Importance of risk assessment,endoscopic hemostasis,and recent advancements in the management of acute non-variceal upper gastrointestinal bleeding

Acute non-variceal upper gastrointestinal bleeding(ANVUGIB)is a common medical emergency in clinical practice.While the incidence has significantly reduced,the mortality rates have not undergone a similar reduction in the last few decades,thus presenting a significant challenge.This editorial outlines the key causes and risk factors of ANVUGIB and explores the current standards and recent updates in risk assessment scoring systems for predicting mortality and endoscopic treatments for achieving hemostasis.Since ANUVGIB predominantly affects the elderly population,the impact of comorbidities may be responsible for the poor outcomes.A thorough drug history is important due to the increasing use of antiplatelet agents and anticoagulants in the elderly.Early risk stratification plays a crucial role in deciding the line of management and predicting mortality.Emerging scoring systems such as the ABC(age,blood tests,co-morbidities)score show promise in predicting mortality and guiding clinical decisions.While conventional endoscopic therapies remain cornerstone approaches,novel techniques like hemostatic powders and over-the-scope clips offer promising alternatives,particularly in cases refractory to traditional modalities.By integrating validated scoring systems and leveraging novel therapeutic modalities,clinicians can enhance patient care and mitigate the substantial morbidity and mortality associated with ANVUGIB.

Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions:Clinical significance

Transoral endoscopic resections in treating upper gastrointestinal submucosal lesions have the advantages of maintaining the integrity of the gastrointestinal lumen,avoiding perforation and reducing gastrointestinal fistulae.They are becoming more widely used in clinical practice,but,they may also present a variety of complications.Gas-related complications are one of the most common,which can be left untreated if the symptoms are mild,but in severe cases,they can lead to rapid changes in the respiratory and circulatory systems in a short period,which can be life-threatening.Therefore,it is important to predict the occurrence of gas-related complications early and take preventive measures actively.Based on the authors'results in the prepublication of the article“Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions,”and in conjunction with our evaluation and additions to the relevant content,radiographs may help screen patients at high risk for gas-related complications.Controlling blood glucose levels,shortening the duration of surgery,and choosing the most appropriate surgical resection may positively impact the prognosis of patients at high risk for gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions.

Validity of Upper Gastro-Intestinal Endoscopic Screening in HCV Cirrhotic Patients Awaiting Antiviral Therapy

Background and Aim: The Egyptian Ministry of Health initiated a nationwide HCV treatment program with the newly developed oral antiviral therapies and formulated national guidelines for treatment allocation which gave favor for patients with advanced fibrosis and early cirrhosis. One of the recommendations for treatment was upper Gastro-intestinal (GIT) endoscopy. This study aimed at estimating the prevalence of varices among those patients and judging the validity of this national recommendation. Methods: This study was carried out at gastrointestinal endoscopy units, Zagazig University Hospitals through the year 2014. The epidemiologic, clinical features and endoscopic findings of patients undergoing preparation for HCV therapy were analyzed. Endoscopic classifications of esophageal and gastric varices were carried out after the Italian liver cirrhosis project and Sarin’s classification respectively. Results: Totally 1143 patients performed upper GIT endoscopy as preparation for HCV treatment. This comprised 22% of all patients undergoing upper GIT endoscopy over that year. There was a fourfold rise in percentage of patients undergoing endoscopy for sofosbuvir-based therapy in this year (22%) when compared to assessment for Interferon/Ribavirin combination therapy (5%) in the previous year. A total of 361 patients had no esophageal or gastric varices. Small sized (grade I), medium sized (grade II) and large sized (grade III) varices were reported in 301, 188 and 293 patients respectively. Thirty patients (2.6%) had gastric varices. The prevalence of varices was higher in Child B in comparison to Child A (statistically not significant, p = 0.243). Conclusion: Screening endoscopy for early cirrhotic patients awaiting oral anti-HCV therapy is valid.

Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions

BACKGROUND Gas-related complications present a potential risk during transoral endoscopic resection of upper gastrointestinal submucosal lesions.Therefore,the identification of risk factors associated with these complications is essential.AIM To develop a nomogram to predict risk of gas-related complications following transoral endoscopic resection of the upper gastrointestinal submucosal lesions.METHODS We collected patient data from the First Affiliated Hospital of the Army Medical University.Patients were randomly allocated to training and validation cohorts.Risk factors for gas-related complications were identified in the training cohort using univariate and multivariate analyses.We then constructed a nomogram and evaluated its predictive performance based on the area under the curve,decision curve analysis,and Hosmer-Lemeshow tests.RESULTS Gas-related complications developed in 39 of 353 patients who underwent transoral endoscopy at our institution.Diabetes,lesion origin,surgical resection method,and surgical duration were incorporated into the final nomogram.The predictive capability of the nomogram was excellent,with area under the curve values of 0.841 and 0.906 for the training and validation cohorts,respectively.CONCLUSION The ability of our four-variable nomogram to efficiently predict gas-related complications during transoral endoscopic resection enhanced postoperative assessments and surgical outcomes.

Magnifying endoscopy in upper gastroenterology for assessing lesions before completing endoscopic removal

Any prognosis of gastrointestinal (GI) cancer is closely related to the stage of the disease at diagnosis.Endoscopic submucosal dissection (ESD) and en bloc endoscopic mucosal resection (EMR) have been performed as curative treatments for many early-stage GI lesions in recent years.The technologies have been widely accepted in many Asian countries because they are minimally invasive and supply thorough histopathologic evaluation of the specimens.However,before engaging in endoscopic therapy,an accurate diagnosis is a precondition to effecting the complete cure of the underlying malignancy or carcinoma in situ.For the past few years,many new types of endoscopic techniques,including magnifying endoscopy with narrow-band imaging (MENBI),have emerged in many countries because these methods provide a strong indication of early lesions and are very useful in determining treatment options before ESD or EMR.However,to date,there is no comparable classification equivalent to "Kudo's Pit Pattern Classification in the colon",for the upper GI,there is still no clear internationally accepted classification system of magnifying endoscopy.Therefore,in order to help unify some viewpoints,here we will review the defining optical imaging characteristics and the current representative classifications of microvascular and microsurface patterns in the upper GI tract under ME-NBI,describe the accurate relationship between them and the pathological diagnosis,and their clinical applications prior to ESD or en bloc EMR.We will also discuss assessing the differentiation and depth of invasion,defying the lateral spread of involvement and targeting biopsy in real time.

Orientation in upper gastrointestinal endoscopy—the only way is up

BACKGROUND Oesophagogastroduodenoscopy is the gold standard investigation for the upper gastrointestinal(UGI)tract.Orientation during endoscopy is challenging and United Kingdom training focusses on technical competence and procedural safety.The reported location of UGI pathologies is crucial to post-endoscopic planning.AIM To evaluate endoscopists’ability to spatially orientate themselves within the UGI tract.METHODS A cross sectional descriptive study elicited,using an anonymised survey,the ability of endoscopists to orientate themselves within the UGI tract.The primary outcome was percentage of correct answers from all surveyed;secondary outcomes were percentage of correct answers from experienced vs novice endoscopists.Pearson’sχ2 test was applied to compare groups.RESULTS Of 188 respondents,86 were experienced endoscopists having completed over 1000 endoscopies.44.4%of respondents correctly identified the anterior stomach and 47.3%correctly identified the posterior of the second part of the duodenum(D2).Experienced endoscopists were significantly more likely than novice to identify the anterior stomach correctly[61.6%vs 31.3%,X2(1,n=188)=11.10,P=0.001].There was no significant difference between the two groups in identifying the posterior of D2.CONCLUSION The majority of endoscopists surveyed were unable to identify key landmarks within the UGI tract.Endoscopic orientation appears to improve with experience yet there are some areas still not well recognised.This has potential considerable impact on post-endoscopic management of patients with posterior duodenal ulcers being more likely to perforate and associated with a higher rebleeding risk.We suggest the development of a consensus statement on endoscopic description.

