AIM: To determine the test characteristics of community based video capsule endoscopy (VCE) in patients undergoing sequential VCE and double balloon enteroscopy (DBE). METHODS: Eighty-nine patients (34 females, 55 mal...AIM: To determine the test characteristics of community based video capsule endoscopy (VCE) in patients undergoing sequential VCE and double balloon enteroscopy (DBE). METHODS: Eighty-nine patients (34 females, 55 males, mean age 66) who underwent both VCE and DBE from 2008-2010 were retrospectively reviewed. Lesions detected at VCE were categorized. Capsule directed DBE followed and included 44 antegrade, 11 retrograde and 34 combined antegrade and retrograde procedures. Lesions detected were compared utilizing the McNemar's test. RESULTS: Angioectasia detection with VCE was 25% and with DBE 35% (P < 0.03) with a calculated sensitivity and specificity of 58% and 93% respectively. Polyps were detected by VCE in 22% and in DBE 20%, (P = 0.6), with a sensitivity and specificity for VCE of 61% and 87%. Small bowel diverticula were only seen in 1% of VCE but in 12% of DBE patients (P < 0.002) with a calculated sensitivity and specificity of VCE of 9% and 100%. CONCLUSION: VCE would be moderately sensitiveand specific overall with considerable variation by lesion. Furthermore, VCE cannot be relied upon to diagnose small bowel diverticula.展开更多
AIM:To assess the feasibility and utility of double balloon enteroscopy(DBE)in the management of small bowel diseases in children. METHODS:Fourteen patients(10 males)with a median age of 12.9 years(range 8.1-16.7)unde...AIM:To assess the feasibility and utility of double balloon enteroscopy(DBE)in the management of small bowel diseases in children. METHODS:Fourteen patients(10 males)with a median age of 12.9 years(range 8.1-16.7)underwent DBE; 5 for Peutz-Jeghers syndrome(PJ syndrome),2 for chronic abdominal pain,4 for obscure gastrointestinal (GI)bleeding,2 with angiomatous malformations(1 blue rubber bleb nevus syndrome)having persistent GI bleeding,and 1 with Cowden's syndrome with multiple polyps and previous intussusception.Eleven procedures were performed under general anesthesia and 3 with deep sedation. RESULTS:The entire small bowel was examined in 6 patients,and a length between 200 cm and 320 cm distal to pylorus in the remaining 8.Seven patients had both antegrade(trans-oral)and retrograde(transanal and via ileostomy)examinations.One patient underwent DBE with planned laparoscopic assistance.The remaining 6 had trans-oral examination only.The median examination time was 118 min(range 95-195). No complications were encountered.Polyps were detected and successfully removed in all 5 patients with PJ syndrome,in a patient with tubulo-villous adenoma of the duodenum,in a patient with significant anemia and occult bleeding,and in a patient with Cowden's syndrome.A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy,and in 1 with a discrete angioma which was treated with argon plasma coagulation.The source of bleeding was identified in a further patient with varices.DBE was normal or revealed minor mucosal friability in the remaining 3 patients.Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved. CONCLUSION:Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children,allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.展开更多
BACKGROUND Capsule endoscopy and balloon-assisted enteroscopy(BAE) enable visualization of rare small bowel conditions such as small intestinal malignant tumors.However,details of the endoscopic characteristics of sma...BACKGROUND Capsule endoscopy and balloon-assisted enteroscopy(BAE) enable visualization of rare small bowel conditions such as small intestinal malignant tumors.However,details of the endoscopic characteristics of small intestinal malignant tumors are still unknown.AIM To elucidate the endoscopic characteristics of small intestinal malignant tumors.METHODS From March 2005 to February 2017,1329 BAE procedures were performed at Keio University Hospital. Of these procedures,malignant tumors were classified into three groups,Group 1: epithelial tumors including primary small intestinal cancer,metastatic small intestinal cancer,and direct small intestinal invasion by an adjacent organ cancer; Group 2: small intestinal malignant lymphoma; and Group 3,small intestinal gastrointestinal stromal tumors. We systematically collected clinical and endoscopic data from patients' medical records to determine the endoscopic characteristics for each group.RESULTS The number of patients in each group was 16(Group 1),23(Group 2),and 6(Group 3),and the percentage of solitary tumors was 100%,43.5%,and 100%,respectively(P < 0.001). Patients' clinical background parameters including age,symptoms,and laboratory data were not significantly different between the groups. Seventy-five percent of epithelial tumors(Group 1) were located in the upper small intestine(duodenum and ileum),and approximately 70% of gastrointestinal stromal tumors(Group 3) were located in the jejunum. Solitary protruding or mass-type tumors were not seen in malignant lymphoma(Group2)(P < 0.001). Stenosis was seen more often in Group 1,(68.8%,27.3%,and 0%;Group 1,2,and 3,respectively; P = 0.004). Enlarged white villi inside and/or surrounding the tumor were seen in 12.5%,54.5%,and 0% in Group 1,2,and 3,respectively(P = 0.001).CONCLUSION The differential diagnosis of small intestinal malignant tumors could be tentatively made based on BAE findings.展开更多
