Endoscopic intervention as a decisive tool in the prognosis of cancer patients.

Cyanacrylate is not free of complications and a more commonly used alternative in clinical practice are prostheses that have the disadvantage of migrating in these cases where there is no stenosis; however, with their fixation using a specific device, migrations are greatly reduced. A good alternative to cyanacrylate, especially in cases of orifices or large tracts in which complications may appear, are the prostheses, which are also easier to handle in clinical practice. Sometimes cancer patients have upper gastrointestinal complications no subsidiary to surgical treatment, like a tumor fistula, that contraindicate chemotherapy. In situations like this, endoscopic intervention can be a potentially profitable alternative that impacts the patient's prognosis.

Chronic follicular pancreatitis: a space occupying lesion with spontaneous resolution.

Follicular pancreatitis (FP) is an extremely odd entity characterized by the presence of a pseudotumor that histologically presents lymphoid aggregates and germinal centers. The authors present the case of a 67-year-old woman with epigastric pain and jaundice. Endoscopic ultrasonography (EUS) was performed, revealing a 14x15 mm hypoechoic area with irregular edges in the head of the pancreas. The in situ cytological study showed polymorphic lymphoid cellularity, without atypia suggesting neoplasia. The cell block and the immunohistochemical study showed a polyclonal population with a pattern suggestive of FP. The patient presented spontaneous clinical improvement. The EUS follow up three months later shown pancreatic parenchyma with homogeneous echogenicity and no space occupying lesions were indentified. Since the diagnosis of FP has been reached after surgery in most cases, the treatment is not well established. However, no recurrences have been reported after surgery and spontaneous resolution has been observed in incomplete resections, which suggests the indication for conservative management. Diagnostic EUS has a fundamental role in the differential diagnosis between FP and pancreatic neoplasms, two entities with very different prognosis, and makes it possible to avoid, in the case of FP, unnecessary surgeries with the associated morbidity and mortality.

Jejunal varix with a high transfusion requirement: therapy with cyanoacrylate with radiological control by double-balloon enteroscopy.

A jejunal varix with high transfusion requirement is treated by double-balloon enteroscopy with cyanoacrylate/ lipiodol with radiological control. The patient had not gastrointestinal hemorrhage or transfusion requeriment after 8 months follow up. Our recent previous article in Rev Esp Enferm Dig on advanced therapeutics by enteroscopy is referenced, providing this new therapeutic possibility.

Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2022.

MR1: ESGE recommends small-bowel capsule endoscopy as the first-line examination, before consideration of other endoscopic and radiological diagnostic tests for suspected small-bowel bleeding, given the excellent safety profile of capsule endoscopy, its patient tolerability, and its potential to visualize the entire small-bowel mucosa.Strong recommendation, moderate quality evidence. MR2: ESGE recommends small-bowel capsule endoscopy in patients with overt suspected small-bowel bleeding as soon as possible after the bleeding episode, ideally within 48 hours, to maximize the diagnostic and subsequent therapeutic yield.Strong recommendation, high quality evidence. MR3: ESGE does not recommend routine second-look endoscopy prior to small-bowel capsule endoscopy in patients with suspected small-bowel bleeding or iron-deficiency anemia.Strong recommendation, low quality evidence. MR4: ESGE recommends conservative management in those patients with suspected small-bowel bleeding and high quality negative small-bowel capsule endoscopy.Strong recommendation, moderate quality evidence. MR5: ESGE recommends device-assisted enteroscopy to confirm and possibly treat lesions identified by small-bowel capsule endoscopy.Strong recommendation, high quality evidence. MR6: ESGE recommends the performance of small-bowel capsule endoscopy as a first-line examination in patients with iron-deficiency anemia when small bowel evaluation is indicated.Strong recommendation, high quality evidence. MR7: ESGE recommends small-bowel capsule endoscopy in patients with suspected Crohn's disease and negative ileocolonoscopy findings as the initial diagnostic modality for investigating the small bowel, in the absence of obstructive symptoms or known bowel stenosis.Strong recommendation, high quality evidence. MR8: ESGE recommends, in patients with unremarkable or nondiagnostic findings from dedicated small-bowel cross-sectional imaging, small-bowel capsule endoscopy as a subsequent investigation if deemed likely to influence patient management.Strong recommendation, low quality evidence. MR9: ESGE recommends, in patients with established Crohn's disease, the use of a patency capsule before small-bowel capsule endoscopy to decrease the capsule retention rate.Strong recommendation, moderate quality evidence. MR10: ESGE recommends device-assisted enteroscopy (DAE) as an alternative to surgery for foreign bodies retained in the small bowel requiring retrieval in patients without acute intestinal obstruction.Strong recommendation, moderate quality evidence. MR11: ESGE recommends DAE-endoscopic retrograde cholangiopancreatography (DAE-ERCP) as a first-line endoscopic approach to treat pancreaticobiliary diseases in patients with surgically altered anatomy (except for Billroth II patients).Strong recommendation, moderate quality evidence.

