Migration of endoscopically placed biliary stents is a well-recognized complication of endoscopic retrograde cholangiopancreatography. Less than 1% of migrated stents however cause intestinal perforation. We present a case of a migrated biliary stent that resulted in duodenal perforation and biliary peritonitis.
Biliary stents; Migration; Duodenal perforation; Biliary peritonitis
Measuring quality is a current need of medical services either to assess their cost-effectiveness or to identify discrepancies requiring refinement. With the advent of bowel cancer screening and increasing patient awareness of bowel symptoms, there has been an unprecedented increase in demand for colonoscopy. Consequently, there is an expanding open-discussion on missed rates of cancer or precancerous polyps during diagnostic/screening colonoscopy and on the rate of adverse events related to therapeutic colonoscopy. Delivering a quality colonoscopy service is therefore a healthcare priority. Colonoscopy is a multi-step process and therefore assessment of all aspects of the procedure must be addressed. Quality in colonoscopy refers to a combination of many patient-centered technical and non-technical skills and knowledge aiming to patient’s safety and satisfaction through a continuous effort for improvement. The benefits of this endless process are hiding behind small details which can eventually make the difference in colonoscopy. Identifying specific quality metrics help to define and shape an optimal service and forms a secure basis of improvement. Τhis paper does not aim to give technical details on how to perform colonoscopy but to summarize what to measure and when, in accordance with the current identified quality indicators and standards for colonoscopy.
Colonoscopy; Quality assurance; Metrics; Standards; Outcome
Crohn’s disease (CD) is a chronic inflammatory condition of the gastrointestinal tract resulting in inflammation, stricturing and fistulae secondary to transmural inflammation. Diagnosis relies on clinical history, abnormal laboratory parameters, characteristic radiologic and endoscopic changes within the gastrointestinal tract and most importantly a supportive histology. The article is intended mainly for the general gastroenterologist and for other interested physicians. Management of small bowel CD has been suboptimal and limited due to the inaccessibility of the small bowel. Enteroscopy has had a significant renaissance recently, thereby extending the reach of the endoscopist, aiding diagnosis and enabling therapeutic interventions in the small bowel. Radiologic imaging is used as the first line modality to visualise the small bowel. If the clinical suspicion is high, wireless capsule endoscopy (WCE) is used to rule out superficial and early disease, despite the above investigations being normal. This is followed by push enteroscopy or device assisted enteroscopy (DAE) as is appropriate. This approach has been found to be the most cost effective and least invasive. DAE includes balloon-assisted enteroscopy, [double balloon enteroscopy (DBE), single balloon enteroscopy (SBE) and more recently spiral enteroscopy (SE)]. This review is not going to cover the various other indications of enteroscopy, radiological small bowel investigations nor WCE and limited only to enteroscopy in small bowel Crohn’s. These excluded topics already have comprehensive reviews. Evidence available from randomized controlled trials comparing the various modalities is limited and at best regarded as Grade C or D (based on expert opinion). The evidence suggests that all three DAE modalities have comparable insertion depths, diagnostic and therapeutic efficacies and complication rates, though most favour DBE due to higher rates of total enteroscopy. SE is quicker than DBE, but lower complete enteroscopy rates. SBE has quicker procedural times and is evolving but the least available DAE today. Larger prospective randomised controlled trial’s in the future could help us understand some unanswered areas including the role of BAE in small bowel screening and comparative studies between the main types of enteroscopy in small bowel CD.
Crohn’s disease; Enteroscopy; Ileoscopy; Balloon-assisted; Device-assisted; Spiral device; Overtube; Stricture; Dilatation
The incidence of rectal carcinoids is rising because of the widespread use of screening colonoscopy. Rectal carcinoids detected incidentally are usually in earlier stages at diagnosis. Rectal carcinoids estimated endoscopically as < 10 mm in diameter without atypical features and confined to the submucosal layer can be removed endoscopically. Here, we review the efficacy and safety of various endoscopic treatments for small rectal carcinoid tumors, including conventional polypectomy, endoscopic mucosal resection (EMR), cap-assisted EMR (or aspiration lumpectomy), endoscopic submucosal resection with ligating device, endoscopic submucosal dissection, and transanal endoscopic microsurgery. It is necessary to carefully choose an effective and safe primary resection method for complete histological resection.