Indications and Findings of Upper Gastrointestinal Endoscopy in Elderly Patients in Parakou, Republic of Benin

Introduction: Elderly people are considered fragile and at greater risk of having malignant gastrointestinal tumors. The objective of this work was to report the reasons for performing gastrointestinal endoscopy and the lesions found during the endoscopy of this target population in Parakou. Patients and Study Methods: This was a descriptive and cross-sectional study with a retrospective collection of data from January 2016 to December 2017, then from January 2020 to December 2021. It took place in the Regional Teaching Hospital of Borgou-Alibori in Parakou and in the private gastrointestinal endoscopy center of Parakou (Northern Gastrointestinal Exploration Center). All patients aged at least 60 years who had undergone an upper gastrointestinal endoscopy during the study period were included. The variables studied were: the sex, age, indications for the examination, endoscopic lesions and data from the anatomo-pathological examination. Results: In total, out of 1540 upper gastrointestinal endoscopies performed during the study period, 249 (16.17%) involved patients aged 60 years and over. The sex ratio was 1.26. The main indication for the examination was epigastric pain (123 cases, i.e. 49.40%) followed by vomiting (53 cases, i.e. 21.29%). In terms of lesions, non-tumorous gastropathy came first in the stomach (206 cases, i.e. 82.73%) while esophageal lesions were dominated by esophageal candidiasis and cardial incompetence (39 cases, i.e. 15.66% in each of the two situations). In the duodenum, ulcer was noted in 30 patients (12.05%). In 38 patients, 12 (31.58%) were tested positive for Helicobacter pylori infection. Cancers of the gastrointestinal tract were confirmed in 11 patients (4.42%). Conclusion: Upper gastrointestinal endoscopy remains an excellent examination for the exploration of the upper gastrointestinal tract. In Parakou, epigastric pain represents the main indication for this examination in subjects over 60 years of age. Inflammatory or ulcerated non-tumorous gastropathy is the most commonly endoscopic lesion. Esophageal and gastric cancers are less common in this population group according to our study.

Advancements in hemostatic strategies for managing upper gastrointestinal bleeding: A comprehensive review

Upper gastrointestinal(GI)hemorrhage presents a substantial clinical challenge.Initial management typically involves resuscitation and endoscopy within 24 h,although the benefit of very early endoscopy(<12 h)for high-risk patients is debated.Treatment goals include stopping acute bleeding,preventing rebleeding,and using a multimodal approach encompassing endoscopic,pharmacological,angiographic,and surgical methods.Pharmacological agents such as vasopressin,prostaglandins,and proton pump inhibitors are effective,but the increase in antithrombotic use has increased GI bleeding morbidity.Endoscopic hemostasis,particularly for nonvariceal bleeding,employs techniques such as electrocoagu-lation and heater probes,with concerns over tissue injury from monopolar electrocoagulation.Novel methods such as Hemospray and Endoclot show promise in creating mechanical tamponades but have limitations.Currently,the first-line therapy includes thermal probes and hemoclips,with over-the-scope clips emerging for larger ulcer bleeding.The gold probe,combining bipolar electrocoagulation and injection,offers targeted coagulation but has faced device-related issues.Future advancements involve combining techniques and improving endoscopic imaging,with studies exploring combined approaches showing promise.Ongoing research is crucial for developing standardized and effective hemorrhage management strategies.

