Endoscopic ultrasound-guided drainage of a fungal liver abscess using a lumen-apposing metal stent: case report and literature review.

Liver abscesses are rare entities for which percutaneous drainage is traditionally employed. The technique is simple, but associated with a significant rate of side effects and patient discomfort. We herein report a case of fungal left liver lobe abscess that was successfully treated by using EUS-guided drainage, with insertion of a large caliber lumen-apposing metal stent. The literature review we performed on the topic seems to favor, at least for abscess in the left and/or caudate liver lobes, EUS as compared to percutaneous drainage.

Colitis cystica profunda of the rectum with adenomatous dysplastic features: Radiologic-pathologic correlation.

Colitis cystica profunda is a rare nonneoplastic condition characterized by the presence of mucus-containing cysts in the submucosa of the right colon and rectum. The etiology is unclear, with a few cases reported in the literature. The presenting symptoms and signs may mimic colorectal adenocarcinoma. We report a case of colitis cystica profunda localized in the rectum, investigated by colonoscopy, CT, MRI, and subsequently surgically treated.

Early radiation-induced mucosal changes evaluated by proctoscopy: predictive role of dosimetric parameters.

BACKGROUND AND PURPOSE: Late rectal complications are assessed according to different scoring systems. Endoscopy can provide a more sensitive estimation of early radiation damage. The aim of this paper is to investigate the correlation between dosimetric parameters and rectal mucosal changes after radiotherapy (RT). MATERIALS AND METHODS: Patients with prostate adenocarcinoma treated with curative or adjuvant RT underwent endoscopy 1 year after RT. Receiver operating characteristics (ROC) analysis was performed to analyze the predictive capability of the dosimetric variables in determining mucosal changes classified by Vienna Rectoscopy Score (VRS). RESULTS: The best dosimetric predictors of grade ≥2 telangiectasia were rectal (r) V(60 Gy) (p=0.014), rV(70 Gy) (p=0.017) and rD(mean) (p=0.018). Similar results were obtained for grade ≥2 VRS. The set of rV(60 Gy)<34.4%, rV(70 Gy)<16.7% and rD(mean)<57.5 Gy was associated with a decreased risk of grade ≥2 telangiectasia and VRS. CONCLUSIONS: rV(60 Gy), rV(70 Gy) and rD(mean) were the strongest predictors of rectal mucosal alterations. In-depth analysis is required to correlate each mucosal alteration with late rectal toxicity in order to suggest early proctoscopy as surrogate end-point for rectal late toxicity in studies aimed at reducing this important complication.

A new regimen of bowel preparation for PillCam colon capsule endoscopy: a pilot study.

BACKGROUND: Colon capsule endoscopy (CCE) represents a new diagnostic, endoscopic technology for colonic exploration. Current protocols of preparation led to discordant rates of adequate cleansing level or CCE excretion. AIM: To evaluate the effect of a new regimen of bowel preparation for CCE on colon cleansing levels and on rate of capsule excretion. STUDY: 60 patients were prospectively enrolled. The new regimen of preparation consisted of a split regimen of PEG administration and of a 45 mL dose of sodium phosphate (NaP). Four senna tablets and a low-residue diet were also included. CCE excretion rate, colon cleansing, and accuracy were assessed. RESULTS: Forty-six patients were included in the final analysis, 13 patients (22%) being excluded because of preparation protocol deviations and one due to CCE technical failure (2%). At CCE, bowel preparation was rated as good in 78% of patients, fair in 20% and poor in 2%. CCE excretion rate occurred in 83% of patients. CCE sensitivity and specificity for significant findings was 100% and 95%, respectively. CONCLUSIONS: The combination of a split-dose of PEG solution with a low dose of NaP boosters resulted in high rates of adequate cleansing level and CCE excretion.

Polyethylene glycol plus simethicone in small-bowel preparation for capsule endoscopy.

BACKGROUND: Small-bowel contents can hamper the quality of video-capsule endoscopy (VCE). No standardized protocol has been proposed and overnight fasting remains the proposed preparation for VCE. AIMS: The aim was to evaluate the effects of 2 regimens of bowel preparation on small intestine cleansing, diagnostic yield and capsule transit times. METHODS: This is a prospective, randomized, blinded, and controlled study. Sixty patients referred for VCE were randomized into 2 groups. Group A ingested 2l of a polyethylene glycol and simethicone solution 16h before VCE. Group B were instructed to consume a fibre-free diet and allowed to consume clear liquids the day before VCE. The small-bowel cleansing was graded as "complete" if the entire wall was assessable, "incomplete" if more than 50% of the wall was visible, and "insufficient" if less than 50% of the wall was visible. RESULTS: In group A, a "complete", "incomplete" and "insufficient" small-bowel cleansing was achieved in 42%, 39% and 19% of cases respectively. In group B, a "complete", "incomplete" and "insufficient" small-bowel cleansing was achieved in 43%, 33% and 24% of cases respectively. No significant differences were observed between the two groups, regarding small-bowel cleansing level (p=0.65). No differences were also observed in the diagnostic yield (48.2%, 13.8% and 38% vs 65.5%, 6.9% and 27.6% of positive, suspicious and no findings respectively, in groups A and B [p=0.39]) and small-bowel transit times (mean 288min and 299 min in groups A and B respectively [p=0.70]). CONCLUSIONS: The results of the present study do not support the use of 2l of a polyethylene glycol and simethicone solution before VCE.

