Impact of periampullary diverticula on the outcome and fluoroscopy time in endoscopic retrograde cholangiopancreatography.

BACKGROUND: It is unclear whether the presence of periampullary diverticula (PAD) affects technical success and complication rates during endoscopic retrograde cholangiopancreatography (ERCP). Moreover, the impact of PAD on fluoroscopy duration is still unknown. The present study aimed to investigate the success rate and difficulty of common bile duct (CBD) cannulation, post-procedure complications and fluoroscopy duration in patients with and without PAD. METHODS: Patients from January 2008 to December 2010 with PAD (group A) and without PAD (group B) and similar indications for therapeutic ERCP were prospectively compared. The comparison included patient characteristics, findings of ERCP, and details of procedure and fluoroscopy time. The influence of papilla's location with respect to the diverticulum on procedure was also investigated. RESULTS: A total of 428 consecutive patients who had undergone therapeutic ERCP for similar indications were divided in two groups according to the presence (group A, 107 patients) or absence (group B, 321 patients) of PAD. The mean age and ASA score of the patients with PAD were significantly higher than those patients without PAD. The main indication was choledocholithiasis. Successful final CBD cannulation was achieved in 97.20% of the patients in group A vs 99.69% in group B (P=0.05). CBD diameter, number of stones and the largest stone size were significantly higher in group A than group B (P<0.001). Complete clearance of the CBD after the first attempt was achieved in 85.86% and 94.75% of the patients in groups A and B, respectively (P=0.03). In both groups, the time needed to complete the procedure and fluoroscopy time was significantly longer in patients with PAD (22.87 vs 18.99 minutes, P<0.001; 76.51 vs 47.42 seconds, P<0.001). There was no significant difference between the two groups in the complication rate. The type of papilla's location with respect to the diverticulum did not influence the total cannulation rate and post-procedure complications. CONCLUSION: The presence of a PAD does not affect the success rate and complications of therapeutic ERCP in expert hands; however, the fluoroscopy time is significantly longer in patients with PAD.

Comparison of three types of precut technique to achieve common bile duct cannulation: a retrospective analysis of 274 cases.

BACKGROUND: The aim of this retrospective study was to evaluate the success rate and complications of three precut techniques of sphincterotomy after failure of conventional techniques of cannulation of common bile duct (CBD). PATIENTS AND METHODS: Between January 2003 and October 2011, 2,903 consecutive ERCPs were performed in patients with naïve major papilla. In 283 patients in whom biliary cannulation was not achieved, precut technique was performed and these patients were included in the study. RESULTS: A total of 274 patients were included in the final analysis. Needle-knife papillotomy (NKP) was performed in 129 cases (47.1 %), suprapapillary fistulotomy (SPF) in 78 patients (28.5 %), and transpancreatic sphincterotomy (TPS) in 67 cases (24.5 %). No significant difference was observed in the initial and eventual success rate of biliary cannulation between the three groups. Overall, complications occurred in 54 patients (19.7 %), of which 33 (25.6 %) were with NKP, 6 (7.7 %) with SPF and 15 (22.4 %) with TPS, respectively, a difference statistically significant favoring the SPF group (p = 0.006). Post-procedure acute pancreatitis was developed in 27 cases (20.9 %) with NKP, compared to two cases (2.6 %) with SPF and 15 cases (22.4 %) with TPS, a difference statistically significant favoring the SPF group. No difference was observed between the groups with regard to the occurrence of post-procedure hemorrhage and perforation. CONCLUSIONS: The three types of precut sphincterotomy have no different overall CBD cannulation rates; SPF reduces post-ERCP pancreatitis risk.

Chronic pharyngitis is associated with severe acidic laryngopharyngeal reflux in patients with Reinke's edema.

