Concordance of Dye-Spraying Chromoendoscopy and Virtual Chromoendoscopy for Colonic Dysplasia Detection in Longstanding Inflammatory Bowel Disease.

BACKGROUND/AIMS: In the past, dye-spraying chromoendoscopy was the technique of choice for colonic surveillance in patients with long-standing extensive inflammatory bowel disease. Recent evidence suggests that virtual chromoendoscopy is an equally acceptable technique. MATERIALS AND METHODS: Eleven gastroenterologists were given a survey with 20 pairs of pictures from inflammatory bowel disease surveillance colonoscopies (10 with nondysplastic lesions, 5 with dysplastic lesions, and 5 with no lesions). Each pair contained the same image captured during colonoscopy using indigo carmine and narrow-band imaging. For each picture, the gastroenterologist assessed the presence/absence of lesion and, when a lesion was identified, assessed the presence/absence of dysplasia and delineated its margins. To compare lesion and dysplasia detection between techniques, sensitivity, specificity, and interobserver agreement were calculated. The chi-square test was used to assess the accuracy of margins delineation. RESULTS: When assessing lesion and dysplasia detection, similar sensitivity and specificity values were obtained for both techniques. Interobserver agreement analysis revealed that dye-spraying chromoendoscopy and virtual chromoendoscopy had a moderate agreement in lesion detection but, for dysplasia detection, dye-spraying chromoendoscopy had a slight agreement [K = 0.11 (0.03-0.18), P < .01] and virtual chromoendoscopy a fair agreement [K = 0.30 (0.22-0.37), P < .01]. Margin delineation was similar between techniques. CONCLUSION: Sensitivity and specificity for lesion and dysplasia detection, as well as the accuracy of margins delineation, were similar between dye-spraying chromoendoscopy and virtual chromoendoscopy. Interobserver agreement for dysplasia detection was suboptimal in both techniques; however, it was superior when using virtual chromoendoscopy. These findings suggest that virtual chromoendoscopy constitutes a valid alternative for dysplasia screening in inflammatory bowel disease.

Endoscopic Treatment of an Idiopathic Pancreaticopleural Fistula.

A 61-year-old man was diagnosed with an exudative pleural effusion with raised amylase and bilirubin levels. The patient had no previous history of acute pancreatitis or trauma and no clinical or radiological signs of chronic pancreatitis. On thoracoabdominal computed tomography, a pancreatic pseudocyst with a pancreaticopleural fistula was identified. Endoscopic retrograde cholangiopancreatography identified a ductal disruption site in the body of the pancreas. Pancreatic sphincterotomy and stent placement in the duct of Wirsung, combined with medical management, allowed fistula closure, pseudocyst reabsorption, and no relapse of the pleural effusion. The relevance of this case lies not only in its rarity but also as it highlights the importance of a multidisciplinary approach in such uncommon conditions. Optimal management of this condition is debatable due to the absence of prospective studies comparing medical, endoscopic, and surgical approaches.

Um homem de 61 anos foi diagnosticado com um derrame pleural exsudativo com níveis elevados de amilase e bilirrubina. O doente não apresentava história prévia de pancreatite aguda, trauma ou sinais e sintomas de pancreatite crónica. Na tomografia computadorizada toracoabdominal, foi identificado um pseudoquisto pancreático com uma fístula pancreatopleural. A colangiopancreatografia retrógrada endoscópica identificou um ponto de disrupção ductal no corpo do pâncreas, pelo que se optou pela realização de esfincterotomia pancreática e colocação de uma prótese plástica no ducto de Wirsung. Esta abordagem, combinada com o tratamento médico, permitiu o encerramento da fístula e resolução do derrame pleural, bem como reabsorção do pseudoquisto pancreático. A relevância deste caso reside não só na sua raridade, mas também porque destaca a importância de uma abordagem multidisciplinar para otimizar o tratamento. Dada a infrequência desta condição clínica, não existem estudos prospectivos que comparem as abordagens médica, endoscópica e cirúrgica.

Prediction of adenoma recurrence after piecemeal endoscopic mucosal resection: interobserver agreement and utilization of the Sydney EMR recurrence tool.

