Accuracy of the Narrow-Band Imaging International Colorectal Endoscopic Classification System in Identification of Deep Invasion in Colorectal Polyps.

BACKGROUND & AIMS: T1 colorectal polyps with at least 1 risk factor for metastasis to lymph node should be treated surgically and are considered endoscopically unresectable. Optical analysis, based on the Narrow-Band Imaging International Colorectal Endoscopic (NICE) classification system, is used to identify neoplasias with invasion of the submucosa that require endoscopic treatment. We assessed the accuracy of the NICE classification, along with other morphologic characteristics, in identifying invasive polyps that are endoscopically unresectable (have at least 1 risk factor for metastasis to lymph node). METHODS: We performed a multicenter, prospective study of data collected by 58 endoscopists, from 1634 consecutive patients (examining 2123 lesions) at 17 university and community hospitals in Spain from July 2014 through June 2016. All consecutive lesions >10 mm assessed with narrow-band imaging were included. The primary end point was the accuracy of the NICE classification for identifying lesions with deep invasion, using findings from histology analysis as the reference standard. Conditional inference trees were fitted for the analysis of diagnostic accuracy. RESULTS: Of the 2123 lesions analyzed, 89 (4.2%) had features of deep invasion and 91 (4.3%) were endoscopically unresectable. The NICE classification system identified lesions with deep invasion with 58.4% sensitivity (95% CI, 47.5-68.8), 96.4% specificity (95% CI, 95.5-97.2), a positive-predictive value of 41.6% (95% CI, 32.9-50.8), and a negative-predictive value of 98.1% (95% CI, 97.5-98.7). A conditional inference tree that included all variables found the NICE classification to most accurately identify lesions with deep invasion (P < .001). However, pedunculated morphology (P < .007), ulceration (P = .026), depressed areas (P < .001), or nodular mixed type (P < .001) affected accuracy of identification. Results were comparable for identifying lesions that were endoscopically unresectable. CONCLUSIONS: In an analysis of 2123 colon lesions >10 mm, we found the NICE classification and morphologic features identify those with deep lesions with >96% specificity-even in non-expert hands and without magnification. ClinicalTrials.gov number NCT02328066.

[Assessment and treatment of acute pancreatitis. Position document of the Catalan Society of Gastroenterology, Catalan Society of Surgery and Catalan Society of the Pancreas]. / Valoración y tratamiento de la pancreatitis aguda. Documento de posicionamiento de la Societat Catalana de Digestologia, Societat Catalana de Cirurgia y Societat Catalana de Pàncrees.

The incidence of acute pancreatitis (AP) is increasing. AP is one of the gastrointestinal diseases that most frequently requires hospital admission in affected individuals. In the last few years, considerable scientific evidence has led to substantial changes in the medical and surgical treatment of this disease. New knowledge of the physiopathology of AP indicates that its severity is influenced by its systemic effects (organ failure), especially if the disease is persistent, and also by local complications (fluid collections or necrosis), especially if these become infected. Treatment should be personalized and depends on the patient's clinical status, the location of the necrosis, and disease stage.

[Cost of screening for hepatocarcinoma in patients with cirrhosis: a prospective study]. / Coste del cribado del hepatocarcinoma en pacientes cirróticos: un estudio prospectivo.

INTRODUCTION: Current clinical guidelines recommend biannual screening for hepatocarcinoma in cirrhotic patients; however, the cost of this preventive activity is unknown. OBJECTIVE: To determine the cost of ultrasound screening for hepatocarcinoma in patients with cirrhosis. PATIENTS AND METHOD: Data on patients diagnosed with liver cirrhosis in a population of 245,042 inhabitants were prospectively gathered. The screening tests performed and cases of hepatocarcinoma diagnosed during the annual follow-up were included in the analysis. The cost of these tests was calculated based on the tariffs paid by insurance companies for health coverage of civil servants. RESULTS: In 2009, there were 374 patients with cirrhosis; of these, 99 were aged > 80 years, with a performance status of >2 or associated comorbidities. During the annual follow-up, the remaining patients underwent a total of 602 visits (abdominal ultrasound, blood test), four contrast-enhanced computed tomography scans, nine magnetic resonance scans, two scintigraphies, four aspiration biopsies, four radiographs and six contrast ultrasound scans. In our environment, the total estimated cost of these procedures was 37,946 €, indicating that the cost of a screening program for hepatocellular carcinoma according to the above-mentioned selection criteria is 0.155 € per inhabitant/year. If only cirrhotic patients suitable for screening are included, the annual cost of screening is 138 € per patient. CONCLUSION: The cost of an ultrasound screening program for hepatocarcinoma is 0.155 € per inhabitant/year. These data should be taken into account when considering population-based screening programs.

