Gastrointestinal stromal tumor of the stomach: How to manage?

Gastrointestinal stromal tumor (GIST) is one of the most common malignant mesenchymal tumors of the stomach. Prognosis of this disease is related to tumor size and mitotic activity and early diagnosis is the only way to improve it. Diagnosis of GIST always requires histological and immunohistochemical confirmation as no imaging modalities can diagnose it conclusively. Endoscopic forceps biopsy results are frequently negative. Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) is a technique which allows tissue samples to be obtained with minimal risks and is accurate in the diagnosis of GIST. From the point of view of the endoscopist, aggressive use of EUS-FNA is the only promising way to allow early diagnosis and early treatment of this disease.

Toxic megacolon associated Clostridium difficile colitis

Toxic megacolon is a severe complication of Clostridium difficile (C. difficile) colitis. As the prevalence of C. difficile colitis increases and treatments become more refractory, clinicians will encounter more patients with C. difficile associated toxic megacolon in the future. Here, we review a case of toxic megacolon secondary to C. difficile colitis and review the current literature on diagnosis and management. We identify both clinical and radiologic criteria for diagnosis and discuss both medical and surgical options for management. Ultimately, we recommend using the Jalen criteria in conjunction with daily abdominal radiographs to help establish the diagnosis of toxic megacolon and to make appropriate treatment recommendations. Aggressive medical management using supportive measures and antibiotics should remain the mainstay of treatment. Surgical intervention should be considered if the patient does not clinically improve within 2-3 d of initial treatment.

Observation of the esophagus, pharynx and lingual root by gastrointestinal endoscopy with a percutaneous retrograde approach

AIM: To evaluate the efficacy of retrograde observation of the esophagus, pharynx, larynx and lingual root.

METHODS: With the beagle dog under anesthesia, the anterior wall of the stomach was fixed on the abdominal wall in a similar way to percutaneous endoscopic gastrostomy. The gastrointestinal scope was inserted via a 12 mm laparoscopic port for subsequent retrograde observation from stomach to the oral cavity.

RESULTS: With this technique, direct observation of gastric cardia was possible without restriction. The cervical esophagus was dilated well, also allowing clear observation of the hypopharyngo-esophageal junction. If the tongue was manually pulled out forward, observation of the lingual root was possible.

CONCLUSION: This procedure is easy and effective for pre-treatment evaluation of the feasibility of endoscopic resection in cases of superficial carcinoma of head and neck.

A novel endoscopic ablation of gastric antral vascular ectasia

An 80-year-old woman was admitted to our hospital because of tarry stool with iron deficiency anemia. Her past history included autoimmune hepatitis. Esophagogastroduodenal endoscopy was performed to investigate the bleeding source and revealed multiple linear gastric vascular malformations in the antrum and cardia, compatible with Gastric antral vascular ectasia (GAVE). Endoscopic ablation was carried out with the tip of the hot biopsy forceps without opening at soft coagulation mode of 80W. The patient tolerated the procedure well and there were no complications associated with endoscopic therapies. After two sessions of endoscopic ablation her anemia improved to around 10 g/dL, an increase of 3.6 g/dL. Various endoscopic treatments have been described to manage GAVE. The most popular is argon plasma coagulation (APC), although APC is associated with over-distension induced by the argon plasma gas. To avoid over-distension and to reduce the abdominal discomfort/pain of this patient, we have used hot biopsy forceps instead of APC. Our case suggests that this procedure is effective, easy and convenient, as no special equipment or skill is necessary.

Endoscopic ultrasound in the papilla and the periampullary region

Endoscopic ultrasound (EUS) provides relevant information when an ampullary or periampullary tumor is suspected. Early detection, T and N staging and Fine Needle Aspiration plus cithologic confirmation, are some of the expected benefits. Exclusion of benign findings like choledocholithiasis or chronic pancreatitis is also important. A correct understanding of the complex ampullary and periampullary anatomy is needed. Knowledge of the individual clinical history and other previous diagnostic images all contribute to a successful EUS examination. Radial and lineal EUS images are uniquely detailed and, at the moment, it seems to be the best way to exclude or confirm malignant or benign findings. We propose a procedural algorithm, including EUS, for suspected ampullary or periampullary tumors. This review summarizes the vast amount of information to be found spread in the literature, and recognizes this small anatomic area as the origin for a clinical entity with proper clinical presentation, proper imaging and proper therapeutic resolutions. The benefits of performing EUS for its study are highlighted.

