Detachable string magnetically controlled capsule endoscopy for the noninvasive diagnosis of esophageal diseases:A prospective,blind clinical study

BACKGROUND Traditional esophagogastroduodenoscopy(EGD),an invasive examination method,can cause discomfort and pain in patients.In contrast,magnetically controlled capsule endoscopy(MCE),a noninvasive method,is being applied for the detection of stomach and small intestinal diseases,but its application in treating esophageal diseases is not widespread.AIM To evaluate the safety and efficacy of detachable string MCE(ds-MCE)for the diagnosis of esophageal diseases.METHODS Fifty patients who had been diagnosed with esophageal diseases were pros-pectively recruited for this clinical study and underwent ds-MCE and conven-tional EGD.The primary endpoints included the sensitivity,specificity,positive predictive value,negative predictive value,and diagnostic accuracy of ds-MCE for patients with esophageal diseases.The secondary endpoints consisted of visualizing the esophageal and dentate lines,as well as the subjects'tolerance of the procedure.RESULTS Using EGD as the gold standard,the sensitivity,specificity,positive predictive value,negative predictive value,and diagnostic accuracy of ds-MCE for esophageal disease detection were 85.71%,86.21%,81.82%,89.29%,and 86%,respectively.ds-MCE was more comfortable and convenient than EGD was,with 80%of patients feeling that ds-MCE examination was very comfortable or comfortable and 50%of patients believing that detachable string v examination was very convenient.CONCLUSION This study revealed that ds-MCE has the same diagnostic effects as traditional EGD for esophageal diseases and is more comfortable and convenient than EGD,providing a novel noninvasive method for treating esophageal diseases.

Rabeprazole vs esomeprazole in non-erosive gastro-esophageal reflux disease: A randomized, double-blind study in urban Asia

AIM：Gastro-esophageal reflux disease (GERD) is becoming increasingly common in Asia. Data on the efficacy of proton pump inhibitors in patients with non-erosive GERD (NERD)in Asia is lacking. This double-blind study compared the efficacy and safety of rabeprazole with esomeprazole in relief of symptoms in patients with NERD.METHODS: One hundred and thirty-four patients with reflux symptoms of NERD and normal endoscopy were randomized to receive rabeprazole 10 mg or esomeprazole 20 mg once daily for 4 wk. Symptoms were recorded in a diary and changes in severity of symptoms noted.RESULTS: At 4 wk of treatment, rabeprazole 10 mg and esomeprazole 20 mg were comparable with regards to the primary endpoint of time to achieve 24-h symptomfree interval for heartburn 8.5 d vs9 d and regurgitation 6 d vs 7.5 d. Rabeprazole and esomeprazole were also similarly efficacious in term of patient's global evaluation with 96% of patients on rabeprazole and 87.9% of patients on esomeprazole, reporting that symptoms improved(P=NS). Satisfactory relief of day- and night-time symptoms was achieved in 98% of patients receiving rabeprazole and 81.4% of patients receiving esomeprazole. Adverse events were comparable in both groups (P = NS).CONCLUSION: Rabeprazole 10 mg has a similar efficacy and safety profile in Asians with NERD as esomeprazole 20 mg. Further study is necessary to investigate whether the small differences between the two drugs seen in this study are related to the improved pharmacodynamicpro perties of rabeprazole. Both drugs were well tolerated.

