Endoscopic Characterization and Outcome of COVID-19 Patients with Secondary Sclerosing Cholangitis: A Case Series of a Tertiary Center.

BACKGROUND AND AIMS: During the coronavirus disease 2019 (COVID-19) pandemic a significant proportion of patients with severe acute respiratory distress syndrome (ARDS) due to COVID-19 infection developed secondary sclerosing cholangitis (SSC) as a hepatobiliary complication. METHODS: 17 patients were endoscopically diagnosed and treated with COVID-19 SSC from February 2020 until October 2022 at our center. We retrospectively reviewed and analyzed the data to define risk factors, establish endoscopic treatment options, and to estimate incidence and outcomes. RESULTS: 258 patients with COVID-19 infection were admitted to our tertiary center and mechanically ventilated. 10 patients developed COVID-19 SSC in-house, and 7 patients were transferred for further endoscopic treatment. All 17 patients were mechanically ventilated, received vasoactive substances and 12 of them were treated with extracorporeal membrane oxygenation therapy. Endoscopic retrograde cholangiography (ERC) was performed in all patients to establish the diagnosis of COVID-19 SSC and evaluate endoscopic treatment options. All ERCs revealed biliary casts. 9 patients had developed severe rarefication of the intrahepatic bile ducts and 4 showed biliary strictures. As endoscopic treatment approaches, casts were removed repeatedly, and strictures were dilated. During the study period, 14 patients died (82%). 3 patients are in follow-up to reassess the need for liver transplantation. CONCLUSIONS: COVID-19 SSC was observed in 2.6 % of the patients with severe COVID-19 in our center. We show that endoscopic approaches offer the opportunity to extract casts and to treat biliary strictures. As the mortality rate of COVID-19 SSC is high, endoscopic treatment can be of great clinical relevance as a bridge to liver transplantation.

Diagnostic Accuracy and Therapeutic Efficacy of Digital Single-Operator Cholangioscopy for Biliary Lesions and Stenosis.

BACKGROUND/AIMS: Digital single-operator cholangioscopy (dSOC) has revolutionized bile duct visualization. Interventions like electrohydraulic or laser lithotripsy, inspection of suspicious areas, and targeted biopsies have become possible quick and easy. One main indication for dSOC remains the evaluation of indeterminate biliary strictures. OBJECTIVE AND METHODS: We analyzed 180 consecutive dSOCs procedures performed in a high-volume tertiary center to evaluate sensitivity, specificity as well as positive and negative predictive values (PPV and NPV) for indeterminate strictures. Furthermore, technical success and complications were analyzed. RESULTS: In 92-97%, the region of interest was reached and successfully visualized. In 83-100%, targeted biopsies were obtained from the suspicious area. Only the distal bile duct was less successful with only 84 and 62%, respectively. In general, dSOC procedures were safe. Cholangitis was the main complication. Regarding the diagnostic accuracy of dSOC of indeterminate biliary strictures, we found a sensitivity of 0.87 and specificity of 0.88, over all. Within the whole cohort, the investigators' assessment directly after dSOC had a PPV of 0.63 and a NPV of 0.97. In patients with biliary lesions or stenosis suspicious for malignancy, the dSOC-based visual diagnosis revealed a very high diagnostic accuracy with sensitivity and specificity of 1.0 (95% CI 0.86-1.0) and 0.76 (95% CI 0.56-0.9) with a PPV of 0.77 (95% CI 0.59-0.9) and a high NPV of 1.0 (95% CI 0.85-1.0). CONCLUSIONS: Our study demonstrates that dSOC has a high diagnostic accuracy as well as a favorable safety profile. Therefore, dSOC should be discussed as standard of care during endoscopic retrograde cholangiography for indeterminate biliary lesions.

White-Light or Narrow-Band Imaging Colonoscopy in Surveillance of Ulcerative Colitis: A Prospective Multicenter Study.

