Performance measures for endoscopy services: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative.

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a list of key performance measures for endoscopy services. We recommend that these performance measures be adopted by all endoscopy services across Europe. The measures include those related to the leadership, organization, and delivery of the service, as well as those associated with the patient journey. Each measure includes a recommendation for a minimum and target standard for endoscopy services to achieve. We recommend that all stakeholders in endoscopy take note of these ESGE endoscopy services performance measures to accelerate their adoption and implementation. Stakeholders include patients and their advocacy groups; service leaders; staff, including endoscopists; professional societies; payers; and regulators.

Investigation of intercellular adhesion molecules (ICAMs) gene expressions in patients with Barrett's esophagus.

The adhesion molecules play a major role in inflammation as well as in neoplastic diseases. The aim of this study is to evaluate the expressions of the adhesion molecules, intercellular adhesion molecule 1 (ICAM-1), ICAM-2, and ICAM-3, in Barrett's esophagus, recognized as a premalign lesion for esophageal cancer and related to inflammation. Eighteen patients with Barrett's esophagus according to endoscopy and 25 volunteers without Barrett's esophagus disease were included in the study. Tissue samples were supplied by biopsy and used for both gene expression and immunohistochemical analysis. The significance of the differences between the two groups was assessed by Student's t test. The ICAM-1 expression level was fivefold higher in the patient group compared with that of the control. There was an increase in the serum level of ICAM-1 in patients compared to that of the controls, but this increase was not significant. ICAM-2 levels were also increased in the patient group, but it was not significant. There was no difference between controls and patients in ICAM-3 levels. Significantly higher levels of ICAM-1 gene expression make us think that ICAM-1 may play an important role in Barrett's esophagus. We think that more studies, with larger patient groups and preferably detailed histopathological and clinical evaluations, are needed to explain the severity of ICAM-1, ICAM-2, and ICAM-3 molecules in Barrett's esophagus.

Investigation of the esophageal Rho-kinase expression in patients with Barrett's esophagus.

The mechanisms responsible for the malignant transformation in Barrett's esophagus (BE) are still poorly understood. The authors have evaluated the role of Rho-kinase (ROCK1 and ROCK2) expressions in patients with BE. All patients underwent upper gastrointestinal system endoscopy, which was confirmed histologically. Real-time PCR revealed no marked change in gene expressions of ROCK1 and ROCK2 at mRNA levels in BE when compared to controls. Immunohistochemical and western blot analyses showed no change in ROCK1 and ROCK2 protein expressions in BE. This study demonstrates that Rho-kinase gene and protein expressions are not modified in BE.

Ultrathin endoscopy for gastrointestinal strictures.

BACKGROUND AND AIM: The assessment and treatment of advanced gastrointestinal (GI) strictures, which are defined as the inability to pass through the strictured segment with standard endoscopes, might require radiological work-up, repeated endoscopies and surgery. The aim of the present study was to assess the role of ultrathin endoscopy (UTE) for the evaluation and treatment of advanced GI strictures. METHODS: Patients in whom an initial diagnostic upper or lower endoscopy attempt was incomplete because of a tight stricture underwent a second procedure with a UTE (5.9 mm diameter) in the same session. An interventional endoscopic therapy was also carried out according to the etiology and nature of the stricture using the same UTE. Diagnostic and therapeutic outcomes were recorded and followed up prospectively. The study was conducted in a tertiary endoscopy center. RESULTS: During a one and half year study period, 62 patients (51 at upper and 11 at lower endoscopy) were detected with advanced GI stricture among 8456 diagnostic upper and 3815 lower endoscopy patients. A complete endoscopic examination was successful with UTE in 40 (78%) patients with upper and in nine patients (82%) with lower GI strictures. An interventional procedure was also carried out in 16 patients with the assistance of UTE. CONCLUSION: UTE is a useful tool for the evaluation of patients with advanced GI strictures. It provides a complete diagnostic endoscopy in most patients and gives an opportunity for therapeutic endoscopic procedures.

Serum cystatin C measurement in differential diagnosis of intra and extrahepatic cholestatic diseases.

