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BACKGROUND AND AIMS: No prior randomized controlled trial (RCT) has reported patient outcomes of large over-the-scope clip (OTSC) compared to standard hemostasis as initial endoscopic treatment of severe NVUGIB. This was our study aim. METHODS: Patients with bleeding ulcers or Dieulafoy's lesions and major stigmata of hemorrhage - SRH (active spurting bleeding, visible vessel, or clot) - or lesser SRH (oozing bleeding or flat spots - with arterial blood flow by Doppler probe) were randomized to OTSC or standard endoscopic hemostasis (with hemoclips or multipolar electrocoagulation - MPEC). Patients and their healthcare providers were blinded to treatments and made all post-randomization management decisions. Ulcer patients received high dose intravenous infusions of proton pump inhibitors (PPI) for 3 days, then 27 days of oral PPI. 30 day outcomes were prospectively recorded; data management was with SAS; and data analysis was by a statistician. RESULTS: 53 patients (25 OTSC, 28 Standard) were randomized, with similar baseline risk factors. However, there were significant differences in OTSC vs. Standard groups in rates of rebleeding (4% vs. 28.6%; p = .017; relative risk 0.10, 95% confidence intervals 0.01, 0.91; number needed to treat 4); severe complications (0 % vs. 14.3%); and post-randomization units of red cell transfusions (0.04 vs. 0.68). All rebleeds occurred in patients with major SRH and none with lesser SRH. CONCLUSION: 1. OTSC significantly reduced rates of rebleeding, severe complications, and post-randomization red cell transfusions. 2. Patients with major stigmata benefited significantly from hemostasis with OTSC, but those with lesser stigmata did not. (ClinicalTrials.gov, Number: NCT03065465).
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Hemostase Endoscópica , Hemorragia Gastrointestinal/terapia , Humanos , Inibidores da Bomba de Prótons , Instrumentos Cirúrgicos , Resultado do TratamentoRESUMO
INTRODUCTION: Esophageal cancer (EC) is an aggressive malignancy with poor prognosis. Mortality and disease stage at diagnosis are important indicators of improvements in cancer prevention and control. We examined United States trends in esophageal adenocarcinoma (EAC) and esophageal squamous cell carcinoma (ESCC) mortality and stage at diagnosis by race and ethnicity. METHODS: We used Surveillance, Epidemiology, and End Results (SEER) data to identify individuals with histologically confirmed EAC and ESCC between 1 January 1992 and 31 December 2016. For both EAC and ESCC, we calculated age-adjusted mortality and the proportion presenting at each stage by race/ethnicity, sex, and year. We then calculated the annual percent change (APC) in each indicator by race/ethnicity and examined changes over time. RESULTS: The study included 19,257 EAC cases and 15,162 ESCC cases. EAC mortality increased significantly overall and in non-Hispanic Whites from 1993 to 2012 and from 1993 to 2010, respectively. EAC mortality continued to rise among non-Hispanic Blacks (NHB) (APC = 1.60, p = 0.01). NHB experienced the fastest decline in ESCC mortality (APC = - 4.53, p < 0.001) yet maintained the highest mortality at the end of the study period. Proportions of late stage disease increased overall by 18.5 and 24.5 percentage points for EAC and ESCC respectively; trends varied by race/ethnicity. CONCLUSION: We found notable differences in trends in EAC and ESCC mortality and stage at diagnosis by race/ethnicity. Stage migration resulting from improvements in diagnosis and treatment may partially explain recent trends in disease stage at diagnosis. Future efforts should identify factors driving current esophageal cancer disparities.
