Innovative Technique for Endoscopic Placement of Sengstaken-Blakemore Tube.

OBJECTIVES: The Sengstaken-Blakemore (SB) tube is used in cases of uncontrolled variceal bleeding. Because of the complexity of the procedure and the lack of visualization, various techniques have been described to avoid blind placement. We report an innovative and simple technique for placement of the SB tube under direct endoscopic visualization. METHODS: A grasp-and-place technique for endoscopic placement of SB tubes is described and a retrospective cohort study chart review of endoscopies done for variceal bleeding in our medical center is reported. All patients with uncontrolled variceal bleeding who required placement of an SB tube from July 1, 2013 through December 31, 2015 were included. The primary outcome analyses were technical success of tube placement and achievement of hemostasis. RESULTS: Of 143 endoscopies done for variceal bleeding, 10 were managed with SB tubes placed endoscopically after initial endoscopic therapy was unsuccessful. Successful placement of the tube was achieved in all of the patients. Hemostasis was achieved in 9 of the 10 patients. CONCLUSIONS: We propose a new grasp-and-place technique for endoscopic placement of SB tubes. Review of our experience shows that massive variceal bleeding can be managed effectively with this technique.

Recurrent Pleural Effusion Secondary to a Pancreatic-Pleural Fistula Treated Endoscopically.

BACKGROUND Pancreatic-pleural fistula (PPF) is an uncommon complication of pancreatitis. Pleural effusions secondary to PPF are caused by fistulization of pancreatic secretions to the thorax derived from the rupture or leakage of a pseudocyst. CASE REPORT We describe the case of a 44-year-old male with recurrent right-sided pleural effusions and alcoholic pancreatitis who presented with epigastric pain and shortness of breath. Pleural fluid analysis revealed an amylase of 7002 U/lt. MRCP showed segmental narrowing and stricture of the proximal main pancreatic duct and an area of walled-off necrosis. The fistula was managed endoscopically with ERCP and placement of a plastic stent into the pancreatic duct. The pleural effusion resolved and subsequent examinations showed no evidence of recurrence. CONCLUSIONS The diagnosis of PPF is challenging. Endoscopic treatment of PPF can be a safe and effective approach.

Low risk of bacteremia after endoscopic variceal therapy for esophageal varices: a systematic review and meta-analysis.

BACKGROUND AND STUDY AIMS: Endoscopic variceal ligation (EVL) and endoscopic variceal sclerotherapy (EVS) are the main therapeutic procedures for the emergency treatment and secondary prophylaxis of esophageal varices in cirrhotics. Post-endoscopic bacteremia has been reported after EVS and EVL, but data on the frequency of bacteremia are conflicting. This study aims to provide incidences of bacteremia after EVS and EVL in different settings through meta-analysis. METHODS: Only prospective or randomized studies were included in this meta-analysis. Binomial distribution was used to compute variance for each study. Random effects models were used as the final model for estimating the effect size and 95 % confidence interval. Adjusted effects were obtained using meta-regression analysis. RESULTS: Nineteen prospective studies involving 1001 procedures in 587 patients were included in the meta-analysis on the risk of bacteremia after EVS or EVL in cirrhotics with esophageal varices. The frequency of bacteremia after endoscopic variceal therapy was 13 %. The frequency of bacteremia after EVS (17 %) was higher than after EVL (6 %) with no statistically significant difference (P = 0.106). The frequency of bacteremia after elective EVS (14 %) was significantly less than after emergency EVS (22 %) (P < 0.001). The frequency of bacteremia after elective EVL (7.6 %) was not significantly different from after emergency EVL (3.2 %) (P = 0.850). CONCLUSIONS: The incidence of bacteremia is low in patients with cirrhosis and varices after esophageal variceal therapy. These results are consistent with our current guidelines that antibiotic prophylaxis before endoscopic variceal therapy is only necessary for bleeding patients.

Estimation of the Adenoma Detection Rate From the Polyp Detection Rate by Using a Conversion Factor in a Predominantly Hispanic Population.

