Colon diverticulosis is not a risk factor for the detection of adenomatous polyps - results of a prospective study.

BACKGROUND AND AIMS: Colon diverticula (CD) and adenomatous polyps are frequently found during colonoscopy. Data from the literature contains inconsistent information about whether patients with CD have a higher risk for colon adenomas. A positive correlation might influence the current guidelines for screening colonoscopies. The aim of this study was to examine whether presence of CD is associated with endoscopic adenoma detection. MATERIALS AND METHODS: This was a prospective study at 2 centers in Germany. Patients with an indication for colonoscopy were included. The number and localization of diverticula were recorded. Detected polyps were resected, and histopathological results were captured. Logistic regression models were fitted to the data to evaluate the association between CD and adenoma detection. RESULTS: A total of 938 colonoscopies was included. CD occurred in 49.1 % of the colonoscopies. The polyp and adenoma detection rates (PDR, ADR) were 50.3 % and 32.3 %. In 37.5 % of the patients with diverticula, at least 1 adenoma was detected, whereas this was the case in 27.3 % in the absence of diverticula. The presence of diverticula was positively correlated with the detection of adenomas in univariate analysis (p = 0.001), but no significant association could be found in multivariable analysis (p = 0.775). Increasing age (p < 0.001), male sex (p = 0.005), and longer withdrawal time (p < 0.001) were significant predictors for adenoma detection in the multivariable analysis. Similar results were also observed for both the distal and the proximal colon. DISCUSSION: Diverticula and adenomas are frequently found during colonoscopies. However, diverticula disease was not significantly associated with adenoma detection after adjustment for relevant prognostic factors. Older age, male sex, and duration of withdrawal time are predictors for the detection of adenomatous polyps.

Cap Assisted Upper Endoscopy for Examination of the Major Duodenal Papilla: A Randomized, Blinded, Controlled Crossover Study (CAPPA Study).

OBJECTIVE: Examination of major duodenal papilla (MDP) by standard forward-viewing esophagogastroduodenoscopy (S-EGD) is limited. Cap assisted esophagogastroduodenoscopy (CA-EGD) utilizes a cap fitted to the tip of the endoscope that can depress the mucosal folds and thus might improve visualization of MDP. The aim of this study was to compare CA-EGD to S-EGD for complete examination of the MDP. METHODS: Prospective, randomized, blinded, controlled crossover study. Subjects scheduled for elective EGD were randomized to undergo S-EGD (group A) or CA-EGD (group B) before undergoing a second examination by the alternate method. Images of the MDP were evaluated by three blinded multicenter-experts. Our primary outcome measure was complete examination of the papilla. Secondary outcome measures were duration and overall diagnostic yield. RESULTS: A total of 101 patients were randomized and completed the study. Complete examination of MDP was achieved in 98 patients using CA-EGD compared to 24 patients using S-EGD (97 vs. 24%, P<0.001). Median duration from intubation of the esophagus until localization of the MDP was shorter with CA-EGD (46. vs. 96 s., P<0.001). In group A, 11 extra lesions and 12 additional incidental findings were detected by secondary CA-EGD, whereas neither were detected by secondary S-EGD in group B (22 vs. 0% and 24 vs. 0%, P<0.001 and P<0.001). CONCLUSION: CA-EGD enabled complete examination of MDP in almost all cases compared to a low success rate of S-EGD. CA-EGD detected a significant amount of lesions and incidental findings when added to S-EGD. CA-EGD is a safe and effective method for examination of MDP.

Sleep in hospitalized children and adolescents: A scoping review.

