Non-sequential narrow band imaging for targeted biopsy and monitoring of gastric intestinal metaplasia

AIM: To evaluate the efficacy of non-sequential narrow band imaging (NBI) for a better recognition of gastric intestinal metaplasia (GIM). METHODS: Previously diagnosed GIM patients underwent targeted biopsy from areas with and without GIM, as indicated by NBI, twice at an interval of 1 year. The authors compared the endoscopic criteria such as light blue crest (LBC), villous pattern (VP), and large long crest (LLC) with standard histology. The results from two surveillance endoscopies were compared with histology results for sensitivity, specif icity, positive predic-tive value (PPV), negative predictive value (NPV), and likelihood ratio of positive test (LR+). The number of early gastric cancer cases detected was also reported. RESULTS: NBI targeted biopsy was performed in 38 and 26 patients during the first and second surveillance endoscopies, respectively. There were 2 early gastric cancers detected in the first endoscopy. No cancer was detected from the second study. Surgical and endoscopic resections were successfully performed in each patient. Sensitivity, specifi city, PPV, NPV, and LR+ of all 3 endoscopic criteria during the first/second surveillances were 78.8%/91.3%, 82.5%/89.1%, 72.8%/77.8%, 86.8%/96.1, and 4.51/8.4, respectively. LBC provided the highest LR+ over VP and LLC. CONCLUSION: Non-sequential NBI is useful for GIM targeted biopsy. LBC provides the most sensitive reading. However, the optimal duration between two surveillances requires further study.

Efficacy of leukocyte esterase dipstick test as a rapid test in diagnosis of spontaneous bacterial peritonitis

AIM: To evaluate the efficacy of dipstick test in diagnosis of spontaneous bacterial peritonitis (SBP) in cirrhotic patients who underwent abdominal paracentesis based on the locally available dipstick test. METHODS: There were 200 consecutive samples from cirrhotic patients who underwent abdominal paracentesis. Urine dipstick (Combur10 Test?M, Roche, Mannheim, Germany) was used as a screening test. A manual cell count with differential study was done in all samples by experienced technicians. The polymorphonuclear (PMN) cell count more than 250 cells/mm3 was used as a diagnostic cut off level. One to three plus dipstick results were used as cut off levels for a positive result. The dipstick test results had to be agreed by three experienced readers. The sensitivity, specificity, positive and negative predictive values and accuracy of two different colorimetric cut off scales (1+ and 2+) were calculated and compared. RESULTS: The prevalence of SBP diagnosed by manual cell count was 21.0%. There were 128 specimens that had a true negative result by dipstick. The sensitivity, specificity, positive and negative predictive values and accuracy of 1+ and 2+ cut off scale to diagnose SBP were 88%, 81%, 55%, 96% and 83% respectively, and 63%, 96%, 82%, 81% and 89% respectively. CONCLUSION: Dipstick test can be used as a rapid test for screening of SBP. The higher cut off colorimetric scale has a better specificity and positive predictive value but a lower sensitivity.

Forward-viewing radial-array echoendoscope for staging of colon cancer beyond the rectum

AIM:To evaluate feasibility of the novel forward-viewing radial-array echoendoscope for staging of colon cancer beyond rectum as the first series.METHODS:A retrospective study with prospectively entered database.From March 2012 to February 2013,a total of 21 patients(11 men)(mean age 64.2 years)with colon cancer beyond the rectum were recruited.The novel forward-viewing radial-array echoendoscope was used for ultrasonographic staging of colon cancer beyond rectum.Ultrasonographic T and N staging were recorded when surgical pathology was used as a gold standard.RESULTS:The mean time to reach the lesion and the mean time to complete the procedure were 3.5 and 7.1min,respectively.The echoendoscope passed through the lesions in 13 patients(61.9%)and reached the cecum in 10 of 13 patients(76.9%).No adverse events were found.The lesions were located in the cecum(n=2),ascending colon(n=1),transverse colon(n=2),descending colon(n=2),and sigmoid colon(n=14).The accuracy rate for T1(n=3),T2(n=4),T3(n=13)and T4(n=1)were 100%,60.0%,84.6%and 100%,respectively.The overall accuracy rates for the T and N staging of colon cancer were 81.0%and52.4%,respectively.The accuracy rates among traversable lesions(n=13)and obstructive lesions(n=8)were 61.5%and 100%,respectively.endoscopic ultrasound and computed tomography had overall accuracy rates of 81.0%and 68.4%,respectively.CONCLUSION:The echoendoscope is a feasible staging tool for colon cancer beyond rectum.However,accuracy of the echoendoscope needs to be verified by larger systematic studies.