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Adenocarcinoma/patologia , Neoplasias Esofágicas/patologia , Carcinoma de Células Escamosas do Esôfago/patologia , Adulto , Etnicidade , Feminino , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Incidência , Masculino , Estados UnidosRESUMO
OBJECTIVE: Recent studies show increased serum and esophageal IgG4 in patients with eosinophilic esophagitis (EoE), suggesting a possible IgG4-involved process. The role of IgG4 in pediatric EoE has not been extensively investigated. Our aim was to analyze IgG4 in esophageal tissue in children in parallel to that in adults with EoE. METHODS: In a retrospective institutional review board-approved study, we performed immunohistochemical staining of IgG4 in esophageal biopsy specimens from 39 subjects: children with EoE (nâ=â16), adults with EoE (nâ=â15), children with reflux esophagitis (nâ=â4), and pediatric controls (nâ=â4). We assessed the relationships between IgG4 staining and clinical, endoscopic, and histopathologic characteristics. RESULTS: Patients with EoE were significantly more likely to stain positively for IgG4 than children with reflux esophagitis or controls (Pâ=â0.015). Fifteen of 31 (48%) EoE cases stained positively for IgG4. None of the reflux esophagitis or control cases stained positively. IgG4 staining had 48% sensitivity and 100% specificity for EoE. There was a trend toward IgG4 staining being associated with foreign body/food impaction (Pâ=â0.153). There was a strong association between distal IgG4 staining and basal zone hyperplasia (Pâ=â0.003). CONCLUSIONS: Our study suggests IgG4 is not a consistent finding of EoE at disease diagnosis. Although IgG4 staining was specific for EoE, it had a poor sensitivity with positive staining in only 48% of EoE patients. Further studies are warranted to fully elucidate the role of IgG4 in EoE.
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Esofagite Eosinofílica/diagnóstico , Esofagite Péptica/diagnóstico , Esôfago/química , Imunoglobulina G/análise , Imuno-Histoquímica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Estudos de Casos e Controles , Criança , Esofagoscopia/estatística & dados numéricos , Esôfago/patologia , Feminino , Humanos , Imuno-Histoquímica/métodos , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estudos Retrospectivos , Sensibilidade e Especificidade , Adulto JovemRESUMO
BACKGROUND & AIMS: For 4 decades, stigmata of recent hemorrhage in patients with nonvariceal lesions have been used for risk stratification and endoscopic hemostasis. The arterial blood flow that underlies the stigmata rarely is monitored, but can be used to determine risk for rebleeding. We performed a randomized controlled trial to determine whether Doppler endoscopic probe monitoring of blood flow improves risk stratification and outcomes in patients with severe nonvariceal upper gastrointestinal hemorrhage. METHODS: In a single-blind study performed at 2 referral centers we assigned 148 patients with severe nonvariceal upper gastrointestinal bleeding (125 with ulcers, 19 with Dieulafoy's lesions, and 4 with Mallory Weiss tears) to groups that underwent standard, visually guided endoscopic hemostasis (control, n = 76), or endoscopic hemostasis assisted by Doppler monitoring of blood flow under the stigmata (n = 72). The primary outcome was the rate of rebleeding after 30 days; secondary outcomes were complications, death, and need for transfusions, surgery, or angiography. RESULTS: There was a significant difference in the rates of lesion rebleeding within 30 days of endoscopic hemostasis in the control group (26.3%) vs the Doppler group (11.1%) (P = .0214). The odds ratio for rebleeding with Doppler monitoring was 0.35 (95% confidence interval, 0.143-0.8565) and the number needed to treat was 7. CONCLUSIONS: In a randomized controlled trial of patients with severe upper gastrointestinal hemorrhage from ulcers or other lesions, Doppler probe guided endoscopic hemostasis significantly reduced 30-day rates of rebleeding compared with standard, visually guided hemostasis. Guidelines for nonvariceal gastrointestinal bleeding should incorporate these results. ClinicalTrials.gov no: NCT00732212 (CLIN-013-07F).