Endoscopic treatment of a large colonic polyp as a cause of colocolonic intussusception in a child

Colocolonic intussusception is an uncommon cause of intestinal obstruction in children. The most common type is idiopathic ileocolic intussusception. However, pathologic lead points occur approximately in 5% of cases. In pediatric patients, Meckel’s diverticulum is the most common lead point, followed by polyps and duplication. We present a case of recurrent colocolonic intussusception which caused colonic obstruction in a 10-year-old boy. A barium enema revealed a large polypoid mass at the transverse colon. Colonoscopy showed a colonic polyp, 3.5 centimeters in diameter, which was successfully removed by endoscopic polypectomy.

Contrast enhanced endoscopic ultrasound: More than just a fancy Doppler

Contrast enhanced endoscopic ultrasound (CEUS) is a new modality that takes advantage of vascular structure and blood flow to distinguish different clinical entities. Contrast agents are microbubbles that oscillate when exposed to ultrasonographic waves resulting in characteristic acoustic signals that are then converted to colour images. This permits exquisite imaging of macro- and microvasculature, providing information to help delineate malignant from non-malignant processes. The use of CEUS may significantly increase the sensitivity and specificity over conventional endoscopic ultrasound. Currently available contrast agents are safe, with infrequent adverse effects. This review summarizes the theory and technique behind CEUS and the current and future clinical applications.

Esophagitis dissecans superficialis and autoimmune bullous dermatoses: A review

Esophagitis dissecans superficialis (EDS) is a rare and severe endoscopic finding characterized by sloughing of large fragments of esophageal mucosal lining. Although EDS has been reported in association with serious illnesses and certain medications, the pathophysiological association of autoimmune bullous dermatoses with EDS has gained remarkable attention. Among these dermatoses, pemphigus vulgaris and pemphigoid frequently present with various types of esophageal involvement including EDS. We review the pathophysiology and clinical features of this involvement with the presentation of our experiences. The importance of endoscopic evaluation of this entity is discussed.

Lubiprostone used with polyethylene glycol in diabetic patients enhances colonoscopy preparation quality

AIM: To assess the additive effect of lubiprostone on the quality of colon preparation in diabetics given single-dosed polyethylene glycol electrolyte (PEG) for colonoscopy.

METHODS: This was an investigator-initiated, single-center, single-blinded prospective trial comparing the efficacy of L + PEG to PEG alone on colon preparation quality in diabetics undergoing screening colonoscopy. The study was approved by our institution’s IRB. The PEG was given as a single-dose to address patient-compliance concerns voiced by our IRB with split-dosing. All patients received only clear liquids the day prior to colonoscopy. Experimental group (Grp L) received PEG + 1 dose L 2 h prior to and 2 h after PEG completion. Control group (Grp C) received only PEG the evening prior to the colonoscopy. Patients were randomly assigned to one of the 2 groups. The endoscopist was blinded to which colon prep was given and all colonoscopies were complete. Upon colonoscopy completion, the endoscopist rated the colon prep-quality by a validated 5-point Likert scale (1-excellent to 5-inadequate).

RESULTS: Sixty patients were enrolled in the study; 30 Grp L and 30 Grp C. Overall, patients were excluded due to study non-completion in 12 (41%) Grp L and 5 (17%) Grp C, P = 0.04. Average colon preparation score Grp L = 2.47 and Grp C = 3.00, P = 0.09. Although this was not statistically significant, there was a trend towards improved colon prep in Grp L. Statistical significance may have been achieved if completion rates had been similar between both study groups.