Isolated Esophageal Crohn’s Disease with Diffuse Stricture

Background: Esophageal strictures are considered to be one of the most challenging matters for gastroenterologist, general and thoracic surgeons in diagnosis and management. They can be grouped into three general categories: intrinsic diseases, extrinsic diseases, and diseases that disrupt esophageal peristalsis and/or lower esophageal sphincter (LES) function. Crohn’s disease (CD) is a very rare cause of esophageal stricture. The prevalence of esophageal CD ranges from 1% to 2% in adults with CD. It is almost diagnosed lately when complications have occurred as Strictures, fissures, esophagobronchial fistulas, and mediastinal abscesses. Case Report: Thirty-nine years old Kurdish patient, referred to our department for evaluation. Although many consultations during the last two years, the Pt was still undiagnosed. She had progressive dysphagia, and weight loss of about 25 kg. She had no other digestive or extra digestive complaint, nor caustic ingestion history and nor drug history. Chest CT scan and UGI Contrast study revealed diffuse smooth and regular esophageal stenosis. Attempts to do upper endoscopy and biopsy failed due to severe stenosis. Prolonged medical history and radiologic signs exclude malignancy, so esophagectomy with stomach pull-through was done by the aid of VATS and laparoscopy with excellent results. Pathological finding of the resected esophagus suggested the diagnosis of Crohn’s disease CD. Conclusions: CD is a rare cause of esophageal stricture and still to be a challenging early diagnosis due to the low specificity of clinical manifestations (aphthous ulcers), histologic findings (absence of granulomas), and endoscopic findings. So many patients have been diagnosed with complications (esophageal strictures, fistulas) which needed surgical treatment, adding greater morbidity and mortality. MIS (thoracoscopy-laparoscopy) is valuable in decreasing the morbidity and mortality and improving the quality of life for those patients.

Esophageal ulceration complicating doxycycline therapy

AIM;TO report present state of iatrogenic drug-induced esophageal injury(DIEI)induced by medications in a private clinic. METHODS:Iatrogenic drug-induced esophageal injury (DIEI)induced by medications has been more frequently reported.In a private clinic we encountered 36 cases of esophageal ulcerations complicating doxycycline therapy in a mainly younger Saudi population(median age 29 years). RESULTS:The most frequent presenting symptoms were odynophagia,retrosternal burning pain and dysphagia(94 %, 75 % and 56 %,respectively).The diagnosis was according to medical history and confirmed by endoscopy in all patients. Beside withdrawal of doxycycline,when feasible,all patients were treated with a proton-pump inhibitor(PPI)and a prokinetic.Thirty patients who reported to the clinic after treatment were improved within 1-7(median 1.7)days. CONCLUSION:Esophageal ulceration has to be suspected in younger patients with odynophagia,retrosternal burning pain and/or dysphagia during the treatment with doxycycline.

Acute esophageal necrosis and liver pathology,a rare combination

Acute esophageal necrosis (AEN) or 'black esophagus' is a clinical condition found at endoscopy. It is a rare entity the exact etiology of which remains unknown. We describe a case of 'black esophagus', first of its kind, in the setting of liver cirrhosis and hepatic encephalopathy.

Esophageal squamous papillomas with focal dermal hypoplasia and eosinophilic esophagitis

Focal dermal hypoplasia(FDH) is a rare disorder of the mesodermal and ectodermal tissues. Here we present an eight-year-old female known to have FDH who presents with poor weight gain and dysphagia. She was diagnosed with multiple esophageal papillomas and eosinophilic esophagitis. She was successfully treated with argon plasma coagulation and ingested fluticasone propionate, which has not been described previously in a child.

