Can Water Exchange Improve Patient Tolerance in Unsedated Colonoscopy A Prospective Comparative Study.

BACKGROUND & AIMS: Unsedated colonoscopy can be painful, poorly tolerated by patients, and associated with unsatisfactory technical performance. Previous studies report an advantage of water exchange over conventional air insufflation in reducing pain during unsedated colonoscopy. Our goal was to analyze the impact of water exchange colonoscopy on the level of maximum pain reported by patients submitted to unsedated colonoscopy, compared to conventional air insufflation. METHODS: We performed a single-center, patient-blinded, prospective randomized comparative study, where patients were either allocated to the water group, in which the method of colonoscopy used was water exchange, or the standard air group, in which the examination was accomplished with air insufflation. RESULTS: A total of 141 patients were randomized, 70 to the water and 71 to the air group. The maximum level of pain reported by patients during unsedated colonoscopy, measured by a numeric scale of pain (0-10), was significantly lower in the water group (3.39 ± 2.32), compared to the air group (4.94 ± 2.10), p < 0.001. The rate of painless colonoscopy was significantly higher in the water group (12.9 vs. 1.4%, p = 0.009). There were no significant differences between the two groups regarding indications for the procedure, quality of bowel preparation, cecal intubation time, withdrawal time, number of position changes, adenoma detection rate, and postprocedural complications. Only the number of abdominal compressions was significantly different, showing that water exchange decreases the number of compressions needed during colonoscopy. CONCLUSIONS: Water exchange was a safe and equally effective alternative to conventional unsedated colonoscopy, associated with less intraprocedural pain without impairing key performance measures.

INTRODUÇÃO E OBJECTIVOS: A colonoscopia sem sedação pode constituir um procedimento doloroso e mal tolerado pelo doente, associando-se a um desempenho técnico subóptimo. Vários estudos demonstraram o benefício do método de troca de água, comparativamente à colonoscopia convencional com insuflação de ar, na redução do nível de dor na colonoscopia sem sedação. O objectivo deste trabalho foi analisar o impacto do método de troca de água no nível máximo de dor referido pelos doentes submetidos a colonoscopia sem sedação, comparativamente à colonoscopia convencional com ar. MÉTODOS: Estudo comparativo unicêntrico, prospectivo e randomizado, cego para o doente, no qual os doentes foram alocados ao grupo água, no qual se utilizou o método de troca de água, ou ao grupo ar, no qual se utilizou a insuflação de ar. RESULTADOS: Foram randomizados 141 doentes, 70 no grupo água e 71 no grupo ar. O nível máximo de dor referido pelos doentes submetidos a colonoscopia sem sedação, avaliado através de uma escala numérica de dor (0­10), foi significativamente inferior no grupo água (3.39 ± 2.32), comparativamente ao grupo ar (4.94 ± 2.10), p < 0.001. A taxa de colonoscopia indolor foi significativamente superior no grupo água (12.9 vs. 1.4%, p = 0.009). Não se verificam diferenças significativas entre os dois grupos relativamente à indicação do exame, qualidade da preparação intestinal, tempo de entubação cecal, tempo de retirada, número de mudanças de posição, taxa de detecção de adenomas, assim como complicações no pósprocedimento. Apenas o número de compressões abdominais foi significativamente diferente, verificando-se que o método de troca de água reduziu o número necessário durante a colonoscopia. CONCLUSÕES: O método de troca de água é seguro e constitui uma alternativa igualmente eficaz à colonoscopia convencional sem sedação, associando-se a uma menor dor durante o procedimento, sem comprometer as medidas de desempenho na colonoscopia.

Endoscopic Ultrasound-Guided Choledochoduodenostomy as Palliative Treatment: A Challenging Case Report.

