COVID-19 and gastrointestinal endoscopy: What should be taken into account?

On March 11, 2020 the World Health Organization declared COVID-19 pandemic, leading to a subsequent impact on the entire world and health care system. Since the causing Severe Acute Respiratory Syndrome Coronavirus 2 houses in the aerodigestive tract, activities in the gastrointestinal outpatient clinic and endoscopy unit should be limited to emergencies only. Health care professionals are faced with the need to perform endoscopic or endoluminal emergency procedures in patients with a confirmed positive or unknown COVID-19 status. With this report, we aim to provide recommendations and practical relevant information for gastroenterologists based on the limited amount of available data and local experience, to guarantee a high-quality patient care and adequate infection prevention in the gastroenterology clinic.

Impact of endoscopy system, high definition, and virtual chromoendoscopy in daily routine colonoscopy: a randomized trial.

BACKGROUND: To improve detection of mucosal lesions during colonoscopy a number of imaging modalities have been suggested, including high definition and virtual chromoendoscopy. Given the theoretical advantage of these new imaging techniques, we aimed to investigate their use for the detection of polyps in patients referred for colonoscopy in a large tertiary hospital. METHODS: Demographic, endoscopic, and histological data from 1855 consecutive patients undergoing colonoscopy were collected prospectively. Patients were randomly assigned to three endoscopy systems (Fujinon, Olympus, or Pentax) in combination with four modalities: conventional white-light colonoscopy (n = 505), high definition white-light colonoscopy (n = 582), virtual chromoendoscopy (n = 285) and high definition virtual chromoendoscopy (n = 483). RESULTS: The mean adenoma detection rate (ADR) was 34.9 %, and the adenoma per colonoscopy rate (APCR) was 2.1. No significant differences were noted between the three endoscopy systems. Moreover, no differences in ADR or APCR were observed between the four imaging modalities. High definition white-light colonoscopy resulted in a significantly higher detection of sessile serrated adenomas (8.2 % vs. 3.8 %; P < 0.01) and adenocarcinomas (2.6 % vs. 0.5 %; P < 0.05) compared with the conventional procedure. CONCLUSIONS: No significant differences in ADR or APCR between different endoscopy systems, high definition, and/or virtual chromoendoscopy could be observed in routine colonoscopies in the general population. High definition endoscopy was associated with a significantly higher detection rate of serrated adenomas and adenocarcinomas.

Chromoendoscopy versus narrow band imaging in UC: a prospective randomised controlled trial.

BACKGROUND: Patients with long-standing UC have an increased risk for the development of colonic neoplastic lesions. Chromoendoscopy (CE) has been proven to enhance neoplasia detection while the role of virtual chromoendoscopy (VC) is still to be defined. OBJECTIVE: To compare the performance of CE to VC for the detection of neoplastic lesions in patients with long-standing UC. DESIGN: A multicentre prospective randomised controlled trial. 131 patients with long-standing UC were randomised between CE with methylene blue 0.1% (n=66) or VC with narrow band imaging (NBI) (n=65). Biopsies were taken from visible lesions and surrounding mucosa. No random biopsies were performed. The primary outcome was the difference in total number of neoplastic lesions detected in each group. RESULTS: There was no significant difference between NBI and CE for neoplasia detection. Mean number of neoplastic lesions per colonoscopy was 0.47 for CE and 0.32 for NBI (p=0.992). The neoplasia detection rate was not different between CE (21.2%) and NBI (21.5%) (OR 1.02 (95% CI 0.44 to 2.35, p=0.964). Biopsies from the surrounding mucosa yielded no diagnosis or dysplasia. The per lesion neoplasia detection was 17.4% for CE and 16.3% for NBI (OR 1.09 (95% CI 0.59 to 1.99, p=0.793). The total procedural time was on average 7 min shorter in the NBI group. CONCLUSION: CE and NBI do not differ significantly for detection of colitis-associated neoplasia. Given the longer withdrawal time for CE and easier applicability, NBI may possibly replace classical CE. TRIAL REGISTRATION NUMBER: NCT01882205; Results.

Pan-Colonic Pressurizations Associated With Relaxation of the Anal Sphincter in Health and Disease: A New Colonic Motor Pattern Identified Using High-Resolution Manometry.

