Negative capsule endoscopy in patients with obscure gastrointestinal bleeding reliable: Recurrence of bleeding on long-term follow-up

AIM: To assess the rate of recurrent bleeding of the small bowel in patients with obscure bleeding already undergone capsule endoscopy (CE) with negative results. METHODS: We reviewed the medical records related to 696 consecutive CE performed from December 2002 to January 2011, focusing our attention on patients with recurrence of obscure bleeding and negative CE. Evaluating the patient follow-up, we analyzed the recurrence rate of obscure bleeding in patient with a negative CE. Actuarial rates of rebleeding during follow-up were calculated, and factors associated with rebleeding were assessed through an univariate and multivariate analysis. A P value of less than 0.05 was regarded as statistically significant. The sensitivity, specificity, and positive and negative predictive values (PPV and NPV) of negative CE were calculated. RESULTS: Two hundred and seven out of 696 (29.7%) CE studies resulted negative in patient with obscure/overt gastrointestinal bleeding. Overall, 489 CE (70.2%) were positive studies. The median follow-up was 24 mo (range 12-36 mo). During follow-up, recurrence of obscure bleeding was observed only in 34 out of 207 negative CE patients (16.4%); 26 out of 34 with obscure overt bleeding and 8 out of 34 with obscure occult bleeding. The younger age (< 65 years) and the onset of bleeding such as melena are independent risk factors of rebleeding after a negative CE (OR = 2.6703, 95%CI: 1.1651-6.1202, P = 0.0203; OR 4.7718, 95%CI: 1.9739-11.5350, P = 0.0005). The rebleeding rate (CE+ vs CE-) was 16.4% vs 45.1% (χ 2 test, P = 0.00001). The sensitivity, specificity, and PPV and NPV were 93.8%, 100%, 100%, 80.1%, respectively. CONCLUSION: Patients with obscure gastrointestinal bleeding and negative CE had a significantly lower rebleeding rate, and further invasive investigations can be deferred.

ERCP in acute pancreatitis:What takes place in routine clinical practice?

AIM:To evaluate the data from a survey carried out in Italy regarding the endoscopic approach to acute pancreatitis in order to obtain a picture of what takes place after the release of an educational project on acute pancreatitis sponsored by the Italian Association for the Study of the Pancreas.METHODS:Of the 1 173 patients enrolled in our survey,the most frequent etiological category was biliary forms(69.3%) and most patients had mild pancreatitis(85.8%).RESULTS:344/1 173(29.3%) underwent endoscopic retrograde cholangiopancreatography(ERCP).The mean interval between the onset of symptoms and ERCP was 6.7 ± 5.0 d;only 89 examinations(25.9%) were performed within 72 h from the onset of symptoms.The main indications for ERCP were suspicion of common bile duct stones(90.3%),jaundice(44.5%),clini cal worsening of acute pancreatitis(14.2%) and cho langitis(6.1%).Biliary and pancreatic ducts were visua lized in 305 patients(88.7%) and in 93 patients(27.0%) respectively.The success rate in obtaining a cholangio gram was statistically higher(P = 0.003) in patients with mild acute pancreatitis(90.6%) than in patients with severe disease(72.2%).Biliary endoscopic sphinc terotomy was performed in 295 of the 305 patients(96.7%) with no difference between mild and severe disease(P = 0.985).ERCP morbidity was 6.1% and mortality was 1.7%;the mortality was due to the complications of acute pancreatitis and not the endoscopic procedure.CONCLUSION:The results of this survey,as with those carried out in other countries,indicate a lack of compliance with the guidelines for the indications for interventional endoscopy.

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient- friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy;however,indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.

冒号囊内视镜检查法: 优点，限制和期望哪个新奇？

Since the first reports almost ten years ago, wireless capsule endoscopy has gained new f ields of application. Colon capsule endoscopy represents a new diagnostic technology for colonic exploration. Clinical trials have shown that colon capsule endoscopy is feasible, accurate and safe in patients suffering from colonic diseases and might be a valid alternative to conventional colonoscopy in selected cases such as patients refusing conventional colonoscopy or with contraindications to colonoscopy or when colonoscopy is incomplete. Despite the enthusiasm surrounding this new technique, few clinical and randomized controlled trials are to be found in the current literature, leading to heterogeneous or controversial results. Upcoming studies are needed to prove the substantial utility of colon capsule endoscopy for colon cancer screening, especially in a low prevalence of disease population, and for other indications such as inflammatory bowel disease. Possible perspectives are critically analysed and reported in this paper.

