Case report of subacute presentation of tricuspid valve thrombus complicated by widespread bilateral pulmonary emboli: a multifactorial aetiology

Background 

Right heart thrombus (RHTh) complicated by pulmonary embolism (PE) usually presents as a medical emergency with significant haemodynamic instability. However, less is known about subacute presentations.

Case summary 

We present a 74-year-old haemodynamically stable gentleman with a 3-week history of mild pleuritic chest pain and exertional dyspnoea preceded by lower respiratory tract infection. Early trans-thoracic echocardiogram (TTE) revealed a 3 cm elongated tricuspid valve thrombus with right ventricular dysfunction, new-onset atrial fibrillation, and new-onset severe left ventricular impairment. Subsequent computed tomography pulmonary angiogram showed widespread bilateral pulmonary emboli with retrograde opacification of the hepatic veins. The RHTh successfully resolved with warfarin therapy with no further complications, and the patient was discharged on Day 8 of hospitalization.

Discussion 

An early TTE is crucial in detecting the RHTh in patients suspected of PE and can significantly change the management compared with uncomplicated PE. The index of suspicion for PE and RHTh should remain high even in subacute cases.

Trends in the medical therapy of patients who discharge from hospital after decompensated heart failure

Funding Acknowledgements

Type of funding sources: None.

Background

Acute heart failure is one of the most common causes of cardiovascular hospitalization. An important factor in the prevention of re-admissions is the optimal medical therapy of heart failure patients.

Purpose

To evaluate medication in patients after hospitalization for acute decompensated heart failure.

Methods

We studied consecutive patients who admitted and discharged from two tertiary hospitals due to decompensated heart failure from June 2019 to December 2020. Their medication was recorded at the time of discharge and one month later.

Results

Overall, 730 patients (61% men), with mean age of 77 ± 12 years, were studied. At discharge, the vast majority of the patients (94%) received diuretic, while 45% of them received either angiotensin converting enzyme inhibitor (ACEI) or angiotensin II receptor blocker (ARB) or sacubitril/valsartan (20%, 12% and 13%, respectively). 74% of the patients received b-blockers, half of the patients (51%) received aldosterone antagonists, 12% Sodium-glucose Cotransporter-2 inhibitors (SGLT2i) , 6% cardiac glycosides, and only 3% ibavradine. In one month of reassessment, the corresponding percentages were: 90% diuretics, 25% ACEI, 16% ARB, 18% sacubitril/valsartan, 78% b-blockers, 53% aldosterone antagonists, 14% SGLT2i, 4% cardiac glycosides and 3% ibavradine. Despite the low dosing regimens at discharge, after one month, the majority of the patients already receiving ACEI, ARB,  sacubitril/valsartan and beta-blockers were up-titrated, while a dose reduction was noticed on diuretics in almost all patients.

Conclusion

There are still considerable margins to improve management of the optimal medical treatment of patients who discharge from hospital after acute heart failure.

Incidence and impact of acute cardiorenal syndrome

Funding Acknowledgements

Type of funding sources: None.

Background

Acute (or type 1) cardio-renal syndrome (ACRS) is defined as the acute kidney injury  in patients hospitalized for acute heart failure (HF), which often is associated to a complex and complicated clinical course. In addition, renal failure is a strong predictor of long-term adverse events in patients with acute heart failure (HF).

Purpose

To investigate the impact of ACRS, what factors are related to its occurrence, and how it affects the outcome of patients hospitalized with acute HF.

Methods

We studied consecutive patients hospitalized with acute HF from January 2019 to December 2020. Renal function as well as other biomarkers were recorded and monitored during hospitalization, and correlated with various clinical characteristics, risk factors and patient outcome.

Results

The sample consists of 612 patients, mean age 77 ± 12 years, 63% men with average duration of hospitalization 6 ± 4 days. A total of 37 deaths (6%) were observed. ACRS was found in 141 patients (23%) and independent prognostic factors for its occurrence were ischemic cardiomyopathy, age, prolonged hospitalization, use of aldosterone antagonists and high CRP upon admission. The incidence of ACRS during hospitalization was an independent prognostic factor of death (r = 0.15, p = 0.02) and anemia (r = 0.24, p = 0.04), while the outcome of death was more common in patients with ACRS - but without statistical significance - compared to patients without ACRS.

