Use of a Novel Artificial Intelligence System Leads to the Detection of Significantly Higher Number of Adenomas During Screening and Surveillance Colonoscopy: Results From a Large, Prospective, US Multicenter, Randomized Clinical Trial.

INTRODUCTION: Adenoma per colonoscopy (APC) has recently been proposed as a quality measure for colonoscopy. We evaluated the impact of a novel artificial intelligence (AI) system, compared with standard high-definition colonoscopy, for APC measurement. METHODS: This was a US-based, multicenter, prospective randomized trial examining a novel AI detection system (EW10-EC02) that enables a real-time colorectal polyp detection enabled with the colonoscope (CAD-EYE). Eligible average-risk subjects (45 years or older) undergoing screening or surveillance colonoscopy were randomized to undergo either CAD-EYE-assisted colonoscopy (CAC) or conventional colonoscopy (CC). Modified intention-to-treat analysis was performed for all patients who completed colonoscopy with the primary outcome of APC. Secondary outcomes included positive predictive value (total number of adenomas divided by total polyps removed) and adenoma detection rate. RESULTS: In modified intention-to-treat analysis, of 1,031 subjects (age: 59.1 ± 9.8 years; 49.9% male), 510 underwent CAC vs 523 underwent CC with no significant differences in age, gender, ethnicity, or colonoscopy indication between the 2 groups. CAC led to a significantly higher APC compared with CC: 0.99 ± 1.6 vs 0.85 ± 1.5, P = 0.02, incidence rate ratio 1.17 (1.03-1.33, P = 0.02) with no significant difference in the withdrawal time: 11.28 ± 4.59 minutes vs 10.8 ± 4.81 minutes; P = 0.11 between the 2 groups. Difference in positive predictive value of a polyp being an adenoma among CAC and CC was less than 10% threshold established: 48.6% vs 54%, 95% CI -9.56% to -1.48%. There were no significant differences in adenoma detection rate (46.9% vs 42.8%), advanced adenoma (6.5% vs 6.3%), sessile serrated lesion detection rate (12.9% vs 10.1%), and polyp detection rate (63.9% vs 59.3%) between the 2 groups. There was a higher polyp per colonoscopy with CAC compared with CC: 1.68 ± 2.1 vs 1.33 ± 1.8 (incidence rate ratio 1.27; 1.15-1.4; P < 0.01). DISCUSSION: Use of a novel AI detection system showed to a significantly higher number of adenomas per colonoscopy compared with conventional high-definition colonoscopy without any increase in colonoscopy withdrawal time, thus supporting the use of AI-assisted colonoscopy to improve colonoscopy quality ( ClinicalTrials.gov NCT04979962).

The various faces of autoimmune endocrinopathies: non-tumoral hypergastrinemia in a patient with lymphocytic colitis and chronic autoimmune gastritis.

Serum gastrin levels exceeding 1000pg/ml (normal, <100) usually raise the suspicion for a neuroendocrine tumor (NET) that secretes gastrin. Rarely, such elevated gastrin levels are seen in patients with pernicious anemia which most commonly is associated with autoimmune gastritis (AG). AG can occur concomitantly with other autoimmune disorders including lymphocytic colitis (LC). Gastrin stimulates enterochromaffin-like cells which increase histamine secretion. Histamine excess can cause diarrhea as can bacterial overgrowth or LC. We present a 57-year-old woman with diarrhea, sporadic epigastric pain, and bloating. She also had a history of interstitial cystitis and took pentosan polysulfate and cetirizine. She had no history of ulcers, renal impairment or carcinoid syndrome. Fasting serum gastrin was 1846pg/ml. Esophagoduodenal gastroscopy and biopsies revealed chronic gastritis and a pH of 7 with low stomach acid. Serum gastrin and plasma chromogranin A were suggestive of a gastrinoma or NET. Pernicious anemia was unlikely. Imaging studies did not reveal any tumor. Random colonic biopsy was compatible with LC, possibly explaining her diarrhea, although we also considered excessive histamine from elevated gastrin, bacterial overgrowth, and pentosan polysulfate which can cause diarrhea and be misleading in this setting, pointing to the diagnosis of gastrinoma. At 4year follow-up in 2012, fasting serum gastrin was 1097pg/ml and the patient asymptomatic taking only cetirizine for nasal allergies. This case illustrates that diarrhea may be associated with very high serum gastrin levels in the setting of chronic gastritis, LC, and interstitial cystitis (pentosan use), without clear evidence for a gastrinoma or NET. If no history of ulcers or liver metastases is present in such cases, watchful observation rather than an extensive/invasive and costly search for a NET may be justified. Considering the various forms of polyglandular syndrome, this may represent a variant and we here provide an algorithm for working up such patients, while also reviewing literature on the intertwined relationship between the immune and endocrine systems.