Upper gastrointestinal bleeding in Bangladeshi children:Analysis of 100 cases

BACKGROUND Upper gastrointestinal bleeding(UGIB)is defined as bleeding that occurs proximal to the ligament of Treitz and can sometimes lead to potentially serious and life-threatening clinical situations in children.Globally,the cause of UGIB differs significantly depending on the geographic location,patient population and presence of comorbid conditions.AIM To observe endoscopic findings of UGIB in children at a tertiary care center of Bangladesh.METHODS This retrospective study was carried out in the department of Pediatric Gastroenterology and Nutrition of Bangabandhu Shiekh Mujib Medical University,a tertiary care hospital of Bangladesh,between January 2017 and January 2019.Data collected from hospital records of 100 children who were 16 years of age or younger,came with hematemesis,melena or both hematemesis and melena.All patients underwent upper gastrointestinal endoscopy(Olympus CV 1000 upper gastrointestinal video endoscope)after initial stabilization.Necessary investigations to diagnose portal hypertension and chronic liver disease with underlying causes for management purposes were also done.RESULTS A total of 100 patients were studied.UGIB was common in the age group 5-10 years(42%),followed by above 10 years(37%).Hematemesis was the most common presenting symptom(75%)followed by both hematemesis and melena(25%).UGIB from ruptured esophageal varices was the most common cause(65%)on UGI endoscopy followed by gastric erosion(5%)and prolapsed gastropathy(2%).We observed that 23%of children were normal after endoscopic examination.CONCLUSION Ruptured esophageal varices were the most common cause of UGIB in children in Bangladesh.Other causes included gastric erosions and prolapsed gastropathy syndrome.

Upper gastrointestinal tract capsule endoscopy using a nurse-led protocol: First reported experience

AIM To test the feasibility and performance of a novel upper gastrointestinal(GI) capsule endoscope using a nurse-led protocol. METHODS We conducted a prospective cohort analysis of patients who declined gastroscopy(oesophagogastroduodenoscopy, OGD) but who consented to upper GI capsule endoscopy. Patients swallowed the upper GI capsule following ingestion of 1 liter of water(containing simethicone). A series of positional changes were used to exploit the effects of water flow and move the upper GI capsule from one gravity-dependent area to another using a nurse-led protocol. Capsule transit time, video reading time, mucosal visualisation, pathology detection and patient tolerance was evaluated.RESULTS Fifty patients were included in the study. The mean capsule transit times in the oesophagus and stomach were 28 s and 68 min respectively. Visualisation of the following major anatomical landmarks was achieved(graded 1-5: Poor to excellent): Oesophagus, 4.8(± 0.5); gastro-oesophageal junction(GOJ), 4.8(± 0.8); cardia, 4.8(± 0.8); fundus, 3.8(± 1.2); body, 4.5(± 1); antrum, 4.5(± 1); pylorus, 4.7(± 0.8); duodenal bulb, 4.7(± 0.7); second part of the duodenum(D2), 4.7(± 1). The upper GI capsule reached D2 in 64% of patients. The mean video reading time was 48 min with standard playback mode and 20 min using Quickview(P = 0.0001). No pathology was missed using Quickview. Procedural tolerance was excellent. No complications were seen with the upper GI capsule. CONCLUSION The upper GI capsule achieved excellent views of the upper GI tract. Future studies should compare the diagnostic accuracy between upper GI capsule and OGD.

Recent advances in diagnostic upper endoscopy

BACKGROUND Esophageo-gastro-duodenoscopy(EGD)is an important procedure used for detection and diagnosis of esophago-gastric lesions.There exists no consensus on the technique of examination.AIM To identify recent advances in diagnostic EGDs to improve diagnostic yield.METHODS We queried the PubMed database for relevant articles published between January 2001 and August 2019 as well as hand searched references from recently published endoscopy guidelines.Keywords used included free text and MeSH terms addressing quality indicators and technological innovations in EGDs.Factors affecting diagnostic yield and EGD quality were identified and divided into the follow segments:Pre endoscopy preparation,sedation,examination schema,examination time,routine biopsy,image enhanced endoscopy and future developments.RESULTS We identified 120 relevant abstracts of which we utilized 67 of these studies in our review.Adequate pre-endoscopy preparation with simethicone and pronase increases gastric visibility.Proper sedation,especially with propofol,increases patient satisfaction after procedure and may improve detection of superficial gastrointestinal lesions.There is a movement towards mandatory picture documentation during EGD as well as dedicating sufficient time for examination improves diagnostic yield.The use of image enhanced endoscopy and magnifying endoscopy improves detection of squamous cell carcinoma and gastric neoplasm.The magnifying endoscopy simple diagnostic algorithm is useful for diagnosis of early gastric cancer.CONCLUSION There is a steady momentum in the past decade towards improving diagnostic yield,quality and reporting in EGDs.Other interesting innovations,such as Raman spectroscopy,endocytoscopy and artificial intelligence may have widespread endoscopic applications in the near future.

