Improved characterization of visible vessels in bleeding ulcers by using magnification endoscopy: results of a pilot study.

BACKGROUND: Not all exposed vessels carry the same risk of recurrent bleeding, and sometimes endoscopic therapy may not be warranted in the setting of profound acid inhibition therapy. OBJECTIVE: To investigate the role of magnification endoscopy (ME) in improving the characterization of exposed vessels in ulcer hemorrhage. DESIGN: Prospective study. SETTING: Single-center teaching hospital. MAIN OUTCOME MEASUREMENTS: Diagnostic accuracy and safety of ME in patients with bleeding peptic ulcers. RESULTS: A total of 43 patients were studied. Exposed vessels were initially categorized as high risk (protuberant, translucent, or pale) in 25 and low risk (nonprotruding through the ulcer floor, pigmented, or dark red) in 18 cases. ME was subsequently performed, and the operator was asked to reclassify the vessel into 1 of these 2 categories. A magnified view provided a clear image of the vessel and allowed visualization of the artery, the site of rupture, and the presence of a clot plugging the hole. In 6 cases previously categorized as low risk, ME clearly showed the 2 ends of the vessel, the longitudinal tear in the vessel wall, and a protuberant aspect that was not seen with standard view. The lesion was then reclassified as high risk (diagnostic gain 33%). The mean procedure time for ME inspection was 7 +/- 4 minutes. No complications occurred. LIMITATIONS: Absence of controls. CONCLUSIONS: In patients with peptic ulcer bleeding and exposed vessels, ME allows clear visualization of the vessel wall and provides detailed clues to further characterize the lesion.

Self-assembled hydro-jet system for submucosal elevation before endoscopic resection of nonpolypoid colorectal lesions (with video).

BACKGROUND: Endoscopic resection of colorectal nonpolypoid lesions requires adequate submucosal lifting of the lesion. OBJECTIVE: To evaluate a self-assembled hydro-jet system for tissue elevation to improve endoscopic resection of colorectal nonpolypoid lesions. DESIGN: Prospective study. SETTING: Single-center teaching hospital. MAIN OUTCOME MEASUREMENTS: Efficacy and safety of the hydro-jet system and rate of complete resection. RESULTS: The system was clinically applied in 31 patients to remove a total of 34 lesions throughout the colon. An adequate submucosal fluid cushion was achieved in all but 1 case without any lifting-associated complications. Complete endoscopic resection was possible in all 33 lifted lesions by using a snare. The size of the resected lesions ranged from 7 to 60 mm. Major intraprocedure bleeding occurred in only 1 case. No perforation or late bleeding was recorded. Histological examination showed a selective accumulation of fluid in the submucosa with edema and dissociation of submucosal structures, with no damage to the muscularis mucosa and very limited "burn effect" hampering assessment of radial margins. LIMITATIONS: Lack of controls. CONCLUSIONS: This inexpensive system allows safe and rapid submucosal lifting of colorectal nonpolypoid lesions to assist endoscopic resection.

Can magnification endoscopy detect residual adenoma after piecemeal resection of large sessile colorectal lesions to guide subsequent treatment? A prospective single-center study.

PURPOSE: This study assesses the ability of magnification endoscopy to detect residual adenomatous tissue after endoscopic piecemeal resection of colorectal polyps and evaluates the impact of the technique on the incidence of recurrence. METHODS: Patients who underwent endoscopic piecemeal resection for large (>2 cm) sessile colorectal polyps were included. After endoscopic piecemeal resection, both the outer resection margins and the central severed area were inspected with magnification endoscopy. Completeness of excision as determined from the magnified surface pattern was compared with that determined histologically. Areas of incomplete resection were treated with additional resection or argon plasma coagulation. RESULTS: A total of 77 lesions were resected. Mean size of the resected lesions was 29 +/- 6 mm (range, 23-60). Complications of resection occurred in eight patients (seven had immediate bleeding that was successfully managed with hemoclip application, and one had delayed perforation that was treated surgically). The sensitivity of magnification endoscopy for predicting remnant adenoma at resection margins was 98% (95% confidence interval 90-100); specificity was 90% (95% confidence interval 79-100). Overall accuracy was 94.5% (95% confidence interval 87.2-98.6). On a mean follow-up of 32 months (range, 18-46) the recurrence rate was 2.6%. CONCLUSIONS: Magnification endoscopy is accurate at predicting remnant tissue after endoscopic piecemeal resection of large sessile colorectal polypoid lesions. When applied on both outer margins and inner portions of the severed area, it is helpful as a guide to subsequent further treatment to decrease recurrence.

