Assessment of multi-modality evaluations of obscure gastrointestinal bleeding

AIMTo determine the frequency of bleeding source detection in patients with obscure gastrointestinal bleeding (OGIB) who underwent double balloon enteroscopy (DBE) after pre-procedure imaging [multiphase computed tomography enterography (MPCTE), video capsule endoscopy (VCE), or both] and assess the impact of imaging on DBE diagnostic yield.METHODSRetrospective cohort study using a prospectively maintained database of all adult patients presenting with OGIB who underwent DBE from September 1st, 2002 to June 30th, 2013 at a single tertiary center.RESULTSFour hundred and ninety five patients (52% females; median age 68 years) underwent DBE for OGIB. AVCE and/or MPCTE performed within 1 year prior to DBE (in 441 patients) increased the diagnostic yield of DBE (67.1% with preceding imaging vs 59.5% without). Using DBE as the gold standard, VCE and MPCTE had a diagnostic yield of 72.7% and 32.5% respectively. There were no increased odds of finding a bleeding site at DBE compared to VCE (OR = 1.3, P = 0.150). There were increased odds of finding a bleeding site at DBE compared to MPCTE (OR = 5.9, P < 0.001). In inpatients with overt OGIB, diagnostic yield of DBE was not affected by preceding imaging.CONCLUSIONDBE is a safe and well-tolerated procedure for the diagnosis and treatment of OGIB, with a diagnostic yield that may be increased after obtaining a preceding VCE or MPCTE. However, inpatients with active ongoing bleeding may benefit from proceeding directly to antegrade DBE.

EUS FNA of Altered Left Adrenal Gland Morphology Suggests Amending CT and PET-CT Attenuation Threshold Values That Predict Malignancy

Introduction: In the setting of an extra-adrenal malignancy, it is a recognized clinical challenge to try and distinguish a benign adrenal mass from a metastatic deposit. Current non-invasive diagnostic tools for adrenal gland evaluation include CT, MRI, PET and PET-CT. Diagnostic interpretative error can occur as evaluations rarely have complete cytologic or histologic correlation for concordance purposes. Aims: To establish the performance characteristics of non-contrast CT attenuation values (Hounsfield units-HU) and the optimal PET-CT maximum standard uptake value (SUVmax) for predicting adrenal malignancy when correlated with adrenal gland endoscopic ultrasound fine needle aspiration (EUS FNA) cytology results. Methods: A prospectively maintained EUS database was reviewed to identify consecutive patients who underwent a left adrenal gland FNA. Non-contrast CT attenuation values and SUVmax scores were calculated. EUS FNA cytology results were used as the reference standard for determining the presence of benign versus malignant adrenal gland status. Results: Sixty-two patients (69 ± 11 years) underwent adrenal EUS FNA, 34 (54.8%) of whom had a clinically suspected or established extra-adrenal malignancy. Non-invasive imaging was suggestive of abnormal adrenal morphology or altered PET-CT FDG activity in 45 (72.6%) patients. Elevated attenuation values (≥10 HU) by non-enhanced CT had a sensitivity and specificity of 100% and 34.6%, respectively. The SUVmax for malignant altered morphology was significantly higher than that for benign lesions [(8.5 ± 3.1 vs 3.3 ± 0.7;(p = 0.0001)]. ROC curve analysis indicated that an optimum cutoff SUVmax of ≥4.1 (AUC 0.92) yielded the best power distinction for malignancy with a sensitivity and specificity of 89% and 100%. Conclusion: When evaluating altered adrenal morphology by non-invasive methods, the performance characteristics of elevated CT attenuation values are suboptimal. But by adopting a SUVmax cut-off value of ≥4.1 could potentially improve such characteristics to detect malignancy.

Evaluating a combined bowel preparation for small-bowel capsule endoscopy:a prospective randomized–controlled study

Background:Capsule endoscopy(CE)is frequently hindered by intra-luminal debris.Our aim was to determine whether a combination bowel preparation would improve small-bowel visualization,diagnostic yield,and the completion rate of CE.Methods:Single-blind,prospective randomized–controlled study of outpatients scheduled for CE.Bowel-preparation subjects ingested 2 L of polyethylene glycol solution the night prior to CE,5mL simethicone and 5mg metoclopramide 20 minutes prior to CE and laid in the right lateral position 30 minutes after swallowing CE.Controls had no solid food after 7 p.m.the night prior to CE and no liquids 4 hours prior to CE.Participants completed a satisfaction survey.Capsule readers completed a small-bowel-visualization assessment.Results:Fifty patients were prospectively enrolled(56%female)with a median age of 54.4 years and 44 completed the study(23 patients in the control group and 21 in the preparation group).There was no significant difference between groups on quartile-based small-bowel visualization(all P>0.05).There was no significant difference between groups in diagnostic yield(P=0.69),mean gastric(P=0.10)or small-bowel transit time(P=0.89).The small-bowel completion rate was significantly higher in the preparation group(100%vs 78%;P=0.02).Bowel-preparation subjects reported significantly more discomfort than controls(62%vs 17%;P=0.01).Conclusions:Combined bowel preparation did not improve small-bowel visualization but did significantly increase patient discomfort.The CE completion rate improved in the preparation group but the diagnostic yield was unaffected.Based on our findings,a bowel preparation prior to CE does not appear to improve CE performance and results in decreased patient satisfaction(ClinicalTrials.gov,No.NCT01243736).