Efficacy of premedication with activated Dimethicone or N-acetylcysteine in improving visibility during upper endoscopy

AIM:To assess the efficacy of N-acetylcysteine(NAC) and activated Dimethicone in improving endoscopic mucosal visibility.METHODS:A total of 148 patients were randomly allocated into four groups to receive one of the following premedications:group A:100 mL water alone;group B:activated Dimethicone plus water(up to 100 mL);group C:NAC plus water(up to 100 mL);and group D:activated Dimethicone and NAC plus water(up to 100 mL).A single endoscopist blinded to the patients group assessed the gastric mucosal visibility scores(range 1-4) at four sites.The sum of the scores from the four sites was considered as the total mucosal visibility score(TMVS).RESULTS:The patients in group B showed a significantly lower TMVS than those of groups A and C(P < 0.001).The TMVS in patients of group D was significantly lower than that of groups A and C(P < 0.001).The TMVS did not significantly differ between groups B and D(P > 0.05).The difference between TMVS of groups C and A was not significant(P > 0.05).CONCLUSION:Premedication with activated Dimethicone 20 min prior to the upper endoscopy leads to the best visibility.NAC does not improve visualization by itself.

Novel treatment options for perforations of the upper gastrointestinal tract:Endoscopic vacuum therapy and over-the-scope clips

Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention.In the past years,covered selfexpanding metal stents were the mainstay of endoscopic therapy.However,two new techniques are now available that enlarge the possibilities of defect closure:endoscopic vacuum therapy(EVT),and over-the-scope clip(OTSC).EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage.Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing,comparable to the application of vacuum therapy in cutaneous wounds.The system is changed every 3-5 d.The overall success rate of EVT in the literature ranges from 84%to 100%,with a mean of 90%;only few complications have been reported.OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope.By bringing the edges of the perforation into the cap,by suction or by dedicated devices,such as anchor or twin grasper,the OTSC can be placed to close the perforation.For acute endoscopy associated perforations,the mean success rate is 90%(range:70%-100%).For other types of perforations(postoperative,other chronic leaks and fistulas)success rates are somewhat lower(68%,and59%,respectively).Only few complications have been reported.Although first reports are promising,further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.

Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy

AIM: To investigate stepwise sedation for elderly patients with mild/moderate chronic obstructive pulmonary disease (COPD) during upper gastrointestinal (GI) endoscopy. METHODS: Eighty-six elderly patients with mild/moderate COPD and 82 elderly patients without COPD scheduled for upper GI endoscopy were randomly assigned to receive one of the following two sedation methods: stepwise sedation involving three-stage administration of propofol combined with midazolam [COPD with stepwise sedation (group Cs), and nonCOPD with stepwise sedation (group Ns)] or continuous sedation involving continuous administration of propofol combined with midazolam [COPD with continuous sedation (group Cc), and non-COPD with continuous sedation (group Nc)]. Saturation of peripheral oxygen (SpO 2 ), blood pressure, and pulse rate were monitored, and patient discomfort, adverse events, drugs dosage, and recovery time were recorded. RESULTS: All endoscopies were completed successfully. The occurrences of hypoxemia in groups Cs, Cc, Ns, and Nc were 4 (9.3%), 12 (27.9%), 3 (7.3%), and 5 (12.2%), respectively. The occurrence of hypoxemia in group Cs was significantly lower than that in group Cc (P < 0.05). The average decreases in value of SpO 2 , systolic blood pressure, and diastolic blood pressure in group Cs were significantly lower than those in group Cc. Additionally, propofol dosage and overall rate of adverse events in group Cs were lower than those in group Cc. Finally, the recovery time in group Cs was significantly shorter than that in group Cc, and that in group Ns was significantly shorter than that in group Nc (P < 0.001). CONCLUSION: The stepwise sedation method is effective and safer than the continuous sedation method for elderly patients with mild/moderate COPD during upper GI endoscopy.

