Tara Santoro

Bulb biopsies for the diagnosis of celiac disease in pediatric patients.

BACKGROUND Celiac disease (CD) is a gluten-dependent enteropathy. The current standard for diagnosing CD involves obtaining 4 biopsy samples from the descending duodenum. It has been suggested that duodenal bulb biopsies may also be useful. OBJECTIVE To assess the utility of bulbar biopsies for the diagnosis of CD in pediatric patients. DESIGN Prospective study. SETTING Single center. PATIENTS Forty-seven consecutively enrolled pediatric patients with celiac serologies and a clinical suspicion of CD. INTERVENTIONS All patients underwent EGD, and 4 biopsy samples were obtained from the duodenal bulb and 4 from the descending duodenum of each child. MAIN OUTCOME MEASUREMENTS The pathologist blindly reported the Marsh histological grade for the diagnosis of CD of the bulb and descending duodenum. RESULTS The diagnosis of CD was histologically confirmed in 89.4% (42/47) of the cases of biopsy samples obtained from the descending duodenum and in all 47 obtained from the bulb. In 35 patients (74.5%), histology was the same in the bulb and duodenum; in 11 (23.4%) cases, the grade of atrophy was higher in the bulb than in the descending duodenum, and 5 (10.6%) had bulb histology positive for CD but negative duodenal findings. One child (2.1%) had a higher histological grade in the duodenum than in the bulb. The diagnostic gain with bulbar biopsies was 10.6%. LIMITATIONS Small sample and absence of a comparison group (asymptomatic children with normal CD antibodies). CONCLUSIONS We suggest examining 4 biopsy samples from the duodenal bulb and 4 from the descending duodenum to improve diagnostic accuracy of CD.

Interobserver agreement among endoscopists on evaluation of polypoid colorectal lesions visualized with the Pentax i-Scan technique.

BACKGROUND AND AIMS Advances in colonoscopy, such as the Pentax i-Scan electronic technique, have the potential to improve the early detection of colorectal cancer. The aim of this multicentre study was to assess the interobserver agreement in the visualization of the surface and margins of colorectal polyps and in distinguishing neoplastic from non-neoplastic polyps. PATIENTS AND METHODS Eight expert endoscopists examined 400 mixed previously recorded images of polyps taken with different Pentax i-Scan settings in order to give an evaluation of the surface of the polyp and regular colonic mucosa, the pit-pattern and the nature of the lesion. RESULTS A total of 400 mixed images of polyps with a diameter >5mm and <10mm were stored for analysis. Overall, there was a Kf agreement of 0.370 (p<0.001) and 0.306 (p<0.001) regarding pit-pattern and margins, respectively. The Kf agreement for the difference between neoplastic and non-neoplastic lesions was of 0.446 (p<0.001). CONCLUSIONS We observed good interobserver agreement in the evaluation of neoplastic and non-neoplastic lesions and poor agreement in the evaluation of pit-pattern and margins. Adequate training is required in order to interpret images acquired with the i-Scan technique.

Endoscopic sealing of a rectovesical fistula with a combination of an over the scope clip and cyano-acrylate injection

The risk of anastomotic fistula after colon resection is currently reported to range from 5% to 10%. If the fistula is symptomatic or pauci-symptomatic the best therapy is a diverting ileostomy for 2-3 months with subsequent recanalization only when a radiological contrast study shows that the fistula has disappeared (1). Recently, technological advances in gastrointestinal accessories have led to the development of a novel type of clip, the over the scope (OVESCO®) clip, currently used for organ closure during natural orifice transluminal endoscopic surgery (NOTES) (2), or in particular cases of bleeding of the gastrointestinal tract (3) or deep wall lesions (4).

Fully covered, self-expandable metal stents for first-step endoscopic treatment of biliary leaks secondary to hepato-biliary surgery: a retrospective study.

BACKGROUND Fully covered self-expanding metal stents are now being used to treat benign biliary diseases. AIMS To assess the outcomes of these stents as first-step therapy in patients with biliary leaks secondary to hepato-biliary surgery. METHODS Thirty patients (56.7% males; mean age: 60.2 ± 13 years) were retrospectively evaluated. The data collected included technical and clinical success, adverse events and follow-up findings (1, 3 and 6 months). RESULTS Technical and clinical success rates were 100%. One early mild post-procedure pancreatitis occurred and resolved spontaneously. Three late stent distal migrations occurred, however cholangiography showed correct leak sealing in all patients. Stents were removed after a mean of 55.9 days. During follow-up no other complications occurred. CONCLUSION In our experience fully covered self-expanding metal stent placement was safe and efficacious as first-step therapy for post-operative biliary leaks. However, prospective comparative studies with plastic stents are required to validate these findings.

Covered removable self-expandable metal stents for the treatment of refractory benign biliary disease

OBJECTIVE:  The aim of the study was to verify the use of covered removable self‐expandable metal stents (CRSEMS) in benign biliary disease after a failure of traditional endoscopic treatment.

Helicobacter pylori infection in bleeding peptic ulcer patients after non-steroidal antiinflammatory drug consumption.

