Critical Analysis of the Applicability of Small Bowel Capsule Endoscopy Performance Measures among 2 Portuguese Centers with Different Capsule Endoscopy Platforms.

Introduction: The European Society of Gastrointestinal Endoscopy (ESGE) identified the need to benchmark the quality of small bowel capsule endoscopy (SBCE) and produced a set of performance measures (PM). The aim of this study is to critically evaluate the accordance of the PM for SBCE in two Portuguese centers with different SBCE platforms. Methods: The authors conducted a cross-sectional analysis of consecutive SBCE performed in an 18-month period in 2 Portuguese centers that used two different SBCE platforms Mirocam® (IntroMedic, Seoul, South Korea) and PillCam® (Medtronic, Yokneam, Israel). A total of 10 PM (6 key, 4 minor) were evaluated and compared between the 2 centers. Results: A total of 493 SBCE were included. The minimum standard established by ESGE was reached in 3/6 key PM (complete visualization, lesion detection rate, and capsule retention rate), and none of the 4 minor PM. PM compliance significantly differed between the 2 centers: complete small bowel visualization 95.9 and 90% (p = 0.01), diagnostic yield 50.6 and 63% (p = 0.005), adequate small bowel cleansing level according to Brotz scale 69.54 and 84.6% (p ≤ 0.001), patients with high risk of capsule retention offered a patency capsule 4.2 and 73% (p ≤ 0.001), respectively. Conclusion: This study highlights and critically discusses technical and organizational issues that should be considered in defining more realistic PM thresholds, aiming to improve SBCE quality.

Introdução: A Sociedade Europeia de Endoscopia Digestiva (ESGE) identificou a necessidade de avaliar a qualidade da enteroscopia por videocápsula (EVC) e produziu um conjunto de medidas de desempenho (MD). O objetivo deste estudo é avaliar criticamente a concordância das medidas de desempenho de EVC em dois centros portugueses com diferentes plataformas de EVC. Métodos: Análise transversal de EVC consecutivas realizadas em 2 centros portugueses, com diferentes plataformas de EVC Mirocam® (IntroMedic, Seul, Coreia) e PillCam® (Medtronic, Yokneam, Israel), respetivamente. Um total de 10 medidas de desempenho (6 principais, 4 minor) foram avaliadas e comparadas entre os 2 centros. Resultados: Foram incluídas 493 EVC. O standard mínimo estabelecido pela ESGE foi alcançado em 3/6 MD principais (visualização completa, taxa de detecção de lesões e taxa de cápsula retida), e nenhum nas quatro MD minor. O cumprimento das MD diferiu significativamente entre os 2 centros: visualização completa do intestino delgado 95,9 e 90% (p = 0,01), taxa de deteção de lesões 50,6% e 63% (p = 0,005), adequada preparação do intestino delgado de acordo com a escala de Brotz 69,54 e 84,6% (p ≤ 0,001), doentes com alto risco de retenção da cápsula a quem foi oferecida cápsula de patência 4,2 e 73% (p ≤ 0,001), respectivamente. Introdução: Este estudo destaca e discute criticamente questões técnicas e organizacionais que devem ser consideradas na definição de limiares de MD mais realistas, com o objetivo de melhorar a qualidade da EVC.

A diffusely enlarged pancreas: the (un)usual suspect.

An 81-years-old female presented with obstructive jaundice and a non-specific clinical picture of nausea and appetite loss. Labs demonstrated a conjugated hyperbilirrubinemia (7.7 mg/dL), increased aspartate aminotransferase and alanine aminotransferase (10xULN and 8xULN, respectively), increased lactate dehydrogenase (10xULN) and serum lipase (3xULN). CA 19.9 was 342 U/mL (Ref value < 37 U/mL). There was no evidence of peripheral lymphadenopathy or hepatosplenomegaly. Imaging (Figure 1A and 1B) revealed a marked homogeneous enlargement of the pancreas (without any well-defined mass), dilation of the extra and intra-hepatic bile ducts and ascites. Endoscopic ultrasound (Figure 1C and 1D) identified an enlarged homogeneous hypoechoic pancreas, without any well-defined lesion, no dilation of the main pancreatic duct, no peripancreatic or celiac enlarged lymph nodes. A fine-needle biopsy was performed yielding, on cytological examination and cell-block technique (Figure 2A and 2B), numerous medium/large sized atypical lymphoid cells that displayed a B-cell lineage immunophenotype (Figure 2A-2F). Even though, further characterization (by flow cytometric immunophenotyping) could not be obtained, a final diagnosis of primary pancreatic lymphoma (PPL) was assumed. Primary pancreatic lymphoma is a remarkably rare tumor of the pancreas, representing approximately 0.5% of all pancreatic neoplasms and <2% of all lymphomas (1,2). A correct diagnosis is crucial because therapeutic management differs from other pancreatic malignancies (pancreatic ductal adenocarcinoma, neuroendocrine tumor and metastases) (2,3). Two morphologic patterns of PPL are recognized: a focal form (occurring in the pancreatic head in 80% of cases) and a rarer diffuse/infiltrative pattern, as depicted herein, emulating an acute/autoimmune pancreatitis (1).