Role of digital chromoendoscopy in detecting minimal change esophageal reflux disease

Endoscopy is a widely used diagnostic tool to detect reflux esophagitis.Although its specificity was reported to be excellent at 90%-95%,its sensitivity was only 50%.Therefore,it is quite difficult to detect these lesions under the standard white light endoscopy especially in patients with minimal change esophageal reflux disease(MERD).In recent years,endoscopic technologies have evolved tremendously;these include high resolution and magnification digital chromoendoscopy.These technologies are useful practically for detecting various subtle lesions along the gastrointestinal tract starting from esophagus to colon.Currently,these technologies can be classified in 2 systems;pre-processed system(NBI,Olympus)and post processed system(FICE and i-SCAN,Fujinon and Pentax respectively).Over a few years,there have been many emerging publications on the benefit of these systems on MERD detection.The overall sensitivities to diagnose MERD were reported as much better than controls.However,large,multi-center and randomized controlled studies comparing these new imaging modalities with the conventional white light chromoendoscopy are warranted to validate its accuracy.Standard,simple and precise endoscopic reading criteria for the identification of MERD are also required.

Differences in characteristics of colorectal neoplasm between young and elderly Thais

AIM: To analyze the differences of clinical characteristics of colorectal neoplasm including polyps between the elderly and young Thai patients.METHODS: Colonoscopy database from December 2000 to October 2004 was retrospectively analyzed. There were 1822 eligible patients who underwent colonoscopy (with a mean age of 56.6 years). Patients were classified into two groups: the older age group (aged ≥ 60 years; n = 989) and the younger age group (aged < 60 years; n = 833). Data were recorded on age, colonoscopic indications, tumor location, colonoscopic findings and their related histological findings. RESULTS: Colorectal malignancy related lesions were more often found in the older age group (21%) than in the younger age group (12%). Left-sided lesions were detected more commonly than right-sided in both age groups in approximately two-thirds of all cases. Hematochezia showed greater association with left-sided lesions in the elderly. No relationship was found between age and neoplasm staging and severity.CONCLUSION: The chance of detecting colorectal neoplasm by colonoscopy was higher in the elderly than in the young Thais. However, both groups had the lesions predominantly located in the left side.

Operable malignant jaundice:To stent or not to stent before the operation?

Traditionally,pre-operative biliary drainage(PBD) was believed to improve multi-organ dysfunction,and for this reason,was practiced worldwide.Over the last decade,this concept was challenged by many reports,including meta-analyses that showed no difference in morbidity and mortality between surgery with,and surgery without PBD,in operable malignant jaundice.The main disadvantages of PBD are seen to be the additional cost of the procedure itself,and the need for longer hospitalization.In addition,many studies showed the significance of specific complications resulting from PBD,such as recurrent jaundice,cholangitis,pancreatitis,cutaneous fistula,and bleeding.However,the results of these studies remain inconclusive as to date there has been no perfect study that equally randomized comparable patients according to the level of obstruction and technique used for PBD.Generally,endoscopic stent insertion(ES) is preferred for common duct obstruction,whereas endoscopic nasobiliary drainage and percutaneous biliary drainage is reserved for hilar obstruction,since ES in hilar block confers a high rate of cholangitis.Although,there is no guideline which either supports or refutes this approach,certain subgroups of patients,including those with symptomatic jaundice,cholangitis,impending renal failure,hilar block requiring preoperative portal vein embolization,and those who need pre-operative neoadjuvant therapy,are suitable candidates for PBD.

Stent-in-stent through a side hole to prevent biliary metallic stent migration

The covered self-expandable metallic stent(SEMS) has been developed to overcome the problem of tissue ingrowth,However,stent migration is a well-known complication of covered SEMS placement.Use of a double pigtail stent to lock the movement of the SEMS and prevent migration has been advised by many experts.Unfortunately,in our case this technique led to an incidental upward migration of the SEMS.We used APC to create a side hole in the SEMS for plastic stent insertion as stent-in-stent.This led to a successful prevention of stent migration.