Circular smooth muscle contributes to esophageal shortening during peristalsis

AIM:To study the angle between the circular smooth muscle(CSM) and longitudinal smooth muscle(LSM) fibers in the distal esophagus.METHODS:In order to identify possible mechanisms for greater shortening in the distal compared to proximal esophagus during peristalsis,the angles between the LSM and CSM layers were measured in 9 cadavers.The outer longitudinal layer of the muscularis propria was exposed after stripping the outer serosa.The inner circular layer of the muscularis propria was then revealed after dissection of the esophageal mucosa and the underlying muscularis mucosa.Photographs of each specimen were taken with half of the open esophagus folded back showing both the outer longitudinal and inner circular muscle layers.Angles were measured every one cm for 10 cm proximal to the squamocolumnar junction(SCJ) by two independent investigators.Two human esophagi were obtained from organ transplant donors and the angles between the circular and longitudinal smooth muscle layers were measured using micro-computed tomography(micro CT) and Image J software.RESULTS:All data are presented as mean ± SE.The CSM to LSM angle at the SCJ and 1 cm proximal to SCJ on the autopsy specimens was 69.3 ± 4.62 degrees vs 74.9 ± 3.09 degrees,P = 0.32.The CSM to LSM angle at SCJ were statistically significantly lower than at 2,3,4 and 5 cm proximal to the SCJ,69.3 ± 4.62 degrees vs 82.58 ± 1.34 degrees,84.04 ± 1.64 degrees,84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees,P = 0.013,P = 0.008,P = 0.004,P = 0.009 respectively.The CSM to LSM angle at SCJ was also statistically significantly lower than the angles at 6,7 and 8 cm proximal to the SCJ,69.3 ± 4.62 degrees vs 80.18 ± 2.09 degrees,81.81 ± 1.75 degrees and 80.96 ± 2.04 degrees,P = 0.05,P = 0.02,P = 0.03 respectively.The CSM to LSM angle at 1 cm proximal to SCJ was statistically significantly lower than at 3,4 and 5 cm proximal to the SCJ,74.94 ± 3.09 degrees vs 84.04 ± 1.64 degrees,84.87 ± 1.04 degrees and 83.72 ± 1.42 degrees,P = 0.019,P = 0.008,P = 0.02 respectively.At 10 cm above SCJ the angle was 80.06 ± 2.13 degrees which is close to being perpendicular but less than 90 degrees.The CSM to LSM angles measured on virtual dissection of the esophagus and the stomach on micro CT at the SCJ and 1 cm proximal to the SCJ were 48.39 ± 0.72 degrees and 50.81 ± 1.59 degrees.Rather than the angle of the CSM and LSM being perpendicular in the esophagus we found an acute angulation between these two muscle groups throughout the lower 10 cm of the esophagus.CONCLUSION:The oblique angulation of the CSM may contribute to the significantly greater shortening of distal esophagus when compared to the mid and proximal esophagus during peristalsis.

In vitro effect of pantoprazole on lower esophageal sphincter tone in rats

AIM:To investigate the in vitro effects of pantoprazole on rat lower esophageal sphincter(LES)tone.METHODS:Rats weighing 250-300 g,provided by the Yeditepe University Experimental Research Center(Yü-DETAM),were used throughout the study.They were anesthetized before decapitation.LES tissues whose mucosal lining were removed were placed in a stan-dard 30-mL organ bath with a modif ied Krebs solution and continuously aerated with 95% oxygen-5% carbon dioxide gas mixture and kept at room temperature.The tissues were allowed to stabilize for 60 min.Sub-sequently,the contractile response to 10-6 mol/L carba-chol was obtained.Different concentrations of freshly prepared pantoprazole were added directly to the tis-sue bath to generate cumulative concentrations of 5×10-6 mol/L,5×10-5 mol/L,and 1.5×10-4 mol/L.Activi-ties were recorded on an online computer via a 4-channeltransducer data acquisition system using the software BSL PRO v 3.7,which also analyzed the data.RESULTS:Pantoprazole at 5×10-6 mol/L caused a small,but statistically insignif icant,relaxation in the car-bachol-contracted LES(2.23% vs 3.95%).The 5×10-5 mol/L concentration,however,caused a signif icant relax-ation of 10.47% compared with the control.1.5×10-4 mol/L concentration of pantoprazol caused a 19.89% relaxation in the carbachol contracted LES(P<0.001).CONCLUSION:This is the fi rst study to demonstrate that pantoprazole has a relaxing effect in isolated LESs.These results might have signif icant clinical implications for the subset of patients using proton pump inhibitors who do not receive full symptomatic alleviation from gastroesophageal reflux disease.

Impact of minimally invasive surgery on the treatment of benign esophageal disorders

