Tolga Erim

Gastric carcinoid tumor after laparoscopic sleeve gastrectomy.

Gastric carcinoid tumor after laparoscopic sleeve gastrectomy Tolga Erim, D.O., Yasar Colak, M.D.*, Samuel Szomstein, M.D. Department of Gastroenterology and Hepatology, Cleveland Clinic Florida, Weston, Florida Department of Gastroenterology, Istanbul Medeniyet Universty, School of Medicine, Istanbul, Turkey The Bariatric and Metabolic Institute, Section of Minimally Invasive Surgery, Department of General Surgery, Cleveland Clinic Florida, Weston, Florida Received June 1, 2015; accepted June 22, 2015

Cholangioscopy: the biliary tree never looked so good!

Purpose of review Endoscopists have long awaited advances in the equipment and techniques for cholangiopancreatoscopy. Since the turn of the millennium, endoscopists have witnessed an explosion in the development and refinement of the capabilities of cholangioscopes as they move from being almost exclusive to tertiary care academic settings to a wider range of practices. Recent findings Studies have tested and constructively critiqued the procedure, hoping to increase the success rate of diagnostic and therapeutic interventions. Many have found significant improvement upon the limitations of radiographic imaging in diagnosing diseases and achieving full clearance of biliary stones. Image quality has improved with a range of features. However, most of these still need to be studied further. The addition of balloon catheters and overtubes has improved stability and access to the biliary ducts, but comes with complications that need to be studied further. Summary Although we still have improvements to yearn for, the future looks bright. As endoscopists continue their commitment to the promise of direct visualization of the biliary trees and the complementary tools for diagnosis and treatment, we are continuing to raise quality of care for patients with complicated biliary diseases.

Spondyloarthropathy-Associated Aortitis and Massive Thickening of the Aortic-Mitral Curtain: Diagnosis by Echocardiography

Cardiac involvement in reactive arthritis is well-recognized, and usually results in aortic regurgitation, proximal aortitis, and conduction system abnormalities. Aortitis is usually recognized in conjunction with aortic regurgitation, but can be diagnosed in isolation as aortic root thickening and subaortic fibrous ridging. We report a case of spondyloarthropathy-associated aortitis diagnosed by transesophageal echocardiography. The case illustrates the aortic root pathology and highlights the unique morphologic echocardiographic feature of this condition, prominent thickening of the aortic-mitral curtain.

The safety of same-day CT colonography following incomplete colonoscopy with polypectomy

Background Concerns about the risk of bowel perforation for same-day computed tomography colonography (CTC) following an incomplete colonoscopy with polypectomy may lead to unnecessarily postponing the CTC. Objective The objective of this article is to describe the complications including colon perforations associated with same-day CTC in a cohort who had polypectomies but an incomplete colonoscopy. Design We conducted a retrospective study. Setting Our study took place in a single, tertiary referral center. Patients We studied consecutive patients who had CTC the same day as an incomplete colonoscopy with polypectomy. Interventions Interventions included optical colonoscopy (OC), endoscopic polypectomies, and same-day CTC. Main outcome measurements: Our main outcome measurements included perforation rate with long-term follow-up. Results A total of 3% of patients undergoing colonoscopy from January 2008 to December 2012 had same-day CTC following incomplete OC, and 72 polypectomies were performed in 34 (or 17%) of these patients. Incomplete colonoscopies were due to colon tortuosity and looping (25), severe angulations (five), colon mass (two), colon stenosis (one), bradycardia (one). Fifty-three percent of the OCs were screening for colon neoplasia, 29% diagnostic and 18% were surveillance of colon polyps. Most polyps were ≤ 5 mm, and found in the left colon. There were no reported complications or perforations associated with same-day CTCs during short- and long-term follow-up. Limitations Limitations of our analysis included retrospective single-center design, small number of patients for the occurrence, referral to same-day CTC was not standardized, inability to establish safety of CTC for specific scenarios such as after complex polypectomies, strictures, or advanced IBD. Conclusions Radiologists’ apprehension to perform a CTC the same day as an incomplete colonoscopy following polypectomies because of perceived risk of perforation may be unfounded. More data are needed to determine the safety of same-day CTC in patients with high-risk findings during colonoscopy such as a stricture, severe IBD, and after complex polypectomies.

Routine Duodenal Biopsies in the Absence of Endoscopic Markers of Celiac Disease Are Not Useful: An Observational Study

Background. European studies have shown the utility of limiting endoscopic biopsies to diagnose celiac disease (CD) to patients that have high-risk symptoms or present with positive serology. However, many centers in the U.S. have open access endoscopy. Patients are referred without prior serologic testing, and endoscopists often decide whether or not to biopsy at the time of procedure. Aims. Evaluate the yield of duodenal biopsies for the diagnosis of CD in patients undergoing upper endoscopy without prior serologic testing. Methods. This retrospective study evaluated the frequency of CD diagnosis based duodenal biopsies. Researchers were interested in the yield of endoscopic stigmata findings in patients with high-risk symptoms versus low risk. Results. Eight hundred and ten patients met entry criteria at the Cleveland Clinic Florida between 2004 and 2008; 320 presented with high-risk symptoms; and 490 low risk. Sixty-one (7.5%) displayed endoscopic stigmata, and 10/61 (16.3%) were diagnosed with CD. Only patients who exhibited endoscopic stigmata were later diagnosed based on histologic findings. The presence of endoscopic stigmata greatly increased the probability of diagnosing CD, with a positive likelihood ratio of 15.6. Conclusions. When performing upper endoscopy without known serological markers for CD, clinicians should limit duodenal biopsies to patients with high-risk symptoms or endoscopic stigmata.