We report the case of an 88-year-old female with obstructive jaundice due to a periampullary tumor. The patient developed acute cholangitis and consequent clinical deterioration, so it was decided to perform palliative biliary drainage. Due to duodenal tumor invasion, it was not possible to perform endoscopic retrograde cholangiopancreatography. A different approach was attempted and it was decided to carry out an endoscopic ultrasound-guided choledochoduodenostomy. This procedure was performed with a linear echoendoscope, and using a duodenal bulbar approach, a fistula was created between the bulb and the common bile duct. A self-expandable fully covered metal biliary stent was placed in the common bile duct under endoscopic and fluoroscopic guidance, allowing biliary drainage. The patient presented clinical improvement. However, 3 weeks after being discharged, she was readmitted to our department with hematemesis associated with the migration of the biliary stent to the duodenal bulb. Endoscopic hemostasis was performed but the patient had multiple bleeding relapses that were controlled through arterial embolization. Despite the migration of the biliary stent, the fistula between the duodenum and the common bile duct remained patent, allowing a successful palliation of the obstructive jaundice. Therefore, despite the occurred complication, we admitted a technical and clinical success of the endoscopic ultrasound-guided choledochoduodenostomy. This is an emerging technique and a valuable alternative for palliative biliary drainage in cases of malignant distal obstruction. This clinical report supports this finding, reporting technical aspects of the procedure, associated complications and their management as well as the clinical outcomes.

Apresentamos o caso de uma doente do sexo feminino, de 88 anos de idade, com icterícia obstrutiva devido a um tumor periampular, complicada com colangite aguda. Foi proposta drenagem biliar paliativa através da colocação de uma prótese biliar por colangiopancreatografia retrógrada endoscópica. No entanto, devido a invasão tumoral do duodeno, não foi possível realizar esta abordagem e como alternativa foi efetuada uma coledocoduodenostomia guiada por ecoendoscopia. Este procedimento foi realizado com um ecoendoscópio linear e, utilizando uma abordagem através do bulbo duodenal, foi criada uma fístula entre o bulbo e a via biliar principal. Uma prótese metálica auto-expansível totalmente coberta foi colocada na via biliar principal com apoio endoscópico e fluoroscópico, permitindo a drenagem biliar. A doente apresentou melhoria do estado clínico com resolução do quadro de colangite aguda. No entanto, tr's semanas após a alta, ela foi novamente internada no nosso serviço por hematemeses associadas à migração da prótese biliar para o bulbo. Foi realizada hemostase endoscópica, no entanto, por apresentar várias recidivas da hemorragia optou-se pela embolização arterial, verificando-se controlo definitivo da hemorragia. Apesar da migração da prótese biliar, a fístula entre o duodeno e o a via biliar principal permaneceu patente, permitindo uma paliação da icterícia obstrutiva. Portanto, admitimos o sucesso técnico e clínico da coledocoduodenostomia guiada por ecoendoscopia. Esta é uma técnica emergente e uma alternativa valiosa para a drenagem biliar paliativa em casos de obstrução distal maligna. O presente caso clínico é representativo desse valor, relatando os aspetos técnicos do procedimento efetuado, complicações associadas e a sua abordagem, bem como a evolução clinica da doente.

Uncommon Solid Pancreatic Neoplasm: The Role of New Modalities of Ultrasound Endoscopy.

Undifferentiated carcinoma with osteoclast-like cells is a rare pancreatic neoplasm with unique ultrasound endoscopic features. A 59-year-old female presented with a 3-month history of weight loss. Abdominal computed tomography and endoscopic ultrasound showed a large pancreatic tumor with a heterogeneous echotexture and liver metastasis. Endoscopic ultrasound fine needle aspiration was used to establish the diagnosis. In this case report, we review the endoscopic, clinical, and pathological features of this type of tumor and describe for the first time the endoscopic features of real-time elastography and contrast enhancement. Real-time elastography revealed a heterogeneous predominantly blue pattern suggestive of pancreatic malignancy, and the contrast-enhanced endosonography showed a hypervascular mass and distinctive vascular (solid) and avascular (liquid/necrotic) components of the lesion, guiding the fine needle aspiration.