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Endossonografia , Hemostase Endoscópica/métodos , Síndrome de Mallory-Weiss/terapia , Úlcera Péptica Hemorrágica/terapia , Ultrassonografia Doppler , Malformações Vasculares/terapia , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Síndrome de Mallory-Weiss/diagnóstico por imagem , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/diagnóstico por imagem , Recidiva , Fluxo Sanguíneo Regional , Medição de Risco/métodos , Índice de Gravidade de Doença , Método Simples-Cego , Resultado do Tratamento , Malformações Vasculares/diagnóstico por imagemRESUMO
PURPOSE OF REVIEW: There has been a decline in mortality associated with upper gastrointestinal (UGI) hemorrhage as the use of urgent endoscopy has increased. This review will examine endoscopic risk stratification of non-variceal UGI bleeding (e.g., ulcers, Dieulafoy lesions, and Mallory-Weiss tears), including the use of the Doppler endoscopic probe (DEP). RECENT FINDINGS: Prospective studies evaluating the use of DEP in non-variceal UGI hemorrhage showed that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared to those with intermediate-risk SRH. Additionally, lesions with a persistently positive DEP signal after endoscopic hemostasis were seen with high-risk SRH and had a higher 30-day rebleeding rate. Residual arterial blood flow underneath ulcers is a significant risk factor for rebleeding. However, if more endoscopic treatment is applied, clinical outcomes for patients with severe non-variceal UGI hemorrhage are improved, as documented by a recent CURE Hemostasis randomized controlled trial (RCT).
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Hemorragia Gastrointestinal/terapia , Trato Gastrointestinal/irrigação sanguínea , Endoscopia Gastrointestinal/métodos , Endossonografia/métodos , Hemorragia Gastrointestinal/diagnóstico , Hemostase Endoscópica/métodos , Humanos , Fluxo Sanguíneo Regional , Medição de Risco/métodosRESUMO
BACKGROUND AND AIMS: Few prospective reports describe the short-term natural history of colon diverticular hemorrhage based on stigmata of recent hemorrhage, and none include blood flow detection for risk stratification or as a guide to definitive hemostasis. Our purposes were to report the 30-day natural history of definitive diverticular hemorrhage based on stigmata and to describe Doppler probe blood flow detection as a guide to definitive hemostasis. METHODS: Different cohorts of patients with severe diverticular bleeding and stigmata on urgent colonoscopy are reported. For 30-day natural history, patients were treated medically. If severe rebleeding occurred, they had surgical or angiographic treatment. We report natural history with major stigmata (active bleeding, visible vessel, or adherent clot) and no stigmata or flat spots after clots were washed away. We also report Doppler probe detection of arterial blood flow underneath stigmata before and after hemostasis in a recent cohort. RESULTS: For natural history, patients with major stigmata treated medically had 65.8% (25/38) rebleeding rates, and 44.7% (17/38) had intervention for hemostasis. Patients with spots or clean bases had no rebleeding. A Doppler probe detected arterial blood flow in 92% of major stigmata--none after hemostasis--and there was no rebleeding. CONCLUSIONS: (1) Patients with major stigmata treated medically had high rates of rebleeding and intervention for hemostasis. (2) Patients with clean diverticula or only flat spots had no rebleeding. (3) High rates of arterial blood flow were detected under major stigmata with a Doppler probe, but with obliteration by hemostasis no rebleeding occurred.
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Colonoscopia/métodos , Divertículo do Colo/complicações , Endossonografia/métodos , Hemorragia Gastrointestinal/etiologia , Monitorização Fisiológica/métodos , Fluxo Sanguíneo Regional/fisiologia , Ultrassonografia Doppler em Cores/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Divertículo do Colo/diagnóstico por imagem , Divertículo do Colo/fisiopatologia , Feminino , Seguimentos , Hemorragia Gastrointestinal/diagnóstico por imagem , Hemorragia Gastrointestinal/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , RecidivaRESUMO
BACKGROUND AND AIMS: For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB). METHODS: Prospective cohort study of 163 consecutive patients with severe PUB and different SRH. RESULTS: All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05). CONCLUSIONS: (1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.