Background and aims: Piecemeal endoscopic mucosal resection (pEMR) allows resection of larger non-invasive colorectal lesions. Adenoma recurrence is an important limitation and occurs in ≤20%. The present study aimed to validate the Sydney EMR recurrence tool (SERT) score as a predictor of both endoscopic and histologic recurrence and evaluate interobserver agreement in adenoma recurrence based on endoscopic scar assessment, among nonexperts in EMR.Methods: Retrospective cohort and cross-sectional study, in which all patients submitted to pEMR in a tertiary care center in Portugal, between 2012 and 2018 were included. SERT-score was calculated for all lesions and compared with the SMSA (size, morphology, site, access) score already validated as a predictor of adenoma recurrence. Image based offline analysis was performed to evaluate adenoma recurrence prediction and assess the interobserver agreement within a heterogeneous group of participants, mostly composed by nonexperts in EMR.Results: There was a moderate positive correlation between the SERT and SMSA scores (p <.001; r = 0.61). SERT-score was significantly associated with endoscopic recurrence (p =.005) and histologic recurrence (p = .015). Endoscopic prediction of recurrence had high coefficient of agreement (k-0.806; p < .001).Conclusion: Histologic recurrence after pEMR can be predicted by SERT score and optical diagnosis of recurrent adenoma has high interobserver agreement between nonexperts in EMR.

Duodenal Crohn's Disease Complicated by Pancreatitis and Common Bile Duct Obstruction.

INTRODUCTION: Crohn's disease (CD) is characterized by segmental and transmural involvement of any portion of the gastrointestinal tract from the mouth to the anus. Duodenal CD is a rare clinical entity, with the majority of the patients being symptomless - its diagnosis requires a high level of clinical suspicion. CASE PRESENTATION: We present the case of a 29-year-old male patient with a 2-month history of weight loss, epigastric pain and postprandial vomiting. He underwent upper endoscopy, which revealed a circumferential duodenal ulcer causing non-transposable luminal stenosis and was medicated with proton pump inhibitors. While awaiting gastroenterology consultation, he presented at the emergency department for sudden onset of abdominal pain with dorsal irradiation, nausea and vomiting. Laboratory tests showed anaemia and increased liver enzymes, amylase and lipase. Abdominal computed tomography showed ectasia of the common bile duct (CBD) and intrahepatic biliary tract and a small amount of gas in the main pancreatic duct associated with duodenal thickening. The case was interpreted as probable CD complicated by pancreatitis and obstruction of the CBD, and he was hospitalized under antibiotic therapy and hydrocortisone with improvement of the condition. After discharge, he underwent colonoscopy that revealed several ulcers in the ileum and magnetic resonance imaging that showed distension of the stomach with reduction of the calibre of the transition from the duodenal bulb to the second portion of the duodenum in a 10- to 15-mm extension, as well as associated dilatation of the intrahepatic bile ducts and CBD and diffuse and regular ectasia of the main pancreatic duct. Combination therapy with azathioprine and infliximab was initiated; the patient presented clinical response at 12 weeks and endoscopic/imaging remission at 9 months. DISCUSSION/CONCLUSION: Hepatobiliary and pancreatic manifestations are common in CD patients involving multiple mechanisms. In this case report, we pre-sent a patient with duodenal CD complicated with pancreatitis and CBD obstruction due to distortion phenomena by duodenal stenosis, a condition that is rarely described.

