Shabana F. Pasha

Double-Balloon Enteroscopy and Capsule Endoscopy Have Comparable Diagnostic Yield in Small-Bowel Disease: A Meta-Analysis

BACKGROUND & AIMS The aim of this study was to compare the diagnostic yield of capsule endoscopy (CE) with double-balloon enteroscopy (DBE) in small-bowel (SB) disease using meta-analysis. METHODS We performed a search of studies comparing CE with DBE in SB disease. Data on diagnostic yield of CE and DBE were extracted, pooled, and analyzed. The weighted incremental yield (IY(W)) (yield of CE--yield of DBE) of CE over DBE and 95% confidence intervals (95% CIs) for pooled data were calculated using a fixed-effect model (FEM) for analyses without, and a random-effect model (REM) for analyses with, significant heterogeneity. RESULTS Eleven studies compared CE and DBE; the pooled overall yield for CE and DBE was 60% (n = 397) and 57% (n = 360), respectively (IY(W), 3%; 95% CI, -4% to 10%; P = .42; FEM). Ten studies reported vascular findings; the pooled yield for CE and DBE was 24% (n = 371) and 24% (n = 364), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .88; REM). Nine studies reported inflammatory findings; the pooled yield for CE and DBE was 18% (n = 343) and 16% (n = 336), respectively (IY(W), 0%; 95% CI, -5% to 6%; P = .89; FEM). Nine studies reported polyps/tumors; the pooled yield for CE and DBE was 11% (n = 343) and 11% (n = 336), respectively (IY(W), -1%; 95% CI, -5% to 4%; P = .76; FEM). CONCLUSIONS CE and DBE have comparable diagnostic yield in SB disease, including obscure gastrointestinal bleeding. CE should be the initial diagnostic test because of its noninvasive quality, tolerance, ability to view the entire SB, and for determining the initial route of DBE. Because of its therapeutic capabilities, DBE may be indicated in patients with a positive finding on CE requiring a biopsy or therapeutic intervention, if suspicion for a SB lesion is high despite a negative CE, and in patients with active bleeding.

The role of endoscopy in Barrett's esophagus and other premalignant conditions of the esophagus

i ( n d m e This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a search of the medical literature was performed using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1).1 The strength of individual recommendations is based on both the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Splanchnic Artery Aneurysms

Autopsy studies suggest that splanchnic artery aneurysms may be more frequent than abdominal aortic aneurysms. These aneurysms are important to recognize because up to 25% may be complicated by rupture, and the mortality rate after rupture is between 25% and 70%. However, little is known about the natural history and clinical presentation of splanchnic artery aneurysms. Splenic artery aneurysms are the most common of the splanchnic artery aneurysms; multiple aneurysms are present in approximately one third of patients. Hepatic artery pseudoaneurysms are more common than true aneurysms because of increasing numbers of hepatobiliary interventional procedures. The diagnosis of splanchnic artery aneurysm should be considered in any patient with abdominal pain, a pulsatile mass, or an abdominal bruit with or without associated bleeding. However, most aneurysms are asymptomatic and are detected incidentally on imaging studies. Treatment, which can be either surgical or interventional radiology-based, should be considered in all patients with symptoms related to the aneurysms, if the aneurysm is more than 2 cm in diameter, if the patient is pregnant, or if there is demonstrated growth of the aneurysm.

The role of endoscopy in the management of acute non-variceal upper GI bleeding

d c p B s i R This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy (ASGE) prepared this text. In preparing this guideline, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the guidelines are drafted. Further controlled clinical studies may be needed to clarify aspects of this guideline. This guideline may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations are based on reviewed studies and are graded on the strength of the supporting evidence1 (Table 1). he strength of individual recommendations is based on oth the aggregate evidence quality and an assessment of the nticipated benefits and harms. Weaker recommendations re indicated by phrases such as “We suggest . . . ,” whereas tronger recommendations are typically stated as “We recmmend . . . .” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This guideline is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these guidelines.

Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy

BACKGROUND The optimal endoscopic treatment for anastomotic biliary strictures after deceased donor liver transplantation is undefined. Endoscopic therapy with conventional methods of biliary dilation and stent placement has been successful but often requires prolonged therapy. OBJECTIVE To determine the outcomes of an aggressive endoscopic approach that uses endoscopic dilation followed by maximal stent placement. SETTING Tertiary-care academic medical center. PATIENTS Of 176 patients who underwent deceased donor liver transplantation between June 1999 and July 2004, 25 were diagnosed with anastomotic biliary strictures. INTERVENTIONS Patients were treated endoscopically with a combined technique of balloon dilation and maximal stent placement. MAIN OUTCOME MEASUREMENTS Treatment outcomes, including bile-duct patency, a need for surgical intervention, morbidity, and mortality, were evaluated retrospectively. RESULTS Endoscopic dilation followed by maximal stent placement was performed until resolution of strictures in 22 of 25 patients (88% immediate success on intent-to-treat analysis). Persistent resolution of strictures was achieved in 18 of these 22 patients. Re-treatment was successful in 2 of 4 patients with recurrent strictures. Overall, 20 of 22 patients who completed endoscopic therapy (91%) avoided surgical intervention. Median duration of endoscopic treatment was 4.6 months. Patients with early onset strictures required a significantly shorter duration of endoscopic therapy (3 vs 9 months; P<.01). Multiple stent placement was not technically difficult, and no major complications were encountered. CONCLUSIONS Aggressive endoscopic therapy with combined biliary dilation and maximal stent placement allows resolution of anastomotic biliary strictures after deceased donor liver transplantation in a relatively short period, with sustained success and minimal complications.

A Novel Histologic Scoring System to Evaluate Mucosal Biopsies From Patients With Eosinophilic Esophagitis

BACKGROUND & AIMS Eosinophilic esophagitis (EoE) is characterized by medically/surgically-resistant gastroesophageal reflux symptoms and dense squamous eosinophilia. Studies suggest that histologic assessment of esophageal eosinophilia alone cannot reliably separate patients with EoE from those with gastroesophageal reflux disease (GERD). Our goal was to develop an assay to identify EoE patients and perhaps differentiate EoE from other causes of esophageal eosinophilia. METHODS A monoclonal antibody specific for an eosinophil secondary granule protein (eosinophil peroxidase [EPX]) was developed and shown to specifically identify intact eosinophils and detect eosinophil degranulation in formalin-fixed specimens. A histopathologic scoring algorithm was developed to analyze data from patient evaluations; the utility of this algorithm was assessed by using archived esophageal tissues from patients with known diagnoses of EoE and GERD as well as controls from 2 tertiary care centers. RESULTS Intraobserver/interobserver blinded evaluations demonstrated a significant difference (P < .001) between scores of samples taken from control subjects, from patients with esophageal eosinophilia who had a diagnosis of EoE, and from patients with GERD (P < .001). This algorithm also was able to identify patients whose clinical course was suggestive of a diagnosis of EoE, but that nonetheless failed to reach the critical threshold number of > or =15 eosinophils in a high-power (40x) microscopy field. CONCLUSIONS A novel immunohistochemical scoring system was developed to address an unmet medical need to differentiate histologic specimens from patients with EoE relative to those with GERD. The availability of a unique anti-EPX-specific monoclonal antibody, combined with the ease/rapidity of this staining method and scoring system, will provide a valuable strategy for the assessment of esophageal eosinophilia.

Comparison of the yield and miss rate of narrow band imaging and white light endoscopy in patients undergoing screening or surveillance colonoscopy: a meta-analysis.