Video capsule endoscopy in life-threatening GI hemorrhage after negative primary endoscopy (with video).

BACKGROUND: Video capsule endoscopy (VCE) continues to evolve as a key diagnostic tool. Traditionally VCE has been used to detect occult and obscure GI bleeding in adult patients. VCE has not been documented or accepted as an early diagnostic tool for acute life-threatening GI hemorrhage. OBJECTIVE: Our purpose was to demonstrate the use of VCE as an early diagnostic tool in acute life-threatening GI hemorrhage. DESIGN: Case series. PATIENTS: Patients with life-threatening GI hemorrhage. INTERVENTIONS: VCE after negative primary endoscopy. RESULTS: VCE allowed rapid diagnosis and reliable data before surgical intervention. Although proving to be a beneficial diagnostic tool for acute GI hemorrhage, VCE was not associated with increased morbidity or mortality rates. LIMITATIONS: This report only focuses on cases where VCE successfully led to a diagnosis. There is no prospective control group to which these patients can be compared. There were no other attempted acute VCE studies in patients with life-threatening bleeding during the time period of these case reports. CONCLUSIONS: The use of VCE is a simple and relatively safe diagnostic tool in the evaluation of continuing GI hemorrhaging in endoscopy-negative patients. The use of VCE can be considered as a another useful tool in the armamentarium of the endoscopist in the evaluation of GI bleeding. Prospective studies should be undertaken to determine the appropriate timing and clinical use in this group of patients.

Cost-minimization analysis of jumbo reusable forceps versus disposable forceps in a high-volume ambulatory endoscopy center.

BACKGROUND: Endoscopists worldwide are faced with the challenge of choosing the most cost-effective and durable equipment. There are limited data comparing the 2 major options for endoscopic forceps: disposable and reusable. Disposable forceps are marketed as the cost-effective alternative to reusable forceps. OBJECTIVE: This study was designed to provide a prospective assessment of the survival and cost of reusable versus disposable forceps to allow more educated decisions when purchasing endoscopic equipment. DESIGN: A 24-month prospective study in a high-volume ambulatory endoscopy center (AEC) with 71 Olympus jumbo reusable forceps (OJRF). A "cost of OJRF per procedure" was generated to compare to the estimated cost of disposable forceps per procedure. SETTING: Gastrointestinal Associates PA of Jackson, Mississippi, which performs approximately 24,000 outpatient procedures per year. PATIENTS: General patient population of this AEC undergoing colonoscopy. MAIN OUTCOME MEASUREMENTS: Mean cost of forceps per procedure and survival of reusable forceps. Cost was derived from purchase price, cleaning costs, repair/maintenance costs, and number of uses. RESULTS: Over the 24-month period, the total cost per procedure was $3.27. The mean number of uses per OJRF was 166.3. Sixty-eight percent of the forceps required no repair throughout the 2-year study, and only 1 forceps was deemed beyond repair. For comparison, disposable forceps were assigned a cost per procedure of $10.00 on the basis of conservative market price. Over a 2-year period this cost-per-procedure difference resulted in a cost savings of $79,482. LIMITATIONS: Failure to determine the average life-span of OJRF because 98% were still functioning properly after 2 years and an average of 166.3 procedures. Evaluation did not include storage and disposal costs, which would add a miniscule additional cost to disposable costs. The study also does not address some of the other arguments for disposables such as performance (quality of specimen) compared with reusables. The estimated average number of uses and durability was only studied for the OJRF. Other forceps may have different average cost per use and durability. CONCLUSIONS: In a large-volume AEC, OJRF are vastly more durable than resusable forceps reported in prior studies and are vastly more cost-effective than disposable forceps. A longer study period would have only revealed more dramatic cost savings and durability.