Colon capsule endoscopy:What we know and what we would like to know

Colonoscopy is usually perceived as an invasive and potentially painful procedure,being also affected by a small,but definite,risk of major complications(cardiopulmonary complications,perforation,hemorrhage)and even mortality.To improve both acceptability and safety,Pill Cam Colon Capsule Endoscopy(CCE)(Given Imaging Ltd,Yoqneam,Israel)has been developed.CCE represents a non-invasive technique that is able to explore the colon without sedation and air insufflation.The Second Generation of Colon Capsule Endoscopy(Pill Cam Colon 2)(CCE-2)was proven to be an accurate tool to detect colonic neoplastic lesions when used in average risk individuals.To date,the evidence supports the use of CCE-2 in case of colonoscopy failure,in patients unwilling to perform colonoscopy and when colonoscopy is contraindicated.Other potential applications,such as colorectal cancer screening or diagnostic surveillance ofinflammatory bowel disease need to be clarified.In this paper,the current"state of the art",potential application of CCE and future needs are evaluated.

Endoscopic retrieval of a duodenal perforating teaspoon

Foreign objects ingestion occur commonly in pediatric patients. The majority of ingested foreign bodies pass spontaneously the gastrointestinal tract and surgery is rarely required for extraction. Endoscopic removal of foreign bodies larger than 10 cm has not yet been described. We present the case of a 16 years old bulimic girl that swallowed a 12 cm long teaspoon in order to provoke vomiting. The teaspoon perforated the duodenum. However, it was removed during gastroscopy and the site of perforation was closed endoscopically. This particular case shows the importance of endoscopy for retrieval of large foreign bodies, and the possibility to endoscopically close a perforated duodenal wall.

Endoscopic therapy of weight regain after bariatric surgery

Weight regain following primary bariatric surgery occurs in a significant proportion of patients and is attributed to epidemiological,anatomical and metabolic factors.Surgical revision of these patients has significant risks and limited benefits.Endoscopic revisions that reduce gastric pouch size and diameter of the gastrojejunal anastomosis may offer an effective,safe,less invasive and even reproducible treatment.We herein discuss the indication,selection and feasibility of different endoscopic techniques that could be used in the management of weight regain following primary bariatric surgery.Future research could optimize a personalized approach not only in the endoscopic management but also in combination with other therapeutic modalities for weight regain after bariatric surgery.

Pediatric T-tube in adult liver transplantation:Technical refinements of insertion and removal

BACKGROUND With the increasing use of extended-criteria donor organs,the interest around Ttubes in liver transplantation(LT)was restored whilst concerns regarding T-tuberelated complications persist.AIM To describe insertion and removal protocols implemented at our institution to safely use pediatric rubber 5-French T-tubes and subsequent outcomes in a consecutive series of adult patients.METHODS Data of consecutive adult LT patients from brain-dead donors,treated from March 2017 to December 2019,were collected(i.e.,biliary complications,adverse events,treatment after T-Tube removal).Patients with upfront hepaticojejunostomy,endoscopically removed T-tubes,those who died or received retransplantation before T-tube removal were excluded.RESULTS Seventy-two patients were included in this study;T-tubes were removed 158 d(median;IQR 128-206 d)after LT.In four(5.6%)patients accidental T-tube removal occurred requiring monitoring only;in 68(94.4%)patients Nelaton drain insertion was performed according to our protocol,resulting in 18(25%)patients with a biliary output,subsequently removed after 2 d(median;IQR 1-4 d).Three(4%)patients required endoscopic retrograde cholangiopancreatography(ERCP)due to persistent Nelaton drain output.Three(4%)patients developed suspected biliary peritonitis,requiring ERCP with sphincterotomy and nasobiliary drain insertion(only one revealing contrast extravasation);no patient required percutaneous drainage or emergency surgery.CONCLUSION The use of pediatric rubber 5-French T-tubes in LT proved safe in our series after insertion and removal procedure refinements.

肛管直肠的异位胃黏膜:首例内镜黏膜下剥离术治疗报道和系统综述

背景:异位胃黏膜(HGM)是报道最多的上皮异位,但却极少出现在直肠肛管。方法:报道了首例内镜黏膜下剥离术(ESD)治疗低位直肠非息肉型HGM。在MEDLINE、EMBASE和Google Scholar上,以“直肠和肛管异位胃黏膜”为关键词进行全面检索。结果:检索到79篇文章,经过筛选最终72例(包括本例)病例纳入分析。17例(24%)患者具有先天畸形,其中直肠重复畸形占大多数。HGM位于肛管和会阴部直肠25例(41%),位于低位、中位和高位盆腔直肠分别为20例(33%)、5例(8%)和11例(18%)。形态学上非息肉型37例(51%),息肉型26例(36%),溃疡型9例(13%)。50例(69%)患者具有特异性肛管直肠症状,其中34例≤18岁的患者中有33例(97%)出现特异性症状。23例(32%)患者出现并发症。50例(83%)患者进行了治疗,其中内镜下切除17例(50%);在12例≥15 mm的病灶中5例(42%)成功进行了分块切除,2例(17%)需行氩离子凝固治疗,2例(17%)术后发现HGM残留。结论:本系统综述显示直肠肛管HGM具有特异性直肠症状,而且会出现一些严重并发症,主要是对于小儿患者,成年患者则有一定的恶变风险。推荐进行完整切除,ESD可以克服传统套圈进行完整切除切除的技术局限,从而避免外科手术。