomicroscopy (CLE) has revealed in vivo tissue changes in vessel, connective tissue and cellular-subcellular structures.