Carcinoid tumor; Rectum; Polypectomy; Endoscopic mucosal resection; Endoscopic submucosal dissection
Tumoral obstructions in almost the entire gastrointestinal tract can be resolved with interventional digestive endoscopy techniques. Self-expanding metal stent (SEMS) insertion in the obstructed colon is a minimally invasive and relatively simple procedure providing an effective first-line treatment for relief of acute malignant obstruction symptoms and serving either as a preoperative or “bridge to surgery” procedure or as palliative definitive care. This technique was introduced in the early 1990s. Although there is still debate about its real value, a lot of reports have been published since then and the procedure is advocated by many surgical groups as the method of choice for the initial treatment of left-sided tumoral colonic obstruction. Before the procedure, colonic obstruction has to be diagnosed by abdominal radiographs, water contrast enema and/or a computed tomography scan. The greatest information is provided by the latter and it is perhaps the method of choice prior to stenting. Skills and training are mandatory, as in all interventional procedures. The key step for success is to cross the malignant stricture with a guidewire. Care must be taken not to over insufflate an obstructed colon during the procedure. SEMS slide over the guidewire through the endoscope working channel or in parallel, outside the endoscope. An average 7% perforation rate has been reported during the procedure and other minor complications can appear in the follow up. However, as a whole, this technique seems to compare favorably with surgery.
Self-expanding metal stent; Malignant colorectal obstruction; Emergency surgery; Interventional endoscopy
AIM: To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge.
METHODS: About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study.
RESULTS: Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms.
CONCLUSION: The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.
Colonoscopy; Conscious sedation; Patient discharge; Recovery room; Complications
AIM: To develop a new continuous suction mouthpiece (CSM) and evaluate its usefulness for screening esophagogastroduodenoscopy (EGD).
METHODS: A total of 196 patients who were scheduled to undergo screening EGD were assigned to one of two groups: a group using the CSM and a group using a conventional mouthpiece. Extent of salivary flow, frequency of saliva suction, number of choking episodes during the examination, and incidence of aspiration pneumonia after the examination were evaluated and compared between the two groups. Adverse events during and after EGD were also examined. In addition, the oral cavity was meticulously examined after the EGD.
RESULTS: The same number of patients was randomly allocated to each group. There were no significant differences between the two groups in sex, age, biopsy procedure, duration of procedure and depth of sedation. Aspiration pneumonia and other significant adverse events were not observed in either group. The grade of extent of salivary flow was significantly lower in patients with the CSM than in patients with the conventional mouthpiece (P < 0.001). Although there was no significant difference, less frequent suctioning and fewer choking episodes were observed in patients with the CSM than in patients with the conventional mouthpiece (P = 0.082 and P = 0.084, respectively). In addition, there were no patients in the CSM group who required saliva suctioning during the procedure.
CONCLUSION: Use of the CSM during screening EGD can reduce the extent of salivary flow. The device is expected to reduce complications and contamination with saliva.
Mouthpiece; Esophagogastroduodenoscopy; Aspiration; Saliva; Suction
Endoscopic ultrasonography is the most accurate procedure for the evaluation of subepithelial lesions. The finding of a homogeneous, hyperechoic, well-delimited lesion, originating from the third layer of the gastrointestinal tract (submucosa) suggests a benign tumor, generally lipoma. As other differential diagnoses have not been reported, echoendoscopists might not pursue a definitive pathological diagnosis or follow-up the patient. This case series aims to broaden the spectrum of differential diagnosis for duodenal hyperechoic third layer subepithelial lesions by providing four different and relevant pathologies with this echoendoscopic pattern.
Endoscopic ultrasonography; Endoscopic ultrasound-guided fine needle aspiration; Duodenum; Subepithelial tumor; Lipoma
Here we present the case of a 35-year-old female patient with long standing dyspepsia and imaging studies showing the presence of multiple cysts in the head and tail of the pancreas. The patient underwent endosonography that confirmed the presence of multiple simple cysts throughout the entirety of the pancreas without dilation of the pancreatic duct. The majority of the cysts were less than one centimeter in size, and the largest cyst showed a honeycomb appearance. Cytology of aspirates from the two largest cysts was compatible with benign pancreatic cysts. Endosonography also revealed cysts within the left kidney and spleen. Genetic testing confirmed Von Hippel-Lindau disease. We highlight this case because it is unusual for Von Hippel-Lindau disease, a rare clinical entity, to present solely with cysts in the absence of more common manifestations, such as hemangioblastomas in the central nervous system and malignancy.
