Esofagitis disecante supeEsofagitis disecante superficial: dos casos de una misma entidad poco frecuente / Esophagitis dissecans superficialis: two cases of the same rare entity

La esofagitis disecante superficial (EDS) es una entidad infrecuente que se caracteriza endoscópicamente por el desprendimiento de las capas superficiales del epitelio esofágico e, histológicamente, por el aspecto bitonal del epitelio escamoso esofágico secundario a la necrosis de los estratos más superficiales. La etiología es desconocida, aunque se ha asociado con la ingesta de determinados fármacos, enfermedades autoinmunes, estasis esofágica y procedimientos endoscópicos. Presentamos dos casos: uno de ellos acontece en una mujer tras un episodio de disfagia abrupta y el segundo en un varón con comorbilidades y clínica de dolor epigástrico. La EDS es una patología que hay que considerar en su adecuado contexto clínico y endoscópico, ya que su curso es autolimitado en comparación con otras entidades de evolución tórpida o que precisan un tratamiento específico. (AU)

Esophagitis dissecans superficialis (EDS) is a rare disease characterized by sloughing of the superficial esophageal mucosa and, histologically, by the bitonal appearance of the squamous epithelium secondary to necrosis of the most superficial layers. Etiology is uncertain, however, it has been associated with some medications, autoimmune diseases, esophageal stasis and endoscopic procedures. Here, two cases are presented, one of them which appeared in a woman after an episode of dysphagia and another one which occurred to a man with comorbidities and epigastric pain. This entity should be considered due to its self-limiting clinical course, compared to other entities with a more torpid evolution or that require more specific treatment. (AU)

A rare endoscopic pattern in a patient with gastroesophageal reflux disease

A 21-year-old man, with personal history of asthma and no usual medication, was referred to gastroenterology appointment due to dysphagia for solids and previous episodes of food impaction in the last 5 months. He also reported nocturnal heartburn without any other warning signs. Upper gastroscopy revealed a peptic stenosis in the distal esophagus. Histopathologic examination showed hyperplasia and numerous intraepithelial eosinophils, without dysplasia or malignancy. Therapy with a double-dose proton pump inhibitor (PPI) was started. (AU)

New technique for the endoscopic removal of long foreign bodies

Removing long foreign bodies (LFBs) is a challenge due to the risk of perforation is high, especially in anatomically narrow or acute angulations areas. Here we report a new technique for removing LFBs under endoscope. (AU)

The role of gastrointestinal endoscopy in Kaposi sarcoma / El papel de la endoscopia gastrointestinal en el sarcoma de Kaposi

We are writing to make endoscopists aware of the paramount of a prompt diagnosis of gastrointestinal Kaposi sarcoma (GI-KS). Patients with GI involvement have a two to five times higher risk of death and will benefit from chemotherapy to improve their survival. However, current evidence found that one out of three patients might have a false negative result even with HHV-8 since other entities such as gastrointestinal stromal tumors, angiosarcoma, and lymphoma shared macroscopic and histopathological characteristics. These cause a delay in treatment and significantly worsen the prognosis. We observed a trend for a positive diagnosis from ulcers and nodules. To our knowledge, this is the largest cohort of patients with GI-KS in the world. Our study suggests that in cases where a complete immunochemistry panel for KS is not available, HHV-8 remains as a bare minimum. However, other gastrointestinal lesions shared histopathological characteristics. Therefore, we suggest taking biopsies from nodular and ulcer-type lesions to increase the probability to establish a histopathological diagnosis.(AU)

Diagnóstico mediante resección endoscópica de una entidad extraña / Gastric lymphangioma. Diagnosis by endoscopic resection of a foreign entity

The lymphangioma is a rare and very uncommon benign tumor at the gastric level. Its diagnosis typically involves imaging tests and endoscopy, and its treatment usually involves surgery. We present a case of an 82-year-old patient who presented with chronic anemia, with a large gastric polyp detected during the initial gastroscopy. Subsequently, an endoscopic resection was performed, confirming histologically that it was a lymphangioma.(AU)

La cápsula endoscópica para el diagnóstico del melanoma intestinal / Cholecystogastric fistula diagnosed by endoscopic ultrasonography

Melanoma is a cancer that frequently metastasises to the small bowel, but most cases are asymptomatic and are diagnosed postmortem. Therefore, CT and PET CT cannot detect all lesions and conventional endoscopic study only detects 10-20% of lesions. In this study, we present the case of a 68-year-old patient with a history of cutaneous melanoma and a diagnosis of intestinal melanoma. Thanks to capsule endoscopy, two lesions compatible with cutaneous melanoma metastasis to the small bowel were detected, allowing a much more effective surgical planning. Capsule endoscopy is an innovative technique that improves preoperative diagnosis, as it is able to detect bowel segments that cannot be inspected by conventional endoscopy. It also has a better resolution than conventional CT, improving sensitivity in the detection of lesions.(AU)