Conclusion

Deterioration of renal function in acute HF is associated with anemia and death. Factors such as ischemic cardiomyopathy, age, length of hospital stay seem to play a role in the onset of ACRS and should be taken into account in these patients, to prevent negative outcomes.

Biomarkers and Gene Polymorphisms in Members of Long- and Short-lived Families: A Longevity Study

Background

The influence of biomarkers in human lifespan has been investigated but with no clear results yet.

Materials and methods

Lipids, Uric Acid (UA), Adiponectin (ADIPOQ), Insulin-like Growth Factor (IGF-1), cholesteryl ester transfer protein (CETP) and angiotensin-converting enzyme (ACE) proteins, as well as CETP, ADIPOQ, insulin-like growth factor binding protein-3 (IGFBP3) and ACE-gene polymorphisms were evaluated in 149 Greek individuals. The Long-Lived Families (LON) (n=84) comprised of 3 generations: long-lived aged ≥90 years (P), offspring (FL1) and their grandchildren (FL2), while the Short-Lived Families (EAD) (n=65) where both parents died <75 years, comprised of 2 generations: middle-aged (FD1) and children (FD2).

Results

Serum CETP and IGF-1 levels were lower, whereas AdipoQ concentrations were higher in P compared with FL1 and FL2 members (CETP: p = 0.03 for both comparisons; IGF-1 p < 0.001 for both comparisons and ADIPOQ: p = 0.001 and p = 0.004, respectively). Furthermore, serum triglycerides, UA and glucose concentrations were higher in FD1 compared with FD2 subjects (p=0.001, 0.02 and ≤0.001, respectively). In FD2 and FL2, CETP levels were lower in individuals with B2B2 compared with B1B1 genotype (p=0.007). Additionally, ACE concentrations were higher in individuals with DD compared with II genotype in both Families (p=0.001). After adjustment for age and gender, CETP levels were lower in P and FL2 individuals with B2B2 compared with the B1B1 genotype (p=0.004 and 0.007, respectively).

Conclusion

Increase serum TGs, UA and GL concentrations were higher in the middle-aged individuals compared with their children in families independently of their lifespan. The serum adiponectin concentration was the highest in the oldest old individuals implying beneficial influence on lifespan. Independently of family's lifespan history, the youngest individuals with CETPB2B2 genotype, compared with individuals with CETPB1B1 genotypes, had lower serum CETP concentrations. The knowledge of the unfavourable gene(s)influencing human lifespan may be helpful in encouraging individuals to follow healthier lifestyle habits and better control their high-risk biomarkers.

CYP3A5 genotyping for assessing the efficacy of treatment with simvastatin and atorvastatin

In this work, we examined the impact of polymorphism in the cytochrome P450 (CYP) 3A5 gene, CYP3A5*1 (6986A > G, rs 776746), on the reduction in the lipid levels caused by simvastatin and atorvastatin. We studied 350 hyperlipidemic patients who received 10-40 mg of atorvastatin (n = 175) or simvastatin (n = 175) daily. Genotyping for CYP3A5 was done by PCR-RFLP analysis. Differences in the lipid profile before and after treatment were expressed as the % difference. The frequency of CYP3A5polymorphism was 13.4% for heterozygotes and 86.6% for homozygotes. Comparison of the responses to same dose of each drug showed that the highest % difference was associated with total cholesterol (TC) in subjects receiving atorvastatin 40 mg compared with simvastatin 40 mg (p = 0.048). However, comparison of the responses to equivalent doses of atorvastatin vs. simvastatin revealed no difference in the % change in any of the lipid parameters examined. In individuals with the same CYP3A5 genotype, a head to head comparison of the efficacy of the same dose of simvastatin vs. atorvastatin revealed an advantage for atorvastatin. For equivalent doses of atorvastatin vs. simvastatin there was no difference in the % change in any of the lipid parameters examined. Within the same genotype there was a significant difference in the % change related to the drug treatment.

Study of common variants of the apolipoprotein E and lipoprotein lipase genes in patients with coronary heart disease and variable body mass index

OBJECTIVE

In the present study, we evaluated the influence of lipoprotein lipase (LPL) and apolipoprotein (apo) E polymorphisms on lipid concentrations of 178 Greek men of similar age with coronary heart disease (CHD), but varying body mass index (BMI).