Von Hippel-Lindau disease; Endosonography; Pancreatic cysts; Hereditary disease; Cysts
An 85-year-old female, with hereditary nonpolyposis colorectal cancer syndrome, underwent a colonoscopy and endoscopic mucosal resection (EMR) of a 25-mm proximal ascending colon polyp (Paris classification 0-Is). Post-procedure, the patient developed abdominal pain in the right iliac fossa which settled 1 h later. An urgent computed tomography (CT) scan of her abdomen was organised which happened 6 h post onset of abdominal pain. She had radiological evidence of perforation on the CT scan but clinically remained well and was managed conservatively. The exact aetiology of this patient’s symptoms is not known. We suspect the radiological findings are probably due to a combination of injectate within the colonic wall and leakage of insufflated air or CO2 following transmural passage of the EMR needle. As EMR is becoming an increasingly effective treatment modality in the management of large sessile polyps, clinicians need to be aware of potential complications of treatment. It is also important to recognise that radiological features of perforation can be seen post EMR in the absence of an EMR associated perforation.
Colonoscopy; Endoscopic mucosal resection; Perforation; Computed tomography scan; Abdominal pain
Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter. Per-oral endoscopic myotomy (POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons. It represents a natural orifice transluminal endoscopic surgery (NOTES) approach to Heller myotomy. POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy. POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery. Initial high success and low complications rates promise a great future for this technique. In fact, POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response. The volume of POEMs performed worldwide has grown exponentially. In fact, surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia. However, the niche of POEM remains to be defined and long term results are awaited. We describe our experience with POEM having performed the first POEM outside of Japan in 2009, the evolution of our technique, and give our perspective on its future.
Per-oral endoscopic myotomy; Achalasia; Heller myotomy; Natural orifice transluminal endoscopic surgery; Per-oral endoscopic myotomy; Minimally invasive surgery
Diagnosis of gastric subepithelial tumor (SET) has shown a rapid increase worldwide. Although, until now, endoscopic ultrasound guided procedures such as fine needle aspiration have shown relatively high accuracy in diagnosis of SET, the most important modality for diagnosis and treatment of SETs is complete resection such as endoscopic or surgical resection. However, endoscopic resection or laparoscopic wedge resection alone also has some limitations. Endoscopic resection is difficult to perform in cases of gastric SET located within deep portion of the gastric layer or a relatively large (larger than 25 mm diameter). On the other hand, gastric SET in a difficult location, such as the gastroesophageal junction or pyloric ring is challenging for laparoscopic surgical resection. The hybrid natural orifice transluminal endoscopic surgery (NOTES) technique is a combined method, including the advantages of both laparoscopic resection and endoscopic resection for gastric SETs. This method may be performed safely with reasonable operation times, less bleeding, and adequate resection margin and regardless of tumor size. In particular, in the case of a difficult location for resection, such as the esophagogastric junction or pyloric ring, hybrid NOTES is currently believed to be an ideal treatment method.
Subepithelial tumor; Hybrid natural orifice transluminal endoscopic surgery; Endoscopic ultrasound
AIM: To evaluate the efficacy, tolerability, acceptability and feasibility of bisacodyl plus low volume polyethyleneglycol-citrate-simeticone (2-L PEG-CS) taken the same day as compared with conventional split-dose 4-L PEG for late morning colonoscopy.
METHODS: Randomised, observer-blind, parallel group, comparative trial carried out in 2 centres. Out patients of both sexes, aged between 18 and 85 years, undergoing colonoscopy for diagnostic investigation, colorectal cancer screening or follow-up were eligible. The PEG-CS group received 3 bisacodyl tablets (4 tablets for patients with constipation) at bedtime and 2-L PEG-CS in the morning starting 5 h before colonoscopy. The control group received a conventional 4-L PEG formulation given as split regimen; the morning dose was taken with the same schedule of the low volume preparation. The Ottawa Bowel Preparation Scale (OBPS) score was used as the main outcome measure.