BACKGROUND & AIMS: Early detection of neoplastic lesions is essential in patients with long-standing ulcerative colitis but the best technique of colonoscopy still is controversial. METHODS: We performed a prospective multicenter study in patients with long-standing ulcerative colitis. Two colonoscopies were performed in each patient within 3 weeks to 3 months. In white-light (WL) colonoscopy, stepwise random biopsy specimens (4 biopsy specimens every 10 cm), segmental random biopsies (2 biopsy specimens in 5 segments), and targeted biopsy specimens were taken. In NBI colonoscopy, segmental and targeted biopsy specimens were taken. The sequence of WL and NBI colonoscopy was randomized. RESULTS: In 36 of 159 patients enrolled (22.6%), 54 lesions with intraepithelial neoplasia (IN) were found (51 low-grade, 3 high-grade). In WL colonoscopy we found 11 IN in stepwise biopsy specimens, 4 in segmental biopsy specimens, and 15 in targeted biopsy specimens. In NBI colonoscopy 7 IN were detected in segmental biopsy specimens and 24 IN were detected in targeted biopsy specimens. Almost all IN were found with one technique alone (κ value of WL vs NBI, -0.86; P < .001). Statistically equivalent numbers of IN were found in NBI colonoscopy with targeted and segmental biopsy specimens as in WL colonoscopy with targeted and stepwise biopsy specimens, but with fewer biopsy specimens (11.9 vs 38.6 biopsy specimens, respectively; P < .001), and less withdrawal time was necessary (23 vs 13 min, respectively; P < .001). CONCLUSIONS: Stepwise biopsy specimens are indispensable in WL colonoscopy. The combination of targeted and segmental biopsy specimens in the NBI technique is as sensitive as targeted together with stepwise biopsy specimens in WL colonoscopy, but requires fewer biopsy specimens and less time. The highest sensitivity should be reached by combining the WL and NBI techniques by switching between the modes.

Pre-study protocol MagPEP: a multicentre randomized controlled trial of magnesium sulphate in the prevention of post-ERCP pancreatitis.

BACKGROUND: Acute pancreatitis is the most common complication of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP). In spite of continuing research, no pharmacologic agent capable of effectively reducing the incidence of ERCP-induced pancreatitis has found its way into clinical practise. A number of experimental studies suggest that intrapancreatic calcium concentrations play an important role in the initiation of intracellular protease activation, an initiating step in the course of acute pancreatitis. Magnesium can act as a calcium-antagonist and counteracts effects in calcium signalling. It can thereby attenuate the intracellular activation of proteolytic digestive enzymes in the pancreas and reduces the severity of experimental pancreatitis when administered either intravenously or as a food supplement. METHODS: We designed a randomized, double-blind, placebo-controlled phase III study to test whether the administration of intravenous magnesium sulphate before and after ERCP reduces the incidence and the severity of post-ERCP pancreatitis. A total of 502 adult patients with a medical indication for ERCP are to be randomized to receive either 4930 mg magnesium sulphate (= 20 mmol magnesium) or placebo 60 min before and 6 hours after ERCP. The incidence of clinical post-ERCP pancreatitis, hyperlipasemia, pain levels, use of analgetics and length of hospital stay will be evaluated. CONCLUSIONS: If magnesium sulphate is found to be effective in preventing post-ERCP pancreatitis, this inexpensive agent with limited adverse effects could be used as a routine pharmacological prophylaxis. TRIAL REGISTRATION: Current Controlled Trials ISRCTN46556454.

Causes of bolus impaction in the esophagus.

BACKGROUND: Bolus impaction in the esophagus is a common indication for emergency endoscopy. The aim of this study was to determine the most common causes of esophageal bolus impaction. METHODS: In this retrospective study, data of 54 patients (41 male, 13 female) with bolus impaction in the esophagus were analyzed. Type and localization of the bolus and the endoscopic extraction tool used were evaluated. In 48 of 54 patients (89%), biopsy samples were taken of the esophagus for histological examination. RESULTS: Mean age of the patients was 53 ± 20 years. Fourteen of 54 patients (26%) had experienced bolus impaction previously. Meat bolus (n = 35, 65%) was the most common cause of esophageal obstruction. In most cases, boluses were found in either the distal (n = 31) or the proximal (n = 18) esophagus. In 22 patients (41%), the bolus was pushed into the stomach by the endoscope. In most other cases the bolus, including foreign bodies, could be removed with the 5-arm polyp grasper or alligator forceps. Main causes of bolus impaction were eosinophilic esophagitis (n = 10) or reflux disease with or without peptic stenosis (n = 10), respectively. CONCLUSION: Bolus impaction is frequently correlated with eosinophilic esophagitis and reflux esophagitis; therefore, diagnostic workup should include esophageal biopsy sampling.

[Acute upper gastrointestinal bleeding after coronary intervention in acute myocardial infarction]. / Akute obere gastrointestinale Blutung nach Koronarintervention bei akutem Myokardinfarkt.