DESIGN

Patients were divided according to their BMI (in kg/m²) into three groups: lean (BMI = 20-24.9), overweight (BMI = 25-29.9), and obese (BMI ≥ 30). Polymorphisms of LPL (HindIII, S447X) and apo E (ε2, ε3, ε4), and lipid parameters were studied.

RESULTS

There was a negative correlation between BMI and high-density lipoprotein cholesterol (HDL-C) concentration (r = -0.272, p < 0.001), as has already been described. Lean homozygotes for the HindIII(+) allele had higher HDL-C levels compared to lean homozygotes for the HindIII(-) allele (p = 0.012). No correlation was found between S447X or apo E polymorphisms and BMI or plasma lipids in any group. Overweight men with the ε3/ε3 and SS genotypes had higher triglycerides concentration compared with overweight men with ε3/ε3 and SX (p = 0.002).

CONCLUSIONS

The HindIII polymorphism alone may influence HDL-C concentration in lean men, in contrast to S447X alone, which has no influence on any lipid parameters. However, the S447X and apo E polymorphisms may have a synergetic effect and alter plasma triglyceride concentration in overweight men.

Sudden cardiac death and diabetes mellitus

Sudden cardiac death (SCD) affects a significant percentage of diabetic patients. SCD in these patients can be due to several factors, such as diastolic dysfunction, heart failure, altered platelet function, inflammation, sympathetic nervous stimulation and other factors. In the present review, we discuss the association between diabetes mellitus and SCD.

Impact of CYP3A5 Gene Polymorphism on Efficacy of Simvastatin

Background: One of the promises of human genetics is individualized therapy. Therefore, we evaluated the impact of CYP3A5 gene polymorphism on the effectiveness of simvastatin (a HMG-CoA reductase inhibitor). Methods: Patients (n = 191) with hypercholesterolemia were treated with simvastatin for at least 6 months and were genotyped for the CYP3A5 polymorphism. Results: The frequency of CYP3A5 polymorphism was 0.5% for WT (wild-type), 15.6% for HT (heterozygous, expressors) and 83.9% for HM (homozygous, non-expressors). Differences in lipid profile before and after dose-response of simvastatin treatment were described as % difference {[(variable after-variable before)/variable before]*100}. There was a trend towards the decrease of low density lipoprotein cholesterol (LDL-C) in HT individuals who had a -35.2% reduction with a dose of 20 mg simvastatin and HM individuals who had a slightly higher decrease (-37.5%) despite the lower dose of simvastatin (10 mg, p = 0.07). Furthermore, HT genotype individuals had significantly higher than expected (6-8%) LDL-C % difference between 20 and 40 mg of simvastatin (-35.2 vs -49.2%, p = 0.037). In individuals with HM genotype a significant LDL-C % difference was found between 10 and 40 mg of simvastatin (-37.5 vs -48.4%, p = 0.023). Conclusion: The individuals with HM polymorphism display a trend towards higher LDL-C reductions compared with HT polymorphism. Within the same genotype, differences between doses were also observed. These findings need to be confirmed in larger studies.

Gene polymorphisms and thyroid function in patients with heart failure

We evaluated nuclear factor kappa B {NFkB, rs28362491 [-94ins/delATTG (W/D)]} and angiotensin converting enzyme {ACE; rs1799752 [Ins(I)/Del(D)]} gene polymorphisms and their correlation with thyroid function in patients with heart failure (HF). Peak oxygen uptake (VO(2)) was evaluated (by Weber classification) during a symptom-limited cardiopulmonary exercise test in 194 patients. Thyroid-stimulating hormone, triiodothyronine (T3), thyroxine (T4), and free (F) T3 and FT4 were also measured. According to their cardiovascular (CV) capacity, patients were subdivided into four groups: group A included patients with peak VO(2) >20 ml/kg/min, group B 16-20 ml/kg/min, group C 10-16 ml/kg/min, and group D 6-10 ml/kg/min. Patients were also genotyped for NFkB and ACE genetic variants. T3 was increased and FT3 was decreased for every raise in Weber's classification (p = 0.007 and p = 0.012, respectively). Del carriers had elevated FT3 levels compared with Ins carriers (p = 0.021). Patients with II genotype had elevated T4 levels compared with ID genotype (p = 0.044). Both T4 and FT4 were decreased in D allele carriers (p = 0.007 and p = 0.045, respectively). Thyroid hormones correlated with CV capacity. Associations between the NFkB and ACE gene polymorphisms and thyroid hormones levels were also observed. Further larger studies are required to clarify genes contribution in HF.