RESULTS: A total of 164 subjects were enrolled and 154 completed the study; 78 in the PEG-CS group and 76 in the split 4-L PEG group. The two groups were comparable at baseline. The OBPS score in the PEG-CS group (3.09 ± 2.40) and in the PEG group (2.39 ± 2.55) were equivalent (difference +0.70; 95%CI: -0.09-1.48). This was confirmed by the rate of successful bowel cleansing in the PEG-CS group (89.7%) and in the PEG group (92.1%) (difference -2.4%; 95%CI: -11.40- 6.70). PEG-CS was superior in terms of mucosa visibility compared to PEG (85.7% vs 72.4%, P = 0.042). There were no significant differences in caecum intubation rate, time to reach the caecum and withdrawal time between the two groups. The adenoma detection rate was similar (PEG-CS 43.6% vs PEG 44.7%). No serious adverse events occurred. No difference was found in tolerability of the bowel preparations. Compliance was equal in both groups: more than 90% of subjects drunk the whole solution. Willingness to repeat the same bowel preparations was about 90% for both regimes.
CONCLUSION: Same-day PEG-CS is feasible, effective as split-dose 4-L PEG for late morning colonoscopy and does not interfere with work and daily activities the day before colonoscopy.
Bowel preparation; Polyethyleneglycol; Simethicone; Ottawa Bowel Preparation Scale; Colonoscopy
AIM: To analyze the diagnostic utility of a small-caliber endoscope (SC-E) and clinicopathological features of false-negative gastric cancers (FN-GCs).
METHODS: A total of 21638 esophagogastroduodenoscopy (EGD) gastric cancer (GC) screening examinations were analyzed. Secondary endoscopic examinations (n = 3352) were excluded because most secondary examinations tended to be included in the conventional endoscopy (C-E) group. Detection rates of GCs and FN-GCs were compared between SC-E and C-E groups. FN-GC was defined as GC performed with EGD within the past 3 years without GC detection. Macroscopic types, histopathological characteristics and locations of FN-GCs were compared with firstly found-gastric cancers (FF-GCs) in detail.
RESULTS: SC-E cases (n = 6657) and C-E cases (n = 11644), a total of 18301 cases, were analyzed. GCs were detected in 16 (0.24%) SC-E cases and 40 C-E (0.34%) cases (P = 0.23) and there were 4 FN-GCs (0.06%) in SC-E and 13 (0.11%) in C-E (P = 0.27), with no significant difference. FN-GCs/GCs ratio between SC-E and C-E groups was not significantly different (P = 0.75). The comparison of endoscopic macroscopic types of FN-GCs tended to be a less advanced type (P = 0.02). Histopathologically, 70.6% of FN-GCs were differentiated and 29.4% undifferentiated type. On the other hand, 43.0% of FF-GCs were differentiated and 53.8% undifferentiated type, so FN-GCs tended to be more differentiated type (P = 0.048).
CONCLUSION: The diagnostic utility of SC-E for the detection of GCs and FN-GCs was not inferior to that of C-E. Careful observation for superficially depressed type lesions in the upper lesser curvature region is needed to decrease FN-GCs.
Gastric cancer; Small-caliber endoscope; False-negative gastric cancer
SJ is a 37-year-old male who presented with one year history of dysphagia, odynophagia and 15 pounds weight loss. He underwent endoscopic evaluation which showed mid esophageal ulcers. It was thought that the cause of the ulcer was the multivitamins and the patient was asked to stop them. Furthermore Esomeprazole therapy was also initiated. Patient’s symptoms persisted but he did not seek any medical attention until about one year later. Meanwhile the patient reported additional 15 pounds of weight loss. We repeated upper endoscopy again which showed evidence of two chronic non bleeding irregular friable ulcerations seen in the mid esophagus, 31 cm from the incisors. Biopsies and frozen section were taken and sent for assessment to the Pathology lab. Immunoperoxidase studies on frozen sections showed the presence of IgM and for most plasma cells IgG. The microscopic and histologic findings were consistent with mucous associated lymphoid tissue lymphoma with plasmocytic differentiation. Computed tomographic scan done showed no evidence of spread to adjacent structures. The patient was referred to oncology and several cycles of radiation and Rituximab therapy were initiated which cured the disease. Subsequent endoscopies with blind biopsies were done which were negative for any neoplastic process.