HISTORY AND ADMISSION FINDINGS: A 73-year-old man with NSTEMI (non-ST segment elevation myocardial infarction) underwent coronary angiography and an in-stent restenosis and thrombosis in ramus circumflexus was found. A drug-eluting stent (DES) was implanted. 12 h after intervention during threefold platelet inhibition the patient presented a gastrointestinal bleeding with melena and the hemoglobin level dropped from 15.3 g/dl to 9.7 g/dl. INVESTIGATIONS: Blood tests revealed a considerable elevation of cardiac enzymes, troponin I, leukocytes and C-reactive protein but normal hemoglobin. In coronary angiography, the stent in ramus circumflexus was found to be occluded. Therefore, a percutaneous coronary intervention with implantation of a DES (Taxus) was performed. In gastroscopy, a 2.5-cm necrotic formation resembling a tumor with an oozing bleeding was identified. The bleeding was stopped after injection of adrenaline. Histological evaluation showed no criteria of malignancy. TREATMENT AND COURSE: With high-dose proton pump blocker therapy, calculated Helicobacter pylori eradication with amoxicillin and clarithromycin, and cessation of NSAID (nonsteroidal anti-inflammatory drugs), the hemoglobin level was stable with 9.7 g/dl. No blood transfusion and no interruption of the dual platelet inhibition were necessary. In control gastroscopy, the initial endoscopically malignancy-suspicious formation presented as a small, superficial, healing ulcer. CONCLUSION: Bleeding complications after stent implantation create a dilemma situation. The risk of a hemorrhagic shock by continuing platelet inhibition therapy and the risk of an acute stent thrombosis with interruption of the platelet inhibition should be carefully calculated considering individual facts and the guidelines.

Gastrointestinal manifestation of systemic sclerosis--thickening of the upper gastrointestinal wall detected by endoscopic ultrasound is a valid sign.

OBJECTIVE: Gastrointestinal (GI) tract involvement has been observed in the majority of patients with SSc. This has been attributed to an accumulation of extracellular matrix within the GI walls. We visualized the walls of the oesophagus, stomach and duodenum with its layers and measured the thickness in SSc patients and control patients utilizing endoscopic ultrasound (EUS). METHODS: Twenty-five SSc patients and 25 controls were evaluated. In addition to analysis of clinical symptoms, endoscopy and EUS (20-MHz miniprobe) were performed. The thickness of the complete wall was measured, and the mucosa, submucosa and muscularis were evaluated separately. RESULTS: Clinical symptoms of SSc patients were dysphagia (14/25) and heartburn (19/25). Endoscopic findings were hiatal hernia (16/25), oesophagitis (6/25), amotility (19/25) and a dehiscent pylorus (15/25). In comparison with controls, SSc patients had significantly thicker oesophageal [SSc 1.619 (0.454) mm, control 1.392 (0.333) mm; P = 0.025], antral [SSc 1.876 (0.635) mm, control 1.599 (0.291) mm; P = 0.029] and duodenal [SSc 1.730 (0.522) mm, control 1.525 (0.222) mm; P = 0.039] walls. Predominantly, submucosa and muscularis were significantly thicker in SSc patients. The presence of dysphagia or amotility was significantly associated with the thickening of the GI walls. CONCLUSIONS: The EUS revealed a significant thickening of the walls of the upper GI tract in SSc patients. Predominantly, the submucosa and muscularis are enlarged. These results strengthen the hypothesis that increased matrix deposition is an important aspect in the pathogenesis of GI involvement in SSc.

Complicated wireless capsule enteroscopy in a patient with Crohn's disease.

An 18-year-old male experienced a first episode of Crohn's disease with inflammation of the colon, stenosis of small intestine and a fistula of the anal sphincter. After resection of the fistula and 30 cm of proximal ileum the patient remained free of symptoms under medication with azathioprine and mesalazine for 6 years. Then, blood in the stool occurred. Diagnostic work-up - gastroscopy and colonoscopy 2004 and 2006, magnetic resonance enteroclysis 2004 and 2006 and wireless capsule enteroscopy 2006 - revealed slight inflammation in the ileum but no bleeding source. The bleeding ceased, but after 2 uneventful years abdominal cramps appeared and diagnostic work-up (magnetic resonance enteroclysis, radiograph) located the capsule still in the terminal ileum proximal to an inflamed stenosis. Corticosteroids were subscribed for 4 weeks, but the capsule stayed in place. Surgery was discussed, but denied by the patient. Finally, the capsule could be taken out by double balloon enteroscopy.

