Device-assisted enteroscopy in the surveillance of intestinal hamartomas in Peutz-Jeghers syndrome.

Background and study aims Peutz-Jeghers syndrome (PJS) is an autosomal-dominant genetic disorder characterized by the formation of hamartomatous polyps in the gastrointestinal tract. These polyps result in significant morbidity due to adverse events (AEs) including intestinal obstruction, bleeding, and malignancy. The aim of this study was to describe the role of device-assisted enteroscopy (DAE) in monitoring and prophylactic polypectomy within the small bowel. Patients and methods Electronic medical records were surveyed to identify all DAE procedures performed in patients with PJS at three US referral centers between January 1, 2007 and January 1, 2020. Individual charts were reviewed to collect and analyze specific data points. Primary end points included AEs associated with DAE-related polypectomy and the rate of laparotomy in PJS patients prior to, and following, index DAE. Secondary data points included patient characteristics, procedural details, and size/location/distribution of small bowel hamartomas. Results Twenty-three patients met our inclusion criteria. Of these, 18 (75%) had previously undergone small bowel surgery prior to index DAE. Between 2007 and 2020, 46 DAEs were performed in these patients with an average of one exam every 2.5 years. A total of 131 polypectomies were performed with an AE rate of 1.5%. None of our cohort required emergent surgery related to AEs of small bowel hamartomas over 336 years of aggregated follow-up. Conclusions Endoscopic management of small bowel polyps in patients with PJS using DAE is an effective strategy for prophylactic removal of hamartomas. DAE surveillance and endoscopic polypectomy is safe and may decrease the need for repeated laparotomy in patients with PJS.

Ischemic Colitis Due to Idiopathic Myointimal Hyperplasia of the Mesenteric Veins.

Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a rare and poorly understood noninflammatory ischemic colitis. First reported by Genta and Haggitt in 1991, the disease typically presents with chronic abdominal pain, weight loss, and diarrhea with or without hematochezia in middle-aged men. IMHMV is frequently misdiagnosed as an inflammatory bowel disease. The pathophysiology of IMHMV involves the proliferation of the intimal smooth muscle in mesenteric veins leading to bowel ischemia. The etiology of this process remains unknown. There are no good medical therapies for IMHMV, and surgical resection, a curative intervention, is typically required to make the diagnosis. We present the case of a 66-year-old man with IMHMV diagnosed with endoscopic biopsies.

Quality of Capsule Endoscopy Reporting in Patients Referred for Double Balloon Enteroscopy.

Background: Abnormal video capsule endoscopy (VCE) findings often require intervention with double balloon enteroscopy (DBE). Accurate VCE reporting is important for procedural planning. In 2017 the American Gastroenterological Association (AGA) published a guideline that included recommended elements for VCE reporting. The aim of this study was to examine adherence to the AGA reporting guidelines for VCE. Methods: The medical records of all patients who underwent DBE at a tertiary academic center between February 1, 2018, and July 1, 2019, were retrospectively reviewed to identify the VCE report that prompted DBE. Data were collected on the presence of each reporting element recommended by the AGA. Differences in reporting between academic and private practices were compared. Results: A total of 129 VCE reports were reviewed (84 private practice and 45 academic practice). Reports consistently included indication, date, endoscopist, findings, diagnosis, and management recommendations. Timing of anatomic landmarks and abnormalities were included in only 87.6% of reports and preparation quality in only 26.2%. Reports from private practice groups were significantly more likely to include the type of capsule (P < 0.001). VCE reports from academic centers were more likely to include adverse outcomes (P < 0.001), pertinent negatives (P = 0.0015), extent of exam (P = 0.009), previous investigations (P = 0.045), medications (P < 0.001), and document communication to patient/referring physician (P = 0.001). Conclusions: Most VCE reports in both private and academic settings included the important elements recommended by the AGA; however only 87% listed the times of landmarks and abnormal findings, which are crucial in determining the type and direction of approach for subsequent interventions. It is unclear whether the quality of VCE reporting influences the outcome of subsequent DBE.

Clinical Predictors of a Positive Ct Angiogram Study Used for the Evaluation of Acute Gastrointestinal Hemorrhage.