Lymphoma; Mucous associated lymphoid tissue; Esophagus
Pseudoachalasia is a rare secondary achalasia, which accounts for only a small subgroup of patients. We describe a 77-year-old woman with recent onset of dysphagia and typical esophageal manometric findings of achalasia. Moreover, esophageal manometric findings of vascular compression at 36 cm from the nose were associated with dysphagia. An upper endoscopy showed the absence of lesions both in the esophagus and gastro-esophageal junction, whilst a 15-mm ulcer on the gastric angulus was detected. The gastric ulcer resulted in being a diffuse signet ring cell carcinoma at histology, suggesting pseudoachalasia. An abdominal computed tomography scan showed an irregular concentric thickening of the gastro-esophageal junction wall extending for 7 cm and a dilated ascending thoracic aorta with no presence of the inferior vena cava, with an enlarged azygos as the source of vascular compression of esophagus. Moreover, cardia involvement from diffuse signet ring cell carcinoma of the gastric angulus was also recognized as the cause of dysphagia. The cancer was not suitable for a surgical approach in an old patient with cardiovascular comorbidities and support therapy was started. In our ambulatory series, pseudoachalasia was eventually diagnosed in 4.7% of 234 consecutive patients with esophageal manometric finding suggestive of achalasia. We also reviewed cases in the literature and aimed to evaluate the reported causes of pseudoachalasia.
Pseudoachalasia; Achalasia; Esophageal vascular compression; Thoracic aorta; Azygos vein
The World Health Organization describes calcifying fibrous tumors (CFTs) as rare, benign lesions characterized by hypocellular, densely hyalinized collagenization with lymphoplasmacytic infiltration. These tumors rarely involve the gastrointestinal (GI) tract. A routine endoscopic upper gastrointestinal screen detected a 10-mm submucosal tumor (SMT) in the lesser curvature of the lower corpus of the stomach of an apparently healthy, 37-year-old woman with no history of Helicobacter pylori infection. Endoscopic ultrasonography (EUS) localized the internally isoechoic, homogeneous SMT mainly within the submucosa. Malignancy was ruled out using endoscopic submucosal dissection (ESD). A pathological examination confirmed complete resection of the SMT, and defined a hypocellular, spindle-cell tumor with a densely hyalinized, collagenous matrix, scattered lymphoplasmacytic aggregates as well as a few psammomatous, dystrophic calcified foci. The mass was immunohistochemically positive for vimentin and negative for CD117 (c-kit protein), CD34, desmin, smooth muscle actin (SMA) and S100. Therefore, the histological findings were characteristic of a CFT. To date, CFT resection by ESD has not been described. This is the first case report of a gastric calcifying fibrous tumor being completely resected by ESD after endoscopic ultrasonography.
Calcifying fibrous tumor; Endoscopic submucosal dissection; Submucosal tumor; Endoscopic ultrasonography
Pseudocysts of the pancreas are not rare, but spontaneous perforation and/or fistulization occurs in fewer than 3% of these pseudocysts. Perforation into the free peritoneal cavity, stomach, duodenum, colon, portal vein, pleural cavity and through the abdominal wall has been reported. Spontaneous rupture of the pancreatic pseudocyst into the surrounding hollow viscera is rare and, may be associated with life-threatening bleeding. Such cases require emergency surgical intervention. Uncomplicated rupture of pseudocyst is an even rarer occurrence. We present a case of spontaneous resolution of a pancreatic pseudocyst with gastric connection without bleeding. A 67-year-old women with a large pancreatic pseudocyst resulting from a complication of chronic pancreatitis was referred to our institution. During hospital stay, there was sudden decrease in the size of epigastric lump. Repeat computed tomography (CT) revealed that the size of the pseudocyst had decreased significantly; however, gas was observed in stomach and pseudocyst along with rent between lesser curvature of stomach and pseudocyst suggestive of spontaneous cystogastric fistula.The fistula tract occluded spontaneously and the patient recovered without any complication or need for surgical treatment. After 5 wk, follow up CT revealed complete resolution of pseudocyst. Esophagogastroduodenoscopy revealed that the orifice was completely occluded with ulcer at the site of previous fistulous opening.
Chronic pancreatitis; Cystogastric fistula; Fistula; Pancreas; Pancreatitis; Pseudocyst
In capsule endoscopy (CE), there is research to develop hardware that enables ‘‘real’’ three-dimensional (3-D) video. However, it should not be forgotten that ‘‘true’’ 3-D requires dual video images. Inclusion of two cameras within the shell of a capsule endoscope though might be unwieldy at present. Therefore, in an attempt to approximate a 3-D reconstruction of the digestive tract surface, a software that recovers information-using gradual variation of shading-from monocular two-dimensional CE images has been proposed. Light reflections on the surface of the digestive tract are still a significant problem. Therefore, a phantom model and simulator has been constructed in an attempt to check the validity of a highlight suppression algorithm. Our results confirm that 3-D representation software performs better with simultaneous application of a highlight reduction algorithm. Furthermore, 3-D representation follows a good approximation of the real distance to the lumen surface.