OBJECTIVES: We evaluated the association between pathological acidic laryngopharyngeal reflux (LPR) events and chronic pharyngitis in patients with Reinke's edema. METHODS: We performed a prospective controlled study in 20 consecutive patients with Reinke's edema without pathological acidic LPR events (group A) and 40 consecutive patients with Reinke's edema with both clinical symptoms and 24-hour pH-metry suggesting acidic LPR (group B). The severity of acidic LPR was assessed by use of the Reflux Finding Score (RFS), the Reflux Symptom Index (RSI), and dual antimony probe 24-hour pH-metry. The patients were evaluated for the presence of chronic pharyngitis by clinical examination and biopsy specimens taken from the posterior pharyngeal wall. The Chi2 test was used to compare the groups for the presence of pharyngitis. In group B, the RSI, the RFS, and the total duration and number of acidic LPR events on 24-hour pH-metry were compared between patients with and without concomitant pharyngitis by use of the Mann-Whitney test. RESULTS: Five patients of group A and 20 patients of group B had chronic pharyngitis. Therefore, more patients with Reinke's edema and clinical signs of LPR tended to have chronic pharyngitis than did those with Reinke's edema and no clinical signs of LPR, but the difference was not statistically significant (p = 0.064; odds ratio, 3.0; 95% confidence interval, 0.9 to 9.8). Among group B patients, those with pharyngitis had significantly more acidic LPR events (p < 0.001) and a greater exposure time to gastric fluid (p = 0.008) than did those without pharyngitis. Their RFS and RSI did not differ significantly (p = 0.692 and p = 0.914, respectively). CONCLUSIONS: Only in the subgroup of patients with Reinke's edema and LPR was there a statistically significant correlation between the pH probe results and the incidence of clinical pharyngitis. Awareness should increase among physicians about addressing chronic pharyngitis in therapy for acidic LPR and/or Reinke's edema.

Double probe pH-monitoring findings in patients with benign lesions of the true vocal folds: comparison with typical GERD and the effect of smoking.

We conducted a pH-monitoring study to determine the prevalence of pathologic gastroesophageal reflux (GER+) and laryngopharyngeal reflux (LPR+) in patients with resected benign true vocal fold lesions (TVFLs) and positive reflux finding score (RFS). We compared our findings with those of patients with typical GER disease (GERD) symptoms and normal laryngoscopy. In the group of patients with TVFLs, we compared the pH-monitoring findings of smokers with those of non-smokers. Seventy-two [females 32, mean (SD) age 49.3 (13.1) years] patients with resected TVFLs (polyps: 32, nodules: 20, Reinke's edema: 12, granulomas: 4, leukoplakia: 4) and 24 [females 14, mean (SD) age 42.2 (13.4) years] patients with typical GERD symptoms, who served as controls for the hypopharyngeal measurements, underwent 24-h double probe, hypopharyngeal and distal esophageal, ambulatory pH monitoring. Thirty-eight (52.8%) patients with TVFLs had GER+ and 52 (72.2%) had LPR+. More laryngopharyngeal reflux episodes (LPREs) were detected in patients with TVFLs compared to those with GERD (P < 0.001). With respect to the specific TVFLs, 12 (37.5%) patients with polyps had GER+ and 24 (75%) had LPR+, 6 (30%) patients with nodules had GER+ and 12 (60%) had LPR+, 6 (50%) patients with Reinke's edema had GER+ and 8 (66.7%) had LPR+ and all the patients with granuloma or leucoplakia had both GER+ and LPR+. Twenty (55.6%) of the 36 smokers and 32 (88.9%) of the 36 non-smokers with TVFLs had LPR+ (P = 0.003), while GER+ was recorded in 16 (44.4%) smokers and 22 (61.1%) non-smokers (P = 0.238). Smokers had significantly less LPREs (P < 0.001). In conclusion, 24-h double probe pH monitoring may detect GER+ and/or LPR+ in a substantial proportion of patients with resected TVFLs and positive RFS. Our study suggests that LPR+ is more prevalent in patients with TVFLs compared with typical GERD patients and that non-smokers with TVFLs are more likely to have LPR+ than smokers with TVFLs.

Successful treatment of intractable bronchobiliary fistula using long-term biliary stenting.

