Diagnostic yield of small bowel capsule endoscopy depends on the small bowel transit time

AIM： To investigate whether the small bowel transit time （SBTT） influences the diagnostic yield of capsule endoscopy （CE）. METHODS： Six hundred and ninety-one consecutive CE procedures collected in a database were analyzed. SBTT and CE findings were recorded. A running mean for the SBl-I- was calculated and correlated to the diagnostic yield with a Spearman＇s correlation test. Subgroup anal- yses were performed for the various indications for the procedure. RESULTS： There was a positive correlation between the diagnostic yield and SBT1- （Spearman＇s rho 0.58, P 〈 0.01）. Positive correlations between diagnostic yield and SB-FI-were found for the indication obscure gastro- intestinal bleeding （r = 0.54, P 〈 0.01）, for polyposis and carcinoid combined （r = 0.56, P 〈 0.01） and for the other indications （r = 0.90, P 〈0.01）, but not for suspected Crohn＇s disease （r = -0.40） CONCLUSION： The diagnostic yield in small bowel capsule endoscopy is positively correlated with the small bowel transit time. This is true for all indications except for suspected Crohn＇s disease.

Appropriateness of indication and diagnostic yield of colonoscopy: First report based on the 2000 guidelines of the American Society for Gastrointestinal Endoscopy

AIM: To assess the appropriateness of referrals and to determine the diagnostic yield of colonoscopy according to the 2000 guidelines of the American Society for Gastrointestinal Endoscopy (ASGE).METHODS: A total of 736 consecutive patients (415males, 321 females; mean age 43.6±16.6 years)undergoing colonoscopy during October 2001-March2002 Were prospectively enrolled in the study. The 2000ASGE guidelines were used to assess the appropriateness of the indications for the procedure. Diagnostic yield was defined as the ratio between significant findings detected on colonoscopy and the total number of procedures performed for that indication.RESULTS: The large majority (64%) of patients had colonoscopy for an indication that was considered'generally indicated'; it was 'generally not indicated' for20%, and it was 'not listed' for 16% in the guidelines.The diagnostic yield of colonoscopy was highest for the 'generally indicated' (38%) followed by 'not listed'(13%) and 'generally not indicated' (5%) categories.In the multivariable analysis, the diagnostic yield was independently associated with the appropriateness of indication that was 'generally indicated' (odds ratio=12.3) and referrals by gastroenterologist (odds ratio = 1.9).CONCLUSION: There is a high likelihood of inappropriate referrals for colonoscopy in an open-access endoscopy system. The diagnostic yield of the procedure is dependent on the appropriateness of indication and referring physician's specialty. Certain indications 'not listed' in the guidelines have an intermediate diagnostic yield and further studies are required to evaluate whether they should be included in future revisions of the ASGE guidelines.

Improvedendoscopicretrogradecholangiopancreatographybrushincreases diagnosticyieldofmalignantbiliarystrictures

AIM: To determine if a new brush design could im-prove the diagnostic yield of biliary stricture brushings. METHODS: Retrospective chart review was performed of all endoscopic retrograde cholangiopancreatography procedures with malignant biliary stricture brushing between January 2008 and October 2012. A standard wire-guided cytology brush was used prior to proto-col implementation in July 2011, after which, a new 9 French wire-guided cytology brush(Infinity sampling device, US Endoscopy, Mentor, OH) was used for all cases. All specimens were reviewed by blinded pa-thologists who determined whether the sample waspositive or negative for malignancy. Cellular yield was quantified by describing the number of cell clusters seen. RESULTS: Thirty-two new brush cases were compared to 46 historical controls. Twenty-five of 32 (78%) cases in the new brush group showed abnormal cellular find-ings consistent with malignancy as compared to 17 of 46(37%) in the historical control group(P = 0.0003). There was also a significant increase in the average number of cell clusters of all sizes(21.1 vs 9.9 clusters, P = 0.0007) in the new brush group compared to his-torical controls. CONCLUSION: The use of a new brush design for brush cytology of biliary strictures shows increased di-agnostic accuracy, likely due to improved cellular yield, as evidenced by an increase in number of cellular clus-ters obtained.