Thanks to the development of minimally invasive surgery, the last 20 years have witnessed a change in the treatment algorithm of benign esophageal disorders. Today a laparoscopic operation is the treatment of choice for esophageal achalasia and for most patients with gastroesophageal reflux disease. Because the pathogenesis of achalasia is unknown, treatment is palliative and aims to improve esophageal emptying by decreasing the functional obstruction at the level of the gastro-esophageal junction. The refinement of minimally invasive techniques accompanied by large, multiple randomized control trials with long-term outcome has allowed the laparoscopic Heller myotomy and partial fundoplication to become the treatment of choice for achalasia compared to endoscopic procedures, including endoscopic botulinum toxin injection and pneumatic dilatation. Patients with suspected gastroesophageal reflux need to undergo a thorough preoperative workup. After establishing diagnosis, treatment for gastroesophageal reflux should be individualized to patient characteristics and a decision about an operation made jointly between surgeon and patient. The indications for surgery have changed in the last twenty years. In the past, surgery was often considered for patients who did not respond well to acid reducing medications. Today, the best candidate for surgery is the patient who has excellent control of symptoms with proton pump inhibitors. The minimally invasive approach to antireflux surgery has allowed surgeons to control reflux in a safe manner, with excellent long term outcomes. Like achalasia and gastroesophageal reflux, the treatment of patients with paraesophageal hernias has also seen a major evolution. The laparoscopic approach has been shown to be safe, and durable, with good relief of symptoms over the long-term. The most significant controversy with laparoscopic paraesophageal hernia repair is the optimal crural repair. This manuscript reviews the evolution of these techniques.

Alginate controls heartburn in patients with erosive and nonerosive reflux disease

AIM:To evaluate the effect of a novel alginate-based compound,Faringel,in modifying reflux characteristics and controlling symptoms.METHODS:In this prospective,open-label study,40 patients reporting heartburn and regurgitation with proven reflux disease(i.e.,positive impedance-pH test/evidence of erosive esophagitis at upper endoscopy) underwent 2 h impedance-pH testing after eating a refluxogenic meal.They were studied for 1 h under basal conditions and 1 h after taking 10 mL Faringel.In both sessions,measurements were obtained in right lateral and supine decubitus positions.Patients also completed a validated questionnaire consisting of a 2-item 5-point(0-4) Likert scale and a 10-cm visual analogue scale(VAS) in order to evaluate the efficacy of Faringel in symptom relief.Tolerability of the treatment was assessed using a 6-point Likert scale ranging from very good(1) to very poor(6).RESULTS:Faringel decreased significantly(P < 0.001),in both the right lateral and supine decubitus positions,esophageal acid exposure time [median 10(25th75th percentil 6-16) vs 5.8(4-10) and 16(11-19) vs 7.5(5-11),respectively] and acid refluxes [5(3-8) vs 1(1-1) and 6(4-8) vs 2(1-2),respectively],but increased significantly(P < 0.01) the number of nonacid reflux events compared with baseline [2(1-3)vs 3(2-5) and 3(2-4) vs 6(3-8),respectively].Percentage of proximal migration decreased in both decubitus positions(60% vs 32% and 64% vs 35%,respectively;P < 0.001).Faringel was significantly effective in controlling heartburn,based on both the Likert scale [3.1(range 1-4) vs 0.9(0-2);P < 0.001] and VAS score [7.1(3-9.8) vs 2(0.1-4.8);P < 0.001],but it had less success against regurgitation,based on both the Likert scale [2.6(1-4) vs 2.2(1-4);P = not significant(NS)] and VAS score [5.6(2-9.6) vs 3.9(1-8.8);P = NS].Overall,the tolerability of Faringel was very good 5(2-6),with only two patients reporting modest adverse events(i.e.,nausea and bloating).CONCLUSION:Our findings demonstrate that Faringel is well-tolerated and effective in reducing heartburn by modifying esophageal acid exposure time,number of acid refluxes and their proximal migration.

Over-the-scope clips in the treatment of gastrointestinal tract iatrogenic perforation:A multicenter retrospective study and a classification of gastrointestinal tract perforations

AIM:To determine the outcome of the management of iatrogenic gastrointestinal tract perforations treated by over-the-scope clip(OTSC)placement.METHODS:We retrospectively enrolled 20 patients(13 female and 7 male;mean age:70.6±9.8 years)in eight high-volume tertiary referral centers with upper or lower iatrogenic gastrointestinal tract perforation treated by OTSC placement.Gastrointestinal tract perforation could be with oval-shape or with round-shape.Ovalshape perforations were closed by OTSC only by suction and the round-shape by the"twin-grasper"plus suction.RESULTS:Main perforation diameter was 10.1±4.3 mm(range 3-18 mm).The technical success rate was 100%(20/20 patients)and the clinical success rate was 90%(18/20 patients).Two patients(10%)who did not have complete sealing of the defect underwent surgery.Based upon our observations we propose two types of perforation:Round-shape"type-1 perforation"and oval-shape"type-2 perforation".Eight(40%)out of the 20 patients had a type-1 perforation and 12 patients a type-2(60%).CONCLUSION:OTSC placement should be attempted after perforation occurring during diagnostic or therapeutic endoscopy.A failed closure attempt does not impair subsequent surgical treatment.

