Increased Risk of Progression to Gastric Adenocarcinoma in Patients with Non-dysplastic Gastric Intestinal Metaplasia Versus a Control Population.

AIM: In previous studies, the 5-year progression rate of gastric intestinal metaplasia to gastric adenocarcinoma has varied substantially. We investigated the incidence rate of dysplasia and gastric adenocarcinoma and the rate of progression among a cohort of patients with non-dysplastic gastric intestinal metaplasia. METHODS: This is a single-center, single-cohort retrospective study. Patients who had undergone an EGD with biopsies from 01/01/1993 to 12/31/2013 were included. The primary outcome of interest was the composite of low-grade dysplasia, high-grade dysplasia, or adenocarcinoma. Time to progression and risk factor subgroup analyses were performed. RESULTS: A total of 1628 subjects were screened, of whom 358 met the inclusion criteria. A total of 21 first-time events were recorded. The annual incidence rate of low-grade dysplasia was 2.1 (95% CI 1.3-3.5) cases per 1000 person-years, 0.5 (95% 0.2-1.3) per 1000 person-years for high-grade dysplasia, and 0.8 (95% CI 0.3-1.6) cases per 1000 person-years for gastric adenocarcinoma. The historical control group had an annual adenocarcinoma incidence rate of 0.07 per 1000 person-years. The event rate in Asians was also noted to be significantly higher between years 0-8 as compared with patients of non-Asian race, and extensive intestinal metaplasia was an independent risk factor (HR = 4.06 (95% CI 1.45-11.34), p = 0.007). CONCLUSIONS: Patients with non-dysplastic gastric intestinal metaplasia may progress to dysplasia and gastric adenocarcinoma. The incidence rate of gastric adenocarcinoma is higher than that of the historical control population (0.07 per 1000 person-years). The presence of extensive intestinal metaplasia was a risk factor for progression of disease. Triennial EGD may be warranted in patients with non-dysplastic gastric intestinal metaplasia.

Appendiceal Adenocarcinoma Presenting as a Rectal Polyp.

Appendiceal adenocarcinoma typically presents as an incidentally noted appendiceal mass, or with symptoms of right lower quadrant pain that can mimic appendicitis, but local involvement of adjacent organs is uncommon, particularly as the presenting sign. We report on a case of a primary appendiceal cancer initially diagnosed as a rectal polyp based on its appearance in the rectal lumen. The management of the patient was in keeping with standard practice for a rectal polyp, and the diagnosis of appendiceal adenocarcinoma was made intraoperatively. The operative strategy had to be adjusted due to this unexpected finding. Although there are published cases of appendiceal adenocarcinoma inducing intussusception and thus mimicking a cecal polyp, there are no reports in the literature describing invasion of the appendix through the rectal wall and thus mimicking a rectal polyp. The patient is a 75-year-old female who presented with spontaneous hematochezia and, on colonoscopy, was noted to have a rectal polyp that appeared to be located within a diverticulum. When endoscopic mucosal resection was not successful, she was referred to colorectal surgery for a low anterior resection. Preoperative imaging was notable for an enlarged appendix adjacent to the rectum. Intraoperatively, the appendix was found to be densely adherent to the right lateral rectal wall. An en bloc resection of the distal sigmoid colon, proximal rectum and appendix was performed, with pathology demonstrating appendiceal adenocarcinoma that invaded through the rectal wall. The prognosis in this type of malignancy weighs heavily on whether or not perforation and spread throughout the peritoneal cavity have occurred. In this unusual presentation, an en bloc resection is required for a complete resection and to minimize the risk of peritoneal spread. Unusual appearing polyps do not always originate from the bowel wall. Abnormal radiographic findings adjacent to an area of gastrointestinal pathology may signify locally advanced disease from a surrounding organ that secondarily involves the gastrointestinal tract. These findings warrant further investigation prior to any intervention to ensure appropriate treatment.

Abdominal compression during endoscopy (the Bolster technique) demonstrates hidden Schatzki rings (with videos).

