Endoscopic ultrasound-guided elastography in the nodal staging of oesophageal cancer

AIM:To assess quantitative endoscopic ultrasound (EUS)guided elastography in the nodal staging of oesophagogastric cancers.METHODS:This was a single tertiary centre study assessing 50 patients with established oesophago-gastric cancer undergoing EUS-guided fine needle aspiration biopsy (FNAB) of lymph nodes between July 2007 and July 2009.EUS-guided elastography of lymph nodes was performed before EUS-FNAB.Standard EUS characteristics were also described.Cytological determination of whether a lymph node was malignant or benign was used as the gold standard for this study.Comparisons of elastography and standard EUS characteristics were made between the cytologically benign and malignant nodes.The main outcome measure was the accuracy of elastography in differentiating between benign and malignant lymph nodes in oesophageal cancers.RESULTS:EUS elastography and FNAB were performed on 53 lymph nodes.Cytological malignancy was found in 23 nodes,one was indeterminate,one was found to be a gastrointestinal stromal tumor and 25 of the nodes were negative for malignancy.On 3 occasions insufficient material was obtained for analysis.The area under the curve for the receiver operating characteristic curve for elastography strain ratio was 0.87 (P<0.0001).Elastography strain ratio had a sensitivity 83%,specificity 96%,positive predictive value 95%,and negative predictive value 86% for distinguishing between malignant and benign nodes.The overall accuracy of elastography strain ratio was 90%.Elastography was more sensitive and specific in determining malignant nodal disease than standard EUS criteria.CONCLUSION:EUS elastography is a promising modality that may complement standard EUS and help guide EUS-FNAB during staging of upper gastrointestinal tract cancer.

Update on risk scoring systems for patients with upper gastrointestinal haemorrhage

Upper gastrointestinal haemorrhage (UGIH) remains a common medical emergency worldwide. It is increasingly recognised that early risk assessment is an important part of management, which helps direct appropriate patient care and the timing of endoscopy. Several risk scores have been developed, most of which include endoscopic findings, although a minority do not. These scores were developed to identify various end-points including mortality, rebleeding or clinical intervention in the form of transfusion, endoscopic therapy or surgery. Recent studies have reported accurate identification of a very low risk group on presentation, using scores which require simple clinical or laboratory parameters only. This group may not require admission, but could be managed with early out-patient endoscopy. This article aims to describe the existing pre- and post-endoscopy risk scores for UGIH and assess the published data comparing them in the prediction of outcome. Recent data assessing their use in clinical practice, in particular the early identification of low-risk patients, are also discussed.

Upper gastrointestinal bleeding in Scotland 2000-2010: Improved outcomes but a significant weekend effect

AIM: To assess numbers and case fatality of patients with upper gastrointestinal bleeding(UGIB),effects of deprivation and whether weekend presentation affected outcomes.METHODS: Data was obtained from Information Services Division(ISD) Scotland and National Records of Scotland(NRS) death records for a ten year period between 2000-2001 and 2009-2010. We obtained data from the ISD Scottish Morbidity Records(SMR01) database which holds data on inpatient and daycase hospital discharges from non-obstetric and nonpsychiatric hospitals in Scotland. The mortality data was obtained from NRS and linked with the ISD SMR01 database to obtain 30-d case fatality. We used 23 ICD-10(International Classification of diseases) codes which identify UGIB to interrogate database. We analysed these data for trends in number of hospital admissions with UGIB,30-d mortality over time and assessed effects of social deprivation. We compared weekend and weekday admissions for differences in 30-d mortality and length of hospital stay. We determined comorbidities for each admission to establish if comorbidities contributed to patient outcome. RESULTS: A total of 60643 Scottish residents were admitted with UGIH during January,2000 and October,2009. There was no significant change in annual number of admissions over time,but there was a statistically significant reduction in 30-d case fatality from 10.3% to 8.8%(P < 0.001) over these 10 years. Number of admissions with UGIB was higher for the patients from most deprived category(P < 0.05),although case fatality was higher for the patients from the least deprived category(P < 0.05). There was no statistically significant change in this trend between 2000/01-2009/10. Patients admitted with UGIB at weekends had higher 30-d case fatality compared with those admitted on weekdays(P < 0.001). Thirty day mortality remained significantly higher for patients admitted with UGIB at weekends after adjusting for comorbidities. Length of hospital stay was also higher overall for patients admitted at the weekend when compared to weekdays,although only reached statistical significance for the last year of study 2009/10(P < 0.0005). CONCLUSION: Despite reduction in mortality for UGIB in Scotland during 2000-2010,weekend admissions show a consistently higher mortality and greater lengths of stay compared with weekdays.

Update on gastric varices

Although less common than oesophageal variceal haemorrhage, gastric variceal bleeding remains a serious complication of portal hypertension, with a high associated mortality. In this review we provide an update on the aetiology, classification and management of gastric varices, including acute bleeding, prevention of rebleeding and primary prophylaxis. We describe the optimum management strategies for gastric varices including drug, endoscopic and radiological therapies, focusing on recent published evidence.