Yield of capsule endoscopy in obscure gastrointestinal bleeding:A comparative study between premenopausal and menopausal women

AIM To evaluate differences in capsule endoscopy(CE) performed in the setting of obscure gastrointestinal bleeding(OGIB) among premenopausal women(PMW) and menopausal women(MW).METHODS Retrospective, single-center study, including female patients submitted to CE in the setting of OGIB between May 2011 and December 2016. Patients were divided into 2 groups according to age, considering fertile age as ≤ 55 years and postmenopausal age as > 55 years. The diagnostic yield(DY), the rebleeding rate and the time to rebleed were evaluated and compared between groups. Rebleeding was defined as a drop of Hb > 2 g/dL or need for transfusional support or presence of melena/hematochezia.RESULTS A hundred and eighty three female patients underwent CE for OGIB, of whom 30.6%(n = 56) were PMW and 69.4%(n = 127) were MW. The DY was 30.4% in PMW and 63.8% in MW. The most common findings were angiodysplasias in both groups(PMW: 21.4%, MW: 44.9%)(P = 0.003). In PMW, only 1.8% required therapeutic endoscopy. In 17.3% of MW, CE findingsled to additional endoscopic treatment. Rebleeding at 1, 3 and 5 years in PMW was 3.6%, 10.2%, 10.2% and 22.0%, 32.3% and 34.2% in MW. Postmenopausal status was significantly associated with higher DY(P < 0.001), TY(P = 0.003), rebleeding(P = 0.031) and lower time to rebleed(P = 0.001).CONCLUSION PMW with suspected OGIB are less likely to have significant findings in CE. In MW DY, need for endoscopic treatment and rebleeding were significantly higher while time to rebleed was lower.

Device-assisted enteroscopy: Are we ready to dismiss the spiral?

Motorized spiral enteroscopy(MSE)is the latest advance in device-assisted enteroscopy.Adverse events related to MSE were discussed in a recent large systematic review and meta-analysis and were directly compared with those of balloon enteroscopy in a case-matched study and a randomized controlled trial.Following the real-life application of MSE,an unexpected safety issue emerged regarding esophageal injury and the technique has been withdrawn from the global market,despite encouraging results in terms of diagnostic and therapeutic yield.We conducted an Italian multicenter real-life prospective study,which was prematurely terminated after the withdrawal of MSE from the market.The primary goals were the evaluation of MSE performance(both diagnostic and therapeutic)and its safety in routine endoscopic practice,particularly in the early phase of introduction in the endoscopic unit.A subanalysis,which involved patients who underwent MSE after unsuccessful balloon enteroscopy,demonstrated,for the first time,the promising performance of MSE as a rescue procedure.Given its remarkable performance in clinical practice and its potential role as a backup technique following a previously failed enteroscopy,it may be more appropriate to refine and enhance MSE in the future rather than completely abandoning it.

Confocal laser endomicroscopy for gastric neoplasm

Confocal laser endomicroscopy(CLE)is a novel endoscopic modality that provides real-time histological information via high-resolution magnified view of the mucosa.CLE has a higher sensitivity,specificity,and diagnostic accuracy in detecting atrophic gastritis as compared to chromoendoscopy and narrow-band imaging.It can even predict low-grade and high-grade intraepithelial neoplasia by analyzing gastric pit patterns.CLE may have some advantages over the standard biopsy protocol,such as higher diagnostic yield and fewer biopsy requirements.Its diagnostic accuracy in detecting superficial gastric cancer is higher than that of white-light endoscopy.Inherent limitations,such as a narrow field of vision,can be surpassed by technological advancements and integration with other detection methods.Artificial intelligence holds promise in automated analysis of histopathological images.Thus,CLE can be helpful in screening for early gastric cancer and may help reduce the risk of complications from repeated biopsies,such as mucosal damage,bleeding,and infection.

Capsule endoscopy:Current status in obscure gastrointestinal bleeding

Capsule endoscopy (CE) is a safe, non invasive diagnostic modality for the evaluation of small bowel lesions. Obscure gastrointestinal bleeding (OGIB) is one of the most important indications of capsule endoscopy. Capsule endoscopy has a very high diagnostic yield especially if the bleeding is ongoing. This technique appears to be superior to other techniques for the detection of suspected lesions and the source of bleeding. Capsule endoscopy has been shown to change the outcome in patients with obscure gastrointestinal (GI) bleed.

Pros and cons of colonoscopy in management of acute lower gastrointestinal bleeding

Acute lower gastrointestinal bleeding （LGIB） is a frequent gastrointestinal cause of hospitalization, particularly in the elderly, and its incidence appears to be on the rise. Endoscopic and radiographic measures are available for the evaluation and treatment of LGIB including flexible sigmoidoscopy, colonoscopy, angiography, radionuclide scintigraphy and multi detector row computed tomography. Although no modality has emerged as the gold standard in the management of LGIB, colonoscopy is the current preferred initial test for the majority of the patients presenting with hema- tochezia felt to be from a colon source. Colonoscopy has the ability to diagnose all sources of bleeding from the colon and, unlike the radiologic modalities, does not require active bleeding at the time of the examination. In addition, therapeutic interventions such as cautery and endoclips can be applied to achieve hemoo stasis and prevent recurrent bleeding. Studies suggest that colonoscopy, particularly when performed earlyin the hospitalization, can decrease hospital length of stay, rebleeding and the need for surgery. However, results from available small trials are conflicting and larger, multicenter studies are needed. Compared to other management options, colonoscopy is a safe procedure with complications reported in less than 2% of patients, including those undergoing urgent examinations. The requirement of bowel preparation （typically 4 or more liters of polyethylene glycol）, the logistical complexity of coordinating after hours colonoscopy, and the low prevalence of stigmata of hemorrhage complicate the use of colonoscopy for LGIB, particularly in urgent situations. This review discusses the above advantages and disadvantages of colonoscopy in the management of acute lower gastrointestinal bleeding in further detail.