INTRODUÇÃO: A Doença de Crohn (DC) é caracterizada pelo envolvimento segmentar e transmural de qualquer porção do trato gastrointestinal desde a boca até ao ânus. A DC duodenal é uma entidade clínica rara, sendo que a maioria dos doentes são assintomáticos − o seu diagnóstico requer um alto grau de suspeição clínica. APRESENTAÇÃO DO CASO: Doente do sexo masculino com 29 anos, apresentou quadro com 2 meses de evolução de perda de peso, dor epigástrica e vómitos pós-prandiais. Realizou endoscopia digestiva alta, que revelou úlcera duodenal circunferencial causando estenose luminal não transponível, tendo sido medicado com inibidor da bomba de protões. Enquanto aguardava pela consulta de Gastroenterologia, recorreu ao serviço de urgência por dor abdominal com irradiação dorsal com início súbito, náuseas e vómitos. Os exames laboratoriais revelaram anemia, aumento dos testes hepáticos e aumento da lípase e amílase. A tomografia computadorizada abdominal mostrou ectasia da via biliar principal (VBP) e dos ductos biliares intra-hepáticos e pequena quantidade de gás no ducto pancreático principal associado a marcado espessamento duodenal. Interpretado como provável DC complicada por pancreatite e obstrução da VBP, foi internado sob antibioterapia e hidrocortisona com melhoria clínica. Após a alta, realizou colonoscopia que revelou várias úlceras no íleo terminal e ressonância magnética que mostrou marcada distensão do estômago com redução do calibre da transição do bulbo duodenal para a segunda porção do duodeno em 10­15 mm extensão; associadamente, dilatação dos ductos biliares intra-hepáticos e da VBP e ectasia difusa e regular do ducto pancreático principal. O doente iniciou terapêutica combinada com azatioprina e infliximab apresentando resposta clínica às 12 semanas e remissão endoscópica/imagiológica aos 9 meses. DISCUSSÃO/CON-CLUSÃO: Manifestações hepatobiliares e pancreáticas são comuns em doentes com DC tendo por base múltiplos mecanismos. Neste caso, mostramos um doente com DC duodenal complicada com pancreatite e obstrução da VBP por distorção causada por estenose duodenal, condição raramente descrita.

Diagnostic yield of endoscopic ultrasonography for dilation of common bile duct of indeterminate cause

Introduction: with the widespread use of abdominal imaging, common bile duct (CBD) dilation is a common problem in the daily practice. However, the significance of a dilated CBD as a predictor of underlying disease has not been well elucidated and there are currently no guidelines for its approach. Methods: this was a retrospective study of patients who underwent endoscopic ultrasonography (EUS) from 2010 to 2017 due to a dilated CBD detected by transabdominal ultrasonography TUS (CBD ≥ 7 mm) or computed tomography (CT) (CBD ≥ 10 mm), with no identified cause (n = 56). The aims were to assess the diagnostic yield of EUS and to identify predictors for a positive EUS. Results: the majority of patients (n = 39) had normal findings on EUS. Abnormal EUS findings were found in 30% (n = 17) of the patients, which included choledocholithiasis (n = 6), ampuloma (n = 3), choledochal cyst (n = 2), benign CBD stenosis (n = 2), cyst of the head of the pancreas (n = 1), cholangiocarcinoma (n = 1), chronic pancreatitis (n = 1) and CBD compression due to adenomegaly (n = 1). Factors that positively related with findings on EUS were increased levels of gamma glutamyl transferase (331 U/l vs 104 U/l, p = 0.039), alkaline phosphatase (226 U/l vs 114 U/l, p = 0.041), total bilirubin (TB) (6.5 g/dl vs 1.2 g/dl, p = 0.035) and the presence of signs/symptoms (p = 0.042). Of the 21 patients (38%) who were asymptomatic with normal liver biochemical tests, four (19%) had findings on EUS. Conclusions: the majority of patients with a dilation of the CDB have a normal EUS. Increased cholestasis enzymes, increased TB and the presence of signs and symptoms are predictors of a positive EUS

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Diagnostic yield of endoscopic ultrasonography for dilation of common bile duct of indeterminate cause.