CONCLUSION: Use of 2-L capsules with PEG resulted in a trend towards improved colon prep over PEG alone in diabetic patients when given as a single-dose regimen.

New endoscopy devices to improve population adherence to colorectal cancer prevention programs

Despite recent advances in medicine, colorectal cancer (CRC) remains one of the greatest hazards for public health worldwide and especially the industrialized world. It has been well documented with concrete data that regular screening colonoscopy aimed at early detection of precancerous polyps can help decrease the incidence of CRC. However, the adherence of the general population to such screening programs has been shown to be lower than that expected, thus allowing CRC to remain a major threat for public health. Various reasons have been suggested to explain the disappointing compliance of the population to CRC screening programs, some of them associated with colonoscopy per se, which is viewed by many people as an unpleasant examination. Governments, medical societies, individual gastroenterologists, as well as the medical industry are working in order to improve endoscopic devices and/or to improve standard colonoscopy. The aim is to improve the acceptance of the population for this method of CRC screening, by providing a painless and reliable examination of the colon. This review focuses on some of the latest improvements in this field.

Anesthesia and sedation in pediatric gastrointestinal endoscopic procedures: A review

Gastrointestinal (GI) endoscopic procedure has become an essential modality for evaluation and treatment of GI diseases. Intravenous (IV) sedation and General Anesthesia (GA) have both been employed to minimize discomfort and provide amnesia. Both these procedures require, at the very least, monitoring of the level of consciousness, pulmonary ventilation, oxygenation and hemodynamics. Although GI endoscopy is considered safe, the procedure has a potential for complications. Increased awareness of the complications associated with sedation during GI endoscopy in children, and involving the anesthesiologists in caring for these children, may be optimal for safety. Belonging to a younger age group, having a higher ASA class and undergoing IV sedation were identified as risk factors for developing complications. Reported adverse events included inadequate sedation, low oxygen saturation, airway obstruction, apnea needing bag mask ventilation, excitement and agitation, hemorrhage and perforation. A complication rate of 1.2% was associated with procedures performed under GA, as compared to 3.7% of complications associated with IV sedation. IV sedation was seen to be independently associated with a cardiopulmonary complication rate 5.3% times higher when compared to GA. GA can therefore be considered safer and more effective in providing comfort and amnesia.

Endoscopic ultrasound-guided celiac plexus neurolysis

Endoscopic celiac plexus neurolysis (CPN) has become the procedure of choice for the management of patients with pancreatic cancer and abdominal pain unresponsive to medical treatment. It is necessary to differentiate between CPN and endoscopic celiac plexus block performed in patients with benign disease. In this review we describe the technique of this procedure with special emphasis on technical details.

Pancreatic pseudocyst drainage guided by endoscopic ultrasound

Pancreatic pseudocysts can be managed conservatively in the majority of patients but some of them will require surgical, endoscopic or percutaneous drainage. Endoscopic drainage represents an efficient modality of drainage with a high resolution rate and lower morbidity and mortality than the surgical or percutaneous approach. In this article we review the endoscopic pseudocyst drainage procedure with special emphasis on technical details.

Endoscopic ultrasound-guided drainage of pelvic collections and abscesses

Pelvic abscesses are usually the end stage in the progression of an infection. They may occur from surgical complications, generalized abdominal infections such as appendicitis or diverticulitis, or from localized infections such as pelvic inflammatory disease or inflammatory bowel disease. Although surgery has been considered as the treatment of choice by some authors, pelvic abscesses can be managed by non-invasive methods such as ultrasound and computed tomography-guided drainage. The development of therapeutic linear echoendoscopes has allowed the endoscopist to perform therapeutic procedures. Recently, endoscopic ultrasonography (EUS)-guided drainage of pelvic collections has been demonstrated to be feasible, efficient and safe. It allows the endoscopist to insert stents and drainage catheters into the abscess cavity which drains through the large bowel. This article reviews technique, current results and future prospects of EUS-guided drainage of pelvic lesions.