Dual therapy versus monotherapy in the endoscopic treatment of high-risk bleeding ulcers: a meta-analysis of controlled trials.

BACKGROUND: There is no definite recommendation on the use of dual endoscopic therapy in patients with severe peptic ulcer bleeding. A systematic review and meta-analysis were performed to determine whether the use of two endoscopic hemostatic procedures improved patient outcomes compared with monotherapy. METHODS: A search for randomized trials comparing dual therapy (i.e., epinephrine injection plus other injection or thermal or mechanical method) versus monotherapy (injection, thermal, or mechanical alone) was performed between 1990 and 2006. Heterogeneity between studies was tested with chi(2) and explained by metaregression analysis. RESULTS: Twenty studies (2,472 patients) met inclusion criteria. Compared with controls, dual endoscopic therapy reduces the risk of recurrent bleeding (OR [odds ratio] 0.59 [0.44-0.80], P= 0.0001) and the risk of emergency surgery (OR 0.66 [0.49-0.89], P= 0.03) and showed a trend toward a reduction in the risk of death (OR 0.68 [0.46-1.02], P= 0.06). Subcategory analysis showed that dual therapy was significantly superior to injection therapy alone for all the outcomes considered, but failed to demonstrate that any combination of treatments is better than either mechanical therapy alone (OR 1.04 [0.45-2.45] for rebleeding, 0.49 [0.50-4.87] for surgery, and 1.28 [0.34-4.86] for death) or thermal therapy alone (OR 0.67 [0.40-1.20] for rebleeding, 0.89 [0.45-1.76] for surgery, and 0.51 [0.24-1.10] for death). CONCLUSIONS: Dual endoscopic therapy proved significantly superior to epinephrine injection alone, but had no advantage over thermal or mechanical monotherapy in improving the outcome of patients with high-risk peptic ulcer bleeding.

Combination of age and sex improves the ability to predict upper gastrointestinal malignancy in patients with uncomplicated dyspepsia: a prospective multicentre database study.

BACKGROUND AND AIMS: Current guidelines recommend endoscopy for dyspeptic patients >45 yr of age and/or with "alarm" symptoms. The management of younger patients with uncomplicated dyspepsia is controversial. The objective of the study was to identify any risk factors predictive of upper gastrointestinal malignancy in patients with uncomplicated dyspepsia and validate their ability in refining indications for endoscopy. METHODS: Prospective database study of consecutive uninvestigated dyspeptic outpatients undergoing endoscopy was performed. A questionnaire including multiple possible prognostic variables was systematically submitted to patients prior to endoscopic examination. Risk factors for upper gastrointestinal malignancy identified were used to derive a prediction rule subsequently validated on an independent population. RESULTS: A total of 5,224 patients with uncomplicated dyspepsia were considered (training sample). Twenty-two (16 males) had malignancy at endoscopy. These patients were about 20 yr older than patients with no malignancy (p < 0.001). The mean age of females with cancer was almost 10 yr higher compared to males (p= 0.08). Such differences in age were confirmed in a split sample of 3,684 patients (p < 0.001 and p < 0.05, respectively). The age cut-offs identified were 35 yr for males and 56 yr for females. CONCLUSIONS: The age threshold for endoscopy should be lowered in males to decrease the risk of missing cancers, and can be safely increased in females without affecting outcomes. In patients with uncomplicated dyspepsia, the combination of age and gender provides a better discriminant power than age alone.