Role of small bowel capsule endoscopy in the diagnosis and management of iron deficiency anemia in elderly: A comprehensive review of the current literature

Iron deficiency anemia(IDA)is common and often under recognized problem in the elderly.It may be the result of multiple factors including a bleeding lesion in the gastrointestinal tract.Twenty percent of elderly patients with IDA have a negative upper and lower endoscopy and two-thirds of these have a lesion in the small bowel(SB).Capsule endoscopy(CE)provides direct visualization of entire SB mucosa,which was not possible before.It is superior to push enteroscopy,enteroclysis and barium radiography for diagnosing clinically significant SB pathology resulting in IDA.Angioectasia is one of the commonest lesions seen on the CE in elderly with IDA.The diagnostic yield of CE for IDA progressively increases with advancing age,and is highest among patients over 85 years of age.Balloon assisted enteroscopy is used to treat the lesions seen on CE.CE has some limitations mainly lack of therapeutic capability,inability to provide precise location of the lesion and false positive results.Overall CE is a very safe and effective procedure for the evaluation of IDA in elderly.

Implications of small-bowel transit time in the detection rate of capsule endoscopy: A multivariable multicenter study of patients with obscure gastrointestinal bleeding

AIMTo define the role of small-bowel transit time in the detection rate of significant small-bowel lesions.METHODSSmall-bowel capsule endoscopy records, prospectively collected from 30 participating centers in the Lombardy Registry from October 2011 to December 2013, were included in the study if the clinical indication was obscure gastrointestinal bleeding and the capsule reached the cecum. Based on capsule findings, we created two groups: P2 (significant findings) and P0-1 (normal/negligible findings). Groups were compared for age, gender, small-bowel transit time, type of instrument, modality of capsule performance (outpatients vs inpatients), bowel cleanliness, and center volume.RESULTSWe retrieved and scrutinized 1,433 out of 2,295 capsule endoscopy records (62.4%) fulfilling the inclusion criteria. Patients were 67 &#x000b1; 15 years old, and 815 (57%) were males. In comparison with patients in the P0-1 group, those in the P2 group (n = 776, 54%) were older (P &#x0003c; 0.0001), had a longer small-bowel transit time (P = 0.0015), and were more frequently examined in low-volume centers (P &#x0003c; 0.001). Age and small-bowel transit time were correlated (P &#x0003c; 0.001), with age as the sole independent predictor on multivariable analysis. Findings of the P2 group were artero-venous malformations (54.5%), inflammatory (23.6%) and protruding (10.4%) lesions, and luminal blood (11.5%).CONCLUSIONIn this selected, prospectively collected cohort of small-bowel capsule endoscopy performed for obscure gastrointestinal bleeding, a longer small-bowel transit time was associated with a higher detection rate of significant lesions, along with age and a low center volume, with age serving as an independent predictor.

Two cameras detect more lesions in the small-bowel than one

AIM:To explore the feasibility of dual camera capsule (DCC)small-bowel(SB)imaging and to examine if two cameras complement each other to detect more SB lesions.METHODS:Forty-one eligible,consecutive patients underwent DCC SB imaging.Two experienced investigators examined the videos and compared the total number of detected lesions to the number of lesions detected by each camera separately.Examination tolerability was assessed using a questionnaire.RESULTS:One patient was excluded.DCC cameras detected 68 positive findings(POS)in 20(50%)cases.Fifty of them were detected by the"yellow"camera,48 by the"green"and 28 by both cameras;44%(n=22)of the"yellow"camera’s POS were not detected by the"green"camera and 42%(n=20)of the"green" camera’s POS were not detected by the"yellow"camera.In two cases,only one camera detected significant findings.All participants had 216 findings of unknown significance(FUS).The"yellow","green"and both cameras detected 171,161,and 116 FUS,respectively;32%(n=55)of the"yellow"camera’s FUS were not detected by the"green"camera and 28%(n=45)of the"green"camera’s FUS were not detected by the "yellow"camera.There were no complications related to the examination,and 97.6%of the patients would repeat the examination,if necessary.CONCLUSION:DCC SB examination is feasible and well tolerated.The two cameras complement each other to detect more SB lesions.