[Impaction of a "sausage bread" in the esophagus--first manifestation of an eosinophilic esophagitis in a 17-year-old patient]. / Eine impaktierte "Wiener Semmel" im Osophagus--Erstmanifestation einer eosinophilen Osophagitis bei einem 17-jährigen Patienten.

A 17-year-old patient was transferred to the emergency room with an impacted food bolus by colleagues from the Department of Otorhinolaryngology. The examination of ear, nose and throat revealed significant amounts of saliva in both recessus piriformis, a radiologic examination of the esophagus showed a foreign body with a diameter of 1.6 cm in the region of the transitional zone of esophagus and stomach with a support level of the contrast medium. Clinical examination and laboratory tests showed no abnormalities. An emergency gastroscopy was performed. The foreign body, already evident in the barium swallow, was found in the distal esophagus. The foreign body was identified as a food bolus and gently advanced into the stomach with the aid of the gastroscope. In the stomach further food residues were detected and the examination was aborted because of increased risk of aspiration. On the next day, an elective gastroscopy was performed. Several biopsies were obtained from the esophagus because eosinophilic esophagitis (EE) was suspected due to clinical symptoms. Histological work-up showed a significant amount of eosinophilic granulocytes (> 15 eosinophils/HPF, 400 x) and reactive changes in the distal esophagus. Therefore, EE was diagnosed. Fluticasone therapy led to amelioration of symptoms and there was no evidence of recurring bolus impaction during follow-up.

A new grading system to evaluate the risk of endoscopic retrograde cholangiopancreatography.

BACKGROUND: The aim of our study was to develop a system to grade the risk of the procedures summarized under the term endoscopic retrograde cholangiopancreatography (ERCP). METHODS: In a controlled prospective study, we evaluated the early complications of ERCP in 526 consecutive patients at a single endoscopy center in a defined period. The relation between endoscopic procedures and related complications was analyzed for significance. A grading system based on significant risk factors and clinical implications was developed. RESULTS: Of the ERCP procedures, 29% were diagnostic and 71% therapeutic. A total of 45 complications occurred in 42 patients: pancreatitis (2%), perforation (1%), cardiorespiratory problems (0.6%), stent-related complications (0.5%), leakages (1.5%), and bleeding (3%). A native papilla was a significant risk factor for the development of complications (P = 0.046). On the basis of these findings, we defined five groups of ERCP-related complications: nonnative papillae with either diagnostic (A) or therapeutic interventions (B); native papillae with diagnostic (C) or therapeutic (D) interventions; and special therapeutic interventions (E). Complication rates differed significantly between individual groups, A versus D (P = 0.013), A versus E (P = 0.010), B versus D (P = 0.005), and B versus E (P = 0.003), as well as between A/B and C/D (P = 0.003). CONCLUSIONS: A grading system based on differentiating between native and nonnative papillae and diagnostic versus therapeutic procedures demonstrated significantly different complication rates. This grading system has the potential to predict the risk of ERCP-related complications.

Continuous non-invasive arterial pressure technique improves patient monitoring during interventional endoscopy.

INTRODUCTION: Close monitoring of arterial blood pressure (BP) is a central part of cardiovascular surveillance of patients at risk for hypotension. Therefore, patients undergoing diagnostic and therapeutic procedures with the use of sedating agents are monitored by discontinuous non-invasive BP measurement (NIBP). Continuous non-invasive BP monitoring based on vascular unloading technique (CNAP, CN Systems, Graz) may improve patient safety in those settings. We investigated if this new technique improved monitoring of patients undergoing interventional endoscopy. METHODS: 40 patients undergoing interventional endoscopy between April and December 2007 were prospectively studied with CNAP(R) in addition to standard monitoring (NIBP, ECG and oxygen saturation). All monitoring values were extracted from the surveillance network at one-second intervals, and clinical parameters were documented. The variance of CNAP values were calculated for every interval between two NIBP measurements. RESULTS: 2660 minutes of monitoring were recorded (mean 60.1+/-34.4 min/patient). All patients were analgosedated with midazolam and pethidine, and 24/40 had propofol infusion (mean 90.9+/-70.3 mg). The mean arterial pressure for CNAP was 102.4+/-21.2 mmHg and 106.8+/-24.8 mmHg for NIBP. Based on the first NIBP value in an interval between two NIBP measurements, BP values determined by CNAP showed a maximum increase of 30.8+/-21.7% and a maximum decrease of 22.4+/-28.3% (mean of all intervals). DISCUSSION: Conventional intermittent blood pressure monitoring of patients receiving sedating agents failed to detect fast changes in BP. The new technique CNAP improved the detection of rapid BP changes, and may contribute to a better patient safety for those undergoing interventional procedures.