OBJECTIVE: Cystatin C is a very potent inhibitor of cysteine proteinases and, it has been clinically applied as a sensitive marker in monitoring of renal and liver functions. The aim of this study was to reveal whether cystatin C may be a useful marker for distinguishing intra- versus extrahepatic cholestasis. MATERIALS AND METHODS: Serum cystatin C concentrations were determined by nephelometric immunoassay using N latex cystatin C kit in 53 patients with cholestatic disorder that included 18 patients with intrahepatic cholestasis , 17 patients with malignant extrahepatic cholestasis , 18 patients with benign extrahepatic cholestasis. Serum cystatin C concentration was also determined in 20 healthy volunteers. RESULTS: Mean serum cystatin C concentration was 2.82 +/- 0.24 mg/l (SD) in patients with intrahepatic cholestasis, 2.05 +/- 0.15 mg/l in patients with extrahepatic malignant cholestasis, 1.37 +/- 0.13 mg/l in extrahepatic benign cholestatic patients and 0.93 +/- 0.24 mg/l in control group. Serum cystatin C concentrations in patients with cholestatic disease were significantly higher than those in the healthy controls (p < 0.001). Moreover, mean serum cystatin C concentration in patients with intrahepatic cholestasis was higher than those in extrahepatic cholestasis groups (p < 0.001). Serum cystatin C concentrations were significantly higher in patients with malignant xtrahepatic cholestasis than in patients with benign extrahepatic cholestasis p < 0.001). There were no correlations patients among serum cystatin C concentrations and serum levels of AST, ALT, ALP, GGT, total and conjugated bilirubin. CONCLUSION: Our results suggested that serum cystatin C level may be a potential biochemical marker both to point out an intrahepatic origin by excluding an extrahepatic source of cholestasis in patients with jaundice and to possibly differentiate bening and malignant extrahepatic cholestatic disorders.

Dexmedetomidine or midazolam in combination with propofol for sedation in endoscopic retrograde cholangiopancreatography: a randomized double blind prospective study.

INTRODUCTION: Interventional endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP), often require sedation during the procedure. The most commonly used drugs for this purpose are midazolam and propofol, which are used as sedative and hypnotic agents with minimal analgesic potential. AIM: To compare the analgesic sedative effects of midazolam-propofol and dexmedetomidine-propofol combinations and their influence on hemodynamic and respiratory variables in patients undergoing ERCP. MATERIAL AND METHODS: Forty adult patients aged 20-78 and undergoing ERCP were randomized to two groups. Patients were premedicated with midazolam (0.05 mg/kg 10 min before the procedure) in group M and with dexmedetomidine (1 µg/kg for 10 min) in group D. Propofol was used for maintenance. The sedation level was monitored using the bispectral index (BIS) to maintain a score between 70 and 80. Hemodynamic and respiratory variables, recovery time and adverse events were recorded. RESULTS: The hemodynamic and respiratory variables were similar in both groups. Total propofol consumption was significantly lower in the dexmedetomidine group (208.5 ±80.0 vs. 154.5 ±66.7 mg; p = 0.011). The recovery period was shorter in group D (time to achieve the Aldrete score 9 was 9.4 ±2.1 vs. 6.6 ±1.1 min; p < 0.001). Changes in hemodynamic and respiratory variables and adverse events were not different between the two groups. CONCLUSIONS: We found a shorter recovery time and comparable sedative and adverse effects with the dexmedetomidine-propofol combination compared with the midazolam-propofol combination. Dexmedetomidine in combination with propofol may be a safe and useful alternative for sedation for ERCP patients.

Performance measures for endoscopy services: A European Society of Gastrointestinal Endoscopy (ESGE) quality improvement initiative.

The European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology present a list of key performance measures for endoscopy services. We recommend that these performance measures be adopted by all endoscopy services across Europe. The measures include those related to the leadership, organization, and delivery of the service, as well as those associated with the patient journey. Each measure includes a recommendation for a minimum and target standard for endoscopy services to achieve. We recommend that all stakeholders in endoscopy take note of these ESGE endoscopy services performance measures to accelerate their adoption and implementation. Stakeholders include patients and their advocacy groups; service leaders; staff, including endoscopists; professional societies; payers; and regulators.

Relationship between liver injury and serum cytokeratin 18 levels in asymptomatic hepatitis B virus carriers and in patients with chronic hepatitis B infection.

BACKGROUND AND STUDY AIMS: Apoptosis represents a well-known mechanism of cell death involved in most chronic liver injuries. Our aim was to investigate the serum fragment level of cytokeratin 18 (CK18), M30, in asymptomatic hepatitis B virus (HBV) carriers and patients with chronic hepatitis B (CHB) and to evaluate the relationship between serum M30 levels and the severity of hepatic injury. PATIENTS AND METHODS: Asymptomatic HBV carriers (n=169), patients with CHB (n=100), and healthy control subjects (n=43) were enrolled in the study. Serum CK18 (M30) levels were analysed in all subjects. Liver biopsy for histopathological assessment was performed in asymptomatic HBV carriers and in patients with CHB infection. RESULTS: Serum CK18 (M30) levels were significantly higher in asymptomatic HBV carriers (198.77±77.62U/L) than in healthy control subjects (146.92±40.18U/L). Patients with CHB (283.02±147.45U/L) had significantly higher CK18 (M30) levels than asymptomatic HBV carriers (p=0.001). The diagnostic efficacy of CK18 (M30) levels in distinguishing patients with HBeAg-negative CHB from asymptomatic HBV carriers was found to be moderate (c-statistics: 0.695), and the diagnostic cut-off value of CK18 (M30) was 262U/L (specificity: 85%, sensitivity: 48%, positive likelihood ratio: 3.35, and negative likelihood ratio: 0.60). There was a positive correlation between serum CK18 (M30) levels and histological activity index scores in asymptomatic HBV carriers and patients with CHB. CONCLUSIONS: Serum CK18 (M30) levels may be a valuable indicator in distinguishing asymptomatic HBV carriers from patients with HBeAg-negative CHB when considered together with ALT and HBV-DNA levels.

