Diagnostic performance of the current risk-stratified approach with computed tomography for suspected choledocholithiasis and its options when negative finding

Background:Several studies evaluated the current guideline of the American Society for Gastrointestinal Endoscopy(ASGE)and reported only suboptimal accuracy.This study evaluated the diagnostic performance of the ASGE guideline based on computed tomography(CT)and role of endoscopic ultrasonography(EUS)and magnetic resonance cholangiopancreatography(MRCP)in patients with suspected choledocholithiasis but negative CT finding.Methods:Patients with suspected choledocholithiasis undergoing ERCP between January 2016 and January 2017 were retrospectively analyzed.All patients underwent CT to detect choledocholithiasis.EUS or MRCP was performed when the CT scan showed negative findings.Patients were classified into the high and intermediate-risk groups,based on predictors from the ASGE criteria.Results:Of 583 patients with suspected choledocholithiasis,340(58.3%)had stones on ERCP(65.9%in the high-risk group and 40.6%in the intermediate-risk group).The accuracy of ASGE guideline for CT was 63.98%(79.12%sensitivity,42.80%specificity)and 36.02%(20.88%sensitivity,57.20%specificity)in the high-risk and intermediate-risk groups,respectively.In 103 patients in the high-risk group underwent both CT and US,the accuracy of CT was higher than that of US for detecting choledocholithiasis(78.64%vs.53.40%),with a significant difference in area under the curve(AUC)(0.78 vs.0.59,P<0.001).Of 339 with negative CT finding,the accuracy of EUS was higher than that of MRCP(90.91%vs.82.76%),but with no significant difference in AUC(0.91 vs.0.83,P=0.347).Conclusions:CT-based ASGE guideline showed superior diagnostic performance than US for predicting choledocholithiasis.The diagnostic options,EUS or MRCP,with negative CT finding showed comparable performance.Therefore,the diagnostic modality should be selected based on availability,experience,cost,and contraindications.

Short health scale: A valid measure of health-related quality of life in Korean-speaking patients with inflammatory bowel disease

AIM To evaluate the short health scale(SHS),a new,simple,four-part visual analogue scale questionnaire that is designed to assess the impact of inflammatory bowel disease(IBD)on health-related quality of life(HRQOL),in Korean-speaking patients with IBD.METHODS The SHS was completed by 256 patients with Crohn’s disease(CD)and ulcerative colitis(UC).Individual SHS items were correlated with inflammatory bowel disease questionnaire(IBDQ)dimensions and with disease activity to assess validity.Test-retest reliability,responsiveness and patient or disease characteristics with probable association with high SHS scores were analyzed.RESULTS Of 256 patients with IBD,139(54.3%)had UC and 117(45.7%)had CD.The correlation coefficients between SHS questions about"symptom burden","activities of daily living",and"disease-related worry"and their corresponding dimensions in the IBDQ ranged from0.62 to 0.71,compared with correlation coefficients ranging from-0.45 to-0.61 for their non-corresponding dimensions.There was a stepwise increase in SHS scores,with increasing disease activity in both CD and UC(all P values<0.001).Reliability was confirmed with test-retest correlations ranging from 0.68 to 0.90(all P values<0.001).Responsiveness was confirmed with the patients who remained in remission.Their SHS scores remained unchanged,except for the SHS dimension"disease-related worry".In the multivariate analysis,female sex was associated with worse"general well-being"(OR=2.28,95%CI:1.02-5.08)along with worse disease activity.CONCLUSION The SHS is a valid and reliable measure of HRQOL in Korean-speaking patients with IBD.

Long-term outcomes of endoscopic submucosal dissection for undifferentiated type early gastric cancer over 2 cm with R0 resection

BACKGROUND Endoscopic submucosal dissection(ESD)for over 2 cm in size undifferentiated type(UD type)early gastric cancer(EGC)confined to the mucosa is not only challenging,but also long-term outcomes are not well known.AIM To evaluate the long-term outcomes of ESD done for UD type EGCs confined to the mucosa over 2 cm in size and compare the results with those where the lesions were less than 2 cm.METHODS 143 patients with UD type EGC confirmed on histology after ESD at a tertiary hospital were reviewed.Cases with synchronous and metachronous lesions and a case with emergency surgery after ESD were excluded.A total of 137 cases were enrolled.79 cases who underwent R0 resection were divided into 2 cm or less(group A)and over 2 cm(group B)in size.RESULTS Among 79 patients who underwent R0 resection,the number in group A and B were 51 and 28,respectively.The mean follow-up period(SD)was 79.71±45.42 months.There was a local recurrence in group A(1/51,2%)and group B(1/28,3.6%)respectively.This patient in group A underwent surgery while the patient in group B underwent repeated ESD with no further recurrences in both patients.There was no regional lymph node metastasis,distant metastasis,and deaths in both groups.With R0 resection strategy for ESD on lesions over 2 cm,20.4%(28/137)of patients were able to avoid surgery compared with expanded indication.CONCLUSION If R0 resection is achieved by ESD,UD type EGCs over 2 cm also showed good and similar clinical outcomes as compared to lesions less than 2 cm when followed for over 5 years.With R0 resection strategy,several patients can avoid surgery.