A scale to measure the worry level in Gastrointestinal Endoscopy with sedation: Development, reliability, and validity

Objective: This study aims to develop a scale to measure the worry level of patients who will undergo gastrointestinal (GI) endoscopy with deep sedation, and to provide scientific references to alleviate their worries. Method: Based on literature review, panel discussion, patient interview and expert consultation, we developed the first version of the scale. After two pre-investigations, the formal version of the scale was formed, and the reliability and validity were tested on 1389 respondents. Reliability was assessed by Cronbach's alpha. Construct validity was tested by confirmatory factor analysis (CFA) and the Spearman correlations analysis. Results: The scale was composed of four dimensions: financial and time costs, sedation, examination, and psychology. It has 15 items. Reliability and validity were acceptable. The Cronbach's alpha of the whole scale was 0.959 and all the factor loadings were > 0.50. The Spearman correlations of the inter-dimensions ranged from 0.614 to 0.836, and the correlation coefficients between the dimensions and the total score were 0.795 to 0.957. The correlation coefficient between the total scale score and the APAIS was 0.833. Conclusions: This scale has good validity and reliability, which is useful for physicians and medical institutions to take appropriate measures to reduce patients' worries. (AU)

Endoscopia urgente frente a endoscopia precoz: ¿tiene algún papel la endoscopia urgente en la hemorragia digestiva alta aguda no varicosa? / Urgent endoscopy versus early endoscopy: Does urgent endoscopy play a role in acute non-variceal upper gastrointestinal bleeding?

Introducción: Las principales guías de práctica clínica recomiendan la realización de endoscopia dentro de las 24horas posteriores a la admisión en urgencias en pacientes con hemorragia digestiva alta no variceal. Sin embargo, es un margen de tiempo muy amplio y el papel de la endoscopia urgente (<6horas) es controvertido. Material y métodos: Estudio prospectivo observacional realizado en Hospital Universitario La Paz, donde son seleccionados todos los pacientes, desde el 1 de enero de 2015 hasta el 30 de abril de 2020, que acudieron a urgencias y fueron sometidos a endoscopia por sospecha de hemorragia digestiva alta. Se establecieron dos grupos de pacientes: endoscopia urgente (<6horas) y precoz (6-24horas). El objetivo primario del estudio fue la mortalidad a los 30días. Resultados: Un total de 1.096 pacientes fueron incluidos, de los cuales 682 fueron sometidos a endoscopia urgente. La mortalidad a los 30 días fue del 6% (5% vs 7,7%, p=0,064) y del resangrado fue del 9,6%. No hubo diferencias estadísticamente significativas en la mortalidad, resangrado, necesidad de tratamiento endoscópico, cirugía y/o embolización, pero sí en la necesidad de transfusión (57,5% vs 68,4%, p<0,001) y el número de concentrados de hematíes transfundidos (2,85±4,01 vs 3,51±4,09, p=0,008). Conclusión: La endoscopia urgente, en pacientes con hemorragia digestiva alta aguda, también el subgrupo de alto riesgo (GBS ≥ 12), no se asoció con una mortalidad menor a los 30 días que la endoscopia precoz. Sin embargo, en los pacientes con lesiones endoscópicas de alto riesgo (Forrest I-IIB), fue un predictor significativo de menor mortalidad. Por lo tanto, se requieren más estudios para la identificación correcta de pacientes, que se beneficien de esta actitud médica (endoscopia urgente). (AU)

Introduction: The main clinical practice guidelines recommend endoscopy within 24hours after admission to the Emergency Department in patients with non-variceal upper gastrointestinal bleeding. However, it is a wide time frame and the role of urgent endoscopy (<6hours) is controversial. Material and methods: Prospective observational study carried out at La Paz University Hospital, where all patients were selected, from January 1, 2015 to April 30, 2020, who attended the Emergency Room and underwent endoscopy for suspected upper gastrointestinal bleeding. Two groups of patients were established: urgent endoscopy (<6hours) and early endoscopy (6-24hours). The primary endpoint of the study was 30-day mortality. Results: A total of 1096 were included, of whom 682 underwent urgent endoscopy. Mortality at 30days was 6% (5% vs 7.7%, P=.064) and rebleeding was 9.6%. There were no statistically significant differences in mortality, rebleeding, need for endoscopic treatment, surgery and/or embolization, but there were differences in the necessity for transfusion(57.5% vs 68.4%, P<.001) and the number of concentrates of transfused red blood cells (2.85±4.01 vs 3.51±4.09, P=.008). Conclusion: Urgent endoscopy, in patients with acute upper gastrointestinal bleeding, as well as the high-risk subgroup (GBS ≥12), was not associated with lower 30-day mortality than early endoscopy. However, urgent endoscopy in patients with high-risk endoscopic lesions (ForrestI-IIB), was a significant predictor of lower mortality. Therefore, more studies are required for the correct identification of patients who benefit from this medical approach (urgent endoscopy). (AU)