Capsule endoscopy; Three-dimensional reconstruction; Phantom; Experiment; PillCam; Software; Accuracy
Gastrointestinal endoscopy has become an important modality for the diagnosis and treatment of various gastrointestinal disorders. One of its major advantages is that it is minimally invasive and has an excellent safety record. Nevertheless, some complications do occur, and endoscopists are well aware and prepared to deal with the commonly recognized ones including bleeding, perforation, infection, and adverse effects from the sedative medications. Air embolism is a very rare endoscopic complication but possesses the potential to be severe and fatal. It can present with cardiopulmonary instability and neurologic symptoms. The diagnosis may be difficult because of its clinical presentation, which can overlap with sedation-related cardiopulmonary problems or neurologic symptoms possibly attributed to an ischemic or hemorrhagic central nervous system event. Increased awareness is essential for prompt recognition of the air embolism, which can allow potentially life-saving therapy to be provided. Therefore, we wanted to review the risk factors, the clinical presentation, and the therapy of an air embolism from the perspective of the practicing endoscopist.
Air embolism; Endoscopy; Endoscopic retrograde cholangiopancreatography; Complications; Therapy
The effect of fetal radiation during endoscopic retrograde cholangiopancreatography (ERCP) on pregnant women is a very interesting topic. Smith et al recently estimated the fetal radiation exposure in pregnant women undergoing ERCPs using thermoluminescent dosimeters (TLDs). The authors concluded that TLDs are unnecessary during ERCP with modified techniques. We believe that an extreme caution is needed in clinical practice before drawing such conclusions when they are not strongly supported by enough experimental evidence. Therefore, we recommend that fetal radiation exposure be monitored in clinical practice by using dosimeters, bearing in mind that all relevant techniques to control and minimize the exposure must be applied.
Endoscopic retrograde cholangiopancreatography; Pregnancy; Fetal radiation exposure; Thermoluminescent dosimeters; Post-endoscopic retrograde cholangio-pancreatography pancreatitis
Endoscopic submucosal dissection (ESD) represents an important advancement in the therapy of early neoplastic gastrointestinal lesions by providing higher en-bloc curative resection rate with lower recurrence compared to endoscopic mucosal resection (EMR) and by sparing the involved organ and protecting patient’s quality of life. Despite these advantages ESD is associated with long procedure times and a higher rate of complications, making ESD a challenging procedure which requires advanced endoscopic skills. Thus, there has been a recognized need for structured training system for ESD to enhance trainee experience and, to reduce the risks of complications and inadequate treatment. ESD has a very flat learning curve. However, we do not have uniformly accepted benchmarks for competency. Nevertheless, it appears that, in Japan, more than 30 supervised gastric ESD procedures are required to achieve technical proficiency and minimize complications. A number of training algorithms have been proposed in Japan with the aim to standardize ESD training. These algorithms cannot be directly applied in the West due to substantial differences including the availability of highly qualified mentors, the type of pathology seen, choice of devices, and trainee’s background. We propose a training algorithm for Western physicians which integrates both hands-on training courses, animal model work as well as visits to expert centers. No specific preceptor training programs have been yet developed but there is a consensus that these programs are important for permeation of ESD worldwide.
Endoscopic submucosal dissection; Training; Learning curve; Early gastrointestinal cancer; Endoscopic mucosal resection
Achalasia is a primary esophageal motor disorder. The etiology is still unknown and therefore all treatment options are strictly palliative with the intention to weaken the lower esophageal sphincter (LES). Current established endoscopic therapeutic options include pneumatic dilation (PD) or botulinum toxin injection. Both treatment approaches have an excellent symptomatic short term effect, and lead to a reduction of LES pressure. However, the long term success of botulinum toxin (BT) injection is poor with symptom recurrence in more than 50% of the patients after 12 mo and in nearly 100% of the patients after 24 mo, which commonly requires repeat injections. In contrast, after a single PD 40%-60% of the patients remain asymptomatic for ≥ 10 years. Repeated on demand PD might become necessary and long term remission can be achieved with this approach in up to 90% of these patients. The main positive predictors for a symptomatic response to PD are an age > 40 years, a LES-pressure reduction to < 15 mmHg and/or an improved radiological esophageal clearance post-PD. However PD has a significant risk for esophageal perforation, which occurs in about 2%-3% of cases. In randomized, controlled studies BT injection was inferior to PD and surgical cardiomyotomy, whereas the efficacy of PD, in patients > 40 years, was nearly equivalent to surgery. A new promising technique might be peroral endoscopic myotomy, although long term results are needed and practicability as well as safety issues must be considered. Treatment with a temporary self expanding stent has been reported with favorable outcomes, but the data are all from one study group and must be confirmed by others before definite recommendations can be made. In addition to its use as a therapeutic tool, endoscopy also plays an important role in the diagnosis and surveillance of patients with achalasia.