Visual characteristics of the papilla to estimate cannulation of the common bile duct - a pilot study.

OBJECTIVES: Performance of endoscopic retrograde cholangiography (ERC) depends mainly on the skills of the examiner, but also on anatomical variants. The aim of the study was to investigate patient- and papilla-related factors for the successful selective cannulation of the common bile duct (CBD). PATIENTS AND METHODS: 50 patients with a papilla with no prior sphincterotomy needing an ERC were enrolled. From a standardized description given by the endoscopist, criteria to characterize the papilla were analyzed. RESULTS: Success was achieved in 92%. Cannulation time was 460 +/- 561 seconds on average. 70% of the papillae were mastered in 300 seconds or less. Concordance between endoscopists concerning descriptive variables was between 86% and 100%. The judgment of the endoscopist concerning expected difficulty was not significantly related to success, demonstrating the necessity of predictive parameters. Typical position of the duodenoscope and performance of precut were significantly related to success. The joint presence of a visible orifice and a typical position of the duodenoscope had a positive predictive value (PPV) of 96%. CONCLUSIONS: Endoscopists can rely on the joint presence of a visible orifice of the papilla and a typical position of the duodenoscope in X-ray to predict the success of ERC.

Factors affecting cecal and ileal intubation time in colonoscopy.

BACKGROUND AND PURPOSE: The time required for a colonoscopy must be justified under economic aspects. The objective of this study was to analyze patient- and staff-related factors influencing the time for cecal and ileal intubation. PATIENTS AND METHODS: A prospective study was performed on 500 consecutive patients undergoing colonoscopy in 2005. The authors analyzed patient age, gender, height, weight, surgical history, the presence of liver cirrhosis and splenomegaly, the number of children given birth, the presence of colorectal cancer and inflammatory bowel disease, the quality of bowel preparation, sedation, and the experience of the attending colonoscopist, the nurse and the team as factors of possible relevance to cecal and ileal intubation time. RESULTS: The cecum was reached in 495/500 examinations (99%). Intubation of terminal ileum was possible in 477/500 patients (96%). Mean cecal and ileal intubation times were 10.5+/-10.2 min and 6.4+/-7.9 min, respectively. Time to cecal intubation was related to the experience of the endoscopist (p=0.009), the nurse (p=0.04) and the whole team (p=0.002), as well as to an adequate cleaning of the bowel (p=0.01). CONCLUSION: A short intubation time requires experienced staff in combination with an adequate cleaning of the bowel without reference to biological or pathologic factors except for colon-shortening surgery. The gain in examination quality by inspecting the terminal ileum comes to the cost of a prolongation of insertion time of 25-30% in experienced hands.

[Female patient with unclear liver lesions after breast cancer. Imaging modalities as a key to diagnosis]. / Patientin mit unklaren Leberraumforderungen nach Mammakarzinom. Die Bildgebung als Schlüssel zur Diagnose.

The case of a 58-year-old female patient with well-differentiated breast cancer (T1 stadium) without axillar lymphadenopathy and with multiple suspect liver lesions is described. Liver metastases of the breast cancer could be excluded histologically, however, serologic testing for echinococcosis was negative. After contrast-enhanced sonography and because of the complex B-mode appearance of the liver lesions, cystic echinococcosis was suspected. This could be verified histologically after hemihepatectomy.

Long-lasting effect of endoscopic dilatation of an esophageal stenosis due to eosinophilic esophagitis.

Eosinophilic esophagitis is a rare disorder mainly affecting pediatric patients, although the number of cases reported in adults, especially young males with dysphagia, is on the increase. The most severe complication is esophageal stenosis. We report the case of a 26 year old white male who presented with dysphagia in 2001. Endoscopy revealed an esophageal stenosis 35 cm aboral without signs of mucosal inflammation, that was dilated once. The patient was asymptomatic until 2004, when he presented again with dysphagia. Eosinophilic esophagitis was diagnosed. Dilatation was repeated. The further clinical course was uneventful with no more episodes of dysphagia.