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Úlcera Duodenal/diagnóstico , Duodeno/irrigação sanguínea , Fluxometria por Laser-Doppler/métodos , Úlcera Péptica Hemorrágica/diagnóstico , Úlcera Gástrica/diagnóstico , Estômago/irrigação sanguínea , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Úlcera Duodenal/cirurgia , Endoscopia do Sistema Digestório/métodos , Feminino , Hemostase Endoscópica/métodos , Humanos , Pessoa de Meia-Idade , Úlcera Péptica Hemorrágica/cirurgia , Estudos Prospectivos , Recidiva , Medição de Risco , Índice de Gravidade de Doença , Úlcera Gástrica/cirurgiaRESUMO
BACKGROUND AND AIMS: Improved medical decisions by using a score at the initial patient triage level may lead to improvements in patient management, outcomes, and resource utilization. There is no validated score for management of lower gastrointestinal bleeding (LGIB) unlike for upper gastrointestinal bleeding. The aim of our study was to compare the accuracies of 3 different prognostic scores [Center for Ulcer Research and Education Hemostasis prognosis score, Charlson index, and American Society of Anesthesiologists (ASA) score] for the prediction of 30-day rebleeding, surgery, and death in severe LGIB. METHODS: Data on consecutive patients hospitalized with severe gastrointestinal bleeding from January 2006 to October 2011 in our 2 tertiary academic referral centers were prospectively collected. Sensitivities, specificities, accuracies, and area under the receiver operator characteristic curve were computed for 3 scores for predictions of rebleeding, surgery, and mortality at 30 days. RESULTS: Two hundred thirty-five consecutive patients with LGIB were included between 2006 and 2011. Twenty-three percent of patients rebled, 6% had surgery, and 7.7% of patients died. The accuracies of each score never reached 70% for predicting rebleeding or surgery in either. The ASA score had a highest accuracy for predicting mortality within 30 days (83.5%), whereas the Center for Ulcer Research and Education Hemostasis prognosis score and the Charlson index both had accuracies <75% for the prediction of death within 30 days. CONCLUSIONS: ASA score could be useful to predict death within 30 days. However, a new score is still warranted to predict all 30 days outcomes (rebleeding, surgery, and death) in LGIB.
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Hemorragia Gastrointestinal/terapia , Hospitalização , Avaliação de Resultados da Assistência ao Paciente , Idoso , Idoso de 80 Anos ou mais , Feminino , Hemorragia Gastrointestinal/mortalidade , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Prospectivos , Curva ROC , Fatores de Risco , Sensibilidade e Especificidade , Índice de Gravidade de Doença , Centros de Atenção Terciária , Resultado do TratamentoRESUMO
BACKGROUND: The sites of origin, causes and outcomes of severe hematochezia have not been compared between cirrhotics and non-cirrhotics. In cirrhotics versus non-cirrhotics presenting with severe hematochezia, we aimed at (1) identifying the site and etiology of gastro-intestinal bleeding and independent predictors of bleeding from the upper gastrointestinal tract versus small bowel or the colon, (2) comparing 30-day clinical outcomes, and (3) proposing an algorithm for management of severe hematochezia. METHODS: In this cohort study from two university-based medical centers, 860 consecutive patients with severe hematochezia admitted from 1995 to 2011 were prospectively enrolled with 160 (18.6 %) cirrhotics. We studied (a) general clinical and laboratory characteristics of cirrhotics versus non-cirrhotics, (b) predictors of bleeding sites in each patient group by multiple variable regression analysis, and compared (c) 30-day outcomes, including rebleeding, surgery and deaths. RESULTS: Cirrhosis independently predicted an upper gastrointestinal source of bleeding (OR 3.47; 95 % CI 2.01-5.96) as well as history of hematemesis, melena in the past 30 days, positive nasogastric aspirate, prior upper gastrointestinal bleeding or use of aspirin or non-steroidal anti-inflammatory. The most prevalent diagnoses were esophageal varices (20 %) in cirrhotics and colon diverticular bleeding (27.1 %) in non-cirrhotics. Thirty-day rates of rebleeding, surgical interventions and deaths were 23.1 versus 15 % (P = 0.01), 14.4 versus 6.4 % (P < 0.001), and 17.5 versus 4.1 % (P < 0.001), in cirrhotics versus non-cirrhotics, respectively. CONCLUSIONS: Cirrhosis predicted an upper gastrointestinal site of bleeding in patients presenting with severe hematochezia. The 30-day rates of rebleeding, surgery, and death were significantly higher in cirrhotics than in non-cirrhotics.