A diffusely enlarged pancreas: the (un)usual suspect

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Cytomegalovirus enterocolitis in a patient with common variable immunodeficiency: A capsule endoscopy-aided diagnosis / Enterocolitis por citomegalovirus en un paciente com inmunodeficiencia común variable Un diagnóstico asistido por cápsula endoscópica

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Severe acute colitis induced by ipilimumab / Colitis aguda grave consecuente a ipilimumab

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Superiority of the Split-dose PEG Regimen for Small-Bowel Capsule Endoscopy: A Randomized Controlled Trial.

GOALS: We aimed to evaluate the small-bowel cleansing quality, the diagnostic yield (DY), the transit time, and the patients' tolerability, by comparing the 2 different polyethylene glycol (PEG) administration schedules. BACKGROUND: The use of bowel purgatives before small-bowel capsule endoscopy (SBCE) is recommended by the ESGE guidelines. Whether this regimen can be further refined by changing the timing of administration is unknown. STUDY: Fifty-seven patients were prospectively enrolled and randomized into 2 groups: group 1 (G1, n=29) received 2 L of PEG in the day before SBCE (time between PEG and SBCE=10 h); and group 2 (G2, n=28) received 1 L of PEG in the day before SBCE and 1 L of PEG in the morning before SBCE (time between PEG and SBCE=4 h). The primary outcome measure was small-bowel cleansing quality. Small-bowel cleansing quality was evaluated according to a previously validated grading scale. RESULTS: The entire and distal half small-bowel cleansing scores were significantly higher among G2 (median score: 8 vs. 10 points, P=0.012; median score: 6 vs. 8 points, P=0.05, respectively). The DY did not differ significantly between groups. There were no significant differences in transit times between the 2 PEG regimens. Both schedules were well tolerated, showing no differences regarding symptoms while ingesting the preparation or after SBCE ingestion. CONCLUSIONS: Split-dose PEG regimen for SBCE preparation improved the small-bowel cleanliness, did not interfere with transit times and was equally well tolerated by the patients. No differences were observed regarding DY. ClinicalTrial.gov registration: NCT02396017.

Endoscopic Management of Foreign Bodies in the Upper Gastrointestinal Tract: An Evidence-Based Review Article.

Gastrointestinal foreign bodies (FB) are comprised of food bolus impaction and intentionally or unintentionally ingested or inserted true FB. Food bolus impaction and true FB ingestion represent a recurrent problem and a true challenge in gastrointestinal endoscopy. More than 80-90% of the ingested true FB will pass spontaneously through the gastrointestinal tract without complications. However, in 10-20% of the cases an endoscopic intervention is deemed necessary. True FB ingestion has its greatest incidence in children, psychiatric patients and prisoners. On the other hand, food bolus impaction typically occurs in the elderly population with an underlying esophageal pathology. The most serious situations, with higher rates of complications, are associated with prolonged esophageal impaction, ingestion of sharp and long objects, button batteries and magnets. Physicians should recognize early alarm symptoms, such as complete dysphagia, distressed patients not able to manage secretions, or clinical signs of perforation. Although many papers are yearly published regarding this subject, our knowledge is mainly based on case-reports and retrospective series. Herein, the authors summarize the existing evidence and propose an algorithm for the best approach to FB ingestion.

A definição de corpo estranho gastrointestinal compreende a ingestão acidental ou voluntária de verdadeiros corpos estranhos e o impacto alimentar. Estas entidades representam uma recorrente e desafiadora problemática para os Gastroenterologistas. Em mais de 80 a 90% dos casos referentes à ingestão de verdadeiros corpos estranhos, o mesmo passa através do tubo digestivo sem complicações. No entanto, em 10 a 20% dos casos é necessária uma intervenção endoscópica. A ingestão de verdadeiros corpos estranhos apresenta o seu pico de incidência em crianças, doentes com perturbações psiquiátricas e reclusos. Por outro lado, o impacto alimentar ocorre tipicamente na população idosa, que, na maioria dos casos apresenta uma patologia esofágica subjacente. As situações mais frequentemente associadas a complicações sérias relacionam-se com a presença prolongada de corpos estranhos ou impacto alimentar no esófago, ingestão de corpos estranhos pontiagudos, compridos, pilhas ou ímanes. O médico deve reconhecer precocemente sinais de alarme tais como disfagia completa, incapacidade de deglutir saliva ou sinais clínicos de perfuração. Apesar da publicação anual de artigos referentes a este tópico, a maioria da evidência existente na atualidade apoia-se apenas em case-reports e séries retrospetivas. Este artigo pretende resumir de modo conciso a evidência atual e propor um algoritmo versando o tratamento endoscópico de verdadeiros corpos estranhos e impacto alimentar do trato digestivo superior.