Capsule endoscopy versus enteroclysis in the detection of small-bowel involvement in Crohn's disease: a prospective trial.

BACKGROUND & AIMS: The aim of this study was to prospectively compare the diagnostic yield of wireless capsule endoscopy (WCE) and enteroclysis in evaluating the extent of small-bowel involvement in Crohn's disease (CD). METHODS: Thirty-one patients (20 men; mean age, 43 y) with endoscopically and histologically proven CD underwent enteroclysis as their initial examination, followed by WCE. The radiologist who performed the small-bowel enema was blinded to the results of standard index endoscopy, which included retrograde ileoscopy. Gastroenterologists were blinded to the results of enteroclysis at the time of interpretation of the WCE video. RESULTS: Abnormal findings were documented in 8 of 31 patients by using enteroclysis and in 22 of 31 patients by using WCE (25.8% vs. 71%, P < .001). In 16 patients with known involvement of the terminal ileum, the diagnostic yield of WCE vs enteroclysis was significantly superior (89% vs 37%, P < .001). In 15 patients without lesions in the terminal ileum, abnormal findings in the proximal small bowel were detected in 7 (46%) patients by WCE and only in 2 (13%) patients by enteroclysis (P < .001). The capsule detected all but 2 lesions diagnosed by enteroclysis. WCE detected additional lesions that were not detected by enteroclysis in 45% of cases. CONCLUSIONS: WCE is superior to enteroclysis in estimating the presence and extent of small-bowel CD. WCE may be a new gold standard for diagnosing ileal involvement in patients with CD without strictures and fistulae.

Combined epinephrine and bipolar probe coagulation vs. bipolar probe coagulation alone for bleeding peptic ulcer: a randomized, controlled trial.

BACKGROUND: Endoscopic treatment with combined modalities is considered standard of care for patients with high-risk peptic ulcer bleeding. This study compared epinephrine injection plus bipolar probe coagulation with bipolar probe coagulation alone in patients with high-risk peptic ulcer bleeding. METHODS: Patients with endoscopically confirmed peptic ulcer bleeding (active or visible vessel) seen from January 2000 through December 2002 were prospectively randomized to two groups. The study group (n = 58) had epinephrine injection followed by bipolar coagulation; the control group (n = 56) was treated by bipolar coagulation alone. The primary outcomes assessed were the rate of initial hemostasis and the rate of recurrent bleeding. Secondary outcomes were the following: need for surgical intervention to control bleeding, transfusion requirements, length of hospital stay (in days), and 30-day mortality. RESULTS: The rate of initial hemostasis was significantly higher in the combination therapy group ( p = 0.02; absolute risk reduction 31.6%: 95% CI [5.4, 57.7]). There was no significant difference between the two treatment groups with respect to all other outcomes measures, except that significantly fewer units of blood were transfused in the combination therapy group ( p = 0.006). CONCLUSIONS: In patients with active peptic ulcer bleeding, epinephrine injection plus bipolar coagulation achieved significantly higher rate of initial hemostasis. All other outcome measures were similar with either treatment in patients with non-bleeding stigmata.

Outpatient management for low-risk nonvariceal upper GI bleeding: a randomized controlled trial.

BACKGROUND: Patients with acute nonvariceal upper GI hemorrhage are routinely hospitalized, regardless of clinical status or endoscopic findings. The aim of this study was to compare outcomes for outpatient versus hospital care of patients with nonvariceal upper GI hemorrhage at low risk of recurrent bleeding. METHODS: Endoscopic and clinical criteria were used to select patients at low risk for recurrent bleeding. Ninety-five consecutive patients were randomized for either early discharge and outpatient care (48) or hospital care (47). Baseline clinical and endoscopic features were comparable. During the first 30 days patients were examined daily by their primary care physician and contacted by a gastroenterologist by telephone to assess clinical status. Rates of recurrent bleeding, hospitalization, surgery, and mortality were determined. RESULTS: All patients underwent endoscopy within 12 hours of the onset of hemorrhage. No patient underwent surgery or died. Rates of recurrent bleeding were 2.1% in the early discharge group and 2.2% in the hospital-treated group (1 patient in each group). Median costs were $340 for the outpatient group and $3940 for the hospital group (p = 0.001). CONCLUSIONS: Outpatient care of patients at low risk for recurrent nonvariceal upper GI hemorrhage is safe and can lead to significant savings in hospital costs.

