Single-balloon versus double-balloon endoscopy for achieving total enteroscopy: a randomized, controlled trial.

BACKGROUND: Balloon endoscopy has been accepted as an effective tool for examining the small intestine. Two types of balloon endoscopy, single and double, are commercially available. The difference in performance between these 2 types of balloon endoscopy has not yet been elucidated. OBJECTIVE: To compare the yield of single-balloon endoscopy (SBE) and double-balloon endoscopy (DBE). DESIGN: Single-center, randomized, controlled trial. SETTING: University hospital in Tokyo, Japan. PATIENTS: Patients with suspected small-bowel disease. INTERVENTIONS: SBE and DBE. MAIN OUTCOME MEASUREMENTS: Outcomes were the total enteroscopy rate, diagnostic yield, complication rate, and clinical outcomes. Analysis was done by intent to treat. RESULTS: The study started in April 2008 and was terminated in April 2010 because of an obvious disadvantage for the SBE group. Thirty-eight patients were enrolled in the study; 18 patients were assigned to the SBE group and 20 to the DBE group. The total enteroscopy rate was 0% in the SBE group and 57.1% in the DBE group (P = .002). In terms of complications, the DBE group had 1 patient with Mallory-Weiss syndrome, and the SBE group had 1 patient with hyperamylasemia. There was no difference in the overall diagnosis rate between the SBE and DBE groups (61.1% vs 50.0%, P = .49). There was no difference in therapeutic outcome between the SBE and DBE groups (27.8% vs 35.0%, P = .63). LIMITATIONS: Relatively small number of study patients. CONCLUSIONS: Total enteroscopy is more easily performed with DBE than with SBE.

Surveillance of small intestinal abnormalities in patients with hepatocellular carcinoma: a prospective capsule endoscopy study.

BACKGROUND: Patients with hepatocellular carcinoma (HCC) sometimes suffer from obscure gastrointestinal bleeding. Portal hypertension (PH), common in cirrhosis, induces esophagogastric varices. Because of the location, PH also may influence mucosal abnormalities in the small intestine. The objective of this study is to estimate the prevalence of small intestinal mucosal abnormalities in HCC patients using capsule endoscopy (CE). PATIENTS AND METHODS: We prospectively conducted CE in HCC patients, and analyzed the findings in relation to hepatic function, the number and size of HCC tumor and findings obtained by conventional endoscopy. RESULTS: Thirty-six patients (aged 66.7 ± 7.5 years, 29 men) underwent CE. Abnormal findings in the small bowel were found in 16 patients (44%), angioectasias in eight patients (22%), erosions in five (14%), varices in four (11%), polyps in four (11%), and submucosal tumor in one (3%). The patients with angioectasia had a larger spleen index than the no abnormal lesions group (85.4 ± 15.8 vs 59.0 ± 24.4, P = 0.02). The former group had been more frequently treated for esophageal varices endoscopically (62% vs 15%, P = 0.02). Large HCC nodules seemed more common in the patients with angioectasia than subjects without abnormal lesions (38% vs 5%, P = 0.06). Small intestinal varices also seemed to have a positive association with large HCC. During the follow up after CE, one patient with small intestinal polyps suffered from obscure gastrointestinal bleeding. CONCLUSIONS: CE revealed that HCC patients frequently have small intestinal mucosal lesions. In particular, small intestinal angioectasia, which may cause obscure gastrointestinal bleeding, seems to be associated with portal hypertension.

Vonoprazan versus conventional proton pump inhibitor-based triple therapy as first-line treatment against Helicobacter pylori: A multicenter retrospective study in clinical practice.

OBJECTIVE: Vonoprazan is a potassium-competitive acid blocker, a new type of acid-suppressing drug, and has recently become available for peptic ulcers, gastroesophageal reflux disease, and Helicobacter pylori (H. pylori) eradication. Its efficacy for H. pylori eradication has been reported. However, the evidence for its efficacy and feasibility remains limited. We aimed to compare the feasibility, effectiveness and safety of vonoprazan-based triple therapy with conventional proton pump inhibitor (PPI)-based triple therapy in multicenter clinical practice. METHODS: We performed a multicenter retrospective study on patients receiving first-line H. pylori eradication therapy between March 2013 and November 2015 with either vonoprazan-based triple therapy or conventional PPI-based triple therapy. RESULTS: A total of 2715 patients aged 63.0 ± 12.1 years (1412 [52.0%] males) were analyzed. Eradication rates were 87.2% (368/422) for vonoprazan-based therapy and 72.4% (1661/2293) for conventional PPI-based therapy (P < 0.01). Among the former group, there were 10 cases of diarrhea, six of nausea/vomiting, and five of rash, but the rates of these adverse events were similar to those in the conventional PPI group. CONCLUSION: Vonoprazan-based triple therapy is feasible, and has a higher rate for H. pylori eradication than conventional PPI as a first-line regimen.

