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BACKGROUND: It is essential to accurately distinguish small benign hyperplastic colon polyps (HP) from sessile serrated lesions (SSL) or adenomatous polyps (TA) based on endoscopic appearances. Our objective was to determine the accuracy and inter-observer agreements for the endoscopic diagnosis of small polyps. METHODS: High-quality endoscopic images of 30 small HPs, SSLs, and TAs were used randomly to create two-timed PowerPoint slide sets-one with and another one without information on polyp size and location. Seven endoscopists viewed the slides on two separate occasions 90 days apart, identified the polyp type, and graded their confidence level. Overall and polyp-specific accuracies were assessed for the group and individual endoscopists. Chi-square tests and Kappa (κ) statistics were used to compare differences as appropriate. RESULTS: When polyp size and location were provided, overall accuracy was 67.1% for TAs, 50.0% for SSLs, and 41.4% for HPs; the corresponding accuracies were 60%, 44.3%, and 34.3% when polyp size and location were withheld (p < .001). Inter-observer agreement was moderate for TAs (κ = 0.50) and fair for SSLs (κ = 0.26) and HPs (κ = 0.29); the corresponding inter-observer agreements were 0.44, 0.31, and 0.17 with polyp size and location withheld. Accuracy was not affected by knowledge of polyp size, location, or confidence level. Endoscopists with ≥ 10 years (vs. < 10 years) of colonoscopy experience had marginally higher (56% vs. 40%, p = 0.05) accuracy for SSL diagnosis. CONCLUSIONS: The ability to distinguish between small TAs, SSLs, and HPs on their endoscopic appearance is poor regardless of the endoscopists' knowledge of polyp size and location.
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Adenoma , Pólipos del Colon , Neoplasias Colorrectales , Humanos , Pólipos del Colon/diagnóstico , Neoplasias Colorrectales/diagnóstico , Variaciones Dependientes del Observador , Adenoma/diagnóstico , Colonoscopía/métodosRESUMEN
BACKGROUND: Dysregulated adipose tissue metabolism has been implicated in the pathogenesis of alcoholic liver disease in murine models. We aimed to characterize serum markers of adipose tissue metabolism and inflammation in patients with severe acute alcoholic hepatitis (AAH) and determine their utility to predict survival in severe AAH. METHODS: A prospective, case-control study design was used. Seventy-six patients hospitalized with severe AAH and 25 ambulatory patients with alcoholic cirrhosis as controls were included. Serum samples were collected for biochemical analyses. Patients were followed for 180 days after enrollment to determine the survival. RESULTS: AAH patients exhibited higher serum glycerol and free fatty acid levels, suggesting enhanced adipose tissue triglyceride hydrolysis. Patients with AAH demonstrated a distinct serum lipidomic profile compared with alcoholic cirrhosis but not in systemic and adipose-specific insulin resistance. AAH patients had higher serum resistin and plasmin activation inhibitor-1 levels, while serum leptin was decreased. Serum levels of the prolipolytic cytokines tumor necrosis factor-α (TNF-α), interleukin (IL)-6, IL-8, and IL-15 were significantly higher in AAH patients. Only 53% of AAH patients survived 180 days after admission, while all cirrhotic patients were alive at the end of the study period. Among patients with severe AAH, white blood cell count, hemoglobin, resistin, IL-6 and TNF-α were associated with 180-day survival, and all 5 markers demonstrated accuracy by area under receiver-operator curve analysis. Serum IL-6 levels ≥38.66 pg/ml most precisely identified deaths in severe AAH. Patients with IL-6 ≥ 38.66 pg/ml had significantly decreased mean survival compared to those with lower levels. CONCLUSIONS: AAH patients demonstrate evidence of increased adipose tissue lipolysis and altered serum lipidomic profile compared with alcoholic cirrhosis patients. IL-6 may be a useful biomarker to risk stratify severe AAH patients at the highest risk of mortality.