Dysphagia lusorium in elderly:A case report

AIM: Late unset of dysphagia due to vascular abnormalities is a rare condition. We aimed to present a case of right subclavian artery abnormalities caused dysphagia in the elderly.METHODS: A 68-year-old female was admitted with dysphagia seven months ago. Upper endoscopic procedures and routine examinations could not demonstrate any etiology. Multislice computed thorax tomography was performed for probable extra- esophagial lesions.RESULTS: Multislice computed thorax tomography showed right subclavian artery abnormality and esophagial compression with this aberrant artery.CONCLUSION: Causes of dysphagia in the elderly are commonly malignancies, strictures and/or motility disorders. If routine examinations and endoscopic procedures fail to show any etiology, rare vascular abnormalities can be considered in such patients. Multislice computed tomography is a usefull choice in such conditions.

Temporal trends in the relative prevalence of dysphagia etiologies from 1999-2009

AIM:To examine the relative prevalence and temporal variation of dysphagia etiologies in patients undergoing upper endoscopy(EGD) over the past decade.METHODS:EGDs with the indication of dysphagia at an urban,university medical center in 1999,2004 and 2009 were retrospectively identified from the electronic medical record.The entire patient chart,including EGD,pathology,manometry,radiographic and clinician reports,was reviewed for demographic and clinical data and to determine the etiology of dysphagia.The number of EGDs in which an esophageal biopsy was performed was also noted.Gastroesophageal reflux disease(GERD) as a cause of dysphagia independent of peptic stricture was defined by symptoms with erosive esophagitis or symptom response to proton pump inhibition(PPI).Cases of eosinophilic esophagitis(EoE) were defined by an appropriate clinical history and histological criteria of ≥ 15 eosinophils per high powered field.PPI-responsive esophageal eosinophilia was not routinely reported prior to 2008.Statistical analysis was performed using one-way analysis of variance to analyze for trends between 1999,2004 and 2009 and a post-hoc Tukey analysis was performed following a significant main effect.RESULTS:A total of 1371 cases(mean age 54 years,43% male) met pre-specified inclusion criteria with 191,504 and 675 cases in 1999,2004 and 2009,respectively.Patients were older in 2004 compared to 2009(mean ± SD,54.0 ± 15.7 years vs 52.3 ± 16.8 years,P = 0.02) and there were more males in 1999 compared to 2004(57.5% vs 40.8%,P = 0.005).Overall,GERD(27.6%) and EoE(7.7%) were the most common identifiable causes of dysphagia.An unspecified diagnosis accounted for 21% of overall cases.There were no significant differences in the relative prevalence of achalasia or other motility disorders,peptic stricture,Schatzki's ring,esophageal cancer or unspecified diagnoses over the 10-year time period.There was,however,a decrease in the relative prevalence of GERD(39.3% vs 24.1%,P < 0.001) and increases in the relative prevalence of EoE(1.6% vs 11.2%,P < 0.001) and oropharyngeal disorders(1.6% vs 4.2%,P = 0.02) from 1999 to 2009.Post-hoc analyses determined that the increase in relative prevalence of EoE was significant between 1999 and 2009 as well as 2004 and 2009(5.4% vs 11.6%,P < 0.001),but not between 1999 and 2004(1.6% P 5.4%,P = 0.21).On the other hand,the decrease in relative prevalence of GERD was significant between 1999 and 2009 and 1999 and 2004(39.3% vs 27.7%,P = 0.006),but not between 2004 and 2009(27.7% vs 24.1%,P = 0.36).There were also significantly more EGDs in which a biopsy was obtained in 1999 compared to 2009(36.7% vs 68.7%,P < 0.001) as well as between 2004 and 2009(37.5% vs 68.7%,P < 0.001).While total EGD volume did increase over the 10-year time period,the percentage of EGDs for the indication of dysphagia remained stable making increasing upper endoscopy an unlikely reason for the observed increased prevalence of EoE.CONCLUSION:EoE has emerged as a dominant cause of dysphagia in adults.Whether this was due to a rise in disease incidence or increased recognition is unclear.