Rectosigmoid findings are not associated with proximal colon cancer: analysis of 6 196 consecutive cases undergoing total colonoscopy.

AIM: To review the risk of proximal colon cancer in patients undergoing colonoscopy. METHODS: We estimated the risk of advanced proximal adenomas and cancers in 6 196 consecutive patients that underwent colonoscopy (mean age 60 years, 65% males, without prior history of colorectal examination). Neoplasms were classified as diminutive adenoma (5 mm or less), small adenoma (6-9 mm), advanced adenoma (10 mm or more, with villous component or high-grade dysplasia) and cancer (invasive adenocarcinoma). The sites of neoplasms were defined as rectosigmoid (rectum and sigmoid colon) and proximal colon (from cecum to descending colon). RESULTS: The trend of the prevalence of advanced proximal adenoma was to increase with severe rectosigmoid findings, while the prevalence of proximal colon cancer did not increase with severe rectosigmoid findings. Among the 157 patients with proximal colon cancer, 74% had no neoplasm in the rectosigmoid colon. Multivariate logistic-regression analysis revealed that age was the main predictor of proximal colon cancer and existence of rectosigmoid adenoma was not a predictor of proximal colon cancer. CONCLUSION: Sigmoidoscopy is inadequate for colorectal cancer screening, especially in older populations.

Rapid detection of mutations in the BRAF gene using real-time polymerase chain reaction and melting curve analysis.

The BRAF gene is mutated in 66% of melanomas and less frequently in various human cancers. More than 80% of these mutations are T to A transversions at nucleotide 1796 (T1796A), leading to a substitution of glutamic acid for valine at amino acid 599 (V599E). We established a new method for rapidly detecting V599E mutations using real-time polymerase chain reaction and melting curve analysis. Furthermore, we examined mutations in gastrointestinal cancer cell lines using this method. We found a mutation in 1 of 12 (8%) colorectal cancer cell lines, but no mutation was detected in 9 gastric cancer cell lines. These results suggest that the BRAF mutation is unlikely to be involved in gastric carcinogenesis.

Utility of single and double balloon endoscopy in patients with difficult colonoscopy: a randomized controlled trial.

AIM: To compare the utility of single-balloon colonoscopy (SBC) or double-balloon colonoscopy (DBC) for difficult colonoscopies. METHODS: Between August 2008 and June 2010, patients in whom total colonoscopy failed within 30 min of insertion were assigned randomly to undergo either SBC or DBC. No sedatives were used. After the endoscopy, all patients were asked to evaluate pain during the procedure on a 10-point analog scale (1 = no pain; 10 = worst imaginable pain) with a questionnaire. The study outcomes were the cecal intubation rate and time, endoscopic findings, complications, and pain score. RESULTS: The SBC and DBC groups included 11 and 10 patients, respectively. All but one SBC patient achieved total colonoscopy successfully. The cecal intubation times were 18 min (range: 10-85 min) and 12.8 min (range: 9.5-42 min) in the SBC and DBC groups, respectively (P = 0.17). No difference was observed in the prevalence of colon polyps between the SBC and DBC groups (45% vs 30%, P = 0.66). SBC showed advanced colon cancer in the ascending colon, which was inaccessible using conventional colonoscopy. The respective pain scores were 5 (1-10) [median (range)] and 5 (1-6) in the SBC and DBC groups (P = 0.64). No complications were noted in any patient. CONCLUSION: The utility of single- and double-balloon endoscopy for colonoscopy seems comparable in patients with incomplete colonoscopy using a conventional colonoscope.

Assessment of the risk factors for colonic diverticular hemorrhage.

