Sandra Lopes

Double-Balloon Enteroscopy and Small Bowel Tumors: A South-European Single-Center Experience

Small bowel tumors are rare, accounting for 1–2% of all gastrointestinal neoplasms. We sought to determine the diagnostic and therapeutic impact of double-balloon enteroscopy (DBE) in patients with small bowel tumors. Between January 2005 and March 2008, 78 patients underwent 96 DBE. All nine patients (seven males; mean age 68xa0±xa011.3xa0years) with small bowel tumors were retrospectively reviewed. Clinical presentation was: mid-gastrointestinal bleeding or iron-deficient anemia (55.6%); abdominal pain (22.2%); nausea/vomiting and abdominal distension (22.2%). Five patients had abnormal findings in previous capsule endoscopy and four in previous radiologic examinations. Route of insertion was exclusively oral and abnormal lesions were detected in all patients (jejunum 8; ileum 1). Biopsies were taken in seven patients and provided definitive histological diagnosis in all except one. There were no complications of DBE. Surgical resection took place in eight patients. Final histologic diagnosis were: primary carcinoma (33.3%), gastrointestinal stromal tumor (GIST) (33.3%), malignant lymphoma (22.2%), and carcinoid tumor (11.1%). Mean follow-up time was 15.4xa0±xa012.7xa0months (range 2–34xa0months). Six patients were submitted to chemotherapy. Two patients died. Small bowel tumors are common in patients submitted to DBE. Given its safety and diagnostic capabilities, DBE should be considered the gold-standard method in the study of these neoplasms.

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:u2002 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).

Virtual chromoendoscopy can be a useful software tool in capsule endoscopy

BACKGROUNDncapsule endoscopy (CE) has revolutionized the study of small bowel. One major drawback of this technique is that we cannot interfere with image acquisition process. Therefore, the development of new software tools that could modify the images and increase both detection and diagnosis of small-bowel lesions would be very useful. The Flexible Spectral Imaging Color Enhancement (FICE) that allows for virtual chromoendoscopy is one of these software tools.nnnAIMSnto evaluate the reproducibility and diagnostic accuracy of the FICE system in CE.nnnMETHODSnthis prospective study involved 20 patients. First, four physicians interpreted 150 static FICE images and the overall agreement between them was determined using the Fleiss Kappa Test. Second, two experienced gastroenterologists, blinded to each other results, analyzed the complete 20 video streams. One interpreted conventional capsule videos and the other, the CE-FICE videos at setting 2. All findings were reported, regardless of their clinical value. Non-concordant findings between both interpretations were analyzed by a consensus panel of four gastroenterologists who reached a final result (positive or negative finding).nnnRESULTSnin the first arm of the study the overall concordance between the four gastroenterologists was substantial (0.650). In the second arm, the conventional mode identified 75 findings and the CE-FICE mode 95. The CE-FICE mode did not miss any lesions identified by the conventional mode and allowed the identification of a higher number of angiodysplasias (35 vs 32), and erosions (41 vs. 24).nnnCONCLUSIONSnthere is reproducibility for the interpretation of CE-FICE images between different observers experienced in conventional CE. The use of virtual chromoendoscopy in CE seems to increase its diagnostic accuracy by highlighting small bowel erosions and angiodysplasias that weren´t identified by the conventional mode.

The effect of metoclopramide in capsule enteroscopy.

Clinical utility of prokinetics in capsule endoscopy (CE) is not clearly established. The objective of this prospective, randomized, single-blind, controlled trial was to determine if metoclopramide is useful in CE by increasing the rate of complete enteroscopy. Ninety-five patients referred for CE were randomized to no metoclopramide (group B, nxa0=xa048) or 10xa0mg metoclopramide (group A, nxa0=xa047). Complete enteroscopy was possible in 38 patients of group A (80.9%) and 37 of group B (77.1%) (Pxa0=xa00.422) with two cases of gastric retention in group B (4.2%; Pxa0=xa00.253). Median gastric transit time was 26xa0min (1–211) in group A and 28xa0min (4–200) in group B (Pxa0=xa00.511). Mean small bowel transit time, calculated after excluding 20 patients with incomplete enteroscopy, was similar in both groups (221.2xa0±xa089xa0min vs. 256xa0±xa082.2xa0min; Pxa0=xa00.083). There were also no differences in the total number of findings (group A 4.5xa0±xa04.7; group B 4.7xa0±xa03.7, Pxa0=xa00,815). Administration of 10xa0mg metoclopramide orally 15xa0min before capsule ingestion did not significantly increase the rate of total enteroscopies and had no effect on transit times. It also did not modify CE diagnostic yield.

Capsule endoscopy assisted by traditional upper endoscopy

BACKGROUND AND AIMSnCapsule endoscopy (CE) can be prevented by difficulties in swallowing the device and/or its gastric retention. In such cases, endoscopic delivery of the capsule to duodenum is very useful. We describe the indications and outcomes of cases in which traditional endoscopic techniques allowed placement of the capsule in duodenum.nnnPATIENTS AND METHODSnThis is a retrospective, descriptive case series. All patients in the above conditions were identified and indications for CE, endoscopic-placement technique, complications and completeness of small bowel imaging were registered.nnnRESULTSnEndoscopic-assisted delivery of the capsule was necessary in 13 patients (2.1% of all CE; 7 males; mean age--47.9 +/- 24.9 years, range 13 to 79 years). Indications for endoscopic delivery included: inability to swallow the capsule (7), gastric retention in previous exams (3), abnormal upper gastrointestinal anatomy (3). In eight patients, the capsule was introduced in GI tract with: foreign body retrieval net alone (3), retrieval net and a translucent cap (2), prototype delivery device (2) or a polypectomy snare (1). Five patients ingested the capsule that was then placed in duodenum with a polypectomy snare (3) or a retrieval net (2). No major complications occurred. Complete small bowel examination was possible in 10 patients (77%).nnnCONCLUSIONSnEndoscopic placement of capsule endoscope in the duodenum is rarely needed. However it may be safely performed by different techniques avoiding some limitations of CE. The best methods for endoscopic delivery of the capsule in the duodenum seem to be retrieval net with a translucent cap when the patient is unable to swallow the device or a retrieval net only to capture the capsule in the stomach when the patients swallows it easily.