BACKGROUND: Acute gastrointestinal (GI) bleeding is one of the leading causes of emergency department visits and hospital admissions. CT angiography (CTA) has had an expanding role in the evaluation of acute GI bleeding because it is rapidly performed, widely available, reasonably sensitive and provides precise localization when positive. We attempted to identify patient and clinical characteristics that predict CTA results in order to help guide the utilization of this modality in patients with acute GI bleeding. METHODS: In this retrospective study, we analyzed all CTAs performed for the evaluation of GI bleeding in the Duke University healthcare system between October 2019 and March 2020. We captured patient characteristics including age, sex, vital signs, hemoglobin, platelets, PT/INR, and anticoagulation status. Study indications were grouped by suspected source of bleeding: upper GI bleeding (hematemesis or coffee-ground emesis) vs small bowel bleeding (melena or "dark stools") vs lower GI bleeding (hematochezia or bright red blood per rectum (BRBPR)). Chi-square, Wilcoxon, t test, and multivariate logistic regression were used to describe and assess the relationship between patient characteristics and study outcomes (Table 1). Table 1 Univariate analysis of patient characteristics by CT angiography outcome Patient Characteristics by Positive CT for GI Bleed No (N = 274) Yes (N = 43) Total (N = 317) p value Gender 0.451  Female 138 (50.4%) 19 (44.2%) 157 (49.5%)  Male 136 (49.6%) 24 (55.8%) 160 (50.5%) Age, median (Q1,Q3) 65 (51,75) 70 (62,80) 66 (52, 76) < 0.012 Heart rate, median (Q1,Q3) 86 (74,100) 89 (72,98) 86 (74, 99) 0.782 MAP, mean (SD) 87.32 (15.52) 81.72 (16.53) 86.56 0.033 Shock index, median (Q1,Q3) 0.70 (0.58, 0.85) 0.78 (0.55, 1.00) 0.71 (0.58, 0.85) 0.352 Hemoglobin 0.332  N 273 43 316  Median (Q1, Q3) 8.50 (6.90, 11.00) 7.70 (6.50, 11.30) 8.45 (6.90, 11.00) Baseline hemoglobin 0.202  N 258 39 297  Median (Q1, Q3) 11.20 (9.40, 13.00) 12.00 (9.40, 14.00) 11.20 (9.40, 13.00) Hemoglobin drop from baseline 0.062  N 258 39 297  Median (Q1, Q3) 2.10 (0.60, 3.70) 2.70 (1.20, 4.80) 2.20 (0.70, 3.80) Platelets, median (Q1, Q3) 219.5 (141, 301) 183 (139, 246) 217 (139, 282) 0.102 INR 0.272  N 263 42 305  Median (Q1, Q3) 1.10 (1.00, 1.30) 1.20 (1.00, 1.30) 1.10 (1.00, 1.30) Anticoagulation 0.131  No 155 (56.6%) 19 (44.2%) 174 (54.9%)  Yes 119 (43.4%) 24 (55.8%) 143 (45.1%) Upper GI bleeding 0.401  No 251 (91.6%) 41 (95.3%) 292 (92.1%)  Yes 23 (8.4%) 2 (4.7%) 25 (7.9%) Small Bowel bleeding 0.761  No 216 (78.8%) 33 (76.7%) 249 (78.5%)  Yes 58 (21.2%) 10 (23.3%) 68 (21.5%) Lower GI bleeding 0.091  No 134 (48.9%) 15 (34.9%) 149 (47.0%)  Yes 140 (51.1%) 28 (65.1%) 168 (53.0%) 1Chi-Square 2Wilcoxon 3Equal Variance T-Test RESULTS: A total of 317 patients underwent CTA between October 2019 and March 2020. Forty-three patients (13.6%) had a CTA positive for active bleeding. Multivariable logistic regression showed that after controlling for age, mean arterial pressure (MAP) and indication, only a hemoglobin drop from baseline was significantly associated with a positive CTA. For each 1 g / dL drop in hemoglobin from the patient's baseline, the odds of a positive CT increased by 1.17 (OR 1.17 95% CI 1.00 - 1.36, p = 0.04). Age (OR 1.02 95% CI 0.99 - 1.04, p = 0.06) and hematochezia / BRBPR (OR 2.09 95% CI 0.94-4.64, p = 0.07) approached statistical significance. CONCLUSIONS: In patients who present to the hospital with GI bleeding, CTA can be a helpful triage tool that is most helpful in older patients with suspected lower GI bleeding with a drop in hemoglobin from baseline. Other clinical factors including MAP and the use of anticoagulants were not predictive of a positive CTA.