PURPOSE: Colonic diverticulosis, although usually asymptomatic, sometimes causes diverticular hemorrhage. Studies about risk factors, other than nonsteroidal anti-inflammatory drugs, for colonic diverticular hemorrhage are limited. We conducted the present study to elucidate their significance as a risk factor. METHODS: Colonic diverticulosis was found in 1,753 patients and diverticular hemorrhage in 44 patients among 9,499 total colonoscopy examinees at the authors' institutions between September 1995 and December 2005. After reviewing their clinical features, we chose two controls for each case with diverticular hemorrhage matched for age, gender, and the location of diverticulosis. We evaluated the effects of comorbidities (hypertension, hyperlipidemia, diabetes mellitus, cerebrovascular disease, ischemic heart disease), habits (alcohol, smoking), and medications, including nonsteroidal anti-inflammatory drugs, by using conditional logistic regression analysis. RESULTS: There were no significant differences between patients with diverticular hemorrhage and those with nonbleeding diverticulosis regarding age (67 +/- 13 vs. 64 +/- 11 years) or gender ratio (male/female ratio: 36/8 vs. 1,237/472). As for location, the proportion of bilateral diverticulosis was larger among patients with hemorrhage (43 vs. 22 percent). In the case-control study, nonsteroidal anti-inflammatory drugs (odds ratio, 15.6; 95 percent confidence interval, 1.1-214; P = 0.04), hypertension (odds ratio, 6.6; 95 percent confidence interval, 2.1-20.5; P = 0.0011), and aspirin and/or other anticoagulant (odds ratio, 3; 95 percent confidence interval, 1.04-8.6; P = 0.042) were shown to be significant risk factors by multivariate analysis. CONCLUSIONS: Hypertension, nonsteroidal anti-inflammatory drugs, and anticoagulants, including aspirin, are independent risk factors for colonic diverticular hemorrhage.

Risk assessment for delayed hemorrhagic complication of colonic polypectomy: polyp-related factors and patient-related factors.

BACKGROUND: Hemorrhage is among the most serious complications of colorectal polypectomy and may occur after a longer postprocedure interval. OBJECTIVE: We aimed to elucidate the risk factors for delayed postpolypectomy hemorrhage, including both polyp characteristics and the general condition of the patients. DESIGN: Retrospective cohort study. PATIENTS: A total of 6617 cases of colorectal polypectomy was performed in 3138 consecutive patients in Japan. MAIN OUTCOME MEASUREMENTS: The risk factors for delayed postpolypectomy hemorrhage were assessed among polyp characteristics (form, size, histologic features) and the method of resection by unconditional logistic regression. Patient conditions (smoking, alcohol, hypertension, diabetes mellitus, hyperlipidemia) were compared between case-control pairs matched on polyp-related characteristics by conditional logistic regression. RESULTS: Hemorrhage occurred in 38 lesions (0.57%) of 37 patients (1.2%): 22 required endoscopic hemostasis and 1 required blood transfusion. Although polyp size was associated with the occurrence of delayed hemorrhage (10.0 +/- 6.9 mm in hemorrhage cases vs 5.6 +/- 3.8 mm in others, P < .0001), other polyp-related factors were not significant. Hypertension was a complication in 25 of 37 (68%) cases and in 21 of 74 (28%) matched controls, showing an adjusted odds ratio of 5.6 (95% CI 1.8-17.2, P = .001). Other patient characteristics were not significant. The interval between polypectomy and hemorrhage was significantly longer in patients with hypertension (median 6 days, range 2-14 days) than in those without hypertension (2.5 days, 1-9 days; P = .019). LIMITATIONS: This study does not provide information regarding prevention of hemorrhage. CONCLUSIONS: Hypertension is a significant risk factor for delayed colorectal postpolypectomy hemorrhage. The interval between polypectomy and hemorrhage can be as long as 14 days in the presence of hypertension.

Relationship between age and site of colorectal cancer based on colonoscopy findings.

BACKGROUND: Colorectal cancer occurs more frequently in older people. Because the population of aged persons is increasing, a better understanding of the characteristics of colorectal cancer with respect to age would be useful. The purpose of this study was to determine whether there is any relationship between the site of colorectal adenoma and adenocarcinoma in the colon and age. METHODS: Colonoscopy was performed (September 1995 to December 1998) on 2942 consecutive patients (1907 men, 1035 women; mean age 61 years, range 11 to 95 years) with no history of colorectal adenoma, adenocarcinoma, or inflammatory bowel disease. The occurrence of colorectal neoplasia, histologically proven as adenoma or adenocarcinoma, was analyzed for a possible association between site in the colon and patient age. RESULTS: Adenocarcinoma was found in 191 patients (196 lesions). The proportion of patients with right-sided colonic adenocarcinoma increased with patient age: < 50 years, 15% (2/13); 50 to 59 years, 21% (8/39); 60 to 69 years, 32% (18/57); 70 to 79 years, 42% (25/49); > or =80 years, 57% (16/28). The proportion of patients with right-sided adenoma did not significantly differ among age groups: < 50 years, 40% (98/246); 50 to 59 years, 41% (280/678); 60 to 69 years, 46% (459/1001); 70 to 79 years, 53% (270/508); and > or =80 years, 57% (87/152). CONCLUSION: The frequency of right-sided colon cancer increases with patient age. Hence, colonoscopy may be indicated in the elderly for colorectal cancer screening. Over half of colon carcinomas may be missed if sigmoidoscopy alone is used for screening.