Sarmed S. Sami

Review article: gastrointestinal angiodysplasia – pathogenesis, diagnosis and management

Angiodysplasia (AD) of the gastrointestinal (GI) tract is an important condition that can cause significant morbidity and –rarely – mortality.

Evaluation of a Minimally Invasive Cell Sampling Device Coupled with Assessment of Trefoil Factor 3 Expression for Diagnosing Barrett's Esophagus: A Multi-Center Case-Control Study

Background Barretts esophagus (BE) is a commonly undiagnosed condition that predisposes to esophageal adenocarcinoma. Routine endoscopic screening for BE is not recommended because of the burden this would impose on the health care system. The objective of this study was to determine whether a novel approach using a minimally invasive cell sampling device, the Cytosponge, coupled with immunohistochemical staining for the biomarker Trefoil Factor 3 (TFF3), could be used to identify patients who warrant endoscopy to diagnose BE. Methods and Findings A case–control study was performed across 11 UK hospitals between July 2011 and December 2013. In total, 1,110 individuals comprising 463 controls with dyspepsia and reflux symptoms and 647 BE cases swallowed a Cytosponge prior to endoscopy. The primary outcome measures were to evaluate the safety, acceptability, and accuracy of the Cytosponge-TFF3 test compared with endoscopy and biopsy. In all, 1,042 (93.9%) patients successfully swallowed the Cytosponge, and no serious adverse events were attributed to the device. The Cytosponge was rated favorably, using a visual analogue scale, compared with endoscopy (p < 0.001), and patients who were not sedated for endoscopy were more likely to rate the Cytosponge higher than endoscopy (Mann-Whitney test, p < 0.001). The overall sensitivity of the test was 79.9% (95% CI 76.4%–83.0%), increasing to 87.2% (95% CI 83.0%–90.6%) for patients with ≥3 cm of circumferential BE, known to confer a higher cancer risk. The sensitivity increased to 89.7% (95% CI 82.3%–94.8%) in 107 patients who swallowed the device twice during the study course. There was no loss of sensitivity in patients with dysplasia. The specificity for diagnosing BE was 92.4% (95% CI 89.5%–94.7%). The case–control design of the study means that the results are not generalizable to a primary care population. Another limitation is that the acceptability data were limited to a single measure. Conclusions The Cytosponge-TFF3 test is safe and acceptable, and has accuracy comparable to other screening tests. This test may be a simple and inexpensive approach to identify patients with reflux symptoms who warrant endoscopy to diagnose BE.

A randomized comparative effectiveness trial of novel endoscopic techniques and approaches for Barrett's esophagus screening in the community.

Objectives:The objective of this study was to compare participation rates and clinical effectiveness of sedated esophagogastroduodenoscopy (sEGD) and unsedated transnasal endoscopy (uTNE) for esophageal assessment and Barrett’s esophagus (BE) screening in a population-based cohort.Methods:This was a prospective, randomized, controlled trial in a community population. Subjects ≥50 years of age who previously completed validated gastrointestinal symptom questionnaires were randomized (stratified by age, sex, and reflux symptoms) to one of three screening techniques (either sEGD or uTNE in a mobile research van (muTNE) or uTNE in a hospital outpatient endoscopy suite (huTNE)) and invited to participate.Results:Of the 459 subjects, 209 (46%) agreed to participate (muTNE n=76, huTNE n=72, and sEGD n=61). Participation rates were numerically higher in the unsedated arms of muTNE (47.5%) and huTNE (45.7%) compared with the sEGD arm (40.7%), but were not statistically different (P=0.27). Complete evaluation of the esophagus was similar using muTNE (99%), huTNE (96%), and sEGD (100%) techniques (P=0.08). Mean recovery times (min) were longer for sEGD (67.3) compared with muTNE (15.5) and huTNE (18.5) (P<0.001). Approximately 80% of uTNE subjects were willing to undergo the procedure again in future. Respectively, 29% and 7.8% of participating subjects had esophagitis and BE.Conclusions:Mobile van and clinic uTNE screening had comparable clinical effectiveness with similar participation rates and safety profile to sEGD. Evaluation time with uTNE was significantly shorter. Prevalence of BE and esophagitis in community subjects ≥50 years of age was substantial. Mobile and outpatient unsedated techniques may provide an effective alternative strategy to sEGD for esophageal assessment and BE screening.

High definition versus standard definition white light endoscopy for detecting dysplasia in patients with Barrett's esophagus

High-definition endoscopy systems provide superior image resolution. The aim of this study was to assess the utility of high definition compared with standard definition endoscopy system for detecting dysplastic lesions in patients with Barretts esophagus. A retrospective cohort study of patients with non-dysplastic Barretts esophagus undergoing routine surveillance was performed. Data were retrieved from the central hospital electronic database. Procedures performed for non-surveillance indications, Barretts esophagus Prague C0M1 classification with no specialized intestinal metaplasia on histology, patients diagnosed with any dysplasia or cancer on index endoscopy, and procedures using advanced imaging techniques were excluded. Logistic regression models were constructed to estimate adjusted odds ratios and 95% confidence intervals comparing outcomes with standard definition and high-definition systems. The high definition was superior to standard definition system in targeted detection of all dysplastic lesions (odds ratio 3.27, 95% confidence interval 1.27-8.40) as well as overall dysplasia detected on both random and target biopsies (odds ratio 2.36, 95% confidence interval 1.50-3.72). More non-dysplastic lesions were detected with the high-definition system (odds ratio 1.16, 95% confidence interval 1.01-1.33). There was no difference between high definition and standard definition endoscopy in the overall (random and target) high-grade dysplasia or cancers detected (odds ratio 0.93, 95% confidence interval 0.83-1.04). Trainee endoscopists, number of biopsies taken, and male sex were all significantly associated with a higher yield for dysplastic lesions. The use of the high-definition endoscopy system is associated with better targeted detection of any dysplasia during routine Barretts esophagus surveillance. However, high-definition endoscopy cannot replace random biopsies at present time.