Endoscopic ultrasonography-guided common bile duct stone removal

Endoscopic ultrasonography has become an important diagnostic and therapeutic tool in endoscopy units. It has a great impact on biliary and pancreatic disease management and its application to retrograde cholangiopancreatography is appealing, although very challenging with current devices. In this article we describe our initial experience with this technique.

Endosonography-guided cholangiopancreatography as a salvage drainage procedure for obstructed biliary and pancreatic ducts

Endoscopic ultrasound allows transmural access to the bile or pancreatic ducts and subsequent contrast injection to provide ductal drainage under fluoroscopy using endoscopic retrograde cholangiopancreatography (ERCP)-based techniques. Differing patient specifics and operator techniques result in six possible variant approaches to this procedure, known as endosonography-guided cholangiopancreatography (ESCP). ESCP has been in clinical use for a decade now, with over 300 cases reported. It has become established as a salvage procedure after failed ERCP in the palliation of malignant biliary obstruction. Its role in the management of clinically severe chronic/relapsing pancreatitis remains under scrutiny. This review aims to clarify the concepts underlying the use of ESCP and to provide technical tips and a detailed step-by-step procedural description.

Splenic rupture following a diagnostic upper endoscopy

Complications following endoscopic procedures have been rarely reported and spontaneous rupture of a normal spleen is an exceptional complication following a gastroscopy. This paper reports a case of a spontaneous rupture of a normal spleen following a gastroscopy.

Gallbladder drainage guided by endoscopic ultrasound

The gold-standard management of acute cholecystitis is cholecystectomy. Surgical intervention may be contraindicated due to permanent causes. To date, the classical approach is percutaneous cholecystostomy in patients unresponsive to medical therapy. However, with this treatment some patients may experience discomfort, complications and a decrease in their quality of life. In these cases, endoscopic ultrasound (EUS)-guided gallbladder drainage may represent an effective minimally invasive alternative. Our objective is to describe in detail this new and not well-known technique: EUS-guided cholecystenterostomy. We will describe how the patient should be prepared, what accessories are needed and how the technique is performed. We will also discuss the possible indications for this technique and will provide a brief review based on published reports and our own experience.

Postcolonoscopy appendicitis in a patient with active ulcerative colitis

Complications due to diagnostic colonoscopy are uncommon and acute appendicitis is a very rare complication of colonoscopy. This poses a diagnostic challenge as the presentation of appendicitis is similar to that of other complications of colonoscopy such as perforation or postpolypectomy syndrome. It is hypothesized that postcolonoscopy appendicitis might be associated with obstruction of the appendiceal lumen with fecal matter during colonoscopy. None of the previous reports in the literature have described findings of appendicitis after colonoscopy in a patient with active ulcerative colitis. We present a case of a 28 year-old man with active ulcerative colitis who underwent colonoscopy and subsequently developed acute appendicitis.

Endoscopic ultrasound guided vascular access and therapy: A promising indication

Endoscopic ultrasound (EUS) is an imaging technique that has consolidated its role as an important tool for diagnosis and therapeutics. In recent years we have seen a dramatic increase in the number of EUS-guided therapeutic indications (celiac plexus neurolysis/block, pseudocyst drainage, etc). Preliminary reports have suggested EUS may also be used to guide vascular access for both imaging and treating different vascular diseases. This review aims to objectively describe the existing evidence in the field.

Endoscopic retrograde cholangiopancreatography associated pancreatitis: A 15-year review

