Establishment of standards for the referral of large nonpedunculated colorectal polyps: an international expert consensus using a modified Delphi process.

BACKGROUND AND AIMS: Resection of colorectal polyps has been shown to decrease the incidence and mortality of colorectal cancer. Large nonpedunculated colorectal polyps are often referred to expert centers for endoscopic resection, which requires relevant information to be conveyed to the therapeutic endoscopist to allow for triage and planning of resection technique. The primary objective of this study was to establish minimum expected standards for the referral of large non-pedunculated colonic polyps for potential endoscopic resection. METHODS: A Delphi method was used to establish consensus on minimum expected standards for the referral of large colorectal polyps among a panel of international endoscopy experts. The expert panel was recruited through purposive sampling, and 3 rounds of surveys were conducted to achieve consensus. Quantitative and qualitative data were analyzed for each round. RESULTS: A total of 24 international experts from diverse continents participated in the Delphi study, resulting in consensus on 19 statements related to the referral of large colorectal polyps. The identified factors, including patient demographic characteristics, relevant medications, lesion factors, photodocumentation, and the presence of a tattoo, were deemed important for conveying the necessary information to therapeutic endoscopists. The mean scores for the statements, which were scored on a scale of 1 to 10, ranged from 7.04 to 9.29, with high percentages of experts considering most statements as a very high priority. Subgroup analysis according to continent revealed some variations in consensus rates among experts from different regions. CONCLUSIONS: The identified consensus statements can aid in improving the triage and planning of resection techniques for large colorectal polyps, ultimately contributing to the reduction of colorectal cancer incidence and mortality.

Endoscopic ultrasound-guided gastrojejunostomy for benign gastric outlet obstruction (GOO): a retrospective analysis of patients and outcomes.

BACKGROUND AND STUDY AIMS: Endoscopic ultrasound-guided gastrojejunostomy (EUS-GJ) has been well utilized in treating malignant gastric outlet obstructions (GOO) given its efficacy and lower risk profile compared to surgery. However, its efficacy and potential for use in patients with benign GOO who are poor surgical candidates is not well documented. The aim of this study was to examine the role of EUS-GJ in treatment of benign GOO in select patients. PATIENTS AND METHODS: This is a single-center, open-label, retrospective descriptive study that included all consecutive patients undergoing EUS-GJ to treat benign causes of GOO. Direct antegrade and direct retrograde methods were utilized. RESULTS: A total of 18 patients were included, 38.9% female with an average age of 63.3 years. Extrinsic GOO was present in (10 of 18) 55.5% of patients and intrinsic etiology was present in (8 of 18) 45.5% of patients. Technical success was achieved in 100% (18 of 18) patients and clinical success was achieved in 94% (17 of 18) patients. In total, 13 patients had follow-up endoscopy, 2 patients were treated relatively recently in time, 1 patient was lost to follow-up, and 2 patients died of other chronic illnesses. Stents remained in place for a median of 286 days (range 88-1444 days). In patients whose stents were removed, 75% (3 of 4) had extrinsic etiologies of GOO. CONCLUSIONS: This study reports a favorable long-term patency with excellent technical and clinical success of EUS-GJ in patients with benign GOO. Despite the limitations of sample size and retrospective nature, it adds to the extremely limited literature of EUS-GJ in management of patients with benign GOO.

A Rare Case of Emphysematous Gastritis Secondary to Organo-Axial Gastric Volvulus Associated With Sarcina ventriculi.

Gastric volvulus is a potentially life-threatening condition that can compromise the blood supply to the stomach predisposing to ischemia, eventually necrosis and cell death associated with gas-forming bacteria. Sarcina ventriculi has been associated with emphysematous gastritis also. We report a case of emphysematous gastritis associated with S. ventriculi in the setting of organo-axial gastric volvulus.

Non-variceal Upper Gastrointestinal Bleeding and Its Endoscopic Management.