Studierfenster: an Open Science Cloud-Based Medical Imaging Analysis Platform.

Imaging modalities such as computed tomography (CT) and magnetic resonance imaging (MRI) are widely used in diagnostics, clinical studies, and treatment planning. Automatic algorithms for image analysis have thus become an invaluable tool in medicine. Examples of this are two- and three-dimensional visualizations, image segmentation, and the registration of all anatomical structure and pathology types. In this context, we introduce Studierfenster ( www.studierfenster.at ): a free, non-commercial open science client-server framework for (bio-)medical image analysis. Studierfenster offers a wide range of capabilities, including the visualization of medical data (CT, MRI, etc.) in two-dimensional (2D) and three-dimensional (3D) space in common web browsers, such as Google Chrome, Mozilla Firefox, Safari, or Microsoft Edge. Other functionalities are the calculation of medical metrics (dice score and Hausdorff distance), manual slice-by-slice outlining of structures in medical images, manual placing of (anatomical) landmarks in medical imaging data, visualization of medical data in virtual reality (VR), and a facial reconstruction and registration of medical data for augmented reality (AR). More sophisticated features include the automatic cranial implant design with a convolutional neural network (CNN), the inpainting of aortic dissections with a generative adversarial network, and a CNN for automatic aortic landmark detection in CT angiography images. A user study with medical and non-medical experts in medical image analysis was performed, to evaluate the usability and the manual functionalities of Studierfenster. When participants were asked about their overall impression of Studierfenster in an ISO standard (ISO-Norm) questionnaire, a mean of 6.3 out of 7.0 possible points were achieved. The evaluation also provided insights into the results achievable with Studierfenster in practice, by comparing these with two ground truth segmentations performed by a physician of the Medical University of Graz in Austria. In this contribution, we presented an online environment for (bio-)medical image analysis. In doing so, we established a client-server-based architecture, which is able to process medical data, especially 3D volumes. Our online environment is not limited to medical applications for humans. Rather, its underlying concept could be interesting for researchers from other fields, in applying the already existing functionalities or future additional implementations of further image processing applications. An example could be the processing of medical acquisitions like CT or MRI from animals [Clinical Pharmacology & Therapeutics, 84(4):448-456, 68], which get more and more common, as veterinary clinics and centers get more and more equipped with such imaging devices. Furthermore, applications in entirely non-medical research in which images/volumes need to be processed are also thinkable, such as those in optical measuring techniques, astronomy, or archaeology.

Clinical Features and Management of Small Bowel Masses Detected During Device-Assisted Enteroscopy: A Multi-Center Experience.

Background: Small bowel mass lesions (SBMLs) are rare, span a range of different histologies and phenotypes, and our understanding of them is limited. Some lesions occur in patients with recognized polyposis syndromes and others arise sporadically. The current literature regarding SBMLs is limited to small retrospective studies, case reports, and small case series. This large multi-center study aims to understand the various clinical presentations, histologies and management options for SBMLs. Methods: After obtaining Institutional Review Board (IRB) approval, electronic records were used to identify all device-assisted enteroscopy (DAE) performed for luminal small bowel evaluation in adult patients at three US referral centers (Duke, LSU and UMass) from January 1, 2014, to October 1, 2020. We identified all patients within this cohort in whom a SBML was detected. Using a focused electronic medical record chart review, we collected patient, procedure, and lesion-related data and used descriptive statistics to explore relationships between these data and outcomes. Results: A total of 218 patients (49 at Duke, 148 at LSU, and 21 at UMass) in this cohort had at least one SBML found on DAE. The most common presenting symptoms were iron-deficiency anemia/bleeding (73.3%) and abnormal imaging (33.6%). Thirty-five percent of patients had symptoms for more than a year prior to their diagnosis. Most patients (71.6%) underwent video capsule endoscopy (VCE) prior to DAE and 84% of these exams showed the lesion. The lesion was seen less frequently (48.9%) on computed tomography (CT) scan performed prior to DAE. The majority of lesions were found on antegrade (56%) or retrograde (29.8%) double-balloon enteroscopy (DBE). The most common lesion phenotypes were submucosal (41.3%) and pedunculated (33%) with a much smaller number being sessile (14.7%) or obstructing/invasive (11%). They were found equally as commonly in the jejunum (46.3%) and ileum (49.5%). Most lesions were 10 - 20 mm in size (47%) but 22.1% were larger than 20 mm. The most common histologies were neuroendocrine tumors (NETs, 20.6%) and hamartomas (20.6%). Primary adenocarcinoma of the small bowel was rare, constituting only 5% of lesions. The majority of polyps (78.4%) were sporadic, compared to 21.7% associated with a polyposis or hereditary cancer syndrome, most commonly Peutz-Jeghers syndrome (18.3%). After DAE, 37.6% were advised to undergo surgical resection and 48% were advised to undergo endoscopic surveillance or no further management because of benign histology or successful endoscopic resection. Conclusions: In this multi-center retrospective study we found that SBMLs are more likely to be sporadic than syndromic, medium in size and either pedunculated or submucosal. NETs and hamartomas predominated and symptoms, most commonly anemia, can be present for more than a year prior to diagnosis. Close to one half of lesions required either no further intervention or only endoscopic surveillance.