BACKGROUND: Calculating the adenoma detection rate (ADR) is a complex process in contrast to the polyp detection rate (PDR) that can be easily calculated. The average adenoma to polyp detection rate quotient (APDRQ) was proposed as a conversion factor to estimate the ADR for individual endoscopists from the endoscopist's PDR. However, this conversion factor was not validated in different practice settings. GOAL: To validate the use of the proposed conversion factor in a practice setting with a predominantly Hispanic population. STUDY: We conducted a retrospective, cross-sectional study (December 2007 to November 2012) of screening colonoscopies at a university practice setting with an 86.9% Hispanic population. The actual ADR and PDR were calculated for all endoscopists. The weighted average of ADR to PDR ratio for each endoscopist was used to obtain APDRQ. The APDRQ was used as a conversion multiplier to estimate each endoscopist's ADR using the single endoscopist's PDR. RESULTS: A total of 2148 screening colonoscopies were included. The average PDR for the whole group was 36.9% (range, 11% to 49%). The actual ADR was estimated as 25.5% (range, 11% to 37%). The average APDRQ for our group was 0.68. The estimated ADR was 25.48% (range, 8% to 33%). There was a high correlation between actual ADR and the estimated ADR (Pearson correlation=0.92). CONCLUSIONS: In a practice setting with a predominantly Hispanic population, a conversion factor can be used to estimate ADR from PDR providing a high degree of correlation with the actual ADR.

Cardiovascular safety profile and clinical experience with high-dose domperidone therapy for nausea and vomiting.

INTRODUCTION: Domperidone is a dopamine receptor antagonist with peripheral prokinetic and central antiemetic properties. Prolongation of the QTc interval with chronic use of oral domperidone in standard doses has been reported in the literature. Our goal was to investigate cardiac toxicity in patients receiving 2-fold greater doses than in previous reports. METHODS: A retrospective chart review was conducted of patients with nausea (N) and vomiting (V) receiving domperidone from 2009 to 2013 under an Investigational New Drug (IND) protocol. Patient demographics, indications for therapy, clinical outcomes, cardiac symptoms and electrocardiogram tracings were reviewed. Prolonged QTc was verified if >470 milliseconds in females (F) and >450 milliseconds in males (M). RESULTS: A total of 64 patients, 44 female (37% Hispanic, 60% white, 3% African American), were taking domperidone for diabetic gastroparesis 45%; idiopathic gastroparesis 36%; chronic N&V 8%; dumping syndrome 5%; cyclic vomiting 5% and conditioned vomiting 1%. Mean duration of therapy was 8 months (range, 3 months to 4 years). Doses ranged from 40 to 120 mg/d with 90% receiving 80 to 120 mg compared with the standard dose of 40 mg. Of note, 73% of subjects benefited from treatment with reduced nausea and vomiting. Thirty-seven patients had follow-up electrocardiograms available, and they showed that the mean QTc at baseline was 424 milliseconds ± 28.4 (SD) compared with 435 milliseconds ± 27.2 (SD) at follow-up (not significant). Ten of these patients had prolonged QTc at F/U ranging from 453 to 509 milliseconds, without any cardiovascular complaints. There was no relationship between prolonged QTc and daily dose of domperidone, body mass index or age. CONCLUSIONS: Our data indicate that at very high dosing, the prokinetic/antiemetic agent domperidone has a low risk of adverse cardiovascular events while exhibiting good clinical efficacy.

Endoscopic mucosal resection recurrence rate for colorectal lesions.

OBJECTIVES: We aimed to evaluate the polyp recurrence rate after endoscopic mucosal resection (EMR) and factors contributing to increased recurrence. METHODS: MEDLINE (from 1966 to 2013), the Cochrane Central Register of Controlled Trials, and the Scopus database were searched in December 2013. Studies evaluating the polyp recurrence rate after colonic EMR were included. All of the articles were assigned a quality score. Standard forms were used to extract data regarding study design, outcome measures, and adverse effects by two independent reviewers. We performed a meta-analysis with a random effects model. Separate analyses were performed for each main outcome by using odds ratio (OR) and risk difference. Heterogeneity was assessed by I(2) measure of inconsistency. RESULTS: For the recurrence rate of colorectal lesions, 30 articles were included, with a total of 3404 patients. The polyp recurrence rate after EMR was 13.1%. Piecemeal resection was associated with a higher recurrence rate compared with en bloc resection (OR 4.39, 95% confidence interval 2.05-9.41; 14 studies). The use of argon plasma coagulation did not affect the polyp recurrence rate (OR 1.23, 95% confidence interval 0.39-3.88). Significant heterogeneity was present among studies. CONCLUSIONS: The recurrence rate of colorectal polyps after EMR is reasonably low; however, piecemeal resection was associated with a higher recurrence rate than en bloc resection after EMR.

Acute pancreatitis as the initial presentation of systematic lupus erythematosus.

Systematic lupus erythematosus (SLE) is a multisystem disease, including the gastrointestinal system in about half of SLE patients. As a rare complication of SLE, acute pancreatitis presents as generalized flare-ups in most cases of patients previously diagnosed with SLE. Here we report a rare case of acute pancreatitis as the initial presentation with later diagnosis of SLE.