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Adipoquinas/sangre , Citocinas/sangre , Hepatitis Alcohólica/sangre , Hepatitis Alcohólica/mortalidad , Índice de Severidad de la Enfermedad , Enfermedad Aguda , Adulto , Biomarcadores/sangre , Estudios de Casos y Controles , Femenino , Hepatitis Alcohólica/diagnóstico , Humanos , Masculino , Persona de Mediana Edad , Mortalidad/tendencias , Estudios Prospectivos , Factores de RiesgoAsunto(s)
Colestasis/etiología , Neoplasias Duodenales/complicaciones , Ictericia Obstructiva/etiología , Lipoma/complicaciones , Neoplasias Gástricas/complicaciones , Anciano , Colangiopancreatografia Retrógrada Endoscópica/instrumentación , Colestasis/diagnóstico por imagen , Colestasis/patología , Colestasis/terapia , Neoplasias Duodenales/diagnóstico por imagen , Neoplasias Duodenales/patología , Biopsia por Aspiración con Aguja Fina Guiada por Ultrasonido Endoscópico , Endosonografía , Humanos , Ictericia Obstructiva/diagnóstico por imagen , Ictericia Obstructiva/patología , Ictericia Obstructiva/terapia , Lipoma/diagnóstico por imagen , Lipoma/patología , Masculino , Stents , Neoplasias Gástricas/diagnóstico por imagen , Neoplasias Gástricas/patología , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
Video 1This video details our case as well as our method for successfully eradicating varices immediately prior to esophageal endoscopic submucosal dissection to minimize risks of variceal hemorrhage.
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Video 1Submucosal nodule in the cecum. After submucosal injection, a circumferential incision of the mucosa surrounding the lesion is performed with DualKnife (Olympus America, Center Valley, Pa, USA). The fore-balloon of the double-balloon endoluminal interventional platform (DBEIP) is deployed and the edges of the circumferential incision are attached with 2 endoscopic clips to the long suture-loop mounted on the fore-balloon of the DBEIP. The fore-balloon is retracted in anal direction, pulling the lesion into the cecum. Careful endoscopic submucosal dissection is performed with DualKnife and HookKnife (Olympus America). Dissection is markedly facilitated by traction and continued until the entire appendix is pulled into the cecum. The tip of the appendix is separated from surrounding tissues, resulting in a full-thickness cecal wall defect. The suture-loop holding the resected appendix is cut with LoopCutter (Olympus America). The resected appendix is removed through DBEIP and the Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, Tex, USA) is advanced into the cecum. The full-thickness defect in the cecal wall is completely closed with 2 continuous sutures. The final view demonstrates the entire resected appendix.
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Pancreatic pseudocysts are often drained endoscopically after 4-6 weeks of maturation. Allowing for developed encapsulation ensures that the cyst walls are strong enough to sustain drainage. However, in 3%-5% of these cases, pseudocysts will rupture spontaneously and put patients at risk of peritonitis. We present the first documented case of pancreatic pseudocyst rupture after upper endoscopy. Exploratory laparotomy confirmed the absence of viscus perforation and highlighted the danger of any procedure that increases intra-abdominal pressure in a patient with a pancreatic pseudocyst. Awareness of this complication should impact our decision when considering endoscopy in patients with pancreatic pseudocysts.