Achalasia; Pneumatic dilation; Botulinum toxin injection; Per oral endoscopic myotomy; Dysphagia; Laparoscopic cardiomyotomy
AIM: To determine the prevalence, location, associations and clinical features of colonic-diverticulosis and its role as a cause of lower-gastroenterology-bleeding.
METHODS: We retrospectively reviewed the medical records of 3649 consecutive patients who underwent a colonoscopy for all indications between 2007 and 2011 at King Khalid University Hospital, Riyadh, Saudi Arabia. The demographic data were collected retrospectively through the hospital’s information system, electronic file system, endoscopic e-reports, and manual review of the files by two research assistants. The demographic information included the age, sex, comorbidities and indication for the colonoscopy. The association among colonic polyps, comorbidities and diverticular disease was also measured.
RESULTS: A total of 270 patients out of 3649 were diagnosed with colonic diverticulosis, with a prevalence of 7.4%. The mean age was 60.82 years ± 0.833, (range 12-110). Females comprised 38.89% (95%CI: 33-44.7) of the study population. The major symptoms were rectal bleeding in 33.6%, abdominal pain in 19.3%, constipation in 12.8% and anemia in 6%. Diverticula were predominantly left-sided (sigmoid and descending colon) in 62%, right-sided in 13% and in multiple locations in 25%. There was an association between the presence of diverticulosis and adenomatous polyps (P-value < 0.001), hypertension (P-value < 0.0001) and diabetes mellitus (P-value < 0.0016). Diverticular disease was the second most common cause of lower gastrointestinal bleeding, in 33.6% (95%CI: 27.7-39.4), after internal hemorrhoids, in 44.6% (95%CI: 40.3-48.9). On multivariable logistic regression, hypertension (OR = 2.30; 95%CI: 1.29-4.10), rectal bleeding (OR = 2.57; 95%CI: 1.50-4.38), and per year increment in age (OR = 1.05; 95%CI: 1.03-1.07) were associated with diverticulosis but not with bleeding diverticular disease. Limitations: A small proportion of the patients included had colonoscopies performed as a screening test.
CONCLUSION: Colonic-diverticulosis was found to have a low prevalence, be predominantly left-sided and associated with adenomatous-polyps. Age, hypertension and rectal bleeding predict the presence of diverticular disease.
Colonic diverticulosis; Diverticular disease; Saudi Arabia; Prevalence; Lower gastrointestinal bleeding; Epidemiology
Ehlers-Danlos syndrome (EDS) is a group of inherited connective tissue disorders caused by collagen synthesis defects. EDS type IV, or vascular EDS, is caused by loss-of-function mutations in the type III pro-collagen gene (COL3A1). Common complications of EDS type IV include gastrointestinal bleeding and bowel perforations, posing diagnostic and therapeutic dilemmas for both surgeons and gastroenterologists. Here, we describe a complicated case of EDS type IV in a 35-year-old caucasian female who presented with overt gastrointestinal bleeding. The patient had a prior history of spontaneous colonic perforation, and an uncomplicated upper endoscopy was performed. A careful ileoscopy was terminated early due to tachycardia and severe abdominal pain, and a subsequent computed tomography scan confirmed the diagnosis of ileal perforation. The patient was managed conservatively, and demonstrated daily improvement. At the time of hospital discharge, no further episodes of gastrointestinal blood loss had occurred. This case highlights the benefit of conservative management for EDS patients with gastrointestinal hemorrhage. It is recommended that surgical treatment should be reserved for patients who fail conservative treatment or in cases of hemodynamic instability. Finally, this case demonstrates the necessity for a higher threshold of operative or endoscopic interventions in EDS type IV patients.
Type-IV Ehlers-Danlos syndrome; Gastrointestinal hemorrhage; Bowel perforation; Conservative management; Non-operative; COL3A1; Connective tissue disorder