Argon plasma coagulation prevents variceal recurrence after band ligation of esophageal varices: preliminary results of a prospective randomized trial.

BACKGROUND: Endoscopic variceal ligation is an established procedure for eradication of esophageal varices. However, varices frequently recur after endoscopic variceal ligation. Argon plasma coagulation has been used as supplemental treatment for eradication of varices and for prevention of variceal recurrence in small uncontrolled series. The aim of this study was to determine whether argon plasma coagulation is effective in reducing variceal recurrence after endoscopic variceal ligation. METHODS: Thirty patients with cirrhosis, a history of acute esophageal variceal bleeding, and eradication of varices by endoscopic variceal ligation were randomized to argon plasma coagulation (16 patients) or observation (14 patients). The 2 groups were similar with respect to all background variables including age, Child-Pugh score, presence of gastric varices, and degree of portal hypertensive gastropathy. In the argon plasma coagulation group, the entire esophageal mucosa 4 to 5 cm proximal to the esophagogastric junction was thermocoagulated circumferentially with argon plasma coagulation in 1 to 3 sessions performed at weekly intervals. Endoscopy was performed every 3 months to check for recurrence of varices in both groups. RESULTS: During the course of the study, no serious complication was noted. After argon plasma coagulation, transient fever occurred in 13 patients and 8 complained of dysphagia or retrosternal pain/discomfort. Mean follow-up for all patients was 16 months (range 9-28 months). No recurrence of varices or variceal hemorrhage was observed in the argon plasma coagulation group, whereas varices recurred in 42.8% (6/14) of the patients in the control group (p < 0.04) and bleeding recurred in 7.2% (1/14). CONCLUSIONS: Argon plasma coagulation of the distal esophageal mucosa after eradication of esophageal varices by endoscopic variceal ligation is safe and effective for reducing the rate of variceal recurrence.

Outcome of endoscopic treatment for peptic ulcer bleeding: Is a second look necessary? A meta-analysis.

BACKGROUND: Endoscopic therapy for GI bleeding is highly effective. Nevertheless, bleeding recurs in 10% to 25% of cases, irrespective of the method of treatment used. Whether a second-look endoscopy with retreatment after initial hemostasis is of clinical value is controversial. A meta-analysis was performed to assess whether systematic second-look endoscopy with retreatment reduces the risks of recurrent bleeding, salvage surgery, and death in patients with peptic ulcer bleeding. METHODS: A systematic review was performed of randomized controlled studies of the value of second-look endoscopy in patients with peptic ulcer bleeding published between 1990 and 2000. Four studies were selected according to predefined criteria. Two investigators extracted the data independently. Pooled risk estimates and number need to treat were calculated for each procedure. Heterogeneity of effects was tested. RESULTS: The absolute risk reduction in clinical recurrent bleeding was 6.2% (p < 0.01). Absolute risk reduction for surgery and mortality were, respectively, 1.7% and 1.0% (not significant). The second look with retreatment significantly reduced the risk of recurrent bleeding compared with control patients (OR 0.64; 95% CI [0.44, 0.95]; p < 0.01), with a number needed to treat of 16. There was no heterogeneity among studies. The risk of surgery as well as the risk of death were not significantly influenced by the second-look endoscopy with retreatment (number needed to treat, respectively, 58 and 97). CONCLUSIONS: Systematic second-look endoscopy with retreatment significantly reduces the risk of recurrent bleeding in patients with peptic ulcer bleeding compared with control patients, but it does not substantially reduce the risk of salvage surgery or mortality.