Indications, Contraindications, and Considerations for Video Capsule Endoscopy.

Video capsule endoscopy is indicated in a broad range of clinical settings, most commonly in evaluating suspected small bowel bleeding. It is also useful in diagnosing Crohn's disease and monitoring patients with known Crohn's. Video capsule endoscopy has a role in evaluating patients with refractory celiac disease symptoms and in surveying patients with polyposis syndromes. The only absolute contraindication to video capsule endoscopy is luminal gastrointestinal tract obstruction. Despite manufacturer statement, video capsule endoscopy can be used safely in patients with implantable cardiac devices including pacemakers, defibrillators, and ventricular assist devices.

Use, Yield, and Risk of Device-assisted Enteroscopy in the United States: Results From a Large Retrospective Multicenter Cohort.

INTRODUCTION: Since 2001, device-assisted enteroscopy (DAE) has revolutionized the diagnostic and therapeutic capabilities for managing small bowel pathology. Though commonly performed, there have been no recent large studies to assess the use, yield, and risks of DAE and none that include all 3 DAE modalities. We hypothesized that DAE is safe with high diagnostic and therapeutic yields achieved within reasonable procedure duration and here we present a large retrospective multicenter US study evaluating the use, yield, and complications of DAE. METHODS: After obtaining institutional review board approval, electronic records were used to identify all DAE's performed for luminal small bowel evaluation in adult patients at 4 US referral centers (Duke University Medical Center, New York University Langone Medical Center, Louisiana State University Health Sciences Center, and University of Massachusetts Medical Center) from January 1, 2014 to January 1, 2019. Electronic medical records were reviewed to collect and analyze a variety of procedure-related outcomes. Using the data pooled across centers, descriptive statistics were generated for the patient and procedure-related characteristics and outcomes; relationships between characteristics and outcomes were explored. RESULTS: A total of 1787 DAE's were performed over this 5-year period (392 at Duke University Medical Center, 887 at Louisiana State University Health Sciences Center, 312 at New York University Langone Medical Center, and 195 at University of Massachusetts Medical Center). Of these, there were 1017 (57%) double-balloon, 391 (29%) single-balloon, and 378 (21%) spiral enteroscopies. The mean age of patients undergoing DAE was 66 years and 53% of examinations were performed on women; 18% of patients in the cohort underwent >1 DAE over this time span. A total of 53% of examinations were performed for suspected small bowel bleeding, 31% were directly guided by video capsule endoscopy findings and 8% were performed for abnormal imaging. A total of 85% of examinations used an antegrade approach and DAE took a mean of 45 minutes to complete; 76% of examinations revealed abnormal findings, with vascular, inflammatory, and neoplastic findings seen in 49%, 17%, and 15% of the cohort, respectively. Older age was significantly associated with any abnormal finding, including arteriovenous malformations (P<0.0001); 50% of examinations included a therapeutic maneuver, most commonly argon plasma coagulation/cautery (43%). There were complications in 16 examinations (0.9%) including 2 perforations (0.1%), 6 cases with bleeding (0.3%) and 1 episode of pancreatitis (0.1%). CONCLUSIONS: DAE is most commonly performed to evaluate suspected small bowel bleeding and is commonly directed by video capsule findings. DAE is safe, has a high diagnostic yield, with 76% of examinations showing abnormal findings, and frequently features therapeutic maneuvers. Advancing age is associated with abnormal findings on DAE.

[Lino Castle - An interior design concept to improve inpatient treatment in child and adolescent psychiatry]. / Burg Lino ­ Ein innenarchitektonisches Konzept zur Verbesserung der stationären Behandlung in der Kinder- und Jugendpsychiatrie.