Upper gastrointestinal bleeding (UGIB) is a major cause of morbidity and mortality. Clinical symptoms that patients may present with include: hematemesis, coffee-ground emesis, melena, and hematochezia. Clinical signs can range from tachycardia to shock. The anatomical landmark that differentiates upper gastrointestinal (GI) bleeds from lower bleeds is the ligament of Treitz. The first steps of treating a patient who presents with signs of UGIB are resuscitation with appropriate fluids and blood products as necessary. The consideration of endoscopy and the urgency at which it should be performed is also vital during initial resuscitation. Endoscopic therapy should ideally be performed within 24 hours of presentation after initial stabilization with crystalloids and blood products. Intravenous proton pump inhibitors are the mainstay in the initial management of upper GI bleeding from a non-variceal etiology, and they should be administered in the acute setting to decrease the probability of high-risk stigmata seen during endoscopy. Pro-kinetic agents can be given 30 minutes to an hour before endoscopy and may aid in the diagnosis of UGIB. There are 3 broad categories of endoscopic management for UGIB: injection, thermal, and mechanical. Each endoscopic method can be used alone or in combination with others; however, the injection technique with epinephrine should always be used in conjunction with another method to increase the success of achieving hemostasis. In this review article, we will review the steps of triage and initial resuscitation in UGIB, causes of UGIB and their respective management, several endoscopic techniques and their effectiveness, and prognosis with a primary focus limited to non-variceal bleeding.

COVID-19, coronavirus, SARS-CoV-2 and the small bowel

Although SARS-CoV-2 may primarily enter the cells of the lungs, the small bowel may also be an important entry or interaction site, as the enterocytes are rich in angiotensin converting enzyme (ACE)-2 receptors. The initial gastrointestinal symptoms that appear early during the course of COVID-19 support this hypothesis. Furthermore, SARSCoV virions are preferentially released apically and not at the basement of the airway cells. Thus, in the setting of a productive infection of conducting airway epithelia, the apically released SARS-CoV may be removed by mucociliary clearance and gain access to the GI tract via a luminal exposure. In addition, post-mortem studies of mice infected by SARS-CoV have demonstrated diffuse damage to the GI tract, with the small bowel showing signs of enterocyte desquamation, edema, small vessel dilation and lymphocyte infiltration, as well as mesenteric nodes with severe hemorrhage and necrosis. Finally, the small bowel is rich in furin, a serine protease which can separate the S-spike of the coronavirus into two “pinchers” (S1 and 2). The separation of the S-spike into S1 and S2 is essential for the attachment of the virion to both the ACE receptor and the cell membrane. In this special review, we describe the interaction of SARS-CoV-2 with the cell and enterocyte and its potential clinical implications

Direct percutaneous endoscopic jejunostomy - Should we move on to singleand double-balloon enteroscopy techniques?

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Systemic inflammatory response and thrombosis due to alterations in the gut microbiota in COVID-19

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Prevention of gastric cancer: a challenging but feasible task / Prevención del cáncer gástrico: una tarea difícil pero factible

Despite its declining incidence gastric cancer still ranks as the second most common malignancy of the digestive tract, accounting for 10% of cancer deaths worldwide. At the time of the diagnosis less than 15% of the patients are in the stage of early cancer, the only stage in which a definite cure of gastric cancer is possible. Therefore the challenges are either early detection or even better prevention of gastric cancer. H. pylori has become recognized as the major risk factor for gastric adenocarcinoma. Epidemiological, biological, histomorphologic, molecular-genetic, epidemiological evidence and more recently few clinical trails have shown that H. pylori eradication has the potential to prevent the development of gastric cancer. Currently, H. pylori eradication is an indication for the prevention of gastric cancer in patients and groups of individuals with strongly increased risk, but further investigations are still required before an implementation of a general and global policy to eradicate H. pylori for the prevention of gastric cancer can be instituted. At present time, the main challenge remains to find out at what point mucosal abnormalities are no longer reversible and gastric cancer development cannot be prevented despite H. pylori eradication.

A pesar de la disminución en su incidencia, aún hoy el cáncer gástrico se presenta como la segunda causa más común de muerte por enfermedad maligna del tubo digestivo, siendo responsable del 10% de las muertes por cáncer a nivel mundial. Al momento del diagnóstico menos del 15% de los pacientes se encuentran en la etapa de cáncer gástrico temprano, el único estadío en el cual es posible su curación. Por lo tanto, el desafío está en la detección temprana o aún mejor, en la prevención del cáncer gástrico. H. pylori ha sido reconocido como el factor de riesgo más importante para el desarrollo del adenocarcinoma de estómago. Evidencia epidemiológica, biológica, histológica, molecular y más recientemente algunos estudios clínicos han demostrado que la erradicación del H. pylori tiene el potencial de prevenir el desarrollo de lesiones premalignas y del cáncer gástrico. Actualmente la erradicación del H. pylori está indicada para la prevención del cáncer gástrico en pacientes y grupos de individuos con alto riesgo, pero futuras investigaciones son aún necesarias antes de que sea establecida una política global para la erradicación del H. pylori en la prevención del cáncer gástrico. Actualmente el mayor desafío radica en encontrar en qué punto los cambios en la mucosa gástrica se tornan irreversibles, siendo el cáncer gástrico no prevenible a pesar de la erradicación del H. pylori.