COVID-19 and the digestive system: protection and management during the SARS-CoV-2 pandemic.

The purpose of this rapid review is to provide an update on the impact of SARS-CoV-2 infection on Gastroenterology and Hepatology departments, our patients, and our new way of working. The gastrointestinal tract and the liver are affected by SARS-CoV-2, especially in patients with immunosuppressive therapies. Patients with liver transplantation should be followed closely. Digestive endoscopy is a high-risk procedure for the transmission of SARS-CoV-2. While the pandemic lasts, we must adapt its indications and promote protective measures for patients and healthcare professionals alike. The COVID-19 pandemic has changed our priorities and the way we work, although we do not know what the repercussions will be after normality is reinstated.

Advanced therapy by device-assisted enteroscopy.

Standard therapy using device-assisted enteroscopy includes different hemostatic therapies, polypectomy, dilation and other possibilities. The most frequent indication is small bowel bleeding. However, other specific settings could require dedicated therapies such as desinvagination, percutaneous enteroscopic jejunostomy, stent placement, endoscopic mucosal resection in polypoid vascular lesions and foreign body extraction. The present review aimed to investigate and describe device-assisted advanced therapies in the small bowel, excluding conventional hemostatic therapies of vascular lesions.

Retrograde enteroclysis by double balloon enteroscopy in a patient with blunt abdominal trauma: small bowel stricture, intraluminal vascular lesion and Crohn's disease.

A 40-year-old male presented to the Emergency Department after a driving accident with blunt abdominal trauma. An abdominal computed tomography (CT) scan revealed a mesenteric injury in the right lower quadrant. He was admitted two months later due to a one-day history of abdominal pain and diarrhea, without fever or blood. The CT angiography showed a pseudoaneurysm located in the proximal ileum and several rigid small bowel (SB) loops with segmental wall thickening of mucosa.

Does it matter how long the small bowel is?

The small bowell (SB) is a very long organ hardly accessible to conventional endoscopy. The revolution entailed by its complete diagnostic exploration with capsule endoscopy (CE) has led to a change in traditional surgical management and its related gold standard - intraoperative enteroscopy. CE is currently the first-line diagnostic strategy for the SB. An emergent technique in its wake has played a key role in the management of patients with SB conditions: to wit, device-assisted enteroscopy (DAE). Thus were developed first double-balloon enteroscopy (DBE), then single-balloon enteroscopy, and most recently motorized spiral enteroscopy.

Role of capsule endoscopy in alarm features and non-responsive celiac disease: A European multicenter study.

BACKGROUND AND AIM: The role of capsule endoscopy (CE) in established celiac disease (CD) remains unclear. Our objective was to analyze the usefulness of CE in the suspicion of complicated CD. METHODS: This was a retrospective multicenter study. One hundred and eighty-nine celiac patients (mean age: 46.6 ± 16.6, 30.2% males) who underwent CE for alarm symptoms (n = 86, 45.5%) or non-responsive CD (n = 103, 54.5%) were included. Diagnostic yield (DY), therapeutic impact and safety were analyzed. RESULTS: Capsule endoscopy was completed in 95.2% of patients (small bowel transit time: 270.5 ± 100.2 min). Global DY was 67.2%, detecting atrophic mucosa (n = 92, 48.7%), ulcerative jejunoileitis (n = 21, 11.1%), intestinal lymphoma (n = 7, 3.7%) and other enteropathies (n = 7, 3.7%, six Crohn's disease cases and one neuroendocrine tumor). The DY of CE was significantly higher in patients presenting with non-responsive disease compared to patients with alarm symptoms (73.8% vs 59.3%, P = 0.035). The new findings of the CE modified management in 59.3% of the cases. There were no major complications. CONCLUSION: Capsule endoscopy may be a moderately helpful and safe diagnostic tool in the suspicion of complicated CD, modifying the clinical course of these patients.