Alverine citrate induced acute hepatitis.

Alverine citrate is a commonly used smooth muscle relaxant agent. A MEDLINE search on January 2004 revealed only 1 report implicating the hepatotoxicity of this agent. A 34-year-old woman was investigated because of the finding of elevated liver function tests on biochemical screening. Other etiologies of hepatitis were appropriately ruled out and elevated enzymes were ascribed to alverine citrate treatment. Although alverine citrate hepatotoxicity was related to an immune mechanism in the first case, several features such as absence of predictable dose-dependent toxicity of alverine citrate in a previous study and absence of hypersensitivity manifestations in our patient are suggestive of a metabolic type of idiosyncratic toxicity.

Postpartum hepatotoxicity due to herbal medicine Teucrium polium.

The hepatotoxicity cases due to herbal medical products have been increased in recent years. Teucrium polium (TP) (mountain germander) is one of the most popular species of the Lamiaceae family and is commonly used for increasing breast milk formation and for relieving gastrointestinal complaints in the last months of pregnancy and postpartum periods. Here are presented 3 cases of serious hepatotoxicity due to TP. Three female patients aged 33, 31, and 37 years were admitted to clinic with jaundice and serious elevated liver enzymes for a period of 2 years. The patients were using TP for approximately 40 days to 3 months. Two of the 3 used TP during their previous pregnancies and were monitored for similar complaints by another center. After discontinuation of TP and supportive care, the liver function tests were decreased to normal limits within 3 months in all 3 patients. In addition to the potential hepatotoxic effect of TP, physiological changes in the postpartum period may increase the severity of hepatotoxicity. TP should be considered in differential diagnosis in patients presenting similar history and complaints, where it is used commonly.

Transnasal endoscopy is preferred by transoral endoscopy experienced patients.

BACKGROUND & AIMS: Both unsedated transoral endoscopy (TOE) and sedated TOE have some drawbacks in clinical practice. Unsedated transnasal endoscopy (TNE) has been suggested as an alternative to both methods. This study aimed to determine the advantages of TNE in patients who have previously undergone unsedated conventional TOE. METHODS: Patients who had received an unsedated TOE in the last 12 months and were scheduled for a second upper endoscopy were included. They were randomized to undergo either unsedated TOE, using a standard endoscope, or unsedated TNE, using an ultrathin endoscope. Post-procedure, patients were asked to complete a questionnaire to assess pain, discomfort and acceptability of the procedure, and to compare the current procedure with their previous unsedated TOE. Endoscope insertion rate, procedure duration, and side-effects were recorded. RESULTS: Each group included 50 patients. With the exception of nasal pain, the tolerability and acceptance were significantly greater in the unsedated TNE group. Significantly more TNE patients (82%) found the current endoscopic procedure to be better than their previous TOE when compared with patients who had received a second TOE (12%). A repeat procedure was significantly more acceptable for TNE patients when compared to the TOE group (68% vs.16%). The duration of endoscopy was significantly shorter in TOE than in TNE (p<0.05). Endoscope insertion failed in 4% and mild epistaxis was observed in 4% of TNE patients. CONCLUSION: Unsedated TNE was better tolerated in endoscopy experienced patients when compared with unsedated TOE. The majority of patients found TNE more acceptable and preferable to TOE, suggesting that TNE should become a more common practice in clinics when applicable.

Drug- and herb-induced liver injury: a case series from a single center.