OBJECTIVES: Only a few studies have applied high-resolution manometry (HRM) to the study of colonic motility in adults and none of them have concurrently evaluated colonic and anal motor activity. The aim of the study was to evaluate colonic and anal motor activity by means of HRM in healthy subjects. As the present study revealed the presence of a new colonic motor pattern (pan-colonic pressurizations) in healthy subjects, three additional studies were conducted: the first and the second to exclude that this motor event results from an artifact due to abdominal wall contraction and to confirm its modulation by cholinergic stimulation, and the third, as pilot study, to test the hypothesis that this colonic pattern is defective in patients with chronic constipation refractory to current pharmacological treatments. METHODS: In both volunteers and patients the HRM catheter was advanced proximally during colonoscopy. RESULTS: In all subjects, pressure increases of 15±3 mm Hg and 24±4 s simultaneously occurring in all colonic sensors (pan-colonic pressurizations) and associated with anal sphincter relaxation were identified. Subjects had 85±38 pan-colonic pressurizations, which increased significantly during meal (P=0.007) and decreased afterward (P=0.01), and were correlated with feelings of and desire to evacuate gas. The mean number of propagating sequences was 47±39, and only retrograde increased significantly postprandially (P=0.01). Pan-colonic pressurizations differed from strain artifacts and significantly increased after prostigmine. In patients pan-colonic pressurizations were significantly reduced as compared with volunteers. CONCLUSIONS: Pan-colonic pressurizations associated with relaxations of the anal sphincter represent a new colonic motor pattern that seems to be defective in patients with treatment-refractory chronic constipation and may have a role in the transport of colonic gas and in the facilitation of the propagating sequence-induced colonic transport.

Diagnosis and Management of Esophageal Fistulas After Lung Transplantation: A Case Series.

Background: Lung transplantations are highly complex procedures, often conducted in frail patients. Through the addition of immunosuppressants, healing can be compromised, primarily leading to the development of bronchopleural fistulas. Although esophageal fistulas (EFs) after lung transplantation remain rare, they are associated with significant morbidity. We aimed to investigate the clinical presentation, diagnostic approaches, and treatment strategies of EF after lung transplantation. Methods: All patients who developed EF after lung transplantation at the University Hospitals Leuven between January 2019 and March 2022 were retrospectively reviewed and the clinical presentations, diagnostic approaches, and treatment strategies were summarized. Results: Among 212 lung transplantation patients, 5 patients (2.4%) developed EF. Three patients were male and median age was 39 y (range, 34-63). Intraoperative circulatory support was required in 3 patients, with 2 needing continued support postoperatively. Bipolar energy devices were consistently used for mediastinal hemostasis. All EFs were right-sided. Median time to diagnosis was 28 d (range, 12-48) and 80% of EFs presented as recurrent respiratory infections or empyema. Diagnosis was made through computed tomography (n = 3) or esophagogastroscopy (n = 2). Surgical repair with muscle flap covering achieved an 80% success rate. All patients achieved complete resolution, with only 1 patient experiencing a fatal outcome during a complicated EF-related recovery. Conclusion: Although EF after lung transplantation remains rare, vigilance is crucial, particularly in cases of right-sided intrathoracic infection. Moreover, caution must be exercised when applying thermal energy in the mediastinal area to prevent EF development and mitigate the risk of major morbidity. Timely diagnosis and surgical intervention can yield favorable outcomes.

Factors influencing outcome of angiographic embolization for gastroduodenal hemorrhage related to peptic ulceration.