INTRODUCTION: with the widespread use of abdominal imaging, common bile duct (CBD) dilation is a common problem in the daily practice. However, the significance of a dilated CBD as a predictor of underlying disease has not been well elucidated and there are currently no guidelines for its approach. METHODS: this was a retrospective study of patients who underwent endoscopic ultrasonography (EUS) from 2010 to 2017 due to a dilated CBD detected by transabdominal ultrasonography TUS (CBD ≥ 7 mm) or computed tomography (CT) (CBD ≥ 10 mm), with no identified cause (n = 56). The aims were to assess the diagnostic yield of EUS and to identify predictors for a positive EUS. RESULTS: the majority of patients (n = 39) had normal findings on EUS. Abnormal EUS findings were found in 30% (n = 17) of the patients, which included choledocholithiasis (n = 6), ampuloma (n = 3), choledochal cyst (n = 2), benign CBD stenosis (n = 2), cyst of the head of the pancreas (n = 1), cholangiocarcinoma (n = 1), chronic pancreatitis (n = 1) and CBD compression due to adenomegaly (n = 1). Factors that positively related with findings on EUS were increased levels of gamma glutamyl transferase (331 U/l vs 104 U/l, p = 0.039), alkaline phosphatase (226 U/l vs 114 U/l, p = 0.041), total bilirubin (TB) (6.5 g/dl vs 1.2 g/dl, p = 0.035) and the presence of signs/symptoms (p = 0.042). Of the 21 patients (38%) who were asymptomatic with normal liver biochemical tests, four (19%) had findings on EUS. CONCLUSIONS: the majority of patients with a dilation of the CDB have a normal EUS. Increased cholestasis enzymes, increased TB and the presence of signs and symptoms are predictors of a positive EUS.

What's next after failure of OTSC(R) for the closure of gastrostomy fi stula? Another OTSC(R)?

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What's next after failure of OTSC® for the closure of gastrostomy fistula? Another OTSC®?

A 55-year-old female patient was diagnosed with squamous cell carcinoma of the nasopharynx stage in 2016 and proposed for radical chemo/radiotherapy. A percutaneous endoscopy gastrostomy was performed in 2016 because of the patient´s difficulty in swallowing. The patient had good response to therapy with disease´s remission so the gastrostomy tube was removed in 2018. After two weeks of conservative management, the patient maintained a gastrocutaneous fistula with extravasation of liquid contents. Endoscopic closure with over the scope clip (OTSC®) was performed.

ASGE high-risk criteria for choledocholithiasis - Are they applicable in cholecystectomized patients?

BACKGROUND AND AIMS: The guidelines by the American Society for Gastrointestinal Endoscopy (ASGE) suggest that in patients with gallbladder in situ, endoscopic retrograde cholangiopancreatography (ERCP) should be performed in the presence of high-risk criteria for choledocholithiasis, after biochemical tests and abdominal ultrasound. There are no specific recommendations for cholecystectomized patients. The aim of this study was to evaluate the applicability of ASGE criteria for ERCP in cholecystectomized patients with suspected choledocholithiasis. METHODS: We conducted a retrospective study that included patients with high-risk ASGE criteria for choledocholithiasis who underwent ERCP from 2013-2016. RESULTS: We included 327 patients in our analysis - 258 with gallbladder in situ (79%) and 69 with cholecystectomy (21%). We showed that the ASGE criteria true positive rate was similar between patients with and without cholecystectomy - the prevalence of choledocholithiasis on ERCP was 71% in cholecystectomized and 70% in non-cholecystectomized. In addition, both the presence and the diameter of the CBD stone were predictors of positive ERCP in both groups. In contrast, the diameter of the CBD was predictor of positive ERCP only in non-cholecystectomized patients. CONCLUSIONS: Although dilatation of the CBD was not a predictive factor for choledocholithiasis in cholecystectomized patients, the ASGE criteria true positive rate was similar to that of non-cholecystectomized patients.

High Efficacy of Repeating Colonoscopy by an Advanced Endoscopist after an Incomplete Colonoscopy.

BACKGROUND AND AIMS: This study aims to evaluate the role of an advanced endoscopist to study the entire colon after an incomplete colonoscopy. METHODS: All patients with an elective incomplete colonoscopy performed under deep sedation in our department between January 2010 and October 2016 were included. Patients with a colonic stenosis, an inadequate bowel preparation, or a colonoscopy performed without deep sedation were excluded. Included patients were followed up to evaluate if and what type of subsequent examinations (colonoscopy by an advanced endoscopist, single-balloon enteroscopy [SBE], and/or CT colonography) was performed to complete the study of the entire colon. Lesions found during these subsequent examinations were also recorded. RESULTS: Ninety-three patients had an incomplete colonoscopy, with no diagnosis of colorectal cancer (CRC) and a high-risk polyp rate of 5.4% (n = 5). Seventy-seven patients with incomplete colonoscopies underwent subsequent examinations, namely CT colonography in 45.5% (n = 35), colonoscopy by an advanced endoscopist in 53.2% (n = 41), and SBE in 13% (n = 10). In the 49 patients who performed either colonoscopy (n = 39) or SBE (n = 10) by an advanced endoscopist, the cecal intubation rate was 100%, and high-risk polyps were found in 26.5% (n = 13) and CRC in 4.1%. CT colonography revealed findings consistent with polyps and CRC in 22.9% (n = 8) and 2.9% (n = 1) of the cases, respectively. Colonoscopy was further repeated in 6 patients with suspected polyps in CT colonography, confirming the initial diagnosis in 5 patients. CONCLUSIONS: Colonoscopy by an advanced endoscopist achieved cecal intubation in all patients, representing a good choice after an incomplete colonoscopy.