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Colon/patología , Neoplasias del Colon/diagnóstico , Neoplasias del Colon/secundario , Granuloma de Células Plasmáticas/diagnóstico , Granuloma de Células Plasmáticas/patología , Inmunoglobulina G/inmunología , Neoplasias del Colon/patología , Diagnóstico Diferencial , Humanos , Inmunohistoquímica , Hígado/patología , Masculino , Persona de Mediana Edad , Radiografía Abdominal , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: Autoimmune pancreatitis (AIP) is increasingly recognized as a form of chronic pancreatitis. Systematic evaluation and management of AIP in the United States is reported only from one center. Our aim was to review the evaluation and management of AIP at a large tertiary center. METHODS: We retrospectively reviewed information on demographics, clinical presentation, laboratory and imaging findings, extrapancreatic involvement, treatment response, and recurrence in 26 patients with AIP treated at the University of Pittsburgh Medical Center from 1998 to 2007. RESULTS: The median age at presentation was 62.5 years (range: 23-86), 65% were men, and 88% were Caucasians. The most common presentation included new-onset mild abdominal pain (65%), jaundice (62%), and weight loss (42%). Pancreatic mass, enlargement, or prominence on imaging was present in 85% of the patients. Serum IgG4 (immunoglobulin-4) was elevated (>140 mg/dl) in 44% (8/18) at presentation. The most common extrapancreatic finding was extrapancreatic/intrahepatic biliary strictures (35%). Peri-pancreatic vascular complications were noted in 23% of the patients. Six patients underwent partial or complete pancreatectomy. Partial or complete response was observed for initial steroid treatment in 19 patients and for methotrexate in 1 patient. Recurrences were common, especially in patients with extrapancreatic manifestations, and usually responded to a combination of steroids and azathioprine. Any one of the commonly used diagnostic criteria (Mayo Clinic's HISORt criteria, the Japanese Pancreas Society criteria, Korean diagnostic criteria) was fulfilled in 85% of cases. CONCLUSIONS: In this second major US series, we confirm several findings previously reported in AIP. Our study highlights the presence of vascular complications in a subset of patients with AIP. The current diagnostic criteria may not identify all AIP patients.
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Enfermedades Autoinmunes/diagnóstico , Pancreatitis Crónica/diagnóstico , Adulto , Anciano , Anciano de 80 o más Años , Enfermedades Autoinmunes/terapia , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis Crónica/terapia , Estudios Retrospectivos , Estados Unidos , Adulto JovenAsunto(s)
Anemia/etiología , Aneurisma Falso/complicaciones , Aneurisma Falso/diagnóstico , Arteria Gastroepiploica , Hemorragia Gastrointestinal/complicaciones , Anciano , Aneurisma Falso/terapia , Embolización Terapéutica , Resultado Fatal , Humanos , Angiografía por Resonancia Magnética , Masculino , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND AND OBJECTIVES: The safety and utility of endoscopic ultrasound (EUS) for the evaluation and management of gastrointestinal (GI) tract disorders among adults has been established. The literature on safety and efficacy in a pediatric referral population (under 21 years of age) is limited. We hypothesized that EUS is safe and useful in the pediatric population. We reviewed the pediatric EUS experience at a single tertiary-care system. We describe the indications, findings, safety, technical success rate, and impact on clinical outcomes. PATIENTS AND METHODS: All patients 21 years of age or younger referred for EUS between 5, 2007 and 11, 2012 were identified from our electronic medical record databases. Retrospective chart review was then conducted to document demographics, procedure indications, procedure type (diagnostic or therapeutic), type of anesthesia used, EUS findings, and the clinical impact of EUS on the subsequent management of the patients. RESULTS: Seventy EUS procedures were attempted in 58 patients during the study. Of these, two EUS procedures were aborted due to inadequate moderate sedation and 68 were successfully completed. The median age at initial endoscopy was 18 years (range 6-21 years), 50% were male and 65% were Caucasian. Four patients underwent EUS-guided pseudocyst drainage. Among the remaining 54 patients, the indications for EUS were the evaluation of GI mucosal/submucosal lesions (n = 14), acute or recurrent pancreatitis (n = 10), localization of suspected insulinoma (n = 8), evaluation of pancreatic abnormalities seen on prior imaging (n = 6), surveillance of tumors or evaluation of luminal lesions in hereditary syndromes (n = 6), abdominal pain of suspected pancreatobiliary origin (n = 5), and other rare indications (n = 5). Fine-needle aspiration was performed in 13 (9 diagnostic, 4 therapeutic) and trans-gastric fine-needle contrast injection of the pancreatic duct was performed in one patient without any complications. Sedation (data available for 66 procedures) included general endotracheal anesthesia in 38 (57%), monitored anesthesia care (MAC) in 19 (29%), and moderate sedation in 9 (14%). There were 4 minor intra-procedural anesthesia-related complications (laryngospasm in 2 and hypoxemia from airway obstruction and secretions in 2) in MAC and general endotracheal anesthesia (GA) cases, and 1 postprocedural complication (fever after pseudocyst drainage). EUS can achieve the diagnostic or therapeutic goal and ruled out suspected pathology in 88% of cases precluding need for additional testing. CONCLUSIONS: (1) EUS in the pediatric population is technically successful and efficacious. (2) Therapeutic and diagnostic EUS impacted clinical care decisions. (3) There is a low risk of immediate significant complications. (4) The overall efficacy and safety support the performance of EUS in a pediatric population by experienced endoscopists.