Common variants of apolipoprotein E and cholesteryl ester transport protein genes in male patients with coronary heart disease and variable body mass index

Plasma lipids are major risk factors for coronary heart disease (CHD). Cholesteryl ester transfer protein (CETP) and apolipoprotein (apo) E genes are involved in lipoprotein metabolism, thus affecting plasma lipid and lipoproteins levels. Furthermore, such polymorphisms have been associated with susceptibility to CHD and obesity. We evaluated the influence of the gene polymorphisms of CETP TaqIB (B1, B2) and I405V (V, I) and apo E (∊2,∊3,∊4) on lipid levels, according to body mass index (BMI) in Greek men with CHD. The TaqIB (B1, B2) polymorphism affected plasma low-density lipoprotein cholesterol levels in overweight men with CHD, whereas the I405V (V, I) polymorphism affected triglyceride concentrations in normal weight men. No correlation was found between BMI and apo E polymorphisms. Large prospective studies are required to investigate the relationships of CETP and apo E polymorphisms with lipids, BMI, and CHD susceptibility.

Risk factors for therapeutic ERCP-related complications: an analysis of 2,715 cases performed by a single endoscopist

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) is now the exclusive endoscopic therapeutic modality for biliary as well as pancreatic diseases. The aim of the present study was to investigate patient- and procedure-related risk factors for post-ERCP complications in a large-scale study of procedures performed by a single experienced endoscopist.

METHODS

This is a retrospective cohort study which included a total of 2,715 therapeutic ERCPs enrolled in the final analysis. Potential important patient- and procedure-related risk factors for overall post-ERCP complications, pancreatitis and post-endoscopic sphincterotomy (ES) bleeding were investigated by univariate and multivariate analyses.

RESULTS

Following the first therapeutic ERCP, 327 patients suffered complications; pancreatitis was observed in 132 (4.9%) patients, hemorrhage in 122 (4.5%) patients, cholangitis in 63 (2.3%) patients, perforation in 3 (0.11%) patients, and basket impaction in 7 (0.26%) patients. History of acute pancreatitis was more common in patients with post-ERCP complications (P<0.001). Female gender, young age (<40 years), periampullary diverticulum, suspected sphincter of Oddi dysfunction, metal stent placement, opacification of main pancreatic duct and suprapapillary fistulotomy were not found to be risk factors for overall post-ERCP complications and post-ERCP pancreatitis (PEP). Multivariate analysis showed a history of acute pancreatitis, difficult cannulation, needle-knife papillotomy, transpancreatic sphincterotomy, opacification of first and second class pancreatic ductules and acinarization as independent risk factors for overall complications and PEP, whereas antiplatelet and anticoagulation drug use were not found to be independent risk factors for post-ES bleeding.

CONCLUSIONS

The results of this study demonstrate that the endoscopist's experience reduces patient- and procedure-related risk factors for post-ERCP complications.

The frequency of 4 common gene polymorphisms in nonagenarians, centenarians, and average life span individuals

Single nucleotide polymorphisms of angiotensin-converting enzyme (ACE) such as rs1799752, nuclear factor kappa B (NFkB) such as rs28362491 and cholesteryl ester transport protein (CETP) such as rs708272 (TaqB1) and rs5882 (I405V) were evaluated in nonagenarians, centenarians, and average life span individuals (controls). The study population (n = 307; 190 nonagenarians, 12 centenarians and 105 middle-aged controls) was genotyped for ACE, NFkB, and CETP genetic variants. The age of nonagenarian and centenarian group ranged between 90 and 111 years; centenarians and controls age ranged from 99 to 111, and from 18 to 80 years, respectively. The I carriers of ACE I/D gene were fewer in nonagenarians compared to centenarians (37.6% vs 62.5%, P = .016). The I carriers of ACE gene were more frequent in centenarians compared to controls (62% vs 41%, P = .045). No differences in frequency of common NFkB and CETP genotypes between patients with exceptional longevity and middle-aged patients were observed.

A prospective analysis of factors influencing fluoroscopy time during therapeutic ERCP

BACKGROUND

Fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) has a linear relationship with radiation exposure to endoscopist, personnel and patients. The aim of this prospective study was to investigate the factors influencing the FT during ERCP.