PURPOSE: Long-term outcome and prognostic factors of transcatheter embolization for gastroduodenal peptic ulcer bleeding are unknown. This study was conducted to evaluate the clinical outcome and factors associated with early recurrent bleeding and 30-day mortality of transcatheter arterial embolization (TAE) for severe, upper gastroduodenal hemorrhage associated with peptic ulcer and refractory to medical and endoscopic therapy. METHODS: A monocenter, retrospective study from 2005 to 2020 including 76 consecutive patients who underwent TAE as first-line therapy for bleeding gastroduodenal peptic ulcers refractory to endoscopic therapy. Patient demographics, endoscopy findings, co-morbidities and interventional procedure findings were recorded. The outcome measures were technical and clinical success, procedure related complications, recurrent bleeding, length of hospital stay, 30-day mortality and overall survival. RESULTS: The technical success rate was 96% and the clinical success rate was 65,8%. The rebleeding and 30-day mortality rate were 30,7% and 22,4% respectively. A higher international normalized ratio (INR) was a statistically significant risk factor for 30-day mortality (OR, 7.15; 95% CI, 1.67-30.70; p = 0.008). The mean overall survival was 3.76 years (1.16---5.09; 95% CI); a lower Charlson Comorbidity Index (CCI) and a lower Rockall score were significantly associated with a longer overall survival (HR, 1.24; 95% CI, 1.14-1.35; p = 0.0001; HR, 1.32; 95% CI, 1.10-1.59; p = 0.003) respectively. Early rebleeding was significantly associated with a lower overall survival (HR, 2.72; 95% CI, 1.57-4.71; p = 0.0004). CONCLUSION: A higher INR was a significant risk factor with a higher 30-day mortality. A lower CCI, a lower Rockall score and the absence of early rebleeding were significantly associated with a longer overall survival.

Implementation of the Aldrete score reduces recovery time after non-anesthesiologist-administered procedural sedation in gastrointestinal endoscopy.

Background and study aims Procedural sedation and analgesia (PSA) by trained non-anesthesiologist physicians and/or nurses is often performed during endoscopic procedures. Discharge from the recovery area after monitored observation is frequently based on fixed time parameters or subjective clinical assessment. In this study, the effect of implementation of the Aldrete score on recovery time after procedural sedation was analyzed in a real-life setting. Patients and methods A prospective observational study of patients undergoing procedural sedation and analgesia during gastroscopy, colonoscopy or endoscopic ultrasound was performed. All procedures were randomly included to represent a real-life situation with different endoscopists, recovery nurses, endoscopy systems and indications. After a first observation period, all endoscopy nurses were trained to implement the Aldrete score when discharging patients, followed by a second observation period. Results During the first observation period, the average time spent in the recovery area was 59 ±â€Š22 minutes after procedural sedation. After implementation of the Aldrete score, the recovery time decreased significantly to 47 ±â€Š25 minutes ( P  < 0.01) with identical doses of procedural sedation and analgesia. The decrease in time was between 19 % and 35 % for the different endoscopic procedures. Conclusions Implementation of the Aldrete score after procedural sedation and analgesia significantly reduces the time spent in the recovery area. The score can be used to safely implement a discharge policy that provides more efficient and standardized management for an endoscopy service.

Clostridium perfringens splenic abscess treated with percutaneous drainage and antibiotic therapy: a case report.

INTRODUCTION: Splenic abscesses are a rare medical entity with high mortality, with Clostridium perfringens being an exceptional pathogen. We present the first case describing an abscess of the spleen in a patient undergoing treatment with adalimumab, an anti-tumour necrosis factor commonly used in inflammatory bowel diseases. PATIENT: We describe the case of a 73-year-old woman, treated with adalimumab therapy, who was found to have a splenic abscess, caused by C. perfringens. RESULT: After antibiotic treatment and percutaneous drainage, the patient recovered both clinically and radiographically. DISCUSSION: We reviewed literature about C. perfringens splenic abscesses. In all cases identified, a splenectomy was performed. This is the first case description of splenic abscess caused by C. perfringens where a percutaneous drainage was performed, leading to complete recovery in our patient. This seems to indicate that a splenectomy is not necessary in all C. perfringens splenic abscesses.

Live Imaging of Primary Neurons in Long-Term Cryopreserved Human Nerve Tissue.

Tissue cryopreservation provides a convenient solution for tackling one of the major problems in neuroscience research, namely, the scarce availability of human nerve tissues, especially if needed alive. While brain tissue can be used only postmortem, live nerve tissue can reasonably well be harvested from the periphery. A valuable source of primary neurons is the intestine, which compared with brain has the advantage to be safely accessible via endoscopy. The nerve tissue innervating the intestine (the enteric nervous system; ENS) can be sampled with regular endoscopic biopsy forceps and remains viable for multiple physiological and immunohistochemical tests, as previously demonstrated. Here, we present a method to preserve, over longer periods of time, human primary neurons contained in these biopsies. The use of a cryoprotective agent and the application of controlled cooling revealed to be crucial to properly store the nerve tissue and to enable functional measurements after thawing. These primary neurons were evaluated for functionality (live imaging) and morphology (histology) up to one year after cryopreservation. Calcium (Ca2+) imaging indicated that human primary neurons remained viable and responded to selective stimulations (serotonergic and nicotinic agonists) after cryopreservation. Additionally, immunohistochemistry performed with specific neuronal markers showed that nerve structure and neuronal morphology were retained, with no signs of cellular damage. In this study, we demonstrate that the human ENS is a realistic source of primary neurons, which can be successfully preserved over long times and as such can be exploited both for gastrointestinal-specific as well as for general neuroscience research.