High short-term rebleeding rate in patients undergoing a second endoscopic therapy for small-bowel angioectasias after recurrent bleeding.

BACKGROUND: Angioectasias represents the most frequently found lesion in the small bowel by device-assisted enteroscopy for obscure gastrointestinal bleeding in Western countries. Recurrence of gastrointestinal bleeding after angioectasias therapy remains unclear and data regarding the efficacy of additional endoscopic therapeutic sessions to reduce the rebleeding rate is limited. AIM: To evaluate the rebleeding rate in small bowel angioectasias after a second endoscopic treatment with balloon-assisted enteroscopy after an initial bleed during the first endoscopic treatment. METHODS: A retrospective double-center study of patients with small-bowel angioectasias undergoing a second enteroscopy treatment due to a first rebleeding episode. The endpoint was rebleeding, defined as the need for a blood transfusion, the presence of overt bleeding or a decrease in hemoglobin ≥ 2 g/dL. RESULTS: Fifteen of 37 (40.5%) patients with small-bowel angioectasias that underwent a second endoscopic therapy after a first rebleeding episode (n = 15) experienced a second rebleeding episode. Kaplan-Meier curve analysis showed that most rebleeding episodes occurred within the first 12 months of follow-up, resulting in a rebleeding rate of 33.1% at 6 months, 39.1% at 12 months and 52.6% at 24 months. CONCLUSIONS: Despite the high absolute short-term rebleeding rate, further endoscopic treatments may be beneficial due to the effective reduction of rebleeding in a subset of patients.

Evidences supporting the vascular etiology of post-double balloon enteroscopy pancreatitis: Study in porcine model.

Double balloon enteroscopy (DBE) is an endoscopic technique broadly used to diagnose and treat small bowel diseases. Among the associated complications of the oral DBE, post-procedure pancreatitis has taken the most attention due to its gravity and the thought that it might be associated to the technique itself and anatomical features of the pancreas. However, as the etiology has not been clarified yet, this paper aims to review the published literature and adds new results from a porcine animal model. Biochemical markers, histological sections and the vascular perfusion of the pancreas were monitored in the pig during DBE practice. A reduced perfusion of the pancreas and bowel, the presence of defined hypoxic areas and disseminated necrotic zones were found in the pancreatic tissue of pigs. All these evidences contribute to support a vascular distress as the most likely etiology of the post-DBE pancreatitis.

Role of capsule endoscopy in suspected celiac disease: A European multi-centre study.

AIM: To analyze the diagnostic yield (DY), therapeutic impact (TI) and safety of capsule endoscopy (CE). METHODS: This is a multi-centre, observational, analytical, retrospective study. A total of 163 patients with suspicion of celiac disease (CD) (mean age = 46.4 ± 17.3 years, 68.1% women) who underwent CE from 2003 to 2015 were included. Patients were divided into four groups: seronegative CD with atrophy (Group-I, n = 19), seropositive CD without atrophy (Group-II, n = 39), contraindication to gastroscopy (Group-III, n = 6), seronegative CD without atrophy, but with a compatible context (Group-IV, n = 99). DY, TI and the safety of CE were analysed. RESULTS: The overall DY was 54% and the final diagnosis was villous atrophy (n = 65, 39.9%), complicated CD (n = 12, 7.4%) and other enteropathies (n = 11, 6.8%; 8 Crohn's). DY for groups I to IV was 73.7%, 69.2%, 50% and 44.4%, respectively. Atrophy was located in duodenum in 24 cases (36.9%), diffuse in 19 (29.2%), jejunal in 11 (16.9%), and patchy in 10 cases (15.4%). Factors associated with a greater DY were positive serology (68.3% vs 49.2%, P = 0.034) and older age (P = 0.008). On the other hand, neither sex nor clinical presentation, family background, positive histology or HLA status were associated with DY. CE results changed the therapeutic approach in 71.8% of the cases. Atrophy was associated with a greater TI (92.3% vs 45.3%, P < 0.001) and 81.9% of the patients responded to diet. There was one case of capsule retention (0.6%). Agreement between CE findings and subsequent histology was 100% for diagnosing normal/other conditions, 70% for suspected CD and 50% for complicated CD. CONCLUSION: CE has a high DY in cases of suspicion of CD and it leads to changes in the clinical course of the disease. CE is safe procedure with a high degree of concordance with histology and it helps in the differential diagnosis of CD.