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AIM: To discover the prevalence and the feasibility of screening for obstructive sleep apnea (OSA) in patients presenting for routine colonoscopy. METHODS: Adult patients having a colonoscopy for routine indications at our outpatient endoscopy center were eligible if they did not carry a diagnosis of OSA or had not had a prior sleep study. All patients were administered the Berlin questionnaire prior to the procedure. Mallampati, neck circumference, height, weight, and BMI were obtained for each patient. Patients were observed for any drops in oxygen saturation < 92% or the presence of snoring for > 10 s. Patients were determined to be high-risk if they met at least 2 of the 3 symptom categories for the Berlin questionnaire. RESULTS: A total of 60 patients were enrolled and completed the study; mean age was 56 years (range 23-72 year). Twenty-six patients had a positive Berlin questionnaire (43.3%), 31 patients had a negative Berlin questionnaire (51.6%) and 3 patients had an equivocal result (5.0%). Patients with a positive Berlin questionnaire were more likely to be of increased weight (mean 210.5 lbs vs mean 169.8 lbs, P = 0.003), increased BMI (33.0 kg/m2vs 26.8 kg/m2, P = 0.0016), and have an increased neck circumference (38.4 cm vs 35.5 cm, P = 0.012). Patients with a positive Berlin questionnaire were more likely to have a drop in oxygen saturation < 92% (76.9% vs 36.4%, P = 0.01). Patients with snoring were more likely to have a positive Berlin questionnaire (8/9 patients vs 1/31 patients with negative Berlin questionnaire; P = 0.0045). CONCLUSION: Risk for OSA is extremely common in a population presenting for a routine colonoscopy, and screening at the time of a colonoscopy offers an excellent opportunity to identify these patients.
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BACKGROUND: This pilot study examined airway characteristics during upper endoscopy to determine who is at high risk for obstructive sleep apnea. METHODS: Patients undergoing routine upper endoscopy were divided into 2 groups according to the Berlin Questionnaire (high and low risk for sleep disordered breathing). Patients underwent routine upper endoscopy using propofol sedation. The airway was then evaluated for no, partial, or complete collapse at the levels of the palate/uvula/tonsils, the tongue base, the hypopharynx, and the larynx. They were given a score of 0 for no collapse, 1 for partial collapse, and 2 for complete collapse. The score for each of these levels was added to give a total score or severity index. The larynx was also evaluated for lateral pharyngeal collapse (minimal, up to 50%, >50%, or 100%). RESULTS: We found that patients with a partial obstruction at the level of the palate/uvula/tonsils, tongue base, hypopharynx, or larynx, or complete obstruction at any level more often had a positive Berlin questionnaire. Patients with a positive Berlin questionnaire were more often of increased weight (mean 197 vs 175 lbs, P=0.19), increased body mass index (31.2 vs 27.42 kg/m2, P=0.11), increased neck circumference (36.7 vs 34.7 cm, P=0.23), and had a higher total airway score (2.61 vs 1.67, P=0.09). CONCLUSIONS: The results of our pilot study represent preliminary data regarding the use of upper endoscopy as a potential tool to evaluate patients for obstructive sleep apnea.