INTRODUÇÃO/OBJETIVO: O presente estudo pretende aval-iar o papel de um endoscopista avançado no estudo do cólon após colonoscopia incompleta (CI). MATERIAL: In-cluíram-se todos os doentes com CI eletiva realizada por especialista, sob sedação profunda entre janeiro de 2010 e outubro de 2016. Excluíram-se doentes com estenose cólica, colonoscopia com preparação inadequada e/ou sem sedação. Avaliaram-se os exames subsequentes (colonoscopia por endoscopista avançado, enteroscopia assistida por monobalão [EAB] e colonografia virtual [CV]) realizados para completar o estudo do cólon e as lesões diagnosticadas. RESULTADOS: Incluíram-se 93 CI, que de-tetaram pólipos de alto risco em 5.4% (n = 5) e não iden-tificaram carcinoma colorretal (CCR). Realizou-se um segundo exame em 82.8% (n = 77) dos doentes, designada-mente, a CV, colonoscopia por endoscopista avançado e EAB em 45.5% (n = 35), 53.2% (n = 41) e 13% (n = 10), res-petivamente. Nos 49 doentes que realizaram colonosco-pia (n = 39) ou SBE (n = 10) por endoscopista avançado, a taxa de entubação cecal foi de 100%, detetando-se póli-pos de alto risco em 26.5% (n = 13) e CCR em 4.1%. Na CV observaram-se achados compatíveis com pólipos em 22.9% (n = 8) e CCR em 2.9% (n = 1) dos casos. A colo-noscopia foi subsequentemente realizada em 6 doentes com suspeita de pólipos na CV, confirmando-se o diag-nóstico em 5 doentes. CONCLUSÃO: A entubação cecal foi conseguida em todos os doentes submetidos a colo-noscopia realizada por endoscopista avançado repre-sentando uma boa opção no estudo subsequente do cólon após uma CI.

Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient?

INTRODUCTION: Along with increased life expectancy, the proportion of elderly patients with choledocholithiasis will increase and with this, the need for endoscopic cholangiopancreatography (ERCP). Current recommendations suggest laparoscopic cholecystectomy in all patients with choledocholithiasis to prevent biliary events. However, adherence to these recommendations is low, especially in older patients. METHODS: Retrospective study that included non-cholecystectomized patients aged > =75 years who underwent ERCP for choledocholithiasis from 2013-2016 (n = 131). A new biliary event was defined as the need for a new ERCP, cholecystitis, cholangitis or gallstone pancreatitis. AIM: The aim of this study was to compare the outcomes of new biliary events and mortality in cholecystectomized vs non-cholecystectomized patients after ERCP. RESULTS: Cholecystectomy was performed in 22% of the patients (92% laparoscopic). The post-cholecystectomy complication rate was 13% and the mortality rate was 7%. During the follow-up period (669 ± 487 days) a new biliary event occurred in 20% of patients - 10% new ERCP, 9% cholecystitis, 9% cholangitis and 2% pancreatitis. Cholecystectomized patients had fewer events (7% vs 24%, p = .048) and longer time to event (p = .016). There was no statistically significant difference in all-cause mortality (14% vs 27%, p = .13), mortality related to lithiasis (0% vs 9%, p = .11) or time to mortality from all causes (p = .07) and related to biliary events (p = .07). CONCLUSIONS: In this group of elderly patients, cholecystectomy after ERCP prevented the occurrence of new biliary events but resulted in a non-statistically significant difference in mortality.