BACKGROUND/AIMS: Drug-induced liver injury (DILI) is common worldwide and has a potentially fatal outcome. It accounts for more than half of the cases of acute liver failure in the United States. Herb-induced liver injury (HILI) is a less documented condition but a growing problem. We present here the clinical characteristics and outcome of patients with drug- and herb-induced liver injury from our center. MATERIALS AND METHODS: In this 4-year retrospective study, 82 patients in whom there was a causal or highly probable relationship between herbal medicine or drug use and liver disease are presented. RESULTS: The mean age of patients was 43.1±14.8 years; sexual distribution was 53 females and 29 males. The major cause of hepatotoxicity was drugs (87.8%), with herbal medicine accounting for 12.2%. The leading causative agents were nonsteroidal anti-inflammatory drugs (NSAIDs) (23.1%), followed by antibiotics (19.5%). The pattern of hepatotoxicity was hepatocellular in 35 patients (42.6%), mixed in 28 (34.1%), and cholestatic in 19 patients (23.1%). Teucrium polium (known popularly as felty germander), which is a traditionally used herbal medicine of the Labiatae family in our region, was the most common cause of herb-induced liver injury and responsible in 7 of 10 herbal hepatotoxic cases. Acute liver failure developed in 3 patients (two patients related with flurbiprofen and diclofenac and one patient due to an isoniazid-rifampicin combination). CONCLUSION: Antibiotics and NSAIDs were the most common etiologic agents for drug-induced liver injury. Surprisingly, herbs follow these groups of drugs and must be questioned more carefully.

The relation between serum cytokeratin 18 and acute pancreatitis: can it be a serological predictive marker?

BACKGROUND/AIMS: Acute pancreatitis is well defined as pancreatic inflammation due to the activation of pancreatic enzymes secondary to several etiological factors. In the majority of patients, the clinical symptoms are self-limited, but it can also cause tissue necrosis and severe organ failures. In experimental animal models, it has been shown that wide apoptotic cell death is related to a clinically mild presentation of acute pancreatitis. Cytokeratin 18, a cytoskeletal protein, is shown to be related with apoptosis. In this study, we aimed to show the relation between serum cytokeratin 18 and the clinical presentation of acute pancreatitis in humans. MATERIALS AND METHODS: A total of 54 acute pancreatitis patients were enrolled into the study. Patients were classified as mild or severe pancreatitis according to Ranson's criteria. There were 36 (66.7%) patients in the mild pancreatitis group (score < 6), and 18 (33.3%) patients in the severe pancreatitis group (score ≥ 6). During the first admission, blood samples were obtained for serum cytokeratin 18 levels. RESULTS: Cytokeratin 18 levels in the mild pancreatitis group were significantly higher than in the severe pancreatitis group (271.2 ± 45.5 vs. 152.6 ± 38.2 IU/L; p < 0.001). There was a negative correlation between the disease activity score (Ranson score) and the serum cytokeratin 18 levels (p < 0.001; r = -0.724). CONCLUSIONS: This first human study suggests that cytokeratin 18 (marker of apoptosis) might be a serological predictive marker for acute pancreatitis for disease activity.

Diagnostic accuracy of cascade stomach by upper gastrointestinal endoscopy in patients with obscure symptoms: a multi-center prospective trial.

AIM: Cascade stomach (CS) is a deformity of stomach, capable of leading dyspepsia, and its actual incidence is unknown. We investigated its frequency and performed a preliminary study to determine endoscopic diagnostic criteria. MATERIAL AND METHODS: One thousand four hundred and seventy-five consecutive patients were enrolled to this study. A criteria for CS in endoscopy was defined as follow: A fundal pouch after cardia, difficulty in passage from fundus to corpus and/or requiring a manoeuvre, an angulation separating fundus-corpus. Cases having all three criteria were considered as complete CS (CCS) only the third one as borderline CS (BCS). RESULTS: CS was diagnosed endoscopically in 33 (2.5%) and radiologically in 32 (2.4%) of patients with dyspepsia. Among endoscopically diagnosed CS patients, CCS was found to be present in 17 and BCS was found to be in 16 patients. Patients in whom CS was diagnosed endoscopically, radiological examination revealed CCS in 18 patients, BCS in 14 patients, and 1 patient with normal findings were detected. There were no significant differences between these two groups (P=0.559). CONCLUSION: CS can be presented with various upper abdominal symptoms, and it can easily be diagnosed when endoscopic criteria are considered.

Preoperative detection of insulinomas: two case reports.

BACKGROUND: Insulinoma is the most common endocrine tumor of the pancreas. Accurate preoperative detection and localization of insulinomas is essential for the appropriate selection of candidates for surgery. We present two cases with benign pancreatic insulinoma. CASE PRESENTATION: Preoperative evaluation for patients with suspected insulinomas has been controversial. Endoscopic ultrasonography (EUS) has a sensitivity of 95% in well skilled operators and well tolerated preoperative imaging method. CONCLUSION: We have detected the insulinomas with EUS before surgery in our patients but other imaging modalities did not help us for localization of them. Patients have been asymptomatic postoperatively with no hypoglycemia on repeat fasting. We reviewed here the different modalities for preoperative localization of insulinoma.