Short article: Capsule endoscopy in graft-versus-host disease.

INTRODUCTION: The gold standard in the diagnosis of gastrointestinal graft-versus-host disease (GVHD) after allogenic hematopoietic stem cell transplantation is conventional endoscopy with histopathological assessment. The role of capsule endoscopy (CE) is uncertain. The aim of the present study was to investigate the accuracy of CE in this setting, comparing the clinical, endoscopic and histological data. METHODS: This was a retrospective single-centre study that included 57 (mean age: 47.18±15.05 years, 57.89% men) patients presenting with GVHD who underwent a valid CE and histopathological analysis by conventional endoscopy between January 2004 and July 2016. The endoscopic scored findings, clinical data and histopathological diagnosis were compared using duodenal histology as the gold standard. RESULTS: CE detected mild (n=4, 7.02%), moderate (n=6, 10.53%) and severe (n=21, 36.84%) grades, with a higher diagnostic yield than conventional endoscopy (54.39 vs. 28.07%, P<0.001). A positive CE predicted positive histology (80.64 vs. 15.38%, P<0.001) with a sensitivity, specificity, negative predictive value and accuracy of 86.21, 78.57, 84.62 and 82.46%. This procedure detected more mild-to-moderate histological lesions than conventional endoscopy (8.77 vs. 3.51%, P=0.25). In addition, 16% of patients with a previous normal endoscopy with biopsies had a pathological CE and there were eight (25.81%) patients with positive CE images unreachable by conventional endoscopy. CONCLUSION: CE is a useful device in GVHD, achieving high accuracy values and diagnostic yield. However, its results may be interpreted in conjunction with clinical and histological features, particularly in mild-to-moderate stages.

Intermediate-risk patients with three to four small adenomas should be considered low risk for colorectal cancer screening.

BACKGROUND AND AIM: Intermediate-risk patients following a colorectal cancer screening program may have differential risk of advanced lesions depending on the findings of an index colonoscopy. The aim of the present study was to comparatively assess advanced colorectal neoplasia risk at the first follow-up colonoscopy among the different intermediate-risk subgroups with a focus on patients with three to four adenomas. METHODS: All patients recruited for a baseline screening colonoscopy between 2006 and 2011 were included. Number, size and histopathological characteristics of adenomas were collected. Main outcome was an advanced colorectal neoplasia detection rate (invasive carcinoma or advanced adenoma) at the first follow-up colonoscopy. Low- and high-risk patients were excluded. RESULTS: Five hundred and sixty-one intermediate-risk patients (63.3% men, mean age: 59.01 ± 6.16 years) underwent indexing and follow-up colonoscopy. By multivariate analysis, three to four adenomas (OR: 3.613 [95% CI: 1.661-7.859], P = 0.001) and adenoma size ≥10 <20 mm (OR: 3.374 [95% CI: 1.618-7.034], P = 0.001) were independent factors associated with advanced colorectal neoplasia. Advanced lesions were detected in 7.66% of cases. Of patients with advanced colorectal neoplasia, 51.16% belonged to the three-to-four-adenoma group and ≥1 of ≥10 <20-mm subgroups (n = 132, 23.53%). These patients demonstrated a higher rate of advanced lesions [OR: 3.886 (95% CI: 2.061-7.325), P < 0.001] than patients with three to four small adenomas of <10 mm (16.67% vs 5.07%, P < 0.001). The association between patients with small adenomas (n = 217, 38.68%) and advanced lesions was not significant (OR: 0.521 [95% CI: 0257-1.056], P = 0.066). CONCLUSION: Intermediate-risk patients with three to four small adenomas achieved a very low advanced lesion rate at follow up. Surveillance interval should be lengthened because these patients should be considered low risk.

The Role of Emergency Endoscopy in Small Bowel Bleeding: A Review.

There is no consensus on the timing and management of emergency overt obscure gastrointestinal bleeding. Emergency capsule endoscopy and balloon-assisted enteroscopy have a high diagnostic and therapeutic yield in these situations. Most lesions detected by small bowel endoscopy are amenable to endoscopic haemostasis, although some lesions still require surgery or interventional radiology. The management of these patients is varied, and doubt persists about which technique should be preferred as first-line treatment. This narrative review analyses the usefulness and impact of small bowel endoscopic techniques in the emergency setting for severe overt obscure gastrointestinal bleeding.