A bronchobiliary fistula (BBF) is an uncommon entity with bilioptysis being a pathognomonic sign. We describe the case of a 41-year-old man who had recurrent BBF, 6 months after resection of the anterior segment of the right lower pulmonary lobe and repair of a BBF due to hepatic hydatid disease. Magnetic resonance cholangiography revealed a communication between the biliary tree and the lower lobe of the right lung. Endoscopic biliary sphincterotomy and repeated insertion of large size biliary plastic stents led to a successful resolution of the symptoms and closure of the fistula.

Severe acute haemorrhagic gastritis controlled by hydrogen peroxide.

A 92-year-old woman presented with severe acute haemorrhagic gastritis due to abuse of non-steroidal anti-inflammatory drugs (NSAIDs). She was treated with instillation of 150 ml 3% hydrogen peroxide (H2O2) every 2 h via a nasogastric tube. The copious amount of bright red blood through the nasogastric tube started to decline substantially after the first administration of H2O2 and continued to reveal clear material during the second and third instillation of H2O2. The total amount of H2O2 administered was 600 ml. No rebleeding and only a few flame-shaped intramucosal haemorrhages were observed on the following four consecutive daily endoscopic evaluations. These are promising observations which will have to be confirmed with respect to the safety and efficacy of H2O2 treatment by further controlled studies.

Aggressive treatment of acute anal fissure with 0.5% nifedipine ointment prevents its evolution to chronicity.

AIM: To investigate the efficacy of topical application of 0.5% nifedipine ointment in healing acute anal fissue and preventing its progress to chronicity. METHODS: Thirty-one patients (10 males, 21 females) with acute anal fissure from September 1999 to January 2005 were treated topically with 0.5% nifedipine ointment (t.i.d.) for 8 wk. The patients were encouraged to follow a high-fiber diet and assessed at 2, 4 and 8 wk post-treatment. The healing of fissure and any side effects were recorded. The patients were subsequently followed up in the outpatient clinic for one year and contacted by phone every three months thereafter, while they were encouraged to come back if symptoms recurred. RESULTS: Twenty-seven of the 31 patients completed the 8-wk treatment course, of them 23 (85.2%) achieved a complete remission indicated by resolution of symptoms and healing of fissure. Of the remaining four unhealed patients (14.8%), 2 opted to undergo lateral sphincterotomy and the other 2 to continue therapy for four additional weeks, resulting in healing of fissure. All the 25 patients with complete remission had a mean follow-up of 22.9 +/- 14 (range 6-52) mo. Recurrence of symptoms occurred in four of these 25 patients (16%) who were successfully treated with an additional 4-wk course of 0.5% nifedipine ointment. Two of the 27 (7.4%) patients who completed the 8-wk treatment presented with moderate headache as a side effect of nifedipine. CONCLUSION: Topical 0.5% nifedipine ointment, used as an agent in chemical sphincterotomy, appears to offer a significant healing rate for acute anal fissure and might prevent its evolution to chronicity.

The role of endoscopic treatment in postoperative bile leaks.

BACKGROUND/AIMS: Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication. METHODOLOGY: An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data. RESULTS: Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention. CONCLUSIONS: ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.

Endoscopic mucosal resection of lateral spreading tumors of the colon using a novel solution.