Crohn's disease of the common bile duct and ampulla causing obstructive jaundice and acute pancreatitis.

Crohns Disease of the Common Bile Duct and Ampulla Causing Obstructive Jaundice and Acute Pancreatitis

Impaired Gallbladder Motility and Increased Gallbladder Wall Thickness in Patients with Nonalcoholic Fatty Liver Disease.

Background/Aims Nonalcoholic fatty liver disease (NAFLD) is currently the most common chronic liver disease worldwide. Along with the increase in the incidence of NAFLD and associated obesity, an increase in gallbladder disease (GD) has been noted. This has led to the identification of a new disease entity called fatty GD. There is a gap in the literature on the dynamics of gallbladder function in patients with NAFLD. Methods An observational case-control study, a total of 50 patients with biopsy proven NAFLD without gallbladder stone/sludge and 38 healthy comparison subjects were enrolled. Fasting, postprandial gallbladder volumes (PGV), gallbladder ejection fraction (GEF), and fasting gallbladder wall thickness (FGWT) were measured by real-time 2-dimensional ultrasonography. Results Fasting gallbladder wall thickness, fasting gallbladder volumes and PGV were significantly higher in patients with NAFLD than control subjects (P < 0.001, P = 0.006, and P < 0.001, respectively). Gallbladder ejection fraction was significantly lower in the NAFLD group than the controls (P = 0.008). The presence of NAFLD was an independent predictor for GEF, PGV, and FGWT. Also, steatosis grade was an independent predictor for GEF, and GEF was significantly lower in the nonalcoholic steatohepatitis (NASH) subgroup than the controls. Conclusions Gallbladder dysfunction and increase in gallbladder wall thickness exists in asymptomatic (without stone/sludge and related symptoms) patients with NAFLD and are useful in identifying fatty GD. Measurement of these variables in NAFLD patients may be useful in identifying those at higher risk for GD.

Direct visualization of the left atrial appendage using esophageal radial endoscopic ultrasound: An alternative to TEE

Preprocedural transesophageal echocardiography (TEE) to exclude left atrial appendage (LAA) thrombus before cardioversion or left atrial catheter ablation is routinely performed to lower the incidence of periprocedural strokes. Conventional TEE was attempted in a 64-year-old man with atrial flutter of unknown duration. He had two unsuccessful attempts at blind esophageal intubation with the TEE probe by two separate operators, both under conscious sedation and under moderate anesthesia. Gastroenterology was consulted

Initial experience with a variable width and extreme tip angulation colonoscope

Screening and surveillance colonoscopies can be affected by colon looping, angulations, diverticulosis, previous surgeries, body mass index, ability to sedate or type of sedation, bowel preparation, and female sex. Incomplete colonoscopies can be economically and emotionally costly and may result in decreased compliance with screening for colon neoplasia [1]. Instruments that improve the cecal intubation and adenoma detection rate, reduce the number of incomplete colonoscopies and improve patient satisfaction are desirable. Studies have shown that pediatric as well as variable stiffness colonoscopes achieve cecal intubation rates similar to standard colonoscopes, but possibly with less pain and with faster cecal intubation times [2, 3]. More recently, ultrathin colonoscopes have been reported to be better at negotiating acute luminal angulations, and patients may require less sedation than when standard colonoscopes are used. However, looping, difficulty removing larger polyps, and a higher ileal intubation failure rate have been reported [1, 4, 5]. We are, to the best of our knowledge, the first to report the ease of use and initial impressions with a newly available variable width colonoscope with extreme tip angulation capability.

Minimally invasive treatment of early gastrointestinal cancers

The diagnostic and therapeutic paradigm of early esophageal, gastric and colorectal cancer is shifting. Historically, surgery was the standard of care for gastrointestinal malignancies, including those at an early stage. However, it is associated with loss of function of the organ, higher morbidity, and associated costs. Endoscopic resection has evolved as a minimally invasive alternative that provides accurate histologic diagnosis, as well as curative resection for many early gastrointestinal malignancies. Endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD), and the recently described submucosal tunneling endoscopic resection (STER) constitute some of these new resection techniques. Appropriate selection of lesions amenable for endoscopic resection is crucial when being used with curative intent. Estimation of eligibility relies entirely in an adequate pre-procedural evaluation of depth of invasion and histology, which correlate with the risk of lymph node metastasis. Adequate histopathologic examination of the resected specimen determines curability of the resection, guiding the need for further therapy. We will review the indications, outcomes, and limitations of EMR, ESD, and STER.