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Doenças do Colo/epidemiologia , Doenças do Esôfago/epidemiologia , Hemorragia Gastrointestinal/epidemiologia , Cirrose Hepática/epidemiologia , Úlcera Péptica Hemorrágica/epidemiologia , Gastropatias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Angiodisplasia/complicações , Aspirina/uso terapêutico , Transfusão de Componentes Sanguíneos , California/epidemiologia , Estudos de Casos e Controles , Estudos de Coortes , Colite Isquêmica/complicações , Doenças do Colo/etiologia , Doenças do Colo/terapia , Diverticulite/complicações , Transfusão de Eritrócitos , Doenças do Esôfago/etiologia , Doenças do Esôfago/terapia , Varizes Esofágicas e Gástricas/complicações , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/terapia , Hematemese/epidemiologia , Hematócrito , Hemorroidas/complicações , Humanos , Intestino Delgado , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Tempo de Tromboplastina Parcial , Úlcera Péptica Hemorrágica/etiologia , Úlcera Péptica Hemorrágica/terapia , Plasma , Inibidores da Agregação Plaquetária/uso terapêutico , Contagem de Plaquetas , Transfusão de Plaquetas , Estudos Retrospectivos , Fatores de Risco , Gastropatias/terapia , Úlcera/complicaçõesRESUMO
Gastrointestinal (GI) bleeding from the colon is a common reason for hospitalization and is becoming more common in the elderly. While most cases will cease spontaneously, patients with ongoing bleeding or major stigmata of hemorrhage require urgent diagnosis and intervention to achieve definitive hemostasis. Colonoscopy is the primary modality for establishing a diagnosis, risk stratification, and treating some of the most common causes of colonic bleeding, including diverticular hemorrhage which is the etiology in 30% of cases. Other interventions, including angiography and surgery, are usually reserved for instances of bleeding that cannot be stabilized or allow for adequate bowel preparation for colonoscopy. We discuss the colonoscopic diagnosis, risk stratification, and definitive treatment of colonic hemorrhage in patients presenting with severe hematochezia.
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Doenças do Colo/terapia , Hemorragia Gastrointestinal/terapia , Doenças do Colo/epidemiologia , Doenças do Colo/etiologia , Colonoscopia/métodos , Diagnóstico Diferencial , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/etiologia , Técnicas Hemostáticas , HumanosRESUMO
OBJECTIVES: Low-value esophagogastroduodenoscopies (EGDs) for uncomplicated gastro-oesophageal reflux disease (GERD) can harm patients and raise patient and payer costs. We developed an electronic health record (EHR) 'eMeasure' to detect low-value EGDs. DESIGN: Retrospective cohort of 518 adult patients diagnosed with GERD who underwent initial EGD between 1 January 2019 and 31 December 2019. SETTING: Outpatient primary care and gastroenterology clinics at a large, urban, academic health centre. PARTICIPANTS: Adult primary care patients at the University of California Los Angeles who underwent initial EGD for GERD in 2019. MAIN OUTCOME MEASURES: EGD appropriateness criteria were based on the American College of Gastroenterology 2012 guidelines. An initial EGD was considered low-value if it lacked a documented guideline-based indication, including alarm symptoms (eg, iron-deficiency anaemia); failure of an 8-week proton pump inhibitor trial or elevated Barrett's oesophagus risk. We performed manual chart review on a random sample of 204 patients as a gold standard of the eMeasure's validity. We estimated EGD costs using Medicare physician and facility fee rates. RESULTS: Among 518 initial EGDs performed (mean age 53 years; 54% female), the eMeasure identified 81 (16%) as low-value. The eMeasure's sensitivity was 42% (95% CI 22 to 61) and specificity was 93% (95% CI 89 to 96). Stratifying across clinics, 62 (74.6%) low-value EGDs originated from 2 (12.5%) out of 16 clinics. Total cost for 81 low-value EGDs was approximately US$75 573, including US$14 985 in patients' out-of-pocket costs. CONCLUSIONS: We developed a highly specific eMeasure that showed that low-value EGDs occurred frequently in our healthcare system and were concentrated in a minority of clinics. These results can inform future QI efforts at our institution, such as best practice alerts for the ordering physician. Moreover, this open-source eMeasure has a much broader potential impact, as it can be integrated into any EHR and improve medical decision-making at the point of care.