Não existe consenso sobre a melhor estratégia e respetivos tempos na abordagem urgente da hemorragia digestiva obscura manifesta. A cápsula endoscópica e a enteroscopia assistida por balão de urgência têm elevada rentabilidade diagnóstica e terapêutica nesta indicação. A maioria das lesões detetadas na endoscopia do intestino delgado são passíveis de hemostase endoscópica, apesar de algumas ainda necessitarem de tratamento cirúrgico ou de técnicas de radiologia de intervenção. A abordagem destes pacientes é variada e persistem dúvidas sobre qual deverá ser a técnica de primeira linha. Este artigo de revisão analisa a utilidade e o impacto das técnicas endoscópicas do intestino delgado em contexto urgente na abordagem da hemorragia digestiva obscura manifesta severa.

[Diagnosis agreement between capsule endoscopy and double-balloon enteroscopy in obscure gastrointestinal bleeding at a referral center]. / Concordancia diagnóstica entre la cápsula endoscópica y enteroscopia de doblebalón en la hemorragia digestiva media en un centro de referencia.

BACKGROUND AND AIM: Capsule endoscopy and double balloon enteroscopy are well-recognized procedures in obscure gastrointestinal bleeding, with many factors that may influence their diagnosis yield. The aim of the present study was to characterize the degree of agreement between both techniques with focus on the type of lesion in a large cohort of patients at a referral center. MATERIAL AND METHOD: One thousand two hundred and nine capsules were administered in 1,078 patients and 381 enteroscopies were performed in 361 patients with obscure-gastrointestinal bleeding from 2004 to 2014. RESULTS: Both procedures were carried out in 332 patients (mean age: 65.22 +/- 15.41, 183 men) and they have a similar diagnosis yield (70.5% vs. 69.6%, p = 0.9). Overall enteroscopy diagnosis yield was higher within patients with a previous positive capsule endoscopy (79.3% vs. 27.9%, p < 0.001). The degree of agreement was very good for polyps (0.89 [95% CI: 0.78-0.99]), good for vascular lesions (0.66 [95% CI: 0.55-0.77]) and tumors(0.66 [95% CI: 0.55-0.76]) and moderate for ulcers (0.56 [95% CI: 0.46-0.67]). Diverticula (0.39 [95% CI: 0.29-0.5]) achieved a fair agreement. The results of CE and DBE differed in 73 patients (22%). CONCLUSIONS: The present study confirms that although overall diagnostic yield by capsule endoscopy and double-balloon enteroscopy is similar, there are many factors which can modify these values, mainly the type of lesion.

Emergency double-balloon enteroscopy combined with real-time viewing of capsule endoscopy: a feasible combined approach in acute overt-obscure gastrointestinal bleeding?

BACKGROUND AND AIM: There are few data concerning emergency double-balloon enteroscopy (DBE) and its usefulness in the management of severe acute obscure gastrointestinal bleeding (OGIB). The aim of this retrospective study was to evaluate emergency DBE and capsule endoscopy (CE) in patients with overt OGIB, analyzing the feasibility of this combined approach. METHODS: Emergency DBE in patients with overt OGIB was defined as performance within 24 h of symptom onset. We reported 27 patients (16 men, mean age: 64.6 ± 17.9 years) with overt severe bleeding who underwent 29 emergency DBE (22 anterograde, 7 retrograde). Of 27 patients, 16 (59.3%) underwent CE with real time (RT) viewing. RESULTS: Patients were diagnosed with the following: Dieulafoy's lesion (DL; n = 11, 40.7%), angioectasia (n = 7, 25.9%), tumors (n = 4, 14.8%), diverticulum (n = 3, 11.1%), ulcers (n = 2, 7.4%). We diagnosed 23 lesions amenable to endoscopic hemostasis and successfully treated 21 of them (77.8%). DL detection rate was statistically higher in the emergency DBE group than in OGIB patients with DBE done 24 h after symptom onset (40.7% vs 0.9%, respectively, P < 0.001). Combined approach with RT viewing by CE correctly modified DBE management in four patients (25%). CONCLUSIONS: Emergency DBE is feasible, safe and effective in acute OGIB and may avoid major surgery, diagnosing and successfully treating most patients. Combined approach with RT viewing by CE is especially useful to identify recurrent bleeding vascular lesions such as DL that may be easily misdiagnosed by non-emergency DBE.