Enteroscopy in small intestinal inflammatory diseases.

The development of new semilong enteroscopes, videopush enteroscope (VPE), has modified the diagnostic and therapeutic approach to inflammatory intestinal diseases owing to the biopsy and therapeutic capacities. In Crohn's Disease, VPE is useful in nonusual clinical presentations: occult intestinal bleeding and in the treatment by dilatation of jejunal and ileal strictures. In atrophic coeliac disease (ACD) VPE is mandatory each time oesogastroduodenoscopy biopsies are noninformative in order to obtain pathologic jejunal biopsis. In addition, in refractory ACD and in the case of jejunal blood loss ACD, VPE is mandatory in the search for ulcerative jejunitis and lymphoma. The management of chronic diarrhea of the adult, classic endoscopy remains the gold standard procedure and is carried out first but in patients with negative results, VPE can proceed immediately. Good results can only be obtained if VPE is performed by endoscopist who is highly interested in this field of investigation.

Intraoperative endoscopy.

Intraoperative endoscopy (IOE) is accepted as the ultimate diagnostic procedure for the complete evaluation of small bowel. Until recent years, operative endoscopy was the complement of sonde enteroscopy. The difficulties of this long and fastidious type of examination, for both the patient and the medical team are well known. It provides incomplete exploration (detubing of certain loops is too rapid), and renders impossible any diagnostic or therapeutic procedure (biopsies, electrocoagulation). The indications of IOE have diminished over recent years during the development of push enteroscopy by upper or double way. Indeed, the latter method makes it possible in a number of cases to obtain complete exploration of the small bowel with biopsies and therapeutic procedures, or an exploration enabling screening for lesions in the first jejunal loops of the lat ileal loops.

Hidden damage revealed.

Nonsteroidal anti-inflammatory drug (NSAID)-induced gastrointestinal lesions should be suspected when a patient receiving NSAID therapy has pain or signs of hemorrhage that are severe enough to warrant an emergency endoscopy. However, with endoscopy, patients receiving NSAID therapy with no particular gastrointestinal symptoms may also be found to have lesions. These lesions are polymorphic in character and lack clear anatomic and clinical parallels with spontaneous lesions. Endoscopically, they are of three types: (1) Advanced focal or diffuse lesions, uncommon and not usually seen in ambulatory patients; (2) large or diffuse, ulcerated or hemorrhagic lesions, that can be differentiated from those seen in typical digestive system pathology; and (3) microlesions, often responsible for false-negative examinations and now detectable through advances in electronic endoscopy. Lower bowel or ileocolonic damage is also a common finding but has only recently come to clinical attention. The endoscopic appearance of these intestinal lesions suggests a superficial inflammatory bowel disease such as hemorrhagic rectocolitis or Crohn's disease.

Gastric mucosal surface in cirrhosis evaluated by magnifying endoscopy and scanning electronic microscopy.

BACKGROUND AND STUDY AIMS: Gastric mucosa may have several tiny patterns in portal hypertension. In this prospective study, we used magnifying endoscopy and scanning electron microscopy (SEM) to better characterize the morphology of gastric mucosa in patients with cirrhosis, and we evaluated the diagnostic accuracy of magnifying endoscopy. PATIENTS AND METHODS: Videotapes of gastric mucosal patterns from 39 cirrhotic patients and 20 control patients were blindly evaluated by the same observer using magnifying endoscopy (magnification x 25) and conventional endoscopy. SEM was performed in 12 other patients. The basic anatomical entities of the gastric architecture on conventional endoscopy were the gastric area in control patients and the mosaic pattern in patients with cirrhosis. RESULTS: With regard to the prevalence of endoscopic patterns in the antrum, the mosaic pattern was more frequent in cirrhotic patients. In the body, the mosaic pattern, white spots, and red marks were significantly more frequent in cirrhotic patients, whereas gastric areas were more frequent in control patients. Concerning the contributions of the techniques, significantly more gastric areas were identified by magnifying endoscopy than by conventional endoscopy. However, in multivariate analysis, only conventional endoscopy with esophageal varices had significant independent diagnostic accuracy for cirrhosis, and magnifying endoscopy of mucosal signs did not add any significant information. SEM did not improve discrimination between control and cirrhotic patients. CONCLUSIONS: Magnifying endoscopy provides more details of the mucosa, thus improving the delineation of gastric mucosal morphology. However, magnifying endoscopy has little clinical value in cirrhosis since it does not improve on the accuracy of conventional endoscopy for the diagnosis of cirrhosis.

Argon laser photocoagulation for upper gastrointestinal haemorrhage: is technique the key to success?

Reports of endoscopic laser photocoagulation have been enthusiastic. However, many technical factors influence the results and discussion of these in the literature has been very limited. We describe the problems encountered in treating 71 patients with bleeding peptic ulcers, and our solutions to them. Failures were due to problems of access and identification of bleeding points, as much as to the laser itself. Results were improved by meticulous endoscopic washing of the ulcer crater and care in setting the laser. These technical factors must be optimised before the true efficacy of this treatment can be assessed in a controlled, randomised clinical trial.

Perioperative endoscopy of the whole small bowel in Crohn's disease.

The aim of this study was to search for small bowel lesions by means of a perioperative endoscopy in 20 patients operated on for Crohn's disease. Seven women and 13 men (mean age 29 years) had a total retrograde exploration to the angle of Treitz during an ileocolectomy (16 of 20 patients) or a colonic or ileal resection (four of 20 patients). Endoscopic exploration was completed, through an enterotomy, from the surgical area to the angle of Treitz. Periendoscopic biopsy samples were taken on macroscopic lesions and every 20 cm systematically. In 13 of 20 cases, various lesions scattered over the whole small intestine were found. These were aphthoid ulcerations (10 patients), superficial ulcerations (seven patients), mucosal oedema (three patients), non-ulcerative stenosis (three patients), erythema (two patients), pseudopolyps (two patients), deep ulcerations (two patients), and ulcerative stenosis (one patient). In seven patients none of the lesions detected at perioperative endoscopy had been recognised by preoperative evaluation or surgical inspection of the serosal surface. A typical granuloma was found at biopsy of lesions identified by endoscopy in three cases and at biopsy of an apparently healthy area in one case. Thus 65% of patients operated on for Crohn's disease had lesions of the small intestine detected by endoscopy, which were unrecognised before surgery in more than half of the cases.