Hospitalized children and adolescents are at risk of short sleep and subsequent adverse health effects, but little is known about actual sleep duration, the factors that cause sleep disturbances in an inpatient pediatric setting, and what has been done to promote sleep in this population. The aim of this review was to systematically identify, categorize, and synthesize the literature on sleep in children and adolescents in an inpatient setting. We searched five electronic databases (PubMed, CENTRAL, CINAHL, PsycINFO, and Scopus) and of the 3770 references identified, 28 were eligible for inclusion. From studies reporting age-specific sleep durations, we found that four out of nineteen fell within the National Sleep Foundations recommendations for age-specific sleep durations. Reported causes of sleep disturbances were primarily related to modifiable, external factors, e.g., nursing care activities and noise from equipment and other patients. Sleep-promoting interventions seemed acceptable to patients, parents, and healthcare professionals. However, the literature in this area is heterogeneous regarding methodology, reporting, and population characteristics. Our findings underline the importance of prioritizing and optimizing sleep in hospitalized pediatric patients and highlight the need for standardization in the planning and reporting of studies within this field.

Carbohydrate malabsorption in patients with non-specific abdominal complaints.

Non-specific abdominal complaints are a considerable problem worldwide. Many patients are affected and many differential diagnoses have to be considered. Among these, carbohydrate malabsorption seems to play an important role. However, so far, only incomplete absorption of lactose is broadly accepted, while the malabsorption of fructose and sorbitol is still underestimated, although in many parts of the world it is much more frequent. Despite the success of dietary interventions in many patients, there are still a lot of unanswered questions that make further investigations necessary.

Long-term outcome and prognostic factors of patients with hilar cholangiocarcinoma.

AIM: To evaluate the long-term outcome and prognostic factors of patients with hilar cholangiocarinoma. METHODS: Ninety-six consecutive patients underwent treatment for malignant hilar bile duct tumors during 1995-2005. Of the 96 patients, 20 were initially treated with surgery (n = 2 R0 / n = 18 R1). In non-operated patients, data analysis was performed retrospectively. RESULTS: Among the 96 patients, 76 were treated with endoscopic transpapillary (ERC, n = 45) and/or percutaneous transhepatic biliary drainage (PTBD, n = 31). The mean survival time of these 76 patients undergoing palliative endoscopic and/or percutaneous drainage was 359 +/- 296 d. The mean survival time of patients with initial bilirubin levels > 10 mg/dL was significantly lower (P < 0.001) than patients with bilirubin levels < 10 mg/dL. The mean survival time of patients with Bismuth stage II (n = 8), III (n = 28) and IV (n = 40) was 496 +/- 300 d, 441 +/- 385 d and 274 +/- 218 d, respectively. Thus, patients with advanced Bismuth stage showed a reduced mean survival time, but the difference was not significant. The type of biliary drainage had no significant beneficial effect on the mean survival time (ERC vs PTBD, P = 0.806). CONCLUSION: Initial bilirubin level is a significant prognostic factor for survival of patients. In contrast, age, tumor stage according to the Bismuth-Corlette classification, and types of intervention are not significant prognostic parameters for survival. Palliative treatment with endoscopic or percutaneous biliary drainage is still suboptimal, new diagnostic and therapeutic tools need to be evaluated.

Carbohydrate malabsorption in clinical routine: a prospective observational study.

BACKGROUND/AIMS: Nonspecific abdominal symptoms are a serious problem throughout the world. Among the multitude of differential diagnoses in carbohydrate malabsorption, only incomplete absorption of lactose is mentioned, while malabsorption of fructose and sorbitol--which occurs much more often, at least in the Western world--is usually not included. METHODOLOGY: During a 6-month period, all patients (n=90; 33 males, median age 45 years, range 10-81; 57 females, median age 47 years, range 15-71) who consecutively presented for H2 exhalation tests were evaluated. In addition to the test results, data were obtained from the referring physicians and from the family doctors responsible for the patients' long-term treatment regarding the role of the test results in the treatment of the patients. Finally, the patients were also asked whether any improvement in their symptoms had followed from the test results. RESULTS: Lactulose tests were normal in only 63% of the patients. As with the other sugars, at least one form of malabsorption was detected in 47 patients (52%). The malabsorption rate was 34% after lactose, 61% after fructose, and 91% after the intake of sorbitol. The referring physicians evaluated the test results as having been important in 52% of the patients, while the family doctors considered that there was some benefit for the patients in 77% of the cases. The patients themselves reported an improvement in 75% of cases. CONCLUSIONS: These data again show that carbohydrate malabsorption is an important differential diagnosis in patients with nonspecific abdominal complaints. However, the data also make it clear that caution is advisable both in establishing the indication for the tests and in interpreting the results. Despite this, carbohydrate malabsorption appears to be an underestimated problem in a considerable number of patients.