Hepatocellular Carcinoma in Chronic Hepatitis B Patients on Third Generation Nucleos(t)ides Analogs: Risk Factors and Performance of a Risk Score.

OBJECTIVE: To investigate hepatocellular carcinoma (HCC) incidence, risk factors and the performance of baseline REACH-B risk score in a Portuguese chronic hepatitis B (CHB) population on antiviral therapy. METHODS: Retrospective study of CHB patients who were treated with tenofovir or entecavir for at least 12 months. Multivariate analysis was performed to identify factors associated with HCC. The Kaplan-Meier method was used to estimate the cumulative incidence of HCC at 1, 3 and 5 years on therapy. The performance of the REACH-B score at baseline was assessed. RESULTS: One hundred and twenty patients initiated nucleos(t)ide analogs (NUC) therapy (age, 47 ± 14 years-old; 83 male; 11% had cirrhosis; 71% tenofovir; 73% HBeAg-negative; 61% treatment-naïve). After a median time under NUC of 39 months, 9 patients (7.5%) developed HCC. The calculated cumulative incidence rates of HCC at 1, 3 and 5 years on therapy were 5.1%, 7.3% and 8.8%, respectively. Independent predictors for HCC occurrence: age and cirrhosis at baseline. Diagnostic accuracy of baseline REACH-B score in predicting HCC development: AUC 0.738, 95%CI: 0.521-0.955. The cutoff value of 8 points had a sensitivity, specificity, positive predictive value and negative predictive value of 75%, 52%, 6% and 98%, respectively in predicting HCC occurrence during therapy. CONCLUSIONS: Older age and cirrhosis at baseline were independent predictors for HCC development. Discriminatory performance of baseline REACH-B score was limited.

OBJECTIVO: Estudar a incidência de carcinoma hepatocelular (CHC), factores de risco e desempenho do score REACH-B (basal) numa população portuguesa de doentes com infecção crónica pelo vírus da hepatite B (VHB) sob análogos dos nucleós(t)idos de 3ª geração (NUC). MÉTODOS: Estudo retrospetivo de uma coorte de doentes com infecção crónica pelo VHB tratados com tenofovir ou entecavir durante pelo menos 12 meses. Foi realizada uma análise multivariada para identificar os factores associados ao desenvolvimento de CHC. Através do método de Kaplan-Meier foi estimada a incidência cumulativa de CHC ao final de 1, 3 e 5 anos sob terapêutica antiviral. RESULTADOS: Cento e vinte doentes iniciaram terapêutica com um NUC (idade, 47 ± 14 anos; 83 género masculino; 11% com cirrose; 71% tenofovir; 73% AgHBe-negativo; 61% naïves). Após um período mediano de 39 meses sob NUC, 9 doentes (7.5%) desenvolveram CHC. A incidência cumulativa de CHC ao final de 1, 3 e 5 anos sob terapêutica antiviral foi de 5,1%, 7,3% e 8,8%, respetivamente. Preditores independentes de CHC: idade e cirrose diagnosticada previamente ao início da terapêutica antiviral. Precisão diagnóstica da aplicação basal do score REACH-B para predizer CHC: AUC 0,738, 95%CI: 0,521-0,955. A utilização do valor cutoff de 8 pontos produziu uma sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de 75%, 52%, 6% e 98%, respetivamente na predição de ocorrência de CHC durante o tratamento. CONCLUSÕES: Idade avançada e a presença de cirrose diagnosticada previamente ao início da terapêutica antiviral demonstraram-se preditores independentes para o desenvolvimento de CHC. O poder discriminatório basal do score REACH-B foi limitado.

Fanconi syndrome and chronic renal failure in a chronic hepatitis B monoinfected patient treated with tenofovir

Tenofovir disoproxil fumarate (TDF) is one of the first-line treatment options in chronic hepatitis B (CHB). Despite its efficacy in suppressing viral load and a high resistance barrier, long life maintenance therapy is required. Registration studies demonstrated TDF to be a safe drug. However, post-marketing experience reported cases of serious nephrotoxicity associated with hypophosphatemia, osteomalacia and, even more recently, Fanconi syndrome associated with TDF therapy in CHB monoinfected patients. Here the authors report a case of a 40 year-old male, with a CHB monoinfection, that, three years after TDF therapy, developed a progressive chronic kidney disease with a serious hypophosphatemia and a secondary osteomalacia that was manifested by bone pain and multiple bone fractures. Further investigational analyses unveiled a proximal renal tubular dysfunction, which fulfilled most of the diagnostic criteria for a Fanconi syndrome. After TDF withdrawal and oral supplementation with phosphate and calcitriol, his renal function stabilized (despite not returning to normal), proximal renal tubular dysfunction abnormalities resolved as well as osteomalacia. In conclusion, physicians should be aware that, in CHB monoinfected patients under TDF therapy, serious renal damage is possible and preventable by timely monitoring serum creatinine and phosphate (AU)

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Jejunal plasmablastic lymphoma presenting as obscure overt gastrointestinal bleeding: diagnosis by wireless capsule endoscopy

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Fanconi syndrome and chronic renal failure in a chronic hepatitis B monoinfected patient treated with tenofovir.