Comparison of urgent and early endoscopy for acute non-variceal upper gastrointestinal bleeding in high-risk patients / Comparación entre endoscopia urgente y temprana para hemorragia digestiva alta no varicosa en pacientes de alto riesgo

Objective: Data regarding early (within 24h) and urgent endoscopy (within 12h) in non-variceal upper gastrointestinal bleeding (NV-UGIB) revealed conflicting results. This study aimed to investigate the impact of endoscopy timing on the outcomes of high-risk patients with NV-UGIB. Patients and methods: From February 2020 to February 2021, consecutive high-risk (Glasgow–Blatchford score ≥12) adults admitted to the emergency department with NV-UGIB were analyzed retrospectively. The primary composite outcome was 30-day mortality from any cause, inpatient rebleeding, need for endoscopic re-intervention, need for surgery or angiographic embolization. Results: 240 patients were enrolled: 152 (63%) patients underwent urgent endoscopy (<12h) and 88 (37%) patients underwent early endoscopy (12–24h). One or more components of the composite outcome were observed in 53 (22.1%) patients: 30 (12.5%) had 30-day mortality, rebleeding occurred in 27 (11.3%), 7 (2.9%) underwent endoscopic re-intervention, and 5 (2.1%) required surgery or angiographic embolization. The composite outcome was similar between the groups. Multivariate analysis showed only hemodynamic instability on admission (OR: 3.05, p=0.006), and the previous history of cancer (OR: 2.42, p=0.029) were significant in predicting composite outcome. In terms of secondary outcomes, the endoscopic intervention was higher in the urgent endoscopy group (p=0.006), whereas the number of transfused erythrocyte suspensions and the length of hospital stay was higher in the early endoscopy group (p=0.002 and p=0.040, respectively). Conclusions: Urgent endoscopy leads to a significant reduction in the length of hospitalization and the number of transfused erythrocyte suspensions in NV-UGIB, which can contribute to patient satisfaction, reduce healthcare expenditure, and improve hospital bed availability. The composite outcome and its sub-outcomes were the same among both groups.(AU)

Objetivo: Los datos en relación con la endoscopia temprana (dentro de las 24h) y urgente (dentro de las 12horas) en la hemorragia digestiva alta no varicosa (HDA-NV) mostraron resultados contradictorios. El objetivo del estudio fue investigar el impacto del momento de la endoscopia en el desenlace de los pacientes de alto riesgo con HDA-NV. Pacientes y métodos: Se realizó un análisis retrospectivo de adultos con HDA-NV consecutivos de alto riesgo (puntuación de Glasgow-Blatchford≥12) ingresados en el servicio de urgencias entre febrero de 2020 y febrero de 2021. El principal resultado compuesto fue mortalidad a los 30días por cualquier causa, nueva hemorragia de pacientes hospitalizados, necesidad de una nueva intervención endoscópica o necesidad de cirugía o embolización angiográfica. Resultados: Se incluyeron 240 pacientes: 152 (63%) se sometieron a endoscopia urgente (<12h) y 88 (37%) a endoscopia temprana (12-24h). Se observaron uno o más de los elementos del resultado compuesto en 53 (22,1%) pacientes: 30 (12,5%) tuvieron mortalidad a los 30 días, se produjo nuevo sangrado en 27 (11,3%), 7 (2,9%) se sometieron a una nueva intervención endoscópica y 5 (2,1%) requirieron cirugía o embolización angiográfica. El resultado compuesto fue similar entre los grupos. El análisis multivariado mostró que solamente la inestabilidad hemodinámica al ingreso (OR: 3,05, p=0,006) y la historia previa de cáncer (OR: 2,42, p=0,029) fueron significativos para predecir el resultado compuesto. En relación con los resultados secundarios, la intervención endoscópica fue más frecuente en el grupo de endoscopia urgente (p=0,006), mientras que el número de transfusiones de suspensiones eritrocíticas y la duración de la estancia hospitalaria fueron mayores en el grupo de endoscopia temprana (p=0,002 y p=0,040, respectivamente). Conclusiones: La endoscopia urgente conduce a una reducción significativa en el tiempo de hospitalización y en el número...(AU)

Prospective cohort study to evaluate premedication with simethicone and n-acetilcysteine for upper diagnostic gastrointestinal endoscopy