Endoscopic treatment of an oesophageal rupture using an over-the-scope clip (OTSC): A case report.

Oesophageal rupture (Boerhaave syndrome) is a rare but serious complication after vomiting. Early intervention is mandatory in order to avoid a deleterious outcome for the patient. This case report describes the endoscopic approach using an over-the-scope clip.

Buried bumper--the endoscopic approach.

Buried bumper syndrome--ingrowth of the internal bumper of a percutaneous endoscopic gastrostomy (PEG) into the gastric wall--is one of the serious long-term complications of enteral nutrition using PEG systems. There are various endoscopic methods of managing the problem. We report here on a case successfully and rapidly treated with the method described by Müller-Gerbes et al., using a papillotome introduced over a guide wire.

[The plasma anion gap is a useful tool for evaluating children with metabolic acidosis]. / Udregning af anion gap hos børn med metabolisk acidose kan bidrage til diagnosen.

Metabolic acidosis occurs frequently in hospitalized children. The causes are many and often apparent from the history and physical examination. However, if the aetiology is unclear, the plasma anion gap is a useful tool for evaluating patients with metabolic acidosis. In this case report we describe two children in which the aetiology to the metabolic acidosis was unknown, one with normal anion gap who was diagnosed with renal tubular acidosis, and one with increased anion gap acidosis due to D-lactic acidosis.

Endoscopic stent therapy in patients with chronic pancreatitis: a 5-year follow-up study.

AIM: This study analyzed clinical long-term outcomes after endoscopic therapy, including the incidence and treatment of relapse. METHODS: This study included 19 consecutive patients (12 male, 7 female, median age 54 years) with obstructive chronic pancreatitis who were admitted to the 2(nd) Medical Department of the Technical University of Munich. All patients presented severe chronic pancreatitis (stage III°) according to the Cambridge classification. The majority of the patients suffered intermittent pain attacks. 6 of 19 patients had strictures of the pancreatic duct; 13 of 19 patients had strictures and stones. The first endoscopic retrograde pancreatography (ERP) included an endoscopic sphincterotomy, dilatation of the pancreatic duct, and stent placement. The first control ERP was performed 4 wk after the initial intervention, and the subsequent control ERP was performed after 3 mo to re-evaluate the clinical and morphological conditions. Clinical follow-up was performed annually to document the course of pain and the management of relapse. The course of pain was assessed by a pain scale from 0 to 10. The date and choice of the therapeutic procedure were documented in case of relapse. RESULTS: Initial endoscopic intervention was successfully completed in 17 of 19 patients. All 17 patients reported partial or complete pain relief after endoscopic intervention. Endoscopic therapy failed in 2 patients. Both patients were excluded from further analysis. One failed patient underwent surgery, and the other patient was treated conservatively with pain medication. Seventeen of 19 patients were followed after the successful completion of endoscopic stent therapy. Three of 17 patients were lost to follow-up. One patient was not available for interviews after the 1(st) year of follow-up. Two patients died during the 3(rd) year of follow-up. In both patients chronic pancreatitis was excluded as the cause of death. One patient died of myocardial infarction, and one patient succumbed to pneumonia. All three patients were excluded from follow-up analysis. Follow-up was successfully completed in 14 of 17 patients. 4 patients at time point 3, 2 patients at time point 4, 3 patients at time point 5 and 2 patients at time point 6 and time point 7 used continuous pain medication after endoscopic therapy. No relapse occurred in 57% (8/14) of patients. All 8 patients exhibited significantly reduced or no pain complaints during the 5-year follow-up. Seven of 8 patients were completely pain free 5 years after endoscopic therapy. Only 1 patient reported continuous moderate pain. In contrast, 7 relapses occurred in 6 of the 14 patients. Two relapses were observed during the 1(st) year, 2 relapses occurred during the 2(nd) year, one relapse was observed during the 3(rd) year, one relapse occurred during the 4(th) year, and one relapse occurred during the 5(th) follow-up year. Four of these six patients received conservative treatment with endoscopic therapy or analgesics. Relapse was conservatively treated using repeated stent therapy in 2 patients. Analgesic treatment was successful in the other 2 patients. CONCLUSION: 57% of patients exhibited long-term benefits after endoscopic therapy. Therefore, endoscopic therapy should be the treatment of choice in patients being inoperable or refusing surgical treatment.