The aim of this article is to review the literature regarding post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis. We searched for and evaluated all articles describing the diagnosis, epidemiology, pathophysiology, morbidity, mortality and prevention of post-ERCP pancreatitis (PEP) in adult patients using the PubMed database. Search terms included endoscopic retrograde cholangiopancreatography, pancreatitis, ampulla of vater, endoscopic sphincterotomy, balloon dilatation, cholangiography, adverse events, standards and utilization. We limited our review of articles to those published between January 1, 1994 and August 15, 2009 regarding human adults and written in the English language. Publications from the reference sections were reviewed and included if they were salient and fell into the time period of interest. Between the dates queried, seventeen large (> 500 patients) prospective and four large retrospective trials were conducted. PEP occurred in 1%-15% in the prospective trials and in 1%-4% in the retrospective trials. PEP was also reduced with pancreatic duct stent placement and outcomes were improved with endoscopic sphincterotomy compared to balloon sphincter dilation in the setting of choledocholithiasis. Approximately 34 pharmacologic agents have been evaluated for the prevention of PEP over the last fifteen years in 63 trials. Although 22 of 63 trials published during our period of review suggested a reduction in PEP, no pharmacologic therapy has been widely accepted in clinical use in decreasing the development of PEP. In conclusion, PEP is a well-recognized complication of ERCP. Medical treatment for prevention has been disappointing. Proper patient selection and pancreatic duct stenting have been shown to reduce the complication rate in randomized clinical trials.

Role of wireless capsule endoscopy in inflammatory bowel disease

Capsule endoscopy (CE) offers state-of-the-art imaging of the small bowel. In Crohn’s disease its clinical role is still uncertain. This report analyses the usefulness of CE in patients with suspected Cronh’s disease, in patients with established Crohn’s disease (when assessing severity, occult gastrointestinal bleeding and/or as a guide to therapy), in patients with inflammatory bowel disease unclassified (IBDU), and in individuals with ulcerative colitis. The first item in this group is the most important although there is no strong evidence to establish the position of CE in the diagnostic workup. In patients with established Crohn’s disease, recently developed activity scores are promising tools for an accurate assessment of severity. As a guide to therapy, CE should be focused on patients with unexplained symptoms when other investigations are inconclusive. In postoperative Crohn’s Disease, international consensus recommended considering CE only if ileocolonoscopy is contraindicated or unsuccessful. In the case of IBDU, studies have shown a significant proportion of patients reclassified with Crohn’s disease. In this setting, CE could have a role determining small bowel involvement. The role of CE in ulcerative colitis is limited. Some authors advocate CE before colectomy for refractory cases in order to exclude Crohn’s disease. In summary, CE offers a new horizon in inflammatory bowel disease, and a better knowledge of mucosal abnormalities that could offer a paradigm shift: changing from symptom-based disease activity estimation to direct mucosal healing monitoring. Nevertheless, randomized controlled studies are still needed to provide stronger evidence in this setting.

Choledochal varices bleeding: A case report

Choledochal varices are a rare cause of hemobilia associated with chronic portal vein thrombosis. We present a case of chronic portal vein thrombosis complicated with bleeding from choledochal varices. The presentation, clinical manifestations and management are described.

Lower gastrointestinal bleeding in the elderly

Lower gastrointestinal bleeding (LGIB) is an important worldwide cause of morbidity and mortality in the elderly. The incidence of LGIB increases with age and corresponds to the increased incidence of specific gastrointestinal diseases that have worldwide regional variation, co-morbid diseases and polypharmacy. The evaluation and treatment of patients is adjusted to the rate and severity of hemorrhage and the clinical status of the patient and may be complicated by the presence of visual, auditory and cognitive impairment due to age and co-morbid disease. Bleeding may be chronic and mild or severe and life threatening, requiring endoscopic, radiologic or surgical intervention. Colonoscopy provides the best method for evaluation and treatment of patients with LGIB. There will be a successful outcome of LGIB in the majority of elderly patients with appropriate evaluation and management.

Endoscopic placement of enteral feeding tubes

Malnutrition is common in patients with acute and chronic illness. Nutritional management of these malnourished patients is an essential part of healthcare. Enteral feeding is one component of nutritional support. It is the preferred method of nutritional support in patients that are not receiving adequate oral nutrition and have a functioning gastrointestinal tract (GIT). This method of nutritional support has undergone progression over recent times. The method of placement of enteral feeding tubes has evolved due to development of new feeding tubes and endoscopic technology. Enteral feeding can be divided into methods that provide short-term and long-term access to the GIT. This review article focuses on the current range of methods of gaining access to the GIT to provide enteral feed.