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Registros Eletrônicos de Saúde , Refluxo Gastroesofágico , Adulto , Humanos , Feminino , Idoso , Estados Unidos , Pessoa de Meia-Idade , Masculino , Estudos Retrospectivos , Medicare , Refluxo Gastroesofágico/diagnóstico , Refluxo Gastroesofágico/complicações , Endoscopia do Sistema Digestório/métodosRESUMO
PURPOSE: The Next Accreditation System requires training programs to demonstrate competence among trainees. Within gastroenterology (GI), there are limited data describing learning curves and structured assessment of competence in esophagogastroduodenoscopy (EGD) and colonoscopy. In this study, the authors aimed to demonstrate the feasibility of a centralized feedback system to assess endoscopy learning curves among GI trainees in EGD and colonoscopy. METHOD: During academic year 2016-2017, the authors performed a prospective multicenter cohort study, inviting participants from multiple GI training programs. Trainee technical and cognitive skills were assessed using a validated competence assessment tool. An integrated, comprehensive data collection and reporting system was created to apply cumulative sum analysis to generate learning curves that were shared with program directors and trainees on a quarterly basis. RESULTS: Out of 183 fellowships invited, 129 trainees from 12 GI fellowships participated, with an overall trainee participation rate of 72.1% (93/129); the highest participation level was among first-year trainees (90.9%; 80/88), and the lowest was among third-year trainees (51.2%; 27/53). In all, 1,385 EGDs and 1,293 colonoscopies were assessed. On aggregate learning curve analysis, third-year trainees achieved competence in overall technical and cognitive skills, while first- and second-year trainees demonstrated the need for ongoing supervision and training in the majority of technical and cognitive skills. CONCLUSIONS: This study demonstrated the feasibility of using a centralized feedback system for the evaluation and documentation of trainee performance in EGD and colonoscopy. Furthermore, third-year trainees achieved competence in both endoscopic procedures, validating the effectiveness of current training programs.
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Colonoscopia/educação , Endoscopia do Sistema Digestório/educação , Gastroenterologia/educação , Acreditação , Competência Clínica , Estudos de Viabilidade , Feminino , Humanos , Curva de Aprendizado , Masculino , Avaliação de Programas e Projetos de Saúde , Estudos ProspectivosRESUMO
Upper gastrointestinal bleeding from peptic ulcer disease is a common clinical event, resulting in considerable patient morbidity and significant health care costs. Inhibiting gastric acid secretion is a key component in improving clinical outcomes, including reducing rebleeding, transfusion requirements, and surgery. Raising intragastric pH promotes clot stability and reduces the influences of gastric acid and pepsin. Patients with high-risk stigmata for ulcer bleeding (arterial bleeding, nonbleeding visible vessels, and adherent clots) benefit significantly from and should receive high-dose intravenous proton pump inhibitors (PPIs) after successful endoscopic hemostasis. For patients with low-risk stigmata (flat spots or clean ulcer base), oral PPI therapy alone is sufficient. For oozing bleeding (an intermediate risk finding), successful endoscopic hemostasis and oral PPI are recommended. Using intravenous PPIs before endoscopy appears to reduce the frequency of finding high-risk stigmata on later endoscopy, but has not been shown to improve clinical outcomes. High-dose oral PPIs may be as effective as intravenous infusion in achieving positive clinical outcomes, but this has not been documented by randomized studies and its cost-effectiveness is unclear.
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Úlcera Péptica Hemorrágica/tratamento farmacológico , Inibidores da Bomba de Prótons/administração & dosagem , Ácido Gástrico/metabolismo , Hemostase Endoscópica , Antagonistas dos Receptores H2 da Histamina/administração & dosagem , Humanos , Úlcera Péptica Hemorrágica/terapia , Resultado do TratamentoRESUMO
This article examines use of the Doppler endoscopic probe (DEP) for risk stratification and as a guide to definitive hemostasis of nonvariceal upper gastrointestinal (NVUGI) bleeding and colonic diverticular hemorrhage. Studies report that lesions with high-risk stigmata of recent hemorrhage (SRH) have a higher rate of a positive DEP signal compared with those without such SRH. Lesions with a persistently positive DEP signal after endoscopic hemostasis have a higher 30-day rebleeding rate. Studies document arterial blood flow underneath stigmata of recent hemorrhage as a risk factor for rebleeding of focal nonvariceal gastrointestinal lesions. With DEP probe as a guide, rates of definitive endoscopic hemostasis and clinical outcomes are improved compared with standard visually guided treatment.