PATIENTS AND METHODS

Between January 2010 and August 2011, patients with naïve papilla undergoing therapeutic ERCP were included in the study. Patient and procedural factors affecting fluoroscopy duration were investigated.

RESULTS

During the study period 549 ERCP records were included in the final analysis. The mean procedural time and FT were 19.53±7.61 min and 48.82±26.43 sec, respectively. There was no effect of age or gender on FT. Univariate analysis showed choledocholithiasis (+17.92 sec; 95%CI: 12.73-23.11, p<0.001), multiple stones (+21.21 sec; 95%CI: 14.31-30.35, p<0.001), stone size >10 mm (+27.514 sec; 95%CI: 16.62-35.71; p<0.001), precut technique (+12.46 sec; 95%CI: 6.32-18.60; p<0.001), periampullary diverticulum (+33.36 sec; 95%CI: 28.49-38.23; p<0.001), mechanical lithotripsy (+31.14 sec; 95%CI: 24.67-37.61; p<0.001) and mechanical lithotripsy plus stent placement (+42.41 sec; 95%CI: 31.93-52.89; p<0.001) to be associated with longer FT. Multivariate analysis identified choledocholithiasis (+13.24 sec; 95%CI: 4.44-22.04; p=0.003), multiple stones (+19.51 sec; 95%CI: 11.72-26.78; p<0.001), stone size >10 mm (+23.95 sec; 95%CI: 14.35-29.45; p<0.001), needle-knife papillotomy (+17.26 sec; 95%CI: 7.77-26.75; p<0.001), periampullary diverticulum (+21.99 sec; 95%CI: 17.81-26.16; p<0.001) and mechanical lithotripsy plus stent placement (+20.39 sec; 95%CI: 7.38-33.40; p=0.002) to prolong FT.

CONCLUSIONS

The identified factors influencing the FT may help endoscopists take appropriate precautions during ERCP to significantly decrease FTs.

CYP8A1 gene polymorphisms and left main coronary artery disease

BACKGROUND

Left main (LM) disease is rare but the most hazardous phenotype of coronary artery disease (CAD). Thus, early detection of participants at high risk of developing left main coronary heart disease (LM-CAD) is crucial. The aim of this study was to identify gene polymorphisms which could distinguish participants who are at high risk of developing LM-CAD. Such a candidate can be the prostaglandin I(2) or prostacyclin (PGI(2)) gene.

METHODS

The DNA of 254 participants (151 participants with angiographically documented LM-CAD and 103 healthy controls) was analyzed for the frequency of C1117A polymorphism in the gene coding CYP8A1.

RESULTS

The genotype distribution was different between the LM-CAD and the control group. Particularly, the CC genotype of CYP8A1 was commoner in the LM-CAD than in the healthy group (P < .001). Allele frequencies were also differently distributed between the 2 groups. C allele frequency was higher in LM-CAD group (P = .016).

CONCLUSIONS

The CC genotype of C1117A polymorphism is associated with higher risk of LM-CAD, which prospectively may have potential importance in screening high-risk populations. However, further investigations in larger populations are required to confirm these findings.

Complex coronary artery anatomy in a patient with prolapsing left atrial myxoma

The case of an asymptomatic patient with prolapsing left atrial myxoma, in whom preoperative coronary angiography revealed a rare coronary artery anatomy in the absence of atherosclerotic obstructive disease, is presented. There was a type IV dual left anterior descending (LAD) artery with intraseptal course of the right aortic sinus-connected (long) LAD artery and an ectopic left circumflex artery originating from the right aortic sinus and having a retroaortic course. The patient underwent successful surgical excision of the mass which was confirmed by histology to be cardiac myxoma. This particular coronary artery anatomy has only been described once, and this is the first reported case of its combination with cardiac myxoma. This report highlights the importance of differentiating between the possible courses of such ectopic coronary arteries. The angiographic signs which enabled differentiation of the intraseptal course of the long LAD artery from the malignant interarterial course with which it is frequently confused are presented.

The role of common variants of the cholesteryl ester transfer protein gene in left main coronary artery disease

BACKGROUND

The cholesteryl ester transfer protein (CETP) has a central role in the lipid metabolism and therefore may alter the susceptibility to atherosclerosis.