Intragastric Balloon for Obesity Treatment: Safety, Tolerance, and Efficacy.

BACKGROUND: Obesity is an increasing worldwide problem associated with a vast number of comorbidities. Decreasing body weight by only 5-10% has been shown to slow and even prevent the onset of obesity-related comorbidities. Between pharmacological therapy and bariatric surgery a great variety of endoscopic techniques are available, the most common being intragastric balloon (IGB). The purpose of this study was to assess the safety, tolerance, and kinetics of IGBs in weight loss. The kinetics of weight loss were evaluated in 2 different contexts and phases: after the IGB's removal and after follow-up that varied between 6 and 12 months. Successful weight loss was defined as ≥10% weight loss after 6-12 months. METHODS: The study included 51 patients who had undergone Orbera® IGB placement between September 2014 and February 2016. Inclusion criteria were age between 18 and 65 years; body mass index (BMI) 28-35 with severe obesity-related disorders; or BMI 35-40. The IGB was removed 6 months later. All patients were followed for a minimum period of 6-12 months. RESULTS: Of 51 patients, 16 were excluded (7 due to intolerance) and 35 patients entered the study, of which 83% were followed for more than 6-12 months. The average weight loss (WL) and % excess WL (%EWL) after 6 months of treatment were 11.94 kg and 42.16%, respectively. At 6-12 months, after removal of the IGB, the mean WL was 8.25 kg and %EWL was 30.27%. Nineteen patients attained a WL of ≥10% the baseline value at IGB removal and 12 maintained their weight below this threshold during the 6-12 following months. CONCLUSIONS: After temporary IGB implantation in overweight or obese individuals, a WL that was ≥10% of weight at baseline was achieved in 54.3% and sustained at 6-12 months in 41.4% of participants. IGBs are an attractive intermediate option between diet and exercise programs and bariatric surgery. In general, IGB placement is a safe and well-tolerated procedure.

INTRODUÇÃO: A obesidade, problema crescente, está associada a um grande número de comorbilidades. A redução do peso corporal em apenas 5­10% mostrou-se eficaz na melhoria e até na prevenção do aparecimento de comorbilidades relacionadas com a obesidade. Entre a terapia farmacológica e a cirurgia bariátrica, temos disponiveis uma grande variedade de técnicas endoscópicas, sendo a mais comum a colocação de balão intragástrico (BIG). O objectivo do estudo foi avaliar a segurança, tolerância e cinética da perda de peso do BIG. A cinética da perda de peso foi avaliada em dois momentos e contextos distintos: após a remoção do balão e depois do periódo de follow-up (PFU), que variou entre 6­12 meses. Eficácia definida como perda de peso 10% após PFU de 6­12 meses. MÉTODOS: O estudo incluiu 51 pacientes que colocaram Orbera® BIG entre setembro de 2014 e fevereiro de 2016. Os critérios de inclusão foram: idade entre 18­65 anos, IMC 28­35 com comorbilidades relacionadas com obesidade e IMC 35­40. O BIG foi removido passados 6 meses. Todos os doentes foram acompanhados por um período minino de 6­12 meses (PFU). RESULTADOS: Dos 51 doentes considerados, 16 foram excluidos (7 por intolerancia) e 35 entraram no estudo, dos quais 83% foram seguidos durante PFU. A perda de peso média (PPM) e % de excesso de peso perdido (EPP) na altura de remoção do BIG foi de 11.94 kg e 42.16%, respetivamente; após PFU, a PPM foi de 8.25 kg e o EPP foi 30.27%. Dezanove alcançaram uma perda de peso na altura de remoção de BIG e 12 mantiveram o seu peso abaixo deste limiar após o PFU. CONCLUSÕES: Após a colocação temporaria do BIG em pacientes com excesso de peso ou obesidade, foi alcançado uma perda de peso superior a 10 em 54.3% na altura de remoção do BIG e sustentada após periodo de follow-up de 6­12 meses em 41.4% dos doentes. Os BIG são uma alternativa intermédia atractiva entre dieta/exercicio fisico e cirurgia bariátrica. Em geral é um procedimento seguro e bem tolerado.