High-resolution manometry reveals different effect of polyethylene glycol, bisacodyl, and prucalopride on colonic motility in healthy subjects: An acute, open label, randomized, crossover, reader-blinded study with potential clinical implications.

BACKGROUND: Polyethylene glycol (PEG), bisacodyl, and prucalopride have been reported to be more effective than placebo in treating patients with constipation but about 50% of the patients still do not respond to these medications. Only bisacodyl and prucalopride are expected to directly stimulate the colonic motility in humans in vivo. As no previous study has done this, the aim of the study was to investigate the effect of PEG, bisacodyl, and prucalopride as compared to placebo on colonic motility assessed by means of the high-resolution manometry (HRM) in healthy subjects. METHODS: Ten healthy subjects have been enrolled in an acute, open label, randomized, reader-blinded, crossover study and requested to undergo a colonoscopy-assisted HRM measuring their colonic motility before and after oral administration of 13.8 g (two doses) PEG, 10 mg bisacodyl, 2 mg prucalopride, and placebo. KEY RESULTS: In the human prepared colon, oral administration of PEG significantly increases the number of low-amplitude long distance propagating contractions (p = 0.007 vs placebo) while bisacodyl significantly increases the number of high-amplitude propagating contractions (HAPCs) (all p < 0.01 vs PEG, prucalopride, and placebo). Prucalopride has no major effect on the number of propagating contractions but increases HAPCs amplitude (p = 0.01). CONCLUSIONS & INFERENCES: In humans, PEG, prucalopride, and bisacodyl have distinct effects on colonic motility. This information has clinical implication, as it indicates that the combination of prucalopride and bisacodyl, normally not considered in clinical practice, could be effective in treating patients with constipation refractory to single medications.

Implementing capnography to help improve patient safety during procedural sedation: quality improvement in a high-volume gastroenterology department.

OBJECTIVE: Respiratory compromise is a major cause of adverse events during procedural sedation; continuous monitoring is vital for identifying and halting decompensation. We performed a quality improvement investigation to assess patient safety during procedural sedation in gastroenterology and the impact of implementing capnography monitoring. PATIENTS AND METHODS: Sedation-related adverse events and interventions were prospectively recorded during the endoscopic procedure and in recovery. Assuming rates in published literature, power analysis determined that at least 1332 patients were required to show a 20% improvement in patient safety. Recorded sedation-related adverse events (mild and severe oxygen desaturations, bradycardia and tachycardia) and interventions were anonymized and aggregated to evaluate the quality improvement. Patient safety under current care was determined before capnography (Medtronic) was implemented in combination with training. RESULTS: Between February 2018 and April 2018, a baseline (1092 patients) for outcomes under current care was completed, with 11.45 events per 100 procedures recorded. Between May 2018 and July 2018, 1044 procedures including capnography monitoring were performed with 5.08 events per 100 procedures recorded. The distribution of American Society of Anesthesiologists scores and procedure types between baseline and capnography were comparable. The absolute difference between baseline and capnography was -6.4 events per 100 procedures [95% confidence interval (CI), -4.1 to -8.7; P ≤ 0.0001]. The 55% reduction in adverse events surpassed the 20% improvement in patient safety set as the goal of this quality improvement. After multivariate regression, the adjusted odds ratio for events after implementation of capnography was 0.46 (95% CI, 0.32-0.66). CONCLUSIONS: Addition of capnography to current care significantly decreased procedure-related safety events.

Delayed Bleeding of the Transplant Duodenum After Simultaneous Kidney-pancreas Transplantation: Case Series.