The efficacy and safety of endoscopic ultrasound-guided fine-needle biopsy in gallbladder masses

Background: Endoscopic ultrasound-guided fine-needle biopsy(EUS-FNB) is a widely used modality for acquiring various target samples, but its efficacy in gallbladder masses is unknown. The aim of this retrospective study was to evaluate the efficacy and safety of EUS-FNB in patients with gallbladder masses. Methods: The study samples were composed of patients from March 2015 to July 2019 who needed to identify the nature of gallbladder masses through EUS-FNB. The outcomes of this study were the adequacy of specimens, diagnostic yields, technical feasibility, and adverse events of the EUS-FNB in gallbladder masses. Results: A total of 27 consecutive patients with a median age of 58 years were included in this study. The 22-gauge FNB needle was feasible in all lesions. The median follow-up period of the patients was 294 days. The specimens sufficient for diagnosis account for 89%(24/27) and 93%(25/27) in cytology and histology, respectively. The overall diagnostic yields for malignancy showed the sensitivity, specificity, positive predictive value, negative predictive value, and accuracy were 95.45% [95% confidence interval(CI): 75.12%-99.76%], 100%(95% CI: 46.29%-10 0%), 10 0%(95% CI: 80.76%-100%), 83.33%(95% CI: 36.48%-99.12%), and 96.30%(95% CI: 80.20%-99.99%), respectively. The subgroup analysis revealed that FNB could obtain sufficient specimens and high diagnostic yields in both gallbladder mass < 20.5 mm group and ≥20.5 mm group. One patient experienced mild abdominal pain after the procedure and recovered within one day. Conclusions: EUS-FNB is a reasonable diagnostic tool for the pretreatment diagnosis of patients with gallbladder masses, especially for patients who may miss the opportunity of surgery and need sufficient specimens to identify the pathological type so as to determine chemotherapy regimens. Further largescale studies are needed to confirm our conclusion.

Molecular diagnostics for congenital heart disease: a narrative review of the current technologies and applications

Congenital heart disease(CHD)is the most common birth defect worldwide.In recent years,the widespread application of innovative molecular diagnostic technologies in clinical scenarios has obviously increased the molecular diagnostic yields of CHD,providing evidence-based guidance for medical decision-making.These molecular diagnostic technologies include chromosome microarray analysis,targeted sequencing,exome sequencing,and genome sequencing.Furthermore,high-throughput sequencing technology has performed excellently in the clinical molecular diagnosis of CHD.This review provides an overview of the current technology and applications in the molecular diagnosis of CHD.The unmet issues and future directions in adapting novel genomic testing technologies to the molecular diagnosis of CHD in clinical settings are also addressed.

Endobronchial Ultrasound-guided Transbronchial Needle Aspiration versus Standard Bronchoscopic Modalities for Diagnosis of Sarcoidosis： A Meta-analysis

Background： Endobronchial ultrasound-guided transbronchial needle aspiration （EBUS-TBNA） is an effective technique used to precisely detect enlarged mediastinal lymph nodes. The efficacy of EBUS-TBNA versus standard modalities for the diagnosis of sarcoidosis remains to be elucidated. In this meta-analysis, we compared the efficacies of these methods. Methods： We searched PubMed, Embase, The Cochrane Library, Wanfang, Cpvip, CNKI, and the bibliographies of the relevant references. We analyzed the data obtained with Revman 5.2 （Nordic Cochrane Center, Copenhagen, Denmark） and Stata 12.0 software （Stata Corporation, College Station, TX, USA）. The Mantel-Haenszel method was used to calculate the pooled odds ratio （OR） and 95% confidence intervals （Cls）. Results： Sixteen studies with a total of 1823 participants met the inclusion criteria, and data were extracted regarding the diagnostic yield of each approach. The ORs for EBUS-TBNA versus transbronchial lung biopsy （TBLB） for the diagnosis of sarcoidosis ranged from 0.26 to 126.58, and the pooled OR was 5.89 （95% CI, 2.20-15.79, P = 0.0004）. These findings indicated that EBUS-TBNA provided a much higher diagnostic yield than TBLB. The pooled OR for EBUS-TBNA ＋ TBLB ＋ endobronchial biopsy （EBB） versus TBNA ＋ TBLB ＋ EBB was 1.54 （95% C1, 0.61-3.93, P = 0.36）, implying that there was no significant difference between their diagnostic yields. However, clinical heterogeneity was reflected in the nature of the studies and in the operative variables. Conclusions： The results of this meta-analysis suggest that EBUS-TBNA ＋ TBLB ＋ EBB could be used for the diagnosis of sarcoidosis, if available. At medical centers without EBUS-TBNA, TBNA ＋ TBLB ＋ EBB could be used instead.