The clinical impact of carbohydrate malabsorption.

Malabsorption of carbohydrates such as fructose, lactose or sorbitol can often be detected among patients suffering from so-called non specific abdominal complaints. Sometimes the differential diagnosis may be difficult. So far successful treatment consists of dietary interventions only. Nevertheless, many questions are remaining still unanswered.

Complications of percutaneous transhepatic biliary drainage in patients with dilated and nondilated intrahepatic bile ducts.

Percutaneous transhepatic biliary drainage (PTBD) have been described as an effective technique to obtain biliary access. Between January 1996 and December 2006, a total of 419 consecutive patients with endoscopically inaccessible bile ducts underwent PTBD. The current retrospective study evaluated success and complication rates of this invasive technique. PTBD was successful in 410/419 patients (97%). The success rate was equal in patients with dilated and nondilated bile ducts (p=0.820). In 39/419 patients (9%) procedure related complications could be observed. Major complications occurred in 17/419 patients (4%). Patients with nondilated intrahepatic bile ducts had significantly higher complication rates compared to patients with dilated intrahepatic bile ducts (14.5% vs. 6.9%, respectively [p=0.022]). Procedure related deaths were observed in 3 patients (0.7%). In conclusion, percutaneous transhepatic biliary drainage is an effective procedure in patients with dilated and nondilated intrahepatic bile ducts. However, patients with nondilated intrahepatic bile ducts showed a higher risk for procedure related complications.

Transpancreatic precut sphincterotomy for cannulation of inaccessible common bile duct: a safe and successful technique.

OBJECTIVE: Obstruction of the biliary tract can lead to severe complications. The common treatment of patients with biliary tract obstruction is the decompression by endoscopic procedures. However, cannulation of the common bile duct can be difficult under certain instances because of anatomical variations or obstruction at the biliary entrance level. Needle-knife or precut sphincterotomy has been described as technique to facilitate biliary access in patients with difficult bile duct cannulation. In the current study, we evaluated success and complication rates of a wire-guided transpancreatic precut technique at our hospital. METHODS: Between January 2003 and June 2006, a total of 108 patients with jaundice but with inaccessible bile ducts using classic techniques (failed primary cannulation or failed needle-knife papillotomy) underwent a wire-guided transpancreatic precut sphincterotomy. Precuts were performed using a soft guide wire placed in the pancreatic duct without injection of contrast fluid into the pancreatic duct. RESULTS: We studied cannulation success and complications associated with postprocedural hospitalization. Bile duct cannulation was successful in 103 (95.4%) of the 108 patients. Five patients (4.6%) required a percutaneous transhepatic biliary drainage. In 108 patients, there were 12 patients (11.1%) with procedure-related complications including acute pancreatitis (n = 6) and bleeding (n=6). Four patients had a mild and transient pancreatitis (pain improvement after 2 days), 2 had severe pancreatitis that was reversible after 7 days of conservative treatment. In 4 cases, a blood transfusion (each with 2 erythrocyte concentrates) became necessary. Perforations and other severe procedure-related deaths did not occur. CONCLUSIONS: Transpancreatic precut sphincterotomy using a soft guide wire is a safe and effective procedure in patients with difficult bile duct access where classic sphincterotomy or needle-knife procedures fail.