What is the best strategy for successful bowel preparation under special conditions?

Adequate bowel preparation is important for successful colonoscopic examination. Several effective colonic cleansing agents are available and routinely prescribed, but each carries its own limitations and benefits from particular dosing regimens. The most frequently prescribed colonic cleansing agent, the polyethylene glycol (PEG) cathartic solution, suffers from low patient compliance in general, due to its unpalatable taste and smell coupled with the large ingested volumes required. However, PEG is preferred over other cathartics for use in individuals of advanced age, sufferers of chronic kidney disease, heart failure and inflammatory bowel disease, and women who are pregnant or lactating. The laxative agents sodium phosphate (NaP) and sodium picosulfate plus magnesium citrate have been applied and have improved patient compliance and tolerance. NaP, however, should be avoided in individuals with impaired renal function or plasma clearance, such as those with chronic kidney disease, who are taking drugs that affect renal function, or who suffer from heart failure. Other special conditions that may affect an individual&#x02019;s tolerance of the cathartic agent or ability to complete the administration routine include stroke, severe constipation, hematochezia, suspicious lower gastrointestinal bleeding, and mental disorders such as dementia. All ingestible bowel preparation solutions can be instilled into the stomach and duodenum through nasogastric tube or esophagogastroduodenoscope with the aid of a water irrigation pump for patients with difficulties swallowing or ingesting the large volumes of fluid required. In addition, dietary regimens based on clear liquids and low-residue foods for 1-4 d prior to the colonoscopy may be supplemental bowel preparation strategies. Achieving an effective and safe cleansing of the bowel is important for successful colonoscopy in all patients, so full knowledge of the individual&#x02019;s condition and capabilities is necessary to select the most appropriate colonic cleansing agent and delivery regimen.

Ascaris-mimicking common bile duct stone: A case report

BACKGROUND In most cases,it is not difficult to differentiate common bile duct(CBD)stone from Ascaris infection because they are different disease entities and have different imaging findings.The two diseases usually demonstrate unique characteristic findings on computed tomography or magnetic resonance cholangiopancreatography.However,we report a rare case from our experience in which a CBD stone mimicked and was misdiagnosed as Ascaris.CASE SUMMARY A 72-year-old male presented with elevated serum liver enzymes.Computed tomography showed a hyper-attenuated,elongated lesion in the CBD lumen and associated biliary inflammation.Magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography revealed a linear filling defect in the bile duct.Moreover,elongated echogenic material with a central hypoechogenic area was seen on endoscopic ultrasound.Although the imaging findings caused us to suspect infection with the nematode Ascaris,the lesion was revealed to be a dark-brown-colored CBD stone through endoscopic extraction.CONCLUSION We report a rare case of a CBD stone that mimicked Ascaris.We also review the literature for side-by-side comparisons of the imaging features of CBD stones and ascariasis.

Large colonic lipoma with a laterally spreading tumor treated by endoscopic submucosal dissection:A case report

BACKGROUND Since fat does not transmit electrical energy well,delayed perforation and postpolypectomy syndrome due to electrical thermal injury are concerns in the endoscopic removal of colonic lipoma.The endoscopic submucosal dissection(ESD)technique concentrates electrical energy conducts to the submucosa,not the adipose tissue.This helps to minimize electrical thermal injury,especially in the case of large colonic lipomas.In rare cases,such as colonic lipomas accompanied by mucosal lesions,it is difficult for endoscopists to decide how to safely remove them.CASE SUMMARY A 78-year-old man underwent colonoscopy for colorectal cancer screening.During colonoscopy,a yellowish submucosal tumor with positive cushion sign was observed in the ascending colon measuring about 4.5 cm.A nodular mucosal lesion of about 2.5 cm was observed on the mucosal surface of the lipoma.The lipoma was so large that it occupied much of the inside of the colon,making it difficult to see the entire laterally spreading tumor(LST)at once.The LST was confined to the surface of the lipoma,which had a semipedunculated shape with a wide neck.The margin of the LST was not observed at the neck of the lipoma.ESD was performed and the colonic lipoma with the LST was successfully removed without complications.After 3 d of hospitalization,the patient was discharged without any symptoms.The final pathology report showed that the lesion consisted of submucosal lipoma and tubulovillous adenoma with lowgrade dysplasia.CONCLUSION ESD is effective and safe for treating a large colonic lipoma with an LST by minimizing electrical thermal injury.