Video capsule endoscopy in patients with known or suspected small bowel stricture previously tested with the dissolving patency capsule.

GOALS: To assess the safety of the Pillcam in patients with known or suspected radiologic stricture, previously tested for small bowel patency using the Given Patency capsule. BACKGROUND: Intestinal stricture contributes a major contraindication to video capsule endoscopy (VCE), because of the risk of capsule retention. STUDY: Twenty-seven patients (16 female, mean age 44.2 y) with known or suspected intestinal stricture were enrolled prospectively. Twenty-four had Crohn's disease, 2 had adhesive syndrome and 1 had a suspected ischemic stricture. Patients underwent the Patency capsule test. In patients in whom the Patency capsule was excreted intact within 72 hours postingestion without occurrence of any adverse event, VCE was performed to assess the presence of strictures or other gastrointestinal pathologies. The following parameters were evaluated: transit time of Patency capsules and/or tags from ingestion to excretion, condition of the Patency capsule at excretion, transit time of the Pillcam capsule, the ability of Pillcam capsule to detect intestinal strictures and small bowel pathologies, any adverse events. RESULTS: Twenty-five patients (92.6%) retrieved the Patency capsule in the stools. Six patients complained of abdominal pain, 4 of whom excreted a nonintact capsule. Hospitalization was required in 1 (4.3%) patient with Crohn's disease due to occlusive syndrome. Fifteen patients (65.3%) excreted an intact Patency capsule after a mean transit time of 25.6 hours without any adverse events. These 15 patients underwent the VCE successfully. CONCLUSIONS: Passage of an intact Patency capsule across a small bowel stricture provides direct evidence of functional patency of the gut lumen and allows a safe VCE. Intestinal strictures should not be considered an absolute contraindication for VCE.

Treatment for painful calcified chronic pancreatitis: extracorporeal shock wave lithotripsy versus endoscopic treatment: a randomised controlled trial.

BACKGROUND: In chronic pancreatitis, obstruction of the main pancreatic duct (MPD) may contribute to the pathogenesis of pain. Pilot studies suggest that extracorporeal shock wave lithotripsy (ESWL) alone relieves pain in calcified chronic pancreatitis. AIM: To compare ESWL alone with ESWL and endoscopic drainage of the MPD for treatment of pain in chronic pancreatitis. SUBJECTS: Patients with uncomplicated painful chronic pancreatitis and calcifications obstructing the MPD. METHODS: 55 patients were randomised to ESWL alone (n = 26) or ESWL combined with endoscopy (n = 29). RESULTS: 2 years after trial intervention, 10 (38%) and 13 (45%) patients of the ESWL alone and ESWL combined with endoscopy group, respectively, had presented pain relapse (primary outcome) (OR 0.77; 95% CI 0.23 to 2.57). In both groups, a similar decrease was seen after treatment in the MPD diameter (mean decrease 1.7 mm; 95% CI 0.9 to 2.6; p<0.001), and in the number of pain episodes/year (mean decrease, 3.7; 95% CI 2.6 to 4.9; p<0.001). Treatment costs per patient were three times higher in the ESWL combined with endoscopy group compared with the ESWL alone group (p = 0.001). The median delay between the onset of chronic pancreatitis and persistent pain relief for both groups was 1.1 year (95% CI 0.7 to 1.6), as compared with 4 years (95% CI 3 to 4) for the natural history of chronic pancreatitis in a reference cohort (p<0.001). CONCLUSIONS: ESWL is a safe and effective preferred treatment for selected patients with painful calcified chronic pancreatitis. Combining systematic endoscopy with ESWL adds to the cost of patient care, without improving the outcome of pancreatic pain.

Endoscopic removal of malfunctioning biliary self-expandable metallic stents.

BACKGROUND: Endoscopic removal of malfunctioning self-expandable metallic biliary stents (SEMS) is difficult and not well described. The aim of this study is to review the indications, the techniques, and the results of SEMS removal in a cohort of patients with malfunctioning stents. METHODS: All patients who underwent an attempt at endoscopic removal of biliary SEMS over a 5-year period were retrospectively identified. The main indications for SEMS removal were the following: distal migration of the stent or impaction to the duodenum, impaction into the bile-duct wall, tissue ingrowth, and inappropriate length of the stent causing occlusion of intrahepatic ducts. SEMS were removed by using foreign-body forceps or polypectomy snares. RESULTS: Endoscopic removal of 39 SEMS (13 uncovered and 26 covered) was attempted in 29 patients (17 men; mean age, 66 years). SEMS extraction was attempted after a mean of 7.5 months (8.75 months standard deviation) post-SEMS insertion. Removal was successful in 20 patients (68.9%) and in 29 SEMS (74.3%). Covered SEMS were effectively removed more frequently than uncovered ones: 24 of 26 (92.3%) and 5 of 13 (38.4%), respectively (p < 0.05). No major complications were recorded. Multivariate analysis showed that the time interval between insertion and removal, SEMS length, stent-mesh design (zigzag vs. interlaced), and indication for removal were not predictive of success at stent removal. CONCLUSIONS: Endoscopic removal of biliary SEMS is feasible and safe in more than 70% of cases. Because only 38% of uncovered SEMS were removable, the presence of a stent covering is the only factor predictive of successful stent extraction. The presence of diffuse and severe ingrowth was the main feature limiting SEMS removal.