Induced liver injury after high-dose methylprednisolone in a patient with multiple sclerosis

A 33-year-old woman with multiple sclerosis, medicated with high doses of methylprednisolone, cyclophosphamide and glatiramer acetate, was referred to our department due to acute liver injury. The laboratory investigation was normal except for weakly positive antinuclear antibodies. Cyclophosphamide and glatiramer acetate were suspended, and intravenous immunoglobulin with maintenance of high doses of methylprednisolone was initiated. The patient developed another episode of acute hepatitis so the immunoglobulin was stopped. After that, she had three more episodes of elevation of liver enzymes with no hepatic insufficiency while medicated only with high doses of methylprednisolone. At this time, liver biopsy showed focal centrilobubar hepatocyte necrosis with minimal interface hepatitis. After the high doses of methylprednisolone were suspended, the patient remained asymptomatic, with normal hepatic enzymes. This case emphasises that, although rare, induced liver injury after high doses of methylprednisolone can occur.

Postsynaptic zinc potentiation elicited by KCl depolarization at hippocampal mossy fiber synapses

The hippocampal mossy fibers contain a substantial quantity of loosely-bound zinc in their glutamatergic presynaptic vesicles, which is released in synaptic transmission processes. Despite the large number of studies about this issue, the zinc changes related to short and long-term forms of potentiation are not totally understood. This work focus on zinc signals associated with chemically-induced mossy fiber synaptic plasticity, in particular on postsynaptic zinc signals evoked by KCl depolarization. The signals were detected using the medium affinity fluorescent zinc indicator Newport Green. The application of large concentrations of KCl, 20 mM and 60 mM, in the extracellular medium evoked zinc potentiations that decreased and remained stable after washout of the first and the second media, respectively. These short and long-lasting enhancements are considered to be due to zinc entry into postsynaptic neurons. We have also observed that following established zinc potentiation, another application of 60 mM KCl only elicited further enhancement when combined with external zinc. These facts support the idea that the KCl-evoked presynaptic depolarization causes higher zinc release leading to zinc influx into the postsynaptic region.

Effect of tolbutamide on tetraethylammonium-induced postsynaptic zinc signals at hippocampal mossy fiber-CA3 synapses

The application of tetraethylammonium (TEA), a blocker of voltage-dependent potassium channels, can induce long-term potentiation (LTP) in the synaptic systems CA3-CA1 and mossy fiber-CA3 pyramidal cells of the hippocampus. In the mossy fibers, the depolarization evoked by extracellular TEA induces a large amount of glutamate and also of zinc release. It is considered that zinc has a neuromodulatory role at the mossy fiber synapses, which can, at least in part, be due to the activation of presynaptic ATP-dependent potassium (KATP) channels. The aim of this work was to study properties of TEA-induced zinc signals, detected at the mossy fiber region, using the permeant form of the zinc indicator Newport Green. The application of TEA caused a depression of those signals that was partially blocked by the KATP channel inhibitor tolbutamide. After the removal of TEA, the signals usually increased to a level above baseline. These results are in agreement with the idea that intense zinc release during strong synaptic events triggers a negative feedback action. The zinc depression, caused by the LTP-evoking chemical stimulation, turns into potentiation after TEA washout, suggesting the existence of a correspondence between the observed zinc potentiation and TEA-evoked mossy fiber LTP.

Glycogenic acanthosis of the esophagus: an unusually endoscopic appearance.

Glycogenic acanthosis of the esophagus is a common benign entity characterized by multifocal plaques of hyperplastic squa-mous epithelium with abundant intracellular glycogen deposits (1). At esophagoscopy these lesions appear as slightly raised grey-white plaques which are usually 2-10 mm in diameter and may be confluent. Although they may involve any segment, the literature suggests that are most common in the distal third (2). A 78-year-old white male admitted to the Medicine Department with microcytic anaemia [haemoglobin: 8.8 g/dl (13-15); mean corpuscular volume: 66 fl] and for a suspicion of lead poisoning. He had a diffuse abdominal pain, nausea, anorexia, asthenia and constipation. There were no symptoms of esophageal reflux or dysphagia. He drank heavily (100 g of wine per day) and smoked three packs of cigarettes a day for 30 years. Current medications included furosemide, perindopril and metformin for hypertension and diabetes mellitus. On examination , he presented cutaneomucosal pallor, tenderness in the lower quadrants and peripheral edema. An upper endoscopy revealed a pale-pink, lobulated and pediculated polyp as large as 7 mm in diameter in the middle esophagus (Fig. 1). A polypectomy was performed and histology demonstrated glycogenic acanthosis (Figs. 2 and 3). A grade B esophagitis in Fig. 1. Upper endoscopy: pediculated polyp as large as 7 mm in the middle esophagus. Fig. 2. Low-power photomicrograph: squamous epithelium thickened by groups of enlarged and clear cells located in the upper layers of the epithelium.