BACKGROUND AND AIMS: Schatzki rings are found in the distal esophagus, are associated with hiatal hernias, and present with intermittent dysphagia to solid foods. They can be identified by radiology (GI series or barium swallow studies) or endoscopy. Rings are not always visualized during endoscopy in patients in whom they are suspected clinically. The Bolster technique involves application of epigastric abdominal pressure, which offers the potential to reveal a Schatzki ring that is otherwise obscured within a reduced hiatal hernia. The aim of this study was to determine whether the Bolster technique improves endoscopic detection of Schatzki rings. METHODS: We reviewed 30 symptomatic patients with a history of a Schatzki ring in a tertiary care center. The Bolster technique was applied to patients in whom the ring was not visible during standard endoscopy. The main outcome measurement was identification of the Schatzki ring after the Bolster technique. RESULTS: A Schatzki ring was visible during standard endoscopy in 26 of the 30 patients. In the remaining 4, the ring was visible only after the application of the Bolster technique. CONCLUSION: The Bolster technique is a simple maneuver that can increase detection rates of Schatzki rings during endoscopy.

Long-term remission of nondysplastic Barrett's esophagus after multipolar electrocoagulation ablation: report of 139 patients with 10 years of follow-up.

BACKGROUND: Ablation of Barrett's esophagus (BE) has been advocated as a method to eliminate the risk of malignant transformation of BE. OBJECTIVE: To provide longer follow-up and determine safety and efficacy of multipolar ablation for nondysplastic BE. DESIGN: Prospective cohort study. SETTING: Gastroenterology Unit at the Policlinica Metropolitana, a tertiary care center in Caracas, Venezuela. PATIENTS: One hundred sixty-six patients with nondysplastic BE and histologic evidence of intestinal metaplasia. INTERVENTIONS: Patients underwent multipolar electrocoagulation ablation therapy to areas of BE identified with magnification chromoendoscopy. The identified areas were treated with a 50-W energy source and a 7F "gold" probe. After complete ablation, patients were followed on an annual basis with magnification chromoendoscopy. At annual visits, biopsy specimens were taken in areas identified at baseline as BE. Targeted biopsy specimens were taken in areas of recurrent BE identified by using magnification chromoendoscopy. MAIN OUTCOME MEASUREMENTS: Mortality, incidence of recurrent BE, incidence of adenocarcinoma in ablated BE, and morbidity associated with multipolar electrocoagulation. RESULTS: One hundred sixty-six patients were recruited for the study; 139 completed at least 10 years of follow-up. Complications developed in less than 5% of patients, all of which were minor. Recurrent BE occurred in less than 5% of patients. No adenocarcinoma or high-grade dysplasia of the esophagus developed in any of the patients. LIMITATION: Uncontrolled clinical trial. CONCLUSIONS: Long-term follow-up of ablation of BE with multipolar electrocoagulation ablation therapy indicates that this is a safe, effective method to ablate BE over the long term.

Classification of villous atrophy with enhanced magnification endoscopy in patients with celiac disease and tropical sprue.

BACKGROUND: Intestinal lesions in celiac disease (CD) and tropical sprue (TS) can be patchy. Improved endoscopic identification of affected areas may increase the diagnostic yield of biopsy specimens. Enhanced magnification endoscopy [EME] combines magnification endoscopy with 3% acetic acid instillation. OBJECTIVE: This study describes endoscopic findings associated with villous atrophy during EME. DESIGN: Patients underwent EME with a magnifying endoscope with acetic-acid application. Surface mucosal patterns were characterized before and after acetic-acid spraying. Observed surface patterns were compared with histologic results obtained from a single targeted biopsy specimen. SETTING: Policlinica Metropolitana in Caracas, Venezuela. PATIENTS: Patients with diagnosed but untreated CD or TS. RESULTS: Fifty-two biopsy specimens were obtained from 27 patients (17 men, 10 women; mean age 50.5 years; range, 24-76 years; 12 with CD and 15 with TS). EME of the duodenum revealed 4 different mucosal patterns: I, normal; II, stubbed; III, ridged; and IV, foveolar. Three of the 4 patterns were strongly associated with the presence of villous atrophy (pattern I, 1/18 [5.5%]; II, 16/17 [94%]; III, 12/12 [100%]; and IV, 5/5 [100%]). EME was more sensitive than standard endoscopy for detecting villous atrophy, 100% versus 58% in CD and 93% versus 20% in TS. Furthermore, EME identified patchy areas of partial villous atrophy in 16 patients (5 CD and 11 TS) in whom standard endoscopy was normal. CONCLUSIONS: EME identifies 3 characteristic endoscopic patterns that correlate with the presence of villous atrophy. EME could help identify patchy areas of partial mucosal atrophy, potentially reducing the need for blind biopsies.

Functional gallbladder and sphincter of oddi disorders.