Lino Castle - An interior design concept to improve inpatient treatment in child and adolescent psychiatry Abstract. Only very few data exist concerning hospital architecture in psychiatry/child and adolescent psychiatry. Previous data suggest that architectural improvements do reduce the application of coercive measures as well as reducing aggressive behavior, endangerment of self and others, and provoking changes in the kind and frequency of medication. In order to improve the overall hospital environment of inpatient treatment, the Center for Child and Adolescent Psychiatry and Psychotherapy of Clienia Littenheid AG developed a spatial and communication concept named "Lino Castle." In cooperation with patients, their parents as well as members of the multidisciplinary team, we implemented a concept that serves to ameliorate the recovery process of the children and adolescents. "Lino Castle" is deeply rooted in the history of the local village and aims to allow patients to feel at ease for the duration of their stay. It hosts seven characters that serve as guardians and protectors of the individual wards and represent various types of disorders and emotional states. The respective architectural concept grew out of the storyline of "Lino Castle" and combines colors, forms, materials, graphics, and furniture to ensure an environment conducive to healing and reduced anxiety. With the implementation of "Lino Castle," we observed that the number of admissions and hospital occupancy increased significantly, whereas the length of stay and the ratio of involuntary admissions in closed wards decreased. We presume that this turn of events is due to higher commitment, acceptance, and less aggressive behavior in the patients, and to higher motivation and work satisfaction in the staff.

A Client/Server based Online Environment for the Calculation of Medical Segmentation Scores.

Image segmentation plays a major role in medical imaging. Especially in radiology, the detection and development of tumors and other diseases can be supported by image segmentation applications. Tools that provide image segmentation and calculation of segmentation scores are not available at any time for every device due to the size and scope of functionalities they offer. These tools need huge periodic updates and do not properly work on old or weak systems. However, medical use-cases often require fast and accurate results. A complex and slow software can lead to additional stress and thus unnecessary errors. The aim of this contribution is the development of a cross-platform tool for medical segmentation use-cases. The goal is a device-independent and always available possibility for medical imaging including manual segmentation and metric calculation. The result is Studierfenster (studierfenster.at), a web-tool for manual segmentation and segmentation metric calculation. In this contribution, the focus lies on the segmentation metric calculation part of the tool. It provides the functionalities of calculating directed and undirected Hausdorff Distance (HD) and Dice Similarity Coefficient (DSC) scores for two uploaded volumes, filtering for specific values, searching for specific values in the calculated metrics and exporting filtered metric lists in different file formats.

Use of the National Institutes of Health Consensus Guidelines Improves the Diagnostic Sensitivity of Gastrointestinal Graft-Versus-Host Disease.

CONTEXT: - Graft-versus-host disease of the gastrointestinal tract is a common complication of hematopoietic stem cell transplant associated with significant morbidity and mortality. Accurate diagnosis can be difficult and is a truly clinicopathologic endeavor. OBJECTIVES: - To assess the diagnostic sensitivity of gastrointestinal graft-versus-host disease using the 2015 National Institutes of Health (NIH) histology consensus guidelines and to analyze histologic findings that support the guidelines. DESIGN: - Patients with allogeneic hematopoietic stem cell transplants were identified via a retrospective search of our electronic medical records from January 1, 2005, to January 1, 2011. Endoscopies with available histology were reviewed by 2 pathologists using the 2015 NIH guidelines. The clinical diagnosis was used as the gold standard. A nontransplant set of endoscopic biopsies was used as a control. RESULTS: - Of the 250 total endoscopies, 217 (87%) had a clinical diagnosis of gastrointestinal graft-versus-host disease. Use of the NIH consensus guidelines showed a sensitivity of 86% and a specificity of 65%. Thirty-seven of 58 (64%) cases with an initial false-negative histopathologic diagnosis were diagnosed as graft-versus-host disease on our review. CONCLUSIONS: - Use of the NIH histology consensus guidelines results in a high sensitivity and specificity, thereby decreasing false-negatives. Additionally, use of the NIH guidelines aids in creating uniformity and diagnostic clarity. Correlation with clinical and laboratory findings is critical in evaluating the differential diagnosis and to avoid false-positives. As expected, increased apoptosis with decreased inflammation was associated with a pathologic diagnosis of graft-versus-host disease and supports the NIH guidelines.