Lateral spreading tumors (LSTs) of the colon are lesions over 10 mm in diameter that are low in height and grow superficially. They are increasingly being diagnosed in Western cohorts. The aim of this study was to investigate the safety and efficacy of dextrose 50% solution in the endoscopic mucosal resection (EMR) of LSTs. The study population consisted of 21 patients with LSTs of the colorectum. The mean size of the LSTs was 23.52+/-13.60 mm. Dextrose 50% solution was injected, via a variceal needle, into the submucosa to lift up the LST sufficiently from the proper muscle layer. Subsequently, a snare was positioned around the lesion and then closed while being pressed against the mucosa, with suction being applied to draw the lesion into the snare. Blended current was used for resection. If necessary, a piecemeal technique was used to achieve complete resection. Immediate and delayed complications were recorded. After the EMR, patients were followed up at 3, 6, and 12 months or later, using total colonoscopy. Endoscopic resection was completed in all LSTs. Of the 21 LSTs, 15 (71.4%) were resected en bloc and 6 (28.6%) piecemeal. The mean amount of injected dextrose 50% solution was 14.86+/-9.13 mL. One patient (4.78%) had immediate bleeding after EMR, which was stopped endoscopically. Histologic examination of resected LSTs showed adenoma with high-grade dysplasia 9 (42.9%), adenoma with low-grade dysplasia 10 (47.6%), and invasive carcinoma 2 (9.5%). Twenty patients were followed up for 37.9+/-24.03 months. Local recurrent disease was detected in 4 patients (20%), all within 6 months of the index EMR. These recurrent lesions were completely resected endoscopically. The contribution of submucosal injection of dextrose 50% is significant for a safe and efficient EMR of LSTs of the colorectum.

Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions.

AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment. METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding and mortality rates were collected and analyzed retrospectively. RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy's lesion over a mean long-term follow-up of 29.8 mo. CONCLUSION: Bleeding from Dieulafoy's lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy's lesions.

Treatment of a duodenal perforation secondary to an endoscopic sphincterotomy with clips.

Perforation is one of the most serious complications of endoscopic sphincterotomy (ES) necessitating immediate surgical intervention. We present a case of successful management of such a complication with endoclipping. A 85-year-old woman developed duodenal perforation after ES. The perforation was identified early and its closure was achieved using three metallic clips in a single session. There was no procedure-related morbidity or complications and our patient was discharged from hospital 10 d later. Endoclipping of duodenal perforation induced by ES is a safe, effective and alternative to surgery treatment.

Long-term results of pneumatic dilation for achalasia: a 15 years' experience.

AIM: Although most patients with achalasia respond to pneumatic dilation, one-third experienced recurrence, and prolonged follow-up studies on parameters associated with various outcomes are scanty. In this retrospective study, we reported a 15-years' experience with pneumatic dilation treatment in patients with primary achalasia, and determined whether previously described predictors of outcome remain significant after endoscopic dilation. METHODS: Between September 1989 and September 2004, 39 consecutive patients with primary symptomatic achalasia (diagnosed by clinical presentation, esophagoscopy, barium esophagogram, and manometry) who received balloon dilation were followed up at regular intervals in person or by phone interview. Remission was assessed by a structured interview and a previous symptoms score. The median dysphagia-free duration was calculated by Kaplan-Meier analysis. RESULTS: Symptoms were dysphagia (n = 39, 100%), regurgitation (n = 23, 58.7%), chest pain (n = 4, 10.2%), and weight loss (n = 26, 66.6%). A total of 74 dilations were performed in 39 patients; 13 patients (28%) underwent a single dilation, 17 patients (48.7%) required a second procedure within a median of 26.7 mo (range 5-97 mo), and 9 patients (23.3%) underwent a third procedure within a median of 47.8 mo (range 37-120 mo). Post-dilation lower esophageal sphincter (LES) pressure, assessed in 35 patients, has decreased from a baseline of 35.8+/-10.4 - 10.0+/-7.1 mmHg after the procedure. The median follow-up period was 9.3 years (range 0.5-15 years). The dysphagia-free duration by Kaplan-Meier analysis was 78%, 61% and 58.3% after 5, 10 and 15 years respectively. CONCLUSION: Balloon dilation is a safe and effective treatment for primary achalasia. Post-dilation LES pressure estimation may be useful in assessing response.

Endoscopic hemoclip placement for postsphincterotomy bleeding refractory to injection therapy: report of two cases.

Bleeding is a serious complication of patients undergoing endoscopic sphincterotomy and is the most common sphincterotomy-associated cause of death. Two patients presented bleeding after endoscopic sphincterotomy. Despite injection treatment with large amounts of epinephrine (1:10,000), the bleeding was uncontrolled. Hemostasis was achieved by placing 2 and 3 hemoclips, respectively at the bleeding site. Our cases suggest that postsphincterotomy bleeding refractory to injection treatment can be safely and effectively controlled by endoscopic hemoclipping, thereby avoiding surgery.