AIM To establish the prevalence of Helicobacter pylori (H. pylori) infection in patients with a bleeding peptic ulcer after consumption of non-steroidal antiinflammatory drugs (NSAIDs). METHODS A very early upper endoscopy was performed to find the source of upper gastrointestinal bleeding and to take biopsy specimens for analysis of H. pylori infection by the rapid urease (CLO) test, histological examination, and bacterial culture. IgG anti-CagA were also sought. The gold standard for identifying H. pylori infection was positive culture of biopsy specimens or contemporary positivity of the CLO test and the presence of H. pylori on tissue sections. RESULTS Eighty patients, 61 males (76.3%), mean age 61.2 ± 15.9 years, were consecutively enrolled. Forty-seven (58.8%) patients occasionally consumed NSAIDs, while 33 (41.3%) were on chronic treatment with low-dose aspirin (LD ASA). Forty-four (55.0%) patients were considered infected by H. pylori. The infection rate was not different between patients who occasionally or chronically consumed NSAIDs. The culture of biopsy specimens had a sensitivity of 86.4% and a specificity of 100%; corresponding figures for histological analysis were 65.9% and 77.8%, for the CLO test were 68.2% and 75%, for the combined use of histology and the CLO test were 56.8% and 100%, and for IgG anti-CagA were 90% and 98%. The highest accuracy (92.5%) was obtained with the culture of biopsy specimens. CONCLUSION Patients with a bleeding peptic ulcer after NSAID/LD ASA consumption frequently have H. pylori infection. Biopsy specimen culture after an early upper gastrointestinal tract endoscopy seems the most efficient test to detect this infection.

Cannulation of the biliary tree under endoscopic control with an echoendoscope, without fluoroscopy: report of a case series.

Introduction: Endoscopic ultrasonography (EUS) is a validated technique allowing precise diagnosis and staging of pancreatic, biliary and ampullary disease. Developments in instruments and accessories have led to a more extensive use of this technology to perform operations. The use of EUS as an operative technique, alone or in conjunction with other endoscopic procedures, has already been described in the literature in several reports. However, despite the use of EUS, fluoroscopy has always been required to perform these operations. There are no data in the literature describing the feasibility, safety and efficacy of operative EUS in the treatment of common bile duct (CBD) obstruction, following a malignant or benign disease, performed completely under EUS guidance without fluoroscopic assistance. Methods: In this series we describe three cases of EUS treatment of CBD diseases performed without fluoroscopic assistance. Results: All the cases were treated by EUS without fluoroscopic assistance and no complications were encountered. Conclusion: Operative EUS without fluoroscopy appears to be a feasible technique. Its major advantages could be to shorten the examination time and to enable biliary or pancreatic operative endoscopy in patients in whom fluoroscopy could be dangerous, such as pregnant women. The endoscopist should have a good training both in EUS and endoscopic retrograde cholangiopancreatography. Prospective, larger studies are needed to confirm our preliminary data.

An ‘omental patch’ created during over-the-scope clipping completely sealed a duodenal perforation after endoultrasonography

Perforation of the inferior knee of the duodenum is a rare complication during endoscopic maneuvers and, in particular, during endoscopic ultrasonography (EUS). A recent study by Carrara and colleagues reported a duodenal perforation rate of 0.09% in a series of 3296 patients who underwent EUS with fine-needle aspiration [Carrara et al. 2010]. The data in the literature on surgical management of these perforations are not currently comforting. An 82-year-old woman was referred to our center after computed tomography had shown a 7 cm diameter pseudocyst and a suspected malignant neoplasia of the proximal third of the common bile duct, causing jaundice. The patient underwent EUS with a linear echoendoscope (Pentax Hamburg, Germany). During retraction of the scope in the duodenum, we observed a full-thickness break of about 12 mm diameter, at the inferior duodenal knee (Figure 1). With an operative gastroscope we immediately placed a sharp-toothed, 10 mm/6 diameter over-the-scope clip (OTSC; OVESCO, Endoscopy, Tubingen, Germany) on the perforation. We preferred a therapeutic endoscope instead of the standard one because of the possibility of mounting a bigger diameter OTSC. During the aspiration we placed the omentum inside the cap. After releasing the OTSC we obtained immediate closure of the perforation, creating an ‘omental patch’ (Figure 2). The correct positioning of the OTSC and the complete closure of the perforation were subsequently confirmed by X-ray, the day after, when the patient underwent transhepatic biliary drainage (percutaneous transhepatic cholangiography). After releasing the drainage across the papilla, contrast was injected to check the correct closure of the defect. CO2 was not used in this case. Figure 1. Perforation of the inferior duodenal genu by endoscopic ultrasonography (EUS). Figure 2. Duodenal perforation sealed by OTSC creating an “omental-patch”. The patient developed peritonitis and died 12 days later of respiratory failure despite fasting, antibiotic therapy, nasogastric tube placement and parenteral nutrition support. As shown in a few reports in the literature [Donatelli et al. 2013; Meduri et al. 2014; Diez-Redondo et al. 2012], given the high rate of morbidity and mortality associated with post-surgical treatment of iatrogenic duodenal perforations, the OTSC should be considered the first option for immediate resolution of this adverse event, taking into account the possible risk of failure. OTSC may play a part in the armamentarium for the acute management of perforations and other such conditions [Bingener and Ibrahim-zada, 2014].

M1690 Detection of HP Infection in Patients With Peptic Ulcer Disease Complicated by Hemorrhage After Assumption of NSAIDs

H. pylori significantly improved reflux symptoms in the subjects with mild atrophy and did not aggravate in those with severe atrophy, but did not change dysmotility symptoms, regardless of the degree of atrophy. Conclusion: The reflux symptoms were improved in the subjects with mild atrophy and were not aggravated in those with severe atrophy, who had PPI-based triple therapy for cancer prevention in Japanese general population.