The functional disorder of the gallbladder (GB) is a motility disorder caused initially either by metabolic abnormalities or by a primary motility alteration. The functional disorders of the sphincter of Oddi (SO) encompass motor abnormalities of either the biliary or the pancreatic SO. Dysfunction of the GB and/or biliary SO produce similar patterns of pain. The pain caused by a dysfunction of the pancreatic SO can be similar to that of acute pancreatitis. The symptom-based diagnostic criteria of motility dysfunction of the GB and biliary SO are episodes of moderate to severe steady pain located in the epigastrium and right upper abdominal quadrant that last at least 30 minutes. GB motility disorder is suspected after gallstones and other structural abnormalities have been excluded. This diagnosis should then be confirmed by a decreased GB ejection fraction induced by cholecystokinin at cholescintigraphy and after disappearance of the recurrent biliary pain after cholecystectomy. Symptoms of biliary SO dysfunction may be accompanied by features of transient biliary obstruction, and those of pancreatic SO dysfunction are associated with elevation of pancreatic enzymes and even pancreatitis. Biliary-type SO dysfunction is more frequently recognized in postcholecystectomy patients. SO manometry is valuable to select patients with sphincter dysfunction; however, because of the high incidence of complications, these patients should be referred to an expert unit for such assessment. Thus invasive tests should be performed only in the presence of compelling clinical evidence and after noninvasive testing has yielded negative findings. The committee recommends that division of the biliary or pancreatic sphincters only be considered when the patient has severe symptoms, meets the required criteria, and other diagnoses are excluded.

Sphincter of Oddi dysfunction in children.

Sphincter of Oddi dysfunction (SOD) is a clinical entity caused by a primary motility alteration of either the biliary or the pancreatic sphincter. SOD is a rare condition that has been scarcely reported in children. Most of the reported literature has been in children with idiopathic recurrent pancreatitis. These children are treated endoscopically by dual sphincterotomy of the pancreatic and common duct sphincters. However, the safety and efficacy of sphincter of Oddi manometry and sphincterotomy in the pediatric population await further study.

Enhanced magnification endoscopy in the upper gastrointestinal tract.

In diseases such as Barrett's esophagus and celiac disease, the mucosal abnormality is patchy or irregular, highlighting the need for targeted biopsies. Enhanced magnification endoscopy is an effective, readily available method that can be used to assist in target biopsies and endoscopic diagnosis leading to an endoscopic classification system. The technique is not difficult and adds only an additional 5 to 10 minutes to a standard endoscopic procedure;however, most endoscopists never receive instruction in magnification endoscopy during their training. The value of this technique is still being explored, but the improvement in diagnostic accuracy will have an impact on decreasing morbidity and mortality without a large increase in cost. Increased use of this technique will aid in the diagnosis of celiac disease and simplify the classification system for Barrett's esophagus. Using enhanced magnification endoscopy at multiple centers in studies will help to determine the intra- and inter-observer variability, define the endoscopic criteria for dysplasia and early neoplastic changes, and standardize the visualized mucosal patterns more clearly.

Normal sphincter of oddi motor function.

With the introduction of endoscopic retrograde cholangiopancreatography (ERCP) manometry, the characteristics of sphincter of Oddi (SO) motor activity have been described. SO manometry is the only available method to measure SO motor activity directly and is usually performed at the time of ERCP. SO manometry is considered to be the gold standard for evaluating patients for sphincter dysfunction. This review reports the technique of SO manometry and normal values for SO manometry. SO motility is characterized by prominent phasic contractions superimposed on a tonic pressure. Elevated basal SO pressure is the most consistent and reliable criteria to diagnose SO dysfunction. Basal pressures obtained from the biliary sphincter are similar to the basal pressure obtained from the pancreatic sphincter. Abnormal SO manometric values are shown. Factors that influence SO pressures, and interpretation of SO manometric tracing are discussed. The most common and serious complication of SO manometry is post-manometry pancreatitis. In healthy volunteers with normal sphincter function, pancreatitis is almost never seen. However, in patients with SO dysfunction, the incidence of pancreatitis is high. The use of new nonperfused microtransducers may reduce this complication.

Short report: socioeconomic and seasonal variations of Helicobacter pylori infection in patients in Venezuela.