Peutz-Jeghers syndrome(PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in associa...Peutz-Jeghers syndrome(PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the smallbowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular smallbowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy,multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.展开更多
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 tomo...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 1<sup>st</sup>, 2002 to June 30<sup>th</sup>, 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.展开更多
Left ventricular assist devices(LVAD)are increasingly become common as life prolonging therapy in patients with advanced heart failure.Current devices are now used as definitive treatment in some patients given the im...Left ventricular assist devices(LVAD)are increasingly become common as life prolonging therapy in patients with advanced heart failure.Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps.Unfortunately,continuous flow LVADs are fraught with complications such as gastrointestinal(GI)bleeding that are primarily attributed to the formation of arteriovenous malformations.With frequent GI bleeding,antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events.Small bowel bleeds account for 15%as the source and patients often undergo multiple endoscopic procedures.Treatment strategies include resuscitative measures and endoscopic therapies.Medical treatment is with octreotide.Novel treatment options include thalidomide,angiotensin converting enzyme inhibitors/angiotensinⅡreceptor blockers,estrogen-based hormonal therapies,doxycycline,desmopressin and bevacizumab.Current research has explored the mechanism of frequent GI bleeds in this population,including destruction of von Willebrand factor,upregulation of tissue factor,vascular endothelial growth factor,tumor necrosis factor-α,tumor growth factor-β,and angiopoetin-2,and downregulation of angiopoetin-1.In addition,healthcare resource utilization is only increasing in this patient population with higher admissions,readmissions,blood product utilization,and endoscopy.While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages,these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.展开更多
文摘AIM: To determine the test characteristics of community based video capsule endoscopy (VCE) in patients undergoing sequential VCE and double balloon enteroscopy (DBE). METHODS: Eighty-nine patients (34 females, 55 males, mean age 66) who underwent both VCE and DBE from 2008-2010 were retrospectively reviewed. Lesions detected at VCE were categorized. Capsule directed DBE followed and included 44 antegrade, 11 retrograde and 34 combined antegrade and retrograde procedures. Lesions detected were compared utilizing the McNemar's test. RESULTS: Angioectasia detection with VCE was 25% and with DBE 35% (P < 0.03) with a calculated sensitivity and specificity of 58% and 93% respectively. Polyps were detected by VCE in 22% and in DBE 20%, (P = 0.6), with a sensitivity and specificity for VCE of 61% and 87%. Small bowel diverticula were only seen in 1% of VCE but in 12% of DBE patients (P < 0.002) with a calculated sensitivity and specificity of VCE of 9% and 100%. CONCLUSION: VCE would be moderately sensitiveand specific overall with considerable variation by lesion. Furthermore, VCE cannot be relied upon to diagnose small bowel diverticula.
文摘AIM:To assess the feasibility and utility of double balloon enteroscopy(DBE)in the management of small bowel diseases in children. METHODS:Fourteen patients(10 males)with a median age of 12.9 years(range 8.1-16.7)underwent DBE; 5 for Peutz-Jeghers syndrome(PJ syndrome),2 for chronic abdominal pain,4 for obscure gastrointestinal (GI)bleeding,2 with angiomatous malformations(1 blue rubber bleb nevus syndrome)having persistent GI bleeding,and 1 with Cowden's syndrome with multiple polyps and previous intussusception.Eleven procedures were performed under general anesthesia and 3 with deep sedation. RESULTS:The entire small bowel was examined in 6 patients,and a length between 200 cm and 320 cm distal to pylorus in the remaining 8.Seven patients had both antegrade(trans-oral)and retrograde(transanal and via ileostomy)examinations.One patient underwent DBE with planned laparoscopic assistance.The remaining 6 had trans-oral examination only.The median examination time was 118 min(range 95-195). No complications were encountered.Polyps were detected and successfully removed in all 5 patients with PJ syndrome,in a patient with tubulo-villous adenoma of the duodenum,in a patient with significant anemia and occult bleeding,and in a patient with Cowden's syndrome.A diagnosis was made in a patient with multiple angiomata not amenable to endotherapy,and in 1 with a discrete angioma which was treated with argon plasma coagulation.The source of bleeding was identified in a further patient with varices.DBE was normal or revealed minor mucosal friability in the remaining 3 patients.Hence a diagnostic yield of 11/14 with therapeutic success in 9/14 was achieved. CONCLUSION:Double balloon enteroscopy can be a useful diagnostic and therapeutic tool for small bowel disease in children,allowing endo-therapeutic intervention beyond the reach of the conventional endoscope.