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Endossonografia/métodos , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/métodos , Ultrassonografia Doppler/métodos , Endossonografia/instrumentação , Trato Gastrointestinal/diagnóstico por imagem , Hemostase Endoscópica/instrumentação , Humanos , Ultrassonografia Doppler/instrumentaçãoRESUMO
BACKGROUND: To evaluate roles of intraoperative endoscopy (IOE) in management of severe obscure GI bleeding (OGIB) before vs. after introduction of video capsule endoscopy (VCE) and deep enteroscopy (DE). METHODS: We retrospectively reviewed prospectively collected data of patients undergoing IOE for severe OGIB in a tertiary referral center. RESULTS: 52 patients had laparotomy/IOE for OGIB, 11 pre and 41 post VCE/DE eras. In the pre VCE/DE era, 36.4% (4/11) had preoperative presumptive diagnoses while in the post VCE/DE era presumptive diagnoses were made in 48.8% (20/41) (p = 0.18). Preoperative evaluation led to correct diagnoses in 18.2% (2/11) in the pre and 51.2% (21/41) in the post VCE/DE era (p = 0.09). Vascular lesions and ulcers were the most common diagnoses, but rebleeding was common. No rebleeding was found among patients with tumors, Meckel's diverticulum, and aortoenteric fistula. CONCLUSIONS: Presumptive diagnoses in the post VCE/DE era were usually accurate. If VCE or DE are negative, the probability of negative IOE is high. Patients with tumors and Meckel's diverticulum were the best candidates for IOE.
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Endoscopia Gastrointestinal/métodos , Hemorragia Gastrointestinal/cirurgia , Hemostase Endoscópica/métodos , Cuidados Intraoperatórios/métodos , Endoscopia por Cápsula , Feminino , Hemorragia Gastrointestinal/diagnóstico , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Resultado do TratamentoRESUMO
The voltage gated sodium channel SCN4A mutations account for non-dystrophic myotonia and include a heterogeneous group of conditions that include hyperkalemic periodic paralysis, paramyotonica congenita, potassium-aggravated myotonia, and hypokalemic periodic paralysis type 2. This case report proposes that a rare variant p.Pro1629Leu in SCN4A can cause a skeletal muscle deficit with intermittent dysphagia.
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Transtornos de Deglutição/genética , Mutação de Sentido Incorreto , Miotonia/genética , Canal de Sódio Disparado por Voltagem NAV1.4/genética , Transtornos de Deglutição/diagnóstico , Feminino , Humanos , Pessoa de Meia-Idade , Músculo Esquelético/metabolismo , Músculo Esquelético/fisiopatologia , Miotonia/diagnóstico , Potássio/metabolismo , SíndromeRESUMO
INTRODUCTION: The role of EUS-guided FNA as a highly sensitive modality in the diagnosis of pancreatic adenocarcinoma is well documented. However, there is little published data on the role of EUS-FNA in diagnosing pancreatic neuroendocrine tumors (NETs). OBJECTIVE: The aim of this study is to compare the sensitivity of EUS-FNA to that of CT-FNA for diagnosing pancreatic NETs. METHODS: This is a single institution retrospective analysis of the operating characteristics of EUS-FNA and CT-FNA in detecting pancreatic NETs. Only patients with a final diagnosis of pancreatic NET were selected for this study. Procedure related data, including tumor size and location, and presence of a cytotechnologist were recorded. The results of each FNA were compared to the final clinico-pathological diagnosis to calculate sensitivity. RESULTS: Twenty-eight patients undergoing FNA (19 by EUS, 9 by CT) were analyzed. NETs diagnosed by EUS-FNA were smaller compared with CT-FNA (2.7 ± 0.9cm vs. 6.5 ± 2.1cm, p = 0.009) and were more often found in the pancreatic head (47.4% vs. 11.1%, p = 0.035). There were no significant differences in sensitivity between EUS-FNA and CT-FNA specimens (73.7% vs. 88.9%, p = 0.33). CONCLUSION: EUS-guided FNA is as sensitive as CT-guided FNA in diagnosing pancreatic NETs, but its main advantage is in the diagnosis of smaller pancreatic NETs in the head of the pancreas. It may also be the preferred approach in the diagnosis of multifocal pancreatic NETs in the setting of MEN I Syndrome.