METHODS

The DNA of 471 subjects [133 subjects with angiographically documented left main coronary artery disease (LMCAD), 241 subjects with more peripheral coronary artery disease (MPCAD) and 97 subjects self reported healthy (Controls)] was analyzed for the frequency of TaqIB and I405V polymorphisms in the gene coding CETP.

RESULTS

There is no significant difference in CETP allele frequency or genotype distribution among LMCAD and MPCAD patients although there is statistical difference between LMCAD and Controls (p = 0.001). Specifically, patients with LMCAD and B1B1 genotype of TaqIB polymorphism were more frequent present compared to Controls (33.8% vs 22.9%, respectively). The frequency of B2B2 genotype was 3 times lower in the LMCAD group compared to Controls (10.5% vs 30.2%, respectively). In the LMCAD group the frequency of B1 allele compared to Controls was higher (62% vs 46%, respectively, p = 0.001). The relationship between TaqIB gene polymorphism and the LMCAD was independent of lipid profile, with the exception of apolipoprotein A.

CONCLUSIONS

These findings indicate that the TaqIB polymorphism may have potential importance in screening individuals at high risk for developing CAD. However, this polymorphism cannot distinguish between LMCAD and MPCAD. Further prospective investigations in larger populations are required to confirm these findings.

Aberrant left internal thoracic artery origin from the extrascalenic part of the subclavian artery

The internal thoracic artery (ITA) is considered to be the optimal conduit for surgical coronary artery revascularization. Variations in ITA anatomy are relatively common and may impact surgical results. The ITA usually arises from the intrascalenic (first) part of the subclavian artery (SCA) and, occasionally, from the interscalenic (second) part. Origination from the extrascalenic (third) part of the SCA is rare, with a reported incidence rate of 0.5% to 1.0% in anatomical studies, and 1.5% in one angiographic study. Such an aberrant ITA descends inferomedially, anterior to the distal attachment of the scalenus anterior muscle, passes posterior to the first rib and enters the thorax, from where it follows its usual course. A patient with a five-year history of in situ grafting of the left ITA to the anterior inter-ventricular artery is presented. Coronary angiography performed because of anterior wall ischemia revealed an aberrantly arising ITA from the extras-calenic part of the SCA. The implications of this ITA variant with regard to bypass surgery, postoperative angiography and subclavian vein catheterization are discussed.

Cholesteryl ester transfer protein gene polymorphisms and longevity syndrome

Purpose:

High levels of high density lipoprotein (HDL) cholesterol are associated with a decreased risk of coronary heart disease (CHD). Subjects with high levels of HDL cholesterol (>70 mg/dl; 1.79 mmol/l) as well as high levels of low density lipoprotein (LDL) cholesterol, could represent a group with longevity syndrome (LS). Since HDL particles are influenced by cholesteryl ester transfer protein (CETP) activity, it is worth studying the CETP polymorphism. The aim of the study was to detect whether 2 genetic variants of the CETP are associated with the LS.

Subjects and Methods:

The study population consisted of 136 unrelated men and women with no personal and family history of CHD; 69 met the criteria for LS and 67 did not meet these criteria and had “normal” HDL cholesterol (>40 and <70 mg/dl; >1.03 and <1.79 mmol/l). All patients were genotyped for the TaqIB and I405V polymorphisms.

Results:

The B2 allele frequency of TaqIB polymorphism was higher in the LS in comparison with the non-LS group (p=0.03) whereas B1 allele frequency was higher in the non-LS group (p=0.03).

Conclusions:

Gene polymorphisms could help decide whether individuals who have increased levels of both LDL cholesterol and HDL cholesterol require treatment. Some of the prerequisites could include that subjects with LS should not only have very high levels of HDL cholesterol but also favorable gene polymorphisms. However, further investigations with a larger sample and including other gene polymorphisms, are needed.

Endoloop-assisted polypectomy for large pedunculated colorectal polyps

BACKGROUND

The use of an endoloop may minimize the risk for bleeding after endoscopic polypectomy of large colorectal polyps. This study aimed to assess the safety and efficacy of colonoscopic ligation of the stalk of large pedunculated polyps by means of an endoloop technique, and to focus particular attention on the instances in which the use of this device was unsuccessful.

METHODS

This study retrospectively evaluated attempted endoloop endoscopic polypectomy in 33 patients (19 men and 14 women; mean age, 62.5 years) with large pedunculated polyps.