文摘BACKGROUND Capsule endoscopy and balloon-assisted enteroscopy(BAE) enable visualization of rare small bowel conditions such as small intestinal malignant tumors.However,details of the endoscopic characteristics of small intestinal malignant tumors are still unknown.AIM To elucidate the endoscopic characteristics of small intestinal malignant tumors.METHODS From March 2005 to February 2017,1329 BAE procedures were performed at Keio University Hospital. Of these procedures,malignant tumors were classified into three groups,Group 1: epithelial tumors including primary small intestinal cancer,metastatic small intestinal cancer,and direct small intestinal invasion by an adjacent organ cancer; Group 2: small intestinal malignant lymphoma; and Group 3,small intestinal gastrointestinal stromal tumors. We systematically collected clinical and endoscopic data from patients' medical records to determine the endoscopic characteristics for each group.RESULTS The number of patients in each group was 16(Group 1),23(Group 2),and 6(Group 3),and the percentage of solitary tumors was 100%,43.5%,and 100%,respectively(P < 0.001). Patients' clinical background parameters including age,symptoms,and laboratory data were not significantly different between the groups. Seventy-five percent of epithelial tumors(Group 1) were located in the upper small intestine(duodenum and ileum),and approximately 70% of gastrointestinal stromal tumors(Group 3) were located in the jejunum. Solitary protruding or mass-type tumors were not seen in malignant lymphoma(Group2)(P < 0.001). Stenosis was seen more often in Group 1,(68.8%,27.3%,and 0%;Group 1,2,and 3,respectively; P = 0.004). Enlarged white villi inside and/or surrounding the tumor were seen in 12.5%,54.5%,and 0% in Group 1,2,and 3,respectively(P = 0.001).CONCLUSION The differential diagnosis of small intestinal malignant tumors could be tentatively made based on BAE findings.
文摘Peutz-Jeghers syndrome(PJS) is a rare, autosomal dominant disease linked to a mutation of the STK 11 gene and is characterized by the development of benign hamartomatous polyps in the gastrointestinal tract in association with a hyperpigmentation on the lips and oral mucosa. Patients affected by PJS have an increased risk of developing gastrointestinal and extra-digestive cancer. Malignancy most commonly occurs in the smallbowel. Extra-intestinal malignancies are mostly breast cancer and gynecological tumors or, to a lesser extent, pancreatic cancer. These polyps are also at risk of acute gastrointestinal bleeding, intussusception and bowel obstruction. Recent guidelines recommend regular smallbowel surveillance to reduce these risks associated with PJS. Small-bowel surveillance allows for the detection of large polyps and the further referral of selected PJS patients for endoscopic enteroscopy or surgery. Video capsule endoscopy, double balloon pushed enteroscopy,multidetector computed tomography and magnetic resonance enteroclysis or enterography, all of which are relatively new techniques, have an important role in the management of patients suffering from PJS. This review illustrates the pathological, clinical and imaging features of small-bowel abnormalities as well as the role and performance of the most recent imaging modalities for the detection and follow-up of PJS patients.
文摘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 1<sup>st</sup>, 2002 to June 30<sup>th</sup>, 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.
文摘Left ventricular assist devices(LVAD)are increasingly become common as life prolonging therapy in patients with advanced heart failure.Current devices are now used as definitive treatment in some patients given the improved durability of continuous flow pumps.Unfortunately,continuous flow LVADs are fraught with complications such as gastrointestinal(GI)bleeding that are primarily attributed to the formation of arteriovenous malformations.With frequent GI bleeding,antiplatelet and anticoagulation therapies are usually discontinued increasing the risk of life-threatening events.Small bowel bleeds account for 15%as the source and patients often undergo multiple endoscopic procedures.Treatment strategies include resuscitative measures and endoscopic therapies.Medical treatment is with octreotide.Novel treatment options include thalidomide,angiotensin converting enzyme inhibitors/angiotensinⅡreceptor blockers,estrogen-based hormonal therapies,doxycycline,desmopressin and bevacizumab.Current research has explored the mechanism of frequent GI bleeds in this population,including destruction of von Willebrand factor,upregulation of tissue factor,vascular endothelial growth factor,tumor necrosis factor-α,tumor growth factor-β,and angiopoetin-2,and downregulation of angiopoetin-1.In addition,healthcare resource utilization is only increasing in this patient population with higher admissions,readmissions,blood product utilization,and endoscopy.While some of the novel endoscopic and medical therapies for LVAD bleeds are still in their development stages,these tools will yet be crucial as the number of LVAD placements will likely only increase in the coming years.