O carcinoma indiferenciado de células do tipo osteoclástico é uma neoplasia rara com achados únicos de ultrassonografia endoscópica. Mulher, de 59 anos de idade, com história de perda ponderal nos últimos 3 meses. A tomografia computorizada e a ultrassonografia endoscópica mostraram um volumoso tumor pancreático com uma ecotextura heterogénea e metástases hepáticas. A punção aspirativa com agulha fina por ultrassonografia endoscópica estabeleceu o diagnóstico. Este caso clínico fará uma revisão dos achados endoscópicos, clínicos e histológicos deste tipo de tumor e descrever pela primeira vez os achados endoscópicos da elastografia em tempo real e do contraste por ultrassonografia. A elastografia em tempo real revelou um padrão heterogéneo predominante azul, sugestivo de malignidade pancreática e o contraste por ultrassonografia mostrou uma massa hipervascular, diferenciando o componente vascular (sólido) do não vascular (tecido necrótico/líquido) da lesão, orientando a punção com agulha fina.

A rare cause of intestinal bleeding: duodenal metastasis from endometrial cancer.

With this report we alert to an extremely rare case of duodenal metastases, from an endometrial adenocarcinoma by lymphatic spread and whose primary manifestation was with gastrointestinal bleeding. We think this is the first case reported of duodenal metastases from endometrial carcinoma and with this presentation.

Nonvariceal upper gastrointestinal bleeding in Portugal: a multicentric retrospective study in twelve Portuguese hospitals.

BACKGROUND: Nonvariceal upper gastrointestinal bleeding (NVUGIB) is associated with important mortality. More information is needed in order to improve NVUGIB management. The aims of this study were: (a) characterizing Portuguese patients and clinical approaches used in NVUGIB, (b) comparing management used in Portugal with management globally used in European countries, (c) identify factors associated with management options, and (d) identify factors associated with adverse outcome. METHODS: ENERGiB was an observational, retrospective cohort study, on NVUGIB with endoscopic evaluation, carried across Europe. This study focuses on Portuguese patients of the ENERGiB study. Patients were managed according to routine care. Later, data were collected from files. Multivariate/univariate analyses were conducted on predictive factors of poor outcome and clinical decisions. RESULTS: Patients (n=404) were mostly men (66.8%), mean age 68, with co-morbidities (72%), frequently on NSAIDs/aspirin. Most were assisted by general medical (57.8%) or surgical team (20.6%), only 19.4% by gastroenterology/GI-bleeding team. PPI was largely used. Gastric/duodenal ulcers, erosive gastritis and esophagitis were the main bleeding causes. 10% had bleeding persistence/recurrence. Death occurred in 24 patients, 20 from a non-bleeding related cause. Poor outcomes were related with age >65, co-morbidities, fresh blood haematemesis, shock/syncope, bleeding through previous nasogastric tube, massive fluid replacement or transfusions besides erythrocytes. CONCLUSIONS: This study contributed to characterization of Portuguese patients and NVUGIB episodes in real clinical setting and identified factors associated with a poor outcome. It also identified differences, especially in the organization of GI bleeding teams, which might help us to improve the management of these patients.

Reprocessing practice in digestive endoscopy units of district hospitals: results of a Portuguese National Survey.

BACKGROUND AND AIM: An inadequate disinfection of endoscopes and associated accessories can result in the transmission of infections to patients. The aim of this study was to access reprocessing practice in the endoscopy units of Portuguese district general hospitals. METHODS: An anonymous questionnaire on cleaning and disinfection methods was sent to all endoscopy units of Portuguese district general hospitals. RESULTS: A total of 25 units responded (93%). All endoscopy units performed manual cleaning (including brushing of accessible channels) before disinfection. Automated endoscope reprocessing machines were available in all units. Manual disinfection was performed in only one unit. In 48% of the surveyed units, endoscopes were systematically disinfected before each session, whereas in 16% this was performed only occasionally. The most commonly used disinfectant was peracetic acid (32%). Disposable papillotomes, biopsy forceps, and polipectomy snares were used in nine (36%), six (24%), and 14 (56%) units, respectively. Disposable papillotomes, forceps, and snares were reused in three (12%), two (8%), and three (12%) units, respectively, always after sterilization. Most units did not perform regular evaluation of reprocessing staff competence (60%), regular microbiological inspection (56%), or registry of reprocessing (56%). CONCLUSION: The data collected suggest that there is a good compliance with standard guidelines. Nevertheless, there is still room for improvement mainly in quality assurance.