OBJECTIVES:Colonoscopy has an appreciable miss rate for adenomas and colorectal cancer. The goal of advanced endoscopic imaging is to improve lesion detection. Compared with standard definition, high-definition (HD) colonoscopes have the advantage of increased field of visualization and higher resolution; narrow band imaging (NBI) utilizes narrow band filters for enhanced visualization of surface architecture and capillary pattern. The objective of this study was to compare the yield and miss rates of HD-NBI and HD-WLE (white light endoscopy) for the detection of colon polyps using meta-analysis.METHODS:A recursive literature search of randomized controlled trials (RCTs) comparing the yield of HD-NBI and HD-WLE for detection of colon polyps in patients undergoing screening/surveillance colonoscopy. Authors were contacted for missing data. In RCT with tandem colonoscopy (RCT-t), findings from the first-pass examinations were used in the yield analysis and from the tandem pass for the miss rate analysis. Data on the yield of polyps were extracted, pooled, and analyzed using RevMan 4.2.9 software. Odds ratio (OR) and 95% confidence intervals (CIs) for the pooled data for the yield and miss rates of NBI and WLE were calculated. A fixed effect model (FEM) was used for analyses without, and a random effect model (REM) for analyses with heterogeneity.RESULTS:The yield analysis revealed no significant difference between HD-NBI and HD-WLE for the detection of adenomas (six studies; n=2,284; OR: 1.01; CI: 0.74–1.37; REM); patients with polyps (six studies; n=2,275; OR: 1.15; CI: 0.8–1.64; REM); patients with adenomas (four studies; n=2,177; OR: 1.0; CI: 0.83–1.20; FEM); detection of adenomas <10 mm (five studies; n=1,618; OR: 1.32; CI: 0.92–1.88; FEM); flat adenomas (five studies; n=1,675; OR: 1.26; CI: 0.62–2.57; REM); and flat adenomas per patient (five studies; n=2,200; OR: 1.63; CI: 0.71–3.74; REM). The miss rate analysis revealed no difference in polyp miss rate (three studies; n=524; OR: 1.17; CI: 0.8–1.71; FEM) or adenoma miss rate (three studies; n=524; OR: 0.65; CI: 0.4–1.06; FEM) between the two techniques.CONCLUSIONS:Compared with HD-WLE, HD-NBI does not increase the yield of colon polyps, adenomas, or flat adenomas, nor does it decrease the miss rate of colon polyps or adenomas in patients undergoing screening/surveillance colonoscopy.

The management of antithrombotic agents for patients undergoing GI endoscopy.

Ruben D. Acosta, MD, Neena S. Abraham, MD, MSCE, FASGE (invited content expert, ad-hoc member), Vinay Chandrasekhara, MD, Krishnavel V. Chathadi, MD, Dayna S. Early, MD, FASGE, Mohamad A. Eloubeidi, MD, MHS, FASGE, John A. Evans, MD, Ashley L. Faulx, MD, FASGE, Deborah A. Fisher, MD, MHS, FASGE, Lisa Fonkalsrud, BSN, RN, CGRN, Joo Ha Hwang, MD, PhD, FASGE, Mouen A. Khashab, MD, Jenifer R. Lightdale, MD, MPH, FASGE, V. Raman Muthusamy, MD, FASGE, Shabana F. Pasha, MD, John R. Saltzman, MD, FASGE, Aasma Shaukat, MD, MPH, FASGE, Amandeep K. Shergill, MD, Amy Wang, MD, Brooks D. Cash, MD, FASGE, previous Committee Chair, John M. DeWitt, MD, FASGE, Chair

Bowel preparation before colonoscopy

This is one of a series of documents discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this document that updates a previously issued consensus statement and a technology status evaluation report on this topic. In preparing this guideline, a search of the medical literature was performed by using PubMed between January 1975 and March 2014 by using the search terms “colonoscopy,” “bowel preparation,” “intestines,” and “preparation.” Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When limited or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Recommendations for appropriate use of endoscopy are based on a critical review of the available data and expert consensus at the time that the documents are drafted. Further controlled clinical studies may be needed to clarify aspects of recommendations contained in this document. This document may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. The recommendations were based on reviewed studies and were graded on the strength of the supporting evidence (Table 1). The strength of individual recommendations is based both on the aggregate evidence quality and an assessment of the anticipated benefits and harms. Weaker recommendations are indicated by phrases such as “we suggest,” whereas stronger recommendations are typically stated as “we recommend.” This guideline is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. It is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from these recommendations and suggestions.

Adverse events associated with EUS and EUS with FNA

c w g g v u 0 w This is one of a series of statements discussing the use of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this document, a search of the medical literature was performed by using PubMed. Additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When few or no data exist from well-designed prospective trials, emphasis is given to results of large series and reports from recognized experts. This document is based on a critical review of the available data and expert consensus at the time that the document was drafted. Further controlled clinical studies may be needed to clarify aspects of this document. This document may be revised as necessary to account for changes in technology, new data, or other aspects of clinical practice. This document is intended to be an educational device to provide information that may assist endoscopists in providing care to patients. This document is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment. Clinical decisions in any particular case involve a complex analysis of the patient’s condition and available courses of action. Therefore, clinical considerations may lead an endoscopist to take a course of action that varies from this document.