Diagnostic Accuracy of Tumor Markers CYFRA21-1 and CA125 in the Differential Diagnosis of Ascites.

BACKGROUND: The usefulness of tumor markers in the differential diagnosis of cancer in patients with ascites remains a matter of controversy. Few studies have reported the measurement of cancer antigen 125 (CA125) and cytokeratin 19 soluble fragments (CYFRA21-1) in ascitic fluid. The aim of the present study was to evaluate the diagnostic accuracy of these tumor markers in the detection of malignant ascites. MATERIALS AND METHODS: We analyzed CA125 and CYFRA21-1 from 143 consecutive undiagnosed patients with ascitis. RESULTS: Use of CA125 gave a sensitivity of 39.7% and a specificity of 98.8%, and CYFRA21-1 a sensitivity of 50.0% and a specificity of 97.6% in differential diagnosis of malignant ascites. For combined use of CA125 plus CYFRA21-1, sensitivity was 65.5% and specificity 96.5%. In patients with negative cytology, these two tumor markers had a sensitivity of 50% and a specificity of 96.5%. CONCLUSION: The determination of tumor markers in ascitic fluid could be useful for the diagnostic assessment of patients with ascites.

How and when should NSAIDs be used for preventing post-ERCP pancreatitis? A systematic review and meta-analysis.

BACKGROUND: Non-steroidal anti-inflammatory drugs (NSAIDs) have been shown to be efficacious to prevent pancreatitis after endoscopic retrograde cholangiopancreatography (ERCP). However, the target patients, the type of NSAID, the route of administration and the time of drug delivery remain unclear, as well as the potential efficacy in reducing the severity of pancreatitis, length of hospital stay and mortality. The objective of the study was to evaluate these questions by performing a systematic review and meta-analysis. METHODS: Multiple searches were performed in the main databases. Randomized controlled trials (RCTs) comparing NSAIDs vs. placebo in the prevention of post-ERCP pancreatitis were included. Primary endpoint of the study was the efficacy for pancreatitis prevention. Sub-analyses were performed to determine the risk reduction in high and low risk patients, and to define optimal time, route of administration, and type of NSAID. Secondary endpoints were safety, moderate to severe pancreatitis prevention and reduction of hospital stay and mortality. RESULTS: Nine RCTs enrolling 2133 patients were included. The risk of pancreatitis was lower in the NSAID group than in the placebo group (RR 0.51; 95%CI 0.39-0.66). The number needed to treat was 14. The risk of moderate to severe pancreatitis was also lower in the NSAID group. (RR 0.46; 95%CI 0.28-0.76). No adverse events related to NSAID use were reported. NSAIDs were effective in both high-risk and unselected patients (RR 0.53; 95%CI 0.30-0.93 and RR 0.57; 95%CI 0.37-0.88). In the subanalyses, only rectal administration of either indomethacin (RR 0.54; 95%CI 0.38-0.75) or diclofenac (RR 0.42; 95%CI 0.21-0.84) was shown to be effective. There were not enough data to perform a meta-analysis in hospital stay reduction. No deaths occurred. CONCLUSION: A single rectal dose of indomethacin or diclofenac before or immediately after ERCP is safe and prevents procedure-related pancreatitis both in high risk and in unselected patients.

Diagnostic accuracy of abdominal ultrasound in the screening of esophageal varices in patients with cirrhosis.

BACKGROUND: Abdominal ultrasound (US) may provide data on the presence of esophageal varices in cirrhosis. We assess the diagnostic accuracy of this procedure. PATIENTS AND METHODS: Retrospective recording of clinical data was carried out in cirrhotic patients who underwent abdominal US and upper gastrointestinal endoscopy. We compared patients with and without large varices and assessed the value of US in predicting the presence of these lesions as well as other significant variables. RESULTS: Of the 353 patients included, 123 (35%) had esophageal varices. The presence of US signs of portal hypertension independently predicted the existence of esophageal varices with a sensitivity of 87.9%, a specificity of 34.9%, a positive predictive value of 40.6%, and a negative predictive value of 85.1%, which could increase to 91.5% if the patient presented plasma albumin and platelet concentrations above the mean values (3.1 g/dl and 122×10 cells/l, respectively). Plasma albumin and platelet concentrations were the two other variables with independent predictive capacity. Applying these selection criteria, up to 30% of screening endoscopies may not be necessary, and up to 43% in patients with compensated cirrhosis. In patients with decompensated cirrhosis, however, US does not have predictive capacity. The results obtained are comparable with those reported for transient elastography. CONCLUSION: Abdominal US is a highly reliable technique for detecting patients with a low risk of presenting esophageal varices. Its use may avoid up to 43% of screening endoscopies in patients with compensated cirrhosis. The results obtained are similar to those observed using transient elastography.