Screening for Barrett’s Esophagus and Esophageal Adenocarcinoma: Rationale, Recent Progress, Challenges, and Future Directions

As the incidence and mortality of esophageal adenocarcinoma continue to increase, strategies to counter this need to be explored. Screening for Barretts esophagus, which is the known precursor of a large majority of adenocarcinomas, has been debated without a firm consensus. Given evidence for and against perceived benefits of screening, the multitude of challenges in the implementation of such a strategy and in the downstream management of subjects with Barretts esophagus who could be diagnosed by screening, support for screening has been modest. Recent advances in the form of development and initial accuracy of noninvasive tools for screening, risk assessment tools, and biomarker panels to risk stratify subjects with BE, have spurred renewed interest in the early detection of Barretts esophagus and related neoplasia, particularly with the advent of effective endoscopic therapy. In this review, we explore in depth the potential rationale for screening for Barretts esophagus, recent advances that have the potential of making screening feasible, and also highlight some of the challenges that will have to be overcome to develop an effective approach to improve the outcomes of subjects with esophageal adenocarcinoma.

The Los Angeles Classification of Gastroesophageal Reflux Disease

Abstract Endoscopic assessment of the esophagus for the presence or absence of gastroesophageal reflux disease (GERD) as well as the assessment of its severity is crucial to formulating decisions about the patients management and prognosis. Therefore, a validated tool is required to ensure agreement among different endoscopists. The Los Angeles classification system of GERD is by far the most widely used system to describe the endoscopic appearance of reflux esophagitis and grade its severity.1 This article is part of an expert video encyclopedia.

The Detection of Oesophageal Varices Using a Novel, Disposable, Probe-based Transnasal Endoscope. A Prospective Diagnostic Pilot Study.

Screening for oesophageal varices (OV) using conventional oesophagogastroduodenoscopy (C‐OGD) is invasive and requires costly monitoring, recovery, and decontamination facilities. We aimed to evaluate the technical feasibility, acceptability and accuracy of a novel, portable and disposable office‐based transnasal endoscope (EG Scan™) compared to C‐OGD as the reference standard.

Editorial: unsedated transnasal endoscopy

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Incidence of metachronous visible lesions in patients referred for radiofrequency ablation (RFA) therapy for early Barrett's neoplasia: a single-centre experience

Objective Evaluate the incidence of metachronous visible lesions (VLs) in patients referred for radiofrequency ablation (RFA) for early Barretts neoplasia. Design This study was conducted as part of the service evaluation audit. Setting Tertiary referral centre. Patients All patients with dysplastic Barretts oesophagus referred for RFA were included for analysis. White light high-resolution endoscopy (HRE), autofluorescence imaging and narrow band imaging were sequentially performed. Endoscopic mucosal resection (EMR) was performed for all VL. Three to six months after EMR, all patients underwent initial RFA and then repeat RFA procedures at three monthly intervals. Interventions All endoscopy reports and final staging by EMR/surgery were evaluated and included for analysis. Results Fifty patients were analysed; median age 73 years, 84% men. 38/50 patients (76%) had a previous EMR due to the presence of VL before referred for ablation; twelve patients had no previous treatment. In total, 151 ablation procedures were performed, median per patient 2.68. Twenty metachronous VL were identified in 14 patients before the first ablation or during the RFA protocol; incidence was 28%. All metachronous lesions were successfully resected by EMR. Upstaging after rescue EMR compared with the initial histology was observed in four patients (28%). Conclusions In total, 28% of patients enrolled in the RFA programme were diagnosed to have metachronous lesions. This high-incidence rate highlights the importance of a meticulous examination to identify and resect any VL before every ablation session. RFA treatment for early Barretts neoplasia should be performed in tertiary referral centres with HRE and EMR facilities and expertise.

Response to Syed et al.

TNE imaging will require a clinical EGD anyway for surveillance biopsies and risk stratifi cation ( 4 ). We demonstrated that portable TNE was well tolerated and acceptable to patients in line with the vast majority of the literature ( 5 ). In our recently performed systematic review and meta-analysis of 34 studies with 6,659 patients, we identifi ed that TNE with <5.9 mm insertion diameter had equivalent success rate, and better patient preference compared with EGD ( 6 ). Th e authors may have also overlooked a recent study from the United States which demonstrated that TNE screening for BE can be accurately performed by physician extenders aft er a modest number of supervised procedures ( 7 ), which argues against challenges in making this technique widely disseminated in the medical community. Although EGD has superior imaging and therapeutic capability, it is not a feasible tool for widespread screening. Hence, we believe that TNE does represent an important and more cost-eff ective alternative to EGD for widespread BE screening purposes as part of a structured screening program.