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BACKGROUND: Most studies of acute necrotizing pancreatitis (ANP) focus on short-term outcomes. We evaluated long-term survival and outcomes following ANP. METHODS: Patients treated for ANP at the University of Pittsburgh Medical Center from 2001 to 2008 were studied. Data on presentation and course during initial hospitalization and follow-up (median 34 months) was extracted. RESULTS: Mean age of patients (n = 167) was 53 ± 16 years; 70 % were male, 94 % white, 71 % transfers, 52 % biliary etiology, and 78 % had first-attack of acute pancreatitis. Majority had severe disease with high Acute Physiology and Chronic Health Evaluation II (APACHE-II) score (median 11), length of stay (median 26 days), intensive care unit (ICU) admission (87 %), presence of systemic inflammatory response syndrome (SIRS) (90 %), persistent organ failure (60 %), and infected necrosis (50 %). Intervention was needed in 74 %. Eighteen (10.8 %) patients died during index hospitalization, 9 (5.4 %) during the first year, and 13 (7.8 %) after 1 year. Median survival was significantly shorter when compared with age- and sex-matched US general population (9.1 vs. 26.1 years, p < 0.001). Increasing age (HR 1.05), persistent organ failure (HR 4.5), and >50 % necrosis (HR 3.8) were independent predictors of death at 1 year. In eligible patients, new-onset diabetes, oral pancreatic enzyme replacement therapy, and disability were noted in 45, 25, and 53 %, respectively. CONCLUSION: ANP significantly impacts long-term survival. A high proportion of patients develop functional derangement and disability following ANP.
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Pancreatitis Aguda Necrotizante/mortalidad , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Pancreatitis Aguda Necrotizante/complicaciones , Pancreatitis Aguda Necrotizante/epidemiología , Estudios Retrospectivos , Análisis de Supervivencia , Atención Terciaria de Salud/estadística & datos numéricos , Resultado del Tratamiento , Estados Unidos/epidemiologíaRESUMEN
INTRODUCTION: Sutureless and glue-free conjunctival autograft as a treatment modality for primary pterygium is recently gaining popularity but conventional technique of suturing conjunctival autograft is still practised widely. AIM: To compare the outcome of sutureless and glue-free technique with sutures for limbal conjunctival autografting in management of primary pterygium. MATERIALS AND METHODS: A prospective interventional study was carried out in 50 consecutive eyes with primary nasal pterygium requiring surgical excision. Simple excision under local anaesthesia was performed followed by closure of the bare sclera by sutureless and glue-free conjunctival autograft in 25 eyes of 25 patients (group 1) and by the conventional method of suturing conjunctival autograft using interrupted 10-0 nylon sutures in 25 eyes of 25 patients (group 2), followed by bandaging for 24 hours in both the groups. Surgical time was recorded for both the techniques. Postoperative discomfort was assessed using preformed questionnaires. The patients were followed up for 6 months. During follow up, graft related complications and recurrence if any were noted. RESULTS: Mean surgical time for group 1 (23.20±1.55 minutes) was significantly less as compared to group 2 (37.76±1.89 minutes); (p=0.001). Postoperative symptoms were seen in less number of patients (20%) and were of shorter duration (2 weeks) in group 1 as compared to group 2 with 20 (80%) patients having symptoms lasting for 4 weeks; (p<0.001). Recurrence rate and conjunctival granuloma formation rate for group 1 (0%) and for group 2 (4%) were statistically insignificant. CONCLUSION: Sutureless and glue-free conjunctival autograft technique is simple, easy, safe, effective and less time consuming than sutured limbal autograft technique with less postoperative discomfort and adverse events encountered with the use of suture material. Postoperative results of both techniques are comparable. Hence sutureless and glue-free conjunctival autografting is a good technique for the treatment of primary pterygium.