Radiofrequency ablation (RFA) vs. argon plasma coagulation (APC) for the management of gastric antral vascular ectasia (GAVE) in patients with and without cirrhosis: results from a retrospective analysis of a large cohort of patients treated at a single center.

INTRODUCTION AND STUDY AIMS: Gastric antral vascular ectasia (GAVE) is a mucosal abnormality associated with multiple conditions, most notably cirrhosis and systemic sclerosis, that causes indolent gastrointestinal bleeding. It is primarily managed with endoscopic therapy. Traditionally, GAVE is endoscopically ablated using argon plasma coagulation (APC) but radiofrequency ablation (RFA) is emerging as an alternative modality. No prior comparison of the 2 modalities has been published. PATIENTS AND METHODS: After receiving IRB approval, we reviewed our electronic health records to identify all patients who underwent endoscopic evaluation for GAVE between January, 2011 and October, 2016. We compared important variables between APC and RFA, as well as between cirrhosis and non-cirrhosis, using the Chi-square test and the Wilcoxon two-sample test as appropriate. RESULTS: During our study period, 81 patients were endoscopically evaluated for GAVE. 24 patients were treated with APC alone, 28 with RFA alone and 25 patients received both treatment modalities. CONCLUSIONS: RFA and APC were both effective in treating bleeding from GAVE. Though we found subtle differences, patients underwent a similar number of treatment sessions and had similar procedure times and a similar time between sessions no matter the treatment modality used.

Late Gastrointestinal Complications of Allogeneic Hematopoietic Stem Cell Transplantation in Adults.

Gastrointestinal (GI) complications including graft-versus-host disease (GVHD) are a major cause of morbidity and mortality in allogenic stem transplant recipients. Although several studies have previously looked into the acute GI complications, fewer smaller studies have reported late complications. In this large study we focus on the late (100 days post-transplant) GI complications in allogenic stem transplant recipients. In this single-center, retrospective study of all adult allogenic stem cell transplant recipients who had their transplant at Duke University over a 6-year period, 479 patients underwent allogenic stem cell transplant, of whom 392 recipients survived for at least 100 days post-transplant. Late GI symptoms were noted in 71 patients, prompting endoscopic evaluation. The primary endpoint of our study was the diagnosis of GI-GVHD based on endoscopic findings, whereas overall survival and nonrelapse mortality were the secondary endpoints. Of the 71 patients who underwent endoscopy, 45 (63%) had GI-GVHD. Of these 45 patients, 39 (87%) had late acute GVHD, 1 (2%) had chronic GVHD, and 5 patients (11%) had overlap disease. Of the patients who did not have GVHD, the symptoms were mostly related to infectious and inflammatory causes. Less common causes included drug toxicity, food intolerance, disease relapse, and motility issues. In a multivariate analysis the factors most indicative of GI-GVHD were histologic findings of apoptosis on the tissue specimen (odds ratio, 2.35; 95% confidence interval, 1.18 to 4.70; P = .015) and clinical findings of diarrhea (odds ratio, 5.43; 95% confidence interval, 1.25 to 23.54; P = .024). The median survival time from the first endoscopy was 8.5 months. The incidence of nonrelapse mortality at 6 months was 31% in patients with GI-GVHD and 19% in patients without GI-GVHD (P = .42). All patients with GI-GVHD were on steroid therapy, and 31% of them received total parenteral nutrition. In our population close to one-fifth of allogenic transplant recipients experienced late GI complications, warranting endoscopic evaluation. Most of these patients were found to have GI-GVHD that had a high incidence of nonrelapse mortality at 6 months and close to one-third of these patients needed total parenteral nutrition.

Non-Meckel's Small Bowel Diverticular Bleeding: Two Case Reports and a Review of the Literature.

Gastrointestinal bleeding from non-Meckel's small bowel diverticulosis is uncommon. Depending on the diverticulum's location, a patient's presentation can suggest either an upper or lower gastrointestinal source. We present two cases of bleeding from non-Meckel's small bowel diverticula. One patient was managed successfully with endoscopic therapy, and the second required surgical resection after two failed attempts at achieving hemostasis endoscopically.

The Diagnostic Yield of Repeated Endoscopic Evaluation in Patients with Gastrointestinal Bleeding and Left Ventricular Assist Devices.