Diagnostic advances of artificial intelligence and radiomics in gastroenterology

Traditional medical imaging,including ultrasound,computed tomography,magnetic resonance imaging,or positron emission tomography,remains widely used diagnostic modalities for gastrointestinal diseases at present.These modalities are used to assess changes in morphology,attenuation,signal intensity,and enhancement characteristics.Gastrointestinal tumors,especially malignant tumors,are commonly seen in clinical practice with an increasing number of deaths each year.Because the imaging manifestations of different diseases usually overlap,accurate early diagnosis of tumor lesions,noninvasive and effective evaluation of tumor staging,and prediction of prognosis remain challenging.Fortunately,traditional medical images contain a great deal of important information that cannot be recognized by human eyes but can be extracted by artificial intelligence(AI)technology,which can quantitatively assess the heterogeneity of lesions and provide valuable information,including therapeutic effects and patient prognosis.With the development of computer technology,the combination of medical imaging and AI technology is considered to represent a promising field in medical image analysis.This new emerging field is called“radiomics”,which makes big data mining and extraction from medical imagery possible and can help clinicians make effective decisions and develop personalized treatment plans.Recently,AI and radiomics have been gradually applied to lesion detection,qualitative and quantitative diagnosis,histopathological grading and staging of tumors,therapeutic efficacy assessment,and prognosis evaluation.In this minireview,we briefly introduce the basic principles and technology of radiomics.Then,we review the research and application of AI and radiomics in gastrointestinal diseases,especially diagnostic advancements of radiomics in the differential diagnosis,treatment option,assessment of therapeutic efficacy,and prognosis evaluation of esophageal,gastric,hepatic,pancreatic,and colorectal diseases.

Diagnosis of gastroesophageal reflux disease in elderly subjects using 24-houres ophageal pH monitoring

Objective To evaluate the relationship between the parameters of 24 hour esophageal pH monitoring and gastroesophageal reflux disease (GERD) among elderly subjects. Methods Twenty four hour esophageal pH monitoring was carried out in 20 elderly subjects without apparent GERD symptoms (controls) and 69 suspected GERD subjects.Results Normal values of the parameters from 20 elderly controls were obtained. Percent of total time, percent of supine time and percent of upright time in which the pH was <4 (indicating reflux) were less than 3.3%, 1.4%, 5.5%, respectively. The number of reflux episodes and episodes lasting longer than 5 minutes were less than 65 and 2 times respectively. The values obtained in 66 GERD suspected subjects were significantly different from those in norrmal controls. The differences of reflux parameters between the esophagitis group and non esophagitis group, such as percent of total time with pH<4, percent of supine time with pH<4 and number of reflux lasting longer than 5 minutes were also significant. Conclusions About 51.6% patients (34/66) with reflux symptoms but without endoscopic evidence of esophagitis were definitely diagnosed as GERD by esophageal pH monitoring. Duration of esophageal acid exposure correlated with the severity of GERD.

Eosinophilic esophagitis-endoscopic distinguishing findings

Eosinophilic esophagitis （EE） is the most frequent con- dition found in a group of gastrointestinal disorders called eosinophilic gastrointestinal diseases. The hypo- thetical pathophysiological mechanism is related to a hypersensitivity reaction. Gastroesophageal reflux dis- ease-like complaints not ameliorated by acid blockade or occasional symptoms of dysphagia or food impac- tion are likely presentations of EE. Due to its unclear pathogenesis and unspecific symptoms, it is difficult to diagnose EE without a strong suspicion. Although histo- togical criteria are necessary to diagnosis EE, there are some characteristic endoscopic features. We present the case of a healthy 55-year-old woman with dyspha- gia and several episodes of esophageal food impaction over the last six months. This case report stresses the most distinguishing endoscopic findings-mucosa rings, white exudative plaques and linear furrows-that can help in the prompt recognition of this condition.