RESULTS

Application of the endoloop was impossible in four patients, and the snare became entangled with the loop in one patient. The remaining 28 patients underwent endoloop-assisted polypectomy. Bleeding occurred in four patients, either because the loop slipped of the stalk after polypectomy (2 patients) or because a thin stalk (< or = 4 mm) was transected by the loop before polypectomy (2 patients).

CONCLUSION

Colonoscopic polypectomy with an endoloop may be safer than conventional polypectomy. The reasons for technical failure of this technique include a narrow left colon lumen, a thin stalk (< or = 4 mm), and close cutting in relation to the site of encirclement by the loop.

Endoscopic Mucosal Resection of Lateral Spreading Tumors of the Colon Using a Novel Solution

Lateral spreading tumors (LSTs) of the colon are lesions over 10 mm in diameter that are low in height and grow superficially. They are increasingly being diagnosed in Western cohorts. The aim of this study was to investigate the safety and efficacy of dextrose 50% solution in the endoscopic mucosal resection (EMR) of LSTs. The study population consisted of 21 patients with LSTs of the colorectum. The mean size of the LSTs was 23.52+/-13.60 mm. Dextrose 50% solution was injected, via a variceal needle, into the submucosa to lift up the LST sufficiently from the proper muscle layer. Subsequently, a snare was positioned around the lesion and then closed while being pressed against the mucosa, with suction being applied to draw the lesion into the snare. Blended current was used for resection. If necessary, a piecemeal technique was used to achieve complete resection. Immediate and delayed complications were recorded. After the EMR, patients were followed up at 3, 6, and 12 months or later, using total colonoscopy. Endoscopic resection was completed in all LSTs. Of the 21 LSTs, 15 (71.4%) were resected en bloc and 6 (28.6%) piecemeal. The mean amount of injected dextrose 50% solution was 14.86+/-9.13 mL. One patient (4.78%) had immediate bleeding after EMR, which was stopped endoscopically. Histologic examination of resected LSTs showed adenoma with high-grade dysplasia 9 (42.9%), adenoma with low-grade dysplasia 10 (47.6%), and invasive carcinoma 2 (9.5%). Twenty patients were followed up for 37.9+/-24.03 months. Local recurrent disease was detected in 4 patients (20%), all within 6 months of the index EMR. These recurrent lesions were completely resected endoscopically. The contribution of submucosal injection of dextrose 50% is significant for a safe and efficient EMR of LSTs of the colorectum.

The role of endoscopic treatment in postoperative bile leaks

BACKGROUND/AIMS

Bile leak is among the most common and serious complications of biliary tract surgery. The aim of this non-randomized study was to evaluate the role of endoscopic intervention as an accepted treatment for this complication.

METHODOLOGY

An endoscopic retrograde cholangiopancreatography (ERCP) database was reviewed retrospectively to identify all cases of bile leak related to cholecystectomy (laparoscopic or open). Patients' records and endoscopy reports were reviewed. Moreover, structured telephone interviews were conducted to collect data.

RESULTS

Twenty-four patients, 4 males and 20 females, with a median age of 54 (range 28-76 years) with suspected postcholecystectomy bile leaks were referred for ERCP performed 3-73 days after operation (mean 9.5 days). All but one case had high-grade bile-like liquid outflowing from the original drainage tubes or the fistulous tract of T-tube. One patient presented with bilious ascites, 17 patients had sudden or gradual abdominal pain, 3 jaundice, 2 abdominal pain with fever, and 1 nausea and vomiting. ERCP was successful in all cases, and revealed leakage from the cystic stump in 10 cases, from a common bile duct (CBD) defect in 6, from a common hepatic duct defect in 3, from the gallbladder bed in 2, from a T-tube track in 1, and complete CBD transection in 2 patients. Seventeen patients were successfully treated by endoscopic sphincterotomy (ES) plus endoprosthesis, 3 by stent placement without sphincterotomy, 2 with complete transection by proximal hepaticojejunostomy, and 2 patients with leakage from the cystic stump and a CBD defect were operated after unsuccessful endoscopic intervention.

CONCLUSIONS

ERCP is recommended as a safe and efficacious intervention to detect and treat postoperative bile leaks. ES plus endoprosthesis is effective for the treatment of bile leakage. Endoscopic stenting without sphincterotomy may be offered as a primary option in young patients with postoperative bile leaks.

Endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula

BACKGROUND/AIMS

The aim of this study was to investigate patients who underwent endoscopic sphincterotomy for "acalculus" cholangitis associated with juxtapapillary diverticula.

METHODOLOGY

In a retrospective study we analyzed 87 patients who underwent endoscopic sphincterotomy for cholangitis; the cholangitis considered "acalculus", when outlining the extra- and intrahepatic bile ducts, we could not observe any intraluminal defect or stricture, and during the clearing of the bile ducts with the balloon, after endoscopic sphincterotomy, there was no evidence of stones, fragments of stones or sludge. Patients who had undergone previous endoscopic sphincterotomy, or who had additional pancreatobiliary diseases were excluded from this study. There were 11 patients with "acalculus" cholangitis associated with juxtapapillary diverticula, and sufficient clinical data available for this study.

RESULTS

Nine patients presented pain, fever, and jaundice. In two patients diagnosis was established via the test of abnormal liver biochemistry. Seven patients had positive blood cultures and three of them developed confusion and hypotension. Endoscopic sphincterotomy succeeded in all cases; no evidence of stones, fragments of stones or sludge was recorded during the clearing of bile ducts, after endoscopic sphincterotomy, with the balloon. Five patients presented mild post-endoscopic sphincterotomy complications successfully treated. In the follow-up period, from 4 months to 7 years after endoscopic sphincterotomy, none of the patients developed symptoms of cholangitis.

CONCLUSIONS

We recommend endoscopic sphincterotomy in patients with "acalculus" cholangitis associated with juxtapapillary diverticula, despite the absence of obvious obstruction, and the possible morbidity which is inherent with an invasive procedure like endoscopic sphincterotomy.

Double Dieulafoy-like lesion in the stomach

Dieulafoy's lesion is an uncommon cause of major gastrointestinal bleeding and may be difficult to recognize. It consists of an arteriole that protrudes through a tiny mucosal defect usually within 6 cm of the gastroesophageal junction on the lesser curve of the stomach. Despite widespread awareness of this entity, it remains a diagnostic challenge for gastroenterologists because of its small size and hidden location. Emergency endoscopy is the most effective method of diagnosing the disease. We report a patient, with double Dieulafoy-like lesion, who was successfully treated endoscopically using hemostatic clip application. The characteristics of the Dieulafoy's lesion, its current diagnosis, and its treatment are discussed.

Needle-knife sphincterotomy

Choledochocele, now classified as choledochal cyst type III, is a rare anomaly of the terminal biliary tree causing abdominal pain, pancreatitis, and obstructive cholestasis. Traditionally, the therapy for this malformation has been surgery. Recently, endoscopic therapy has been used alternatively for the treatment of choledochocele mainly in adults. We report two patients with recurrent episodes of acute pancreatitis found to be caused by a large choledochocele; both patients were treated by needle-knife sphincterotomy without complications. They remained asymptomatic at 1 and 2 years' follow-up, respectively. Despite the fact that the risk of bleeding seems to be higher using needle-knife sphincterotomy, when the Choledochocele is large, our experience suggests that needle-knife sphincterotomy can be performed accurately and safely. Further studies are necessary to confirm the safety and effectiveness of needle-knife sphincterotomy in large choledochocles.

Successful treatment of duodenal bulb obstruction caused by a gallstone (Bouveret's syndrome) after endoscopic mechanical lithotripsy

Because of acute symptoms in the upper abdomen, upper gastrointestinal endoscopy was performed in a 68-year-old man. A large perforated gallstone was embedded in the duodenum, causing complete obstruction of the duodenal bulb. The stone was crushed successfully by endoscopic mechanical lithotripsy. The patient was referred for surgery, and was discharged after a successful and uneventful cholecystectomy.

Treatment of proctalgia fugax with botulinum A toxin

Two recent studies described a temporal association between a high-amplitude and high-frequency myoelectrical activity of the anal sphincter and the occurrence of proctalgia, which suggest that paroxysmal hyperkinesis of the anus may cause proctalgia fugax. We describe a single case of proctalgia fugax responding to anal sphincter injection of Clostridium botulinum type A toxin. The presumed aetiology of proctalgia fugax is discussed and the possible mechanism of action of botulinum toxin (BTX) in this condition is outlined. Botulinum A toxin seems to be a promising treatment for patients with proctalgia fugax, and further trials appear to be worthwhile for this condition, which has been described as incurable.