INTRODUCTION: Left ventricular assist devices (LVADs) are increasingly common in patients with advanced heart failure. GI bleeding (GIB) occurs in 20-30 % of these patients and can arise anywhere in the GI tract. Given the high rates of GIB in this population, our aim was to determine the diagnostic yield of repeated endoscopic evaluation in these patients. METHODS: We performed a retrospective review of all 257 patients who had LVADs placed between 2008 and 2013 at Duke University Hospital and identified all patients who underwent any endoscopic evaluation for GIB. RESULTS: Of the 257 patients with LVADs placed, 78 (30 %) underwent at least one endoscopy for GIB. A source was identified in 36 % of cases, most commonly angioectasias (53.6 %). Treatment was performed in 67.9 % of patients and hemostasis was achieved in all. 64.1 % of the cohort underwent a second endoscopy for GIB. 42.9 % of these exams revealed a bleeding source. Endoscopic treatment was employed in 76.2 %. 38.5 % of the cohort underwent a third endoscopic exam for bleeding and a source was identified in 53.3 % with angioectasias remaining most common (56.3 %). By Fisher's exact and Chi-square testing, only the presence of a bleeding source (p = 0.0034) and use of hemostatic therapy (p = 0.0127) on the index examination were significantly associated with re-bleeding. CONCLUSIONS: GIB is common in patients with LVADs. The diagnostic and therapeutic yield of endoscopy is remains high with repeated interventions. Despite these high yields, a large portion of the cohort requires repeated interventions for recurrent bleeding.

The Diagnostic Yield of Site and Symptom-Based Biopsies for Acute Gastrointestinal Graft-Versus-Host Disease: A 5-Year Retrospective Review.

BACKGROUND: Graft-versus-host disease (GVHD) complicates half of hematopoietic stem cell transplants (HCT), and the gastrointestinal tract is commonly affected. Endoscopic biopsies have a key role in the diagnosis. The optimal procedure(s) to perform and site(s) to biopsy remain unclear. METHODS: We retrospectively analyzed the charts of all adult patients who underwent allogeneic HCT at Duke University Medical Center between 1/1/05 and 1/1/11 and extracted data from those who underwent endoscopic biopsy for suspected GVHD. All histology was re-evaluated by blinded pathologists using 2006 NIH diagnostic criteria and then compared to the original clinical diagnosis of GVHD. RESULTS: A total of 169 adult patients underwent 250 endoscopic procedures to evaluate GVHD. The sensitivity of biopsies for clinical GVHD was 76 and 72% for upper and lower tract sites, respectively. In the presence of nausea, upper tract biopsies were positive for GVHD in 65%, 70% while lower tract biopsies were positive in 61-70%. In the presence of diarrhea, lower tract biopsies were positive in 65%, while upper tract sites were positive in 64-69%. Twenty six (40%) of the sixty-five endoscopies that simultaneously sampled upper and lower tract sites had discordant results. All were histologically positive for GVHD, yet 15% of upper tract biopsies and 25% of lower tract biopsies were negative. CONCLUSIONS: In this large review, the overall sensitivity of biopsies taken during EGD and Flex-Sig was 76 and 72%, respectively. A symptom-driven biopsy approach was not clearly supported as upper tract and lower tract biopsies were similarly diagnostic for GVHD regardless of symptoms.

Deep enteroscopy with a conventional colonoscope: initial multicenter study by using a through-the-scope balloon catheter system.

BACKGROUND AND AIMS: The advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories. METHODS: We performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position. RESULTS: A total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. The average advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. There were no procedural adverse outcomes reported in the 98 cases. CONCLUSIONS: The TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using a conventional colonoscope without the need for an overtube. Procedure time is shorter than that of other forms of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.

A computational method for planning complex compound distributions under container, liquid handler, and assay constraints.

A systematic method for assembling and solving complex compound distribution problems is presented in detail. The method is based on a model problem that enumerates the mathematical equations and constraints describing a source container, liquid handler, and three types of destination containers involved in a set of compound distributions. One source container and one liquid handler are permitted in any given problem formulation, although any number of compound distributions may be specified. The relative importance of all distributions is expressed by assigning weights, which are factored into the final mathematical problem specification. A computer program was created that automatically assembles and solves a complete compound distribution problem given the parameters that describe the source container, liquid handler, and any number and type of compound distributions. Business rules are accommodated by adjusting weighting factors assigned to each distribution. An example problem, presented and explored in detail, demonstrates complex and nonintuitive solution behavior.