BACKGROUND: In simultaneous pancreas-kidney (SPK) transplant recipients, the majority of complications described in the literature, are early postoperative complications. However, there is growing attention for late complications associated with SPK transplantation. METHODS: In this case series, we present 3 cases, 2 enterically and 1 bladder-derived SPK transplant patients, with anastomotic hemorrhage of the donor duodenum as a very late complication, >10 years after transplantation (11, 22, and 18 y later, respectively). RESULTS: In our center, 122 SPK transplantations have been performed between January 1992 and June 2018. The 3 cases reported here are the only patients in our cohort presenting with delayed anastomotic hemorrhage of the donor duodenum (2.5%). In the first 2 patients, reintervention with reconstruction of the anastomosis was performed. A congestive and friable mucosa was seen, and the resection specimen showed enlarged and congestive submucosal veins in both patients. There was no recurrence of bleeding after reintervention. In the third patient, enteric derivation was not possible because of the extremely fragile intestinal tissue perioperatively, and a conservative approach was taken. As possible precipitating factors are concerned, all 3 of our patients were taking low-dose aspirin and/or clopidogrel as secondary cardiovascular prevention. CONCLUSIONS: Bleeding of the transplanted donor duodenum can present as a late complication, several years after SPK transplantation. The development of enlarged, congestive submucosal veins could play a role in these late bleedings, and antiplatelet therapy could be a precipitating factor. Further research is necessary to investigate the pathophysiology, the prevalence, optimal treatment, and the consequent influence on mortality, morbidity, and graft loss after SPK transplantation.

Long-term outcome of transcatheter embolotherapy for acute lower gastrointestinal hemorrhage.

OBJECTIVES: We sought to assess the safety, short- and long-term efficacy, and durability of transcatheter embolization for lower gastrointestinal hemorrhage (LGH) unresponsive to endoscopic therapy and to analyze the overall survival of the embolized patients. METHODS: Between January 1997 and January 2008, 122 patients were referred for angiographic evaluation to control major LGH. Overall, 43 patients (35.3%) presented with angiographic signs of contrast extravasation. In 39 patients (26 men, 13 women; mean age 67.7 years), a transcatheter embolization was performed to stop the bleeding. RESULTS: In all 39 patients, no contrast extravasation could be depicted on completion of angiography after embolization. Rebleeding occurred in eight patients (20%), in six of them within the first 30 days after embolization. Ischemic intestinal complications requiring surgery occurred in four patients (10%) within 24 h after embolization. Long-term follow-up depicted estimated survival rates of 70.6, 56.5, and 50.8% after 1, 3, and 5 years, respectively. CONCLUSIONS: Transcatheter embolotherapy to treat lower gastrointestinal bleeding is very effective, with a relatively low rebleeding and ischemic complication rate, mostly occurring within the first month after the embolization. Long-term follow-up shows a very low late rebleeding rate, and half of the embolized patients survive more than 5 years. This study shows that the majority of patients presenting with lower gastrointestinal bleeding, unresponsive to endoscopic therapy, do not benefit from transcatheter embolization. In cases of angiography extravasation, a good immediate clinical outcome-defined as high immediate success with acceptable rebleeding-and ischemic complication rate may be obtained.

The treatment of advanced colorectal cancer: where are we now and where do we go?

The treatment of patients with metastatic colorectal cancer has changed dramatically over recent years. The more optimal use of 5-fluorouracil (5-FU) in association with folinic acid (FA), the development of new drugs such as irinotecan and oxaliplatin and of the oral fluoropyrimidines, capecitabine and UFT, have contributed to increased therapeutic options and to the improved outcome of patients with metastatic colorectal cancer. It is shown that combination therapy with 5-FU/FA and irinotecan or oxaliplatin is more active than 5-FU/FA in the first-line treatment of advanced colorectal cancer. Irinotecan and oxaliplatin are also active in the second-line treatment of colorectal cancer. The oral fluoropyrimidines seem to have an activity comparable to that of intravenous 5-FU/FA in the first-line treatment of metastatic colorectal cancer. New agents acting on novel targets are under development: epidermal growth factor inhibitors, vascular endothelial growth inhibitors, COX-2 inhibitors and farnesyl transferase inhibitors might play a role in the future in the treatment of colon cancer.