Epinephrine volume reduction of giant colon polyps facilitates endoscopic assessment and removal.

BACKGROUND: Management of giant colon polyps (>3 cm) can be a challenge for the therapeutic endoscopist, especially the endoscopist in training. Challenges include the potential for bleeding and the difficult technical aspects of removing giant polyps. Years of clinically observing the effects of epinephrine injection to reduce bleeding revealed epinephrine's pronounced volume-reducing effect. This epinephrine volume reduction (EVR) greatly facilitates assessment and removal of giant polyps while decreasing the need for piecemeal resection. OBJECTIVE: Our purpose was to demonstrate the use of EVR in facilitating the evaluation and removal of giant colon polyps. DESIGN: Case reports defining the technique of EVR. SETTING: Busy ambulatory endoscopy center with more than 22,000 cases in 2006. PATIENTS: General population of patients treated in this ambulatory endoscopy center for giant colon polyps. INTERVENTIONS: EVR and polypectomy. OUTCOME MEASUREMENTS: Pre-EVR and post-EVR volumes in giant polyps. Relative ease of removal of pre-EVR versus post-EVR polyp and observations for complications. RESULTS: Typically greater than 80% reduction in polyp volume was achieved, greatly easing endoscopic evaluation and removal while virtually eliminating the need for piecemeal resection. EVR was associated with no acute or delayed bleeding complications. LIMITATIONS: May be limited by inexperienced endoscopist's lack of injection and polypectomy skills. The technical difficulty in objective measurements of in vivo size and lack of blinded observations with a control group present the potential for observer bias. CONCLUSIONS: The use of EVR is a simple, cheap, and practical tool that facilitates giant polyp assessment and removal. This technique may greatly benefit endoscopists in the management of giant colon polyps. A prospective controlled trial of EVR should be undertaken to further define the optimal methods and benefits for the removal of giant colon polyps.

Crystal-storing histiocytosis due to massive accumulation of charcot-leyden crystals: a unique association producing colonic polyposis in a 78-year-old woman with eosinophilic colitis.

Crystal-storing histiocytosis is a rare diagnosis that to date has only been associated with 2 conditions: intracytoplasmic accumulation of crystallized immunoglobulins in patients with lymphoproliferative disorders or plasma cell dyscrasias, and histiocytic accumulations of phagocytosed clofazimine, a drug used to treat lepromatous leprosy. We describe a 78-year-old woman with a past medical history of dermatologic mastocytosis and peripheral eosinophilia who presented with diarrhea and weight loss, and was found at colonoscopy to have polyposis limited to the right and transverse colon. She eventually underwent subtotal colectomy to remove the segment of polyposis. At gross examination, the colonic mucosa contained numerous polyps ranging from 1 to 7 mm which on histologic evaluation proved to represent mucosal and submucosal collections of histiocytes whose cytoplasm was distended by numerous brightly eosinophilic crystals. An intense eosinophilic infiltrate surrounded the histiocyte collections and also mildly involved the intervening colonic mucosa and superficial submucosa. Electron microscopy confirmed the presence of intracytoplasmic material identical to Charcot-Leyden crystals within histiocytes, representing the breakdown products of degranulated eosinophils. This is the first reported case of crystal-storing histiocytosis produced by massive accumulation of Charcot-Leyden crystals in eosinophilic colitis.