Technical skills and training of upper gastrointestinal endoscopy for new beginners

The incidence of gastric cancer remains high in SouthKorea.Upper gastrointestinal(GI) endoscopy,i.e.,esophagogastroduodenoscopy(EGD),has a higher diagnostic specificity and sensitivity than the upper GI series.Additionally,EGD has the ability to biopsy,through taking a tissue of the pathologic lesion.Successful training of EGD procedural skills require a few important things to be learned and remembered,including the posture of an examinee(e.g.,left lateral decubitus and supine) and examiner(e.g.,one-man standing method vs one-man sitting method),basic skills(e.g.,tip deflection,push forward and pull back,and air suction and infusion),advanced skills(e.g.,paradoxical movement,J-turn,and U-turn),and intubation techniques along the upper GI tract(e.g.,oral cavity,pharynx,larynx including vocal cord,upper and middle and lower esophagus,gastroesophageal junction,gastric fundus,body,and antrum,duodenal bulb,and descending part of duodenum).In the current review,despite several limitations,we explained the intubation method of EGD for beginners.We hope this will be helpful to beginners who wish to learn the procedure.

Ultraslim endoscopy with flexible spectral imaging color enhancement for upper gastrointestinal neoplasms

AIM:To conduct a preliminary study on the effect of flexible spectral imaging color enhancement (FICE) used in combination with ultraslim endoscopy by focusing on the enhanced contrast between tumor and non-tumor lesions. METHODS: We examined 50 lesions of 40 patients with epithelial tumors of the upper gastrointestinal tract before endoscopic submucosal dissection using ultraslim endoscopy with conventional natural color imag ing and with FICE imaging. We retrospectively invest igated the effect of the use of FICE on endoscopic diagn osis in comparison with normal light. RESULTS: Visibility of the epithelial tumors of the upper gastrointestinal tract with FICE was superior to normal light in 54% of the observations and comparable to normal light in 46% of the observations. There was no lesion for which visibility with FICE was inferior to that with normal light. FICE visualized 69.6% of hyperemic lesions and 58.8% of discolored lesions better than conventional endoscopy with natural color imaging. FICE sign if icantly improved the visibility of lesions with hyp ere mia or discoloration compared with normocolored lesions. CONCLUSION: This study suggests that the use of FICE would improve the ability of ultraslim endoscopy to detect epithelial tumors of the upper gastrointestinal tract.

Timing of upper gastrointestinal endoscopy does not influence short-term outcomes in patients with acute variceal bleeding

AIM To examine the association between the timing of endo-scopy and the short-term outcomes of acute variceal bleeding in cirrhotic patients.METHODS This retrospective study included 274 consecutive patients admitted with acute esophageal variceal bleeding of two tertiary hospitals in Korea. We adjusted confounding factors using the Cox proportional hazards model and the inverse probability weighting （IPW） method. The primary outcome was the mortality of patients within 6 wk.RESULTS A total of 173 patients received urgent endoscopy （ i.e. , ≤ 12 h after admission）, and 101 patients received non-urgent endoscopy （〉 12 h after admission）. The 6-wk mortality rate was 22.5% in the urgent endoscopy group and 29.7% in the non-urgent endoscopy group, and there was no significant difference between the two groups before （P = 0.266） and after IPW （P = 0.639）. The length of hospital stay was statistically different between the urgent group and non-urgent group （P = 0.033）; however, there was no significant difference in the in-hospital mortality rate between the two groups （8.1%vs 7.9%, P = 0.960）. In multivariate analyses, timing of endoscopy was not associated with 6-wk mortality （hazard ratio, 1.297; 95% confdence interval, 0.806-2.089; P = 0.284）.CONCLUSION In cirrhotic patients with acute variceal bleeding, the timing of endoscopy may be independent of short-term mortality.