Introduction: The use of premedication for upper gastrointestinal endoscopy (UGE) is not widely established in western countries. The primary aim of the study was to compare gastric visibility according to the total visibility score (TVS). The secondary aim was to assess complications, diagnostic yield, endoscopic procedure time, sedation dose and patient satisfaction. Methods: A single center prospective cohort study was performed of consecutive adults undergoing an UGE in the afternoon working shift. After completing enrolment in the control group, patients were administered 200 mg simethicone and 500 mg N-acetylcysteine diluted in 100 ml of water >15 minutes before the procedure. All procedures were recorded and a single, blinded endoscopist evaluated the TVS after recruitment of both cohorts. Patient satisfaction was evaluated using the Spanish translation of the American Society of Gastrointestinal Endoscopy satisfaction questionnaire. Results: 205 patients were included in the study, 103 females (50.2%) with a median age of 54.8-years (IQR: 41.2-65.2). 104 were enrolled to the control group and 101 to the intervention group. Patients receiving premedication presented a higher rate of adequate (74.3% vs 45.2; difference 95% CI: 16,3-41,9%, p<0.001) and excellent gastric visibility (23.8% vs 7.7%; difference 95% CI: 6,3-25,8%, p=0.002). Propofol dose was similar, although the median procedure time was lower in the group of no intervention [5 (IQR: 4-7) vs 6 minutes (IQR: 5-7); p=0.03]. Procedure related adverse events were similar, except that patient without premedication experienced more nausea episodes. Major and minor endoscopic findings and the satisfaction questionnaire showed no differences between both groups. Conclusion: Patients receiving premedication with simethicone and N-acetylcysteine had a better gastric visibility score, without any increase in adverse events or affecting the patients’ satisfaction (AU)

Underwater versus conventional endoscopic mucosal resection for sessile colorectal polyps: an updated systematic review and meta-analysis

Background: underwater endoscopic mucosal resection (uEMR) without submucosal injection for sessile colorectal polyps was introduced as a new replacement for conventional EMR (cEMR). However, the optimal resection strategy remains a topic of debate. Hence, this meta-analysis was performed to compare the efficacy and safety of uEMR and cEMR in patients with sessile colorectal polyps. Methods: a comprehensive search of the literature from 2000 till January 2022 was performed from Medline, CENTRAL and Embase for randomized controlled trials (RCTs) comparing cEMR vs uEMR for colorectal polyps. The evaluated outcomes included en bloc resection, R0 resection, procedure time, overall bleeding and recurrence. Pooled risk ratios (RR) with 95 % confidence interval were calculated using a random effect model. Results: six studies were included, out of which four were full-text articles and two were conference abstracts. En bloc resection (RR 1.26, 95 % CI: 1.00-1.60), R0 resection (RR 1.10, 95 % CI: 0.96-1.26), overall bleeding (RR 0.85, 95 % CI: 0.54-1.34) and recurrence rate (RR 0.75, 95 % CI: 0.45-1.27) were comparable between uEMR and cEMR. However, uEMR was associated with a shorter procedure time (mean difference [MD] -1.55 minutes, 95 % CI: -2.71 to -0.39). According to the subgroup analysis, uEMR led to a higher rate of en bloc resection (RR 1.41, 95 % CI: 1.07-1.86) and R0 resection (RR 1.19, 95 % CI: 1.01-1.41) for polyps ≥ 10 mm in size. Conclusion: both uEMR and cEMR have a comparable safety and efficacy. For polyps larger than 10 mm, uEMR may have an advantage over cEMR and should be the topic for future studies (AU)

Predicting the future: introducing business analytics to endoscopy units

Background and aims: currently, most endoscopy software only provides limited statistics of past procedures, while none allows patterns to be extrapolated. To overcome this need, the authors applied business analytic models to predict future demand and the need for endoscopists in a tertiary hospital Endoscopy Unit. Methods: a query to the endoscopy database was performed to retrieve demand from 2015 to 2021. The graphical inspection allowed inferring of trends and seasonality, perceiving the impact of the COVID-19 pandemic, and selecting the best forecasting models. Considering COVID-19’s impact in the second quarter of 2020, data for esophagogastroduodenoscopy (EGD) and colonoscopy was estimated using linear regression of historical data. The actual demand in the first two quarters of 2022 was used to validate the models. Results: during the study period, 53,886 procedures were requested. The best forecasting models were: a) simple seasonal exponential smoothing for EGD, colonoscopy and percutaneous endoscopic gastrostomy (PEG); b) double exponential smoothing for capsule endoscopy and deep enteroscopy; and c) simple exponential smoothing for endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS). The mean average percentage error ranged from 6.1 % (EGD) to 33.5 % (deep enteroscopy). Overall, 8,788 procedures were predicted for 2022. The actual demand in the first two quarters of 2022 was within the predicted range. Considering the usual time allocation for each technique, 3.2 full-time equivalent endoscopists (40 hours-dedication to endoscopy) will be required to perform all procedures in 2022. Conclusions: the incorporation of business analytics into the endoscopy software and clinical practice may enhance resource allocation, improving patient-focused decision-making and healthcare quality (AU)