Endoscopic stent therapy for patients with chronic pancreatitis: results from a prospective follow-up study.

OBJECTIVES: Obstruction of the pancreatic duct is a common feature of chronic pancreatitis and often requires interventional therapy. The current prospective study investigated clinical success in 19 patients after initial endoscopic retrograde pancreaticography and relapse rates during a 2-year follow-up period. METHODS: Seventeen of 19 patients with chronic pancreatitis (stage III according to the Cambridge classification) were treated by sphincterotomy and stent insertion. Endoscopic retrograde pancreaticography failed in 2 patients. RESULTS: Strictures were cannulated, dilated, and stones were removed with a dormia basket in 13 of 17 patients. Extracorporeal shock wave lithotripsy was necessary in 5 patients. Polyethylene stents (7F-11.5F) were placed into the dilated pancreatic duct. Mean duration of internal pancreatic stenting was 5.6 months. Three of 17 patients had recurrence of pain during the first follow-up year after stent extraction; in the second follow-up year, another 2 patients had a relapse. Overall, patients' assessment of the stent therapy revealed complete satisfaction in 17 of 19 patients. CONCLUSIONS: Endoscopic stent therapy is a safe, minimally invasive, and effective procedure in patients experiencing pain attacks during chronic pancreatitis associated with dilated pancreatic duct. According to our results, a relapse rate of approximately 30% can be expected within 2 years after stent extraction. These patients may be treated by repeated stent therapy.

Endoscopic papillotomy, syn. sphincterotomy: results from the past two years.

Endoscopic papillotomy, introduced in 1973, is now an established endoscopic procedure for treatment of various diseases of the papilla, bile duct, and pancreas. This article describes the use of this technique, the various instruments that can be employed, the instances in which it is indicated, and its associated complications and risks. Alternative treatments are also summarized.

ERCP or EUS for tissue diagnosis of biliary strictures? A prospective comparative study.

BACKGROUND: The accuracy of ERCP-based brush cytology or forceps biopsy for tissue diagnosis is relatively low (usually not exceeding 70%). By contrast, reported accuracy rates for EUS-guided FNA of pancreatobiliary masses are over 80%. This prospective study compared these two modalities for the first time in the diagnosis of indeterminate biliary strictures and pancreatic tumors. METHODS: Fifty consecutive patients (29 men, 21 women; mean age 62.1 years) with obstructive jaundice in whom a tissue diagnosis was required were included. During ERCP, intraductal specimens were obtained with a forceps and with two different types of brush (conventional and spiral suction) in random order. During EUS, only visible mass lesions or localized bile duct wall thickening were aspirated (22-gauge needle), with at least two passes yielding material sufficient for assessment. A cytopathologist was not present in the procedure room to evaluate specimen adequacy. The reference methods were surgery, other biopsy results, follow-up until death, or the conclusion of the study (mean follow-up 20 months). RESULTS: The final diagnoses were malignancy, 28 (16 pancreatic, 12 biliary), and benign biliary stricture, 22. Sensitivity and specificity for ERCP-guided biopsy were 36% and 100%, respectively; for ERCP-guided cytology (when using conventional and spiral suction brushes), 46% and 100%, respectively; and for EUS-guided FNA, 43% and 100%, respectively. If the punctured lesions are considered (n=28) alone, the sensitivity of EUS-guided FNA was 75%. In general, sensitivity was better for ERCP-based techniques in the subgroup biliary tumor (ERCP 75% vs. EUS 25%), whereas EUS-guided biopsy was superior for pancreatic mass (EUS 60% vs. ERCP 38%). CONCLUSIONS: For biliary strictures, combined ERCP- and EUS-guided tissue acquisition seems to be the best approach to tissue diagnosis. From a clinical standpoint, it appears reasonable, when a tissue diagnosis is required, to start with ERCP if biliary malignancy is suspected and with EUS when a pancreatic tumor is thought to be the cause of a biliary stricture.