Utilidad diagnóstica y terapéutica de la endoscopía de doble balón: experiencia con 225 exámenes / Diagnostic and therapeutic utility of double balloon endoscopy: experience with 225 procedures

Introducción: la endoscopía de doble balón (EDB) es un nuevo método endoscópico para examinar el intestino delgado. Objetivo: evaluar el rendimiento diagnóstico y terapéutico de la EDB. Pacientes y métodos: todos los pacientes que fueron evaluados por sospecha de patología del intestino delgado durante un período de 2 1/2 años en un estudio de cohorte prospectivo unicéntrico. A todos los pacientes se les realizó al menos una EGD y una colonoscopía previa. Todos los pacientes recibieron preparación del intestino delgado el día previo al procedimiento usando preparación estándar de colon. Resultados: se realizaron 225 EDB en 178 pacientes (95 hombres, 83 mujeres; edad mediana 59 años, rango 12-93); vía oral (n=160), vía anal (n=65). Las indicaciones de EDB incluyeron (una o más indicaciones por paciente): sangrado gastrointestinal de origen oscuro (n=83), sospecha o evaluación de pacientes con enfermedad de Crohn (n=35), diarrea, malabsorción o sospecha de enfermedad celíaca (n=11), búsqueda y remoción de pólipos en pacientes con síndrome de Peutz-Jehgers o síndrome de poliposis adenomatosa familiar (n=23), búsqueda de tumor primario o seguimiento (n=14), dolor abdominal(n=6) y misceláneas (isquemia, engrosamiento de pliegues en estudios radiológicos, etc); (n=6). La duración media del procedimiento fue de 50 minutos (rango 20- 150 min). La exposición media a radiación fue 206 d Gy/cm2 (rango 0-1492). La inserción media en intestino delgado fue de 180 cm, con un rango de 5 cm a a totalidad del intestino delgado (650 cm, rango 20 cm a 650 cm), inserción media por vía oral fue de 240 cm, y por vía anal 65 cm (rango 10 cm a 150 cm). Un nuevo diagnóstico fue realizado o confirmado en 108 de 178 pacientes (60%). Los hallazgos incluyeron: angiodisplasias, ulceraciones, yeyunopatía por hipertensión portal, estenosis, pólipos (incluyendo hamartomas en pacientes con síndrome de Peutz-Jeghers y lipoma), yeyunitis isquémica y normal. DBE resultó en una intervención...

Introduction: Double balloon enteroscopy (DBE) is a new endoscopic method for the examination of the small intestine. Objective: To determine the diagnostic yield and therapeutic utility of DBE. Patients and methods: All patients undergoing DBE using a Fujinon intestinoscope for suspected small bowel diseases during a 2 1/2 year period were studied in a prospective single-center cohort study. All patients underwent rior EGD and colonoscopy. Patients underwent small bowel cleansing on the day before the procedure using a standard colon lavage solution. Results: 225 DBE in 178 patients, (95 males, 83 females; mean age 59 years-old, range 12-93); oral route (n=160), anal (n=65). Indications (one or more per patient): GI bleeding (n=83), suspected Crohn’s disease or evaluation of small bowel involvement or complications (n=35), diarrhea or malabsorption or suspected celiac disease (n=11), polyp removal in Peutz-Jeghers’ syndrome or familial polyposis (n=23), tumor surveillance or search of primary tumor (n=14), abdominal pain (n=6) and miscellaneous (n=6). Mean duration of the procedure was 50 min, range 20 min to 150 min. Mean radiation exposure: 206 d Gy/cm2 (range 0-1492). The overall mean depth of small bowel insertion was 180 cm, ranging from 5 cm to the entire small bowel (650 cm). The mean depth of insertion via the oral route was 240 cm (range 20 cm to 650 cm) and via the anal route it was 65 cm (range 10 cm a 150 cm). A new diagnosis was reached in 108/178 patients (60%). Findings included: angiodysplasia, ulcerations, stenosis, polyps, portal jejunopathy, ischemic jejunitis and normal. DBE resulted in a therapeutic intervention (endoscopic, medical or surgical, excluding blood transfusions) in 64% (115/178) of the patients. Conclusions: DBE was clinically useful for reaching a new diagnosis and to start new therapies, change existing therapies, and perform an operative intervention or to provide therapeutic endoscopy in...