RESUMO
With mortality due to gastrointestinal (GI) bleeding remaining stable, the focus on endoscopic hemostasis has been on improving other outcomes such as rebleeding rate, need for transfusions, and need for angiographic embolization or surgery. Over the past few years, a number of devices have emerged to help endoscopically assess and treat bleeding GI lesions. These include the Doppler endoscopic probe, hemostatic powder, and over-the-scope clip. Also, new applications have been described for radiofrequency ablation. In this article, we will discuss these evolving tools and techniques that have been developed, including an analysis of their efficacy and limitations.
Assuntos
Ablação por Cateter , Endoscopia Gastrointestinal/métodos , Hemorragia Gastrointestinal/terapia , Hemostase Endoscópica/métodos , Hemostáticos/administração & dosagem , Ablação por Cateter/efeitos adversos , Ablação por Cateter/instrumentação , Ablação por Cateter/mortalidade , Endoscópios Gastrointestinais , Endoscopia Gastrointestinal/efeitos adversos , Endoscopia Gastrointestinal/instrumentação , Endoscopia Gastrointestinal/mortalidade , Desenho de Equipamento , Hemorragia Gastrointestinal/diagnóstico , Hemorragia Gastrointestinal/mortalidade , Hemostase Endoscópica/efeitos adversos , Hemostase Endoscópica/instrumentação , Hemostase Endoscópica/mortalidade , Hemostáticos/efeitos adversos , Humanos , Fatores de Risco , Resultado do TratamentoRESUMO
RATIONALE: Consideration of lung transplantation in patients with systemic sclerosis (SSc) remains guarded, often due to the concern for esophageal dysfunction and the associated potential for allograft injury and suboptimal post-lung transplantation outcomes. OBJECTIVES: The purpose of this study was to systematically report our single-center experience regarding lung transplantation in the setting of SSc, with a particular focus on esophageal dysfunction. METHODS: We retrospectively reviewed all lung transplants at our center from January 1, 2000 through August 31, 2012 (n = 562), comparing the SSc group (n = 35) to the following lung transplant diagnostic subsets: all non-SSc (n = 527), non-SSc diffuse fibrotic lung disease (n = 264), and a non-SSc matched group (n = 109). We evaluated post-lung transplant outcomes, including survival, primary graft dysfunction, acute rejection, bronchiolitis obliterans syndrome, and microbiology of respiratory isolates. In addition, we defined severe esophageal dysfunction using esophageal manometry and esophageal morphometry criteria on the basis of chest computed tomography images. For patients with SSc referred for lung transplant but subsequently denied (n = 36), we queried the reason(s) for denial with respect to the concern for esophageal dysfunction. MEASUREMENTS AND MAIN RESULTS: The 1-, 3-, and 5-year post-lung transplant survival for SSc was 94, 77, and 70%, respectively, and similar to the other groups. The remaining post-lung transplant outcomes evaluated were also similar between SSc and the other groups. Approximately 60% of the SSc group had severe esophageal dysfunction. Pre-lung transplant chest computed tomography imaging demonstrated significantly abnormal esophageal morphometry for SSc when compared with the matched group. Importantly, esophageal dysfunction was the sole reason for lung transplant denial in a single case. CONCLUSIONS: Relative to other lung transplant indications, our SSc group experienced comparable survival, primary graft dysfunction, acute rejection, bronchiolitis obliterans syndrome, and microbiology of respiratory isolates, despite the high prevalence of severe esophageal dysfunction. Esophageal dysfunction rarely precluded active listing for lung transplantation.