Tenofovir disoproxil fumarate (TDF) is one of the first-line treatment options in chronic hepatitis B (CHB). Despite its efficacy in suppressing viral load and a high resistance barrier, long life maintenance therapy is required. Registration studies demonstrated TDF to be a safe drug. However, post-marketing experience reported cases of serious nephrotoxicity associated with hypophosphatemia, osteomalacia and, even more recently, Fanconi syndrome associated with TDF therapy in CHB monoinfected patients.Here the authors report a case of a 40 year-old male, with a CHB monoinfection, that, three years after TDF therapy, developed a progressive chronic kidney disease with a serious hypophosphatemia and a secondary osteomalacia that was manifested by bone pain and multiple bone fractures. Further investigational analyses unveiled a proximal renal tubular dysfunction, which fulfilled most of the diagnostic criteria for a Fanconi syndrome. After TDF withdrawal and oral supplementation with phosphate and calcitriol, his renal function stabilized (despite not returning to normal), proximal renal tubular dysfunction abnormalities resolved as well as osteomalacia. In conclusion, physicians should be aware that, in CHB monoinfected patients under TDF therapy, serious renal damage is possible and preventable by timely monitoring serum creatinine and phosphate.

Chronic tubulointerstitial nephritis induced by 5-aminosalicylate in an ulcerative colitis patient: a rare but serious adverse event.

The 5-aminosalicylate is widely prescribed in inflammatory bowel disease patients. Its potential for renal damage has been seldom described. We report a case of a 23-year-old man who started 5-aminosalicylate after being diagnosed with ulcerative colitis. One year after, a significant decline on his creatinine clearance was noted, however, at that time, he was on an acute flare of his bowel disease and the 5-aminosalicylate dose was increased. Six months later, his renal function kept worsening and, on drug-induced toxicity suspicion, 5-aminosalicylate was halted and a kidney biopsy demonstrated a chronic tubulointerstitial nephritis. Steroids and azathioprine were started leading to partial recovery and stabilisation of his renal function. Physicians who prescribe 5-aminosalicylate to patients with inflammatory bowel disease should be aware of this adverse event.

Re-bleeding events in patients with obscure gastrointestinal bleeding after negative capsule endoscopy.

AIM: To investigate long-term re-bleeding events after a negative capsule endoscopy in patients with obscure gastrointestinal bleeding (OGIB) and the risk factors associated with the procedure. METHODS: Patients referred to Hospital Egas Moniz (Lisboa, Portugal) between January 2006 and October 2012 with OGIB and a negative capsule endoscopy were retrospectively analyzed. The following study variables were included: demographic data, comorbidities, bleeding-related drug use, hemoglobin level, indication for capsule endoscopy, post procedure details, work-up and follow-up. Re-bleeding rates and associated factors were assessed using a Cox proportional hazard analysis. The Kaplan-Meier method was used to estimate the cumulative incidence of re-bleeding at 1, 3 and 5 years, and the differences between factors were evaluated. RESULTS: The study population consisted of 640 patients referred for OGIB investigation. Wireless capsule endoscopy was deemed negative in 113 patients (17.7%). A total of 64.6% of the population was female, and the median age was 69 years. The median follow-up was forty-eight months (interquartile range 24-60). Re-bleeding occurred in 27.4% of the cases. The median time to re-bleeding was fifteen months (interquartile range 2-33). In 22.6% (n = 7) of the population, small-bowel angiodysplasia was identified as the culprit lesion. A univariate analysis showed that age > 65 years old, chronic kidney disease, aortic stenosis, anticoagulant use and overt OGIB were risk factors for re-bleeding; however, on a multivariate analysis, there were no risk factors for re-bleeding. The cumulative risk of re-bleeding at 1, 3 and 5 years of follow-up was 12.9%, 25.6% and 31.5%, respectively. Patients who presented with overt OGIB tended to re-bleed sooner (median time for re-bleeding: 8.5 mo vs 22 mo). CONCLUSION: Patients with OGIB despite a negative capsule endoscopy have a significant re-bleeding risk; therefore, these patients require an extended follow-up strategy.