Two case reports of acute upper gastrointestinal bleeding from duodenal ulcers after Roux-en-Y gastric bypass surgery: Endoscopic diagnosis and therapy by single balloon or push enteroscopy after missed diagnosis by standard esophagogastroduodenoscopy

The diagnosis and opportunity for endoscopic therapy of gastric or duodenal lesions may be missed at esophagogastroduodenoscopy(EGD) because of technical difficulty in intubating at EGD the postoperatively excluded stomach and proximal duodenum in patients status post Roux-en-Y gastric bypass(RYGB). Two cases are reported of acute upper gastrointestinal bleeding 10 or 11 years status postRYGB, performed for morbid obesity, in which the EGD was non-diagnostic due to failure to intubate the excluded stomach and proximal duodenum, whereas subsequent push enteroscopy or single balloon enteroscopy were diagnostic and revealed 4-cm-wide or 5-mm-wide bulbar ulcers and even permitted application of endoscopic therapy. These case reports suggest consideration of push enteroscopy, or single balloon enteroscopy, where available, in the endoscopic evaluation of acute UGI bleeding in patients status post RYGB surgery when the EGD was non-diagnostic because of failure to intubate these excluded segments.

Usefulness of duodenal biopsy during routine upper gastrointestinal endoscopy for diagnosis of celiac disease

AIM： To describe the trend in duodenal biopsy performance during routine upper gastrointestinal endoscopy in an adult Spanish population, and to analyze its value for the diagnosis of celiac disease in clinical practice. METHODS： A 15 year-trend （1990 to 2004） in duodenal biopsy performed when undertaking upper gastrointestinal endoscopy was studied. We analysed the prevalence of celiac disease in the overall group, and in the subgroups with anaemia and/or chronic diarrhoea. RESULTS： Duodenal biopsy was performed in 1033 of 13 678 upper gastrointestinal endoscopies （7.6%）; an increase in the use of such was observed over the study period （1.9% in 1990-1994, 5% in 1995-1999 and 12.8% in 2000-2004）. Celiac disease was diagnosed in 22 patients （2.2%）, this being more frequent in women than in men （3% and 1% respectively）. Fourteen out of 514 （2.7%） patients with anaemia, 12 out of 141 （8.5%） with chronic diarrhoea and 8 out of 42 （19%） with anaemia plus chronic diarrhoea had celiac disease. A classical clinical presentation was observed in 55% of the cases, 23% of the patients had associated dermatitis herpetiformis and 64% presented anaemia; 9% were diagnosed by familial screening and 5% by cryptogenetic hypertransaminasaemia. CONCLUSION： Duodenal biopsy undertaken during routine upper gastrointestinal endoscopy in adults, has been gradually incorporated into clinical practice, and is a useful tool for the diagnosis of celiac disease in high risk groups such as those with anaemia and/or chronic diarrhoea.

Role of upper endoscopy in diagnosing opportunistic infections in human immunodeficiency virus-infected patients

Highly active antiretroviral therapy (HAART) has dramatically decreased opportunistic infections (OIs) in human immunodef iciency virus (HIV)-infected patients. However,gastrointestinal disease continues to account for a high proportion of presenting symptoms in these patients. Gastrointestinal symptoms in treated patients who respond to therapy are more likely to the result of drug-induced complications than OI. Endoscopic evaluation of the gastrointestinal tract remains a cornerstone of diagnosis,especially in patients with advanced immunodeficiency,who are at risk for OI. The peripheral blood CD4 lymphocyte count helps to predict the risk of an OI,with the highest risk seen in HIV-infected patients with low CD4 count (< 200 cells/mm3). This review provides an update of the role of endoscopy in diagnosing OI in the upper gastrointestinal tract in HIV-infected patients in the era of HAART.