Endoscopic hemoclip application in the treatment of nonvariceal gastrointestinal bleeding: short-term and long-term benefits.

We conducted an uncontrolled retrospective study to evaluate endoscopic hemoclip application as the first-choice hemostatic treatment of gastrointestinal bleeding lesions from a wide variety of sources. Clinical data, endoscopic findings, complications, and short- and long-term outcomes were also investigated. A total of 52 patients (men/women, 36/16; age, 65 +/- 11.5 years) were included in the study. Hemoclipping was technically successful in 51 cases (98%). The average number of therapeutic endoscopic sessions needed to achieve permanent hemostasis was 1.42 +/- 1.2 (range, 1-4). The number of hemoclips required for hemostasis depended on the nature of bleeding with the average number of hemoclips used being 3.11 +/- 1.12 (range, 2-8). No complications occurred, although 1 patient presented recurrent bleeding and was operated on. No further hemorrhage occurred during a median follow-up period of 17.32 +/- 5.4 months (range, 2-53). Endoscopic hemoclipping provided an effective and safe modality for achieving hemostasis in gastrointestinal bleeding from a wide variety of sources, with long-term benefits.

Recurrent cholangitis as the first manifestation of an intraductal papillary mucinous tumor of the pancreas.

Intraductal papillary mucinous tumor is a rare pancreatic tumor originating from the epithelium of the pancreatic duct and exhibiting papillary proliferation of tall columnar epithelial cells. The usual clinical presentation is recurrent episodes of pancreatitis due to hypersecretion of mucin and obstruction of a markedly dilated pancreatic duct. We describe a 74-year-old man who presented recurrent attacks of cholangitis, due to a common bile duct obstruction from thick pancreatic mucus reflux, as the first manifestation of intraductal papillary mucinous tumor.

Endoclipping for gastric perforation after endoscopic polypectomy: an alternative treatment to avoid surgery.

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.

Hematemesis as a presenting symptom of lung cancer with synchronous metastases to the esophagus and stomach. A case report.

A rare case of upper gastrointestinal hemorrhage due to synchronous metastases to the esophagus and stomach from an asymptomatic lung cancer is reported. A 51-year-old white man presented with hematemesis and an emergency endoscopy revealed submucosal tumorous lesions with central ulcerations in the esophagus and stomach. A needle aspiration biopsy revealed the presence of cellular proliferation of adenocarcinoma, which led to the diagnosis of lung cancer, along with a chest radiograph revealing a tumor in the right middle lung field. The importance of conducting an upper gastrointestinal endoscopic examination for staging of patients with lung cancer is stressed.

Postpolypectomy bleeding: incidence, risk factors, prevention, and management.

Endoscopic polypectomy is at the forefront of colorectal cancer (CRC) prevention. However, endoscopic polypectomy is not completely free of complications, with bleeding being one of the most common complications encountered. In view of the ongoing campaign to introduce colorectal cancer screening to the population, addressing the issue of colonoscopic complications, and postpolypectomy bleeding (PPB) in particular is becoming more important. Despite the fact that the overall incidence of PPB is low, predisposing factors need to be elucidated to further decrease the frequency of this complication. Furthermore, the role of various techniques of PPB prophylaxis remains controversial. We review recent studies on the incidence, risk factors, prophylaxis, and management of PPB.

Efficacy of colchicine in the treatment of mesenteric panniculitis in a young patient.

Mesenteric panniculitis (MP) is a rare inflammatory and fibrotic disease of the mesentery of unknown etiology. It has various clinical and radiological manifestations, posing a diagnostic challenge for clinicians. Its diagnosis is indicated via radiologic imaging and is usually confirmed via peritoneal biopsies. We describe a case of a patient with histopathologically proven MP, in which steroid dependence was successfully managed with colchicine.