Infection by Helicobacter pylori is recognized as a risk factor for gastric cancer and peptic ulcer disease. Venezuela has regions with different gastric cancer risks; the Andean region has the highest gastric cancer mortality in the country. We performed a cross-sectional study on 357 patients who underwent endoscopy attending 2 private (n = 76) and one public hospital in Caracas, Venezuela (n = 215), and one public hospital in the Andes (n = 66) to determine H. pylori infection (by a rapid biopsy urease test and histology). The proportion of infected patients in Caracas was significantly higher in public hospitals (72%) than in private hospitals (46%; P = 0.00001), and there was no significant variation the Andes and Caracas (P = 0.7001). When analyzing the data from the public hospital in Caracas, we found that the frequency of infected patients was significantly higher during the rain (96%) than during the dry months (70%, P = 0.00000001). Differences in prevalence of infection in symptomatic patients was not related to the risk of gastric cancer but to socioeconomic differences. Rain-dependent factors that may be exacerbating the clinical activity of nonulcer dyspepsia in people infected with H. pylori deserve further study.

Intestinal metaplasia of the gastric cardia: A prospective study with enhanced magnification endoscopy.

OBJECTIVE: There are no endoscopic features that distinguish intestinal metaplasia of the cardia (CIM) from the normal cardia. Biopsy specimens are therefore randomly obtained from normal-appearing mucosa with significant potential sampling errors. Enhanced magnification endoscopy involves the combined use of magnification endoscopy with acetic acid instillation. This study assessed the value of enhanced magnification endoscopy in detecting CIM. METHODS: Patients undergoing elective upper endoscopy were invited to participate in the study. Patients were included if the squamocolumnar junction and the esophagogastric junction were judged to be at the same level. Enhanced magnification endoscopy was performed with 3% acetic acid instillation. Standard endoscopy was followed by magnification endoscopy and repeated after acetic acid spraying. Surface patterns were characterized before and after acetic acid spraying. The observed surface patterns were compared with histological results obtained from a single targeted biopsy specimen of each pattern. RESULTS: The overall prevalence of CIM was 34.8% (86/247 patients). After excluding 52 patients because of endoscopic evidence of Barrett's esophagus, 195 patients were eligible for participation in the study. In the study group, CIM was detected in 86 patients (44.1%) in targeted biopsy samples. No dysplasia was identified. Enhanced magnification endoscopy detected four different patterns of the mucosal surface: I) round pits, II) reticular, III) villous, and IV) ridged. The yields of detection of intestinal metaplasia according to endoscopic patterns were I) 0%, II) 5.3% (odds ratio = 0.05), III) 57.7% (odds ratio = 7.5, p = 0.0001), and IV) 95.8% (odds ratio = 42.8, p = 0.0001). CONCLUSIONS: CIM is more common than previously reported. Enhanced magnification endoscopy identifies two characteristic endoscopic patterns, villous (pattern III) and ridged (pattern IV), with outstanding clarity and resolution that correlate with histological identification of CIM with a single targeted biopsy sample. Enhanced magnification endoscopy will permit longitudinal studies of an entity that can be identified endoscopically.

Lamividine (3-TC) en el tratamiento de la hepatítis crónica secundaria a infección por virus de la hepatítis B: reporte preliminar en pacientes venezolanos / Lamuvidine (3-TC) in the treatment of chronic hepatitis secundary to hepatitis B virus infection: preliminar report in venezuelan patients

La infección por virus de la hepatítis B (VHB) es una causa importante de enfermedad hepática, tanto aguda como crónica. El interferón alfa (IFN) ha sido desde su introducción inicial a mediados de la década de los 80, el tratamiento de elección para la hepatítis crónica por virus B, siendo los porcentajes de respuesta observandos alrededor del 30 por ciento y 40 por ciento. El IFN se activo contra el VHB principalmente incrementando la citólisis de los hepatocitos infectados por este virus por intermedio de mecanismos de inmunidad celular, por lo necesario que exista un sistema inmune activo para que este medicamento pueda ser efectivo en erradicar el virus B. El lamivudine o 3-TC, un análogo de nucleósido, utilizado inicialmente en el tratamiento de la infección por virus de la inmunodeficiencia humana (VIH), demostró que administrado a dosis de 100 a 300 mg diarios suprime el VHB-ADN hasta niveles indetectables en el suero de los pacientes infectados. En conclusión el lamivudine a dosis de 150 mg. diarios es seguro y efectivo en el tratamiento de la hepatopatía causada por virus B, logrando la seroconversión del HBeAg a anti Hbe en la mayoría de los casos