[Impact Analysis of a new, Cross-sector Service Provision of Gastroenterologic Endoscopic Services in Accordance with 115f SGB V (Hybrid-DRG): Allocation Matrix and Cost Analysis]

BACKGROUND

With the introduction of §115f SGB V, the prerequisites for "sector-equal remuneration" ('Hybrid DRG') have been created. In an impact analysis, we assigned inpatient gastroenterological endoscopic (GAEN) cases in a matrix of future hybrid DRG versus outpatient surgery (AOP) or inpatient treatment.

METHODS

In selected DRGs (G47B, G67A, G67B, G67C, G71Z, H41D, H41E) an allocation matrix of GAEN cases was created on medical grounds. For this purpose, service groups from the DGVS service catalog ('Leistungskatalog') were assigned to the groups: 'Hybrid-DRG', 'AOP' and 'Inpatient' by a group of experts based on the DGVS position paper. Cost data from the DGVS-DRG project for the 2022 data year from 36 InEK calculation hospitals with a total of 232,476 GAEN cases were evaluated.

RESULTS

26 service groups from the DGVS service catalog were assigned to a "Hybrid-DRG", 24 to the "inpatient" group, and 12 to the "AOP" group. 7 performance groups were splitted "depending on the OPS code" and classified at this level. Cases with additional fees were excluded from a hybrid DRG because these cannot be agreed there.The cost analysis shows that services that are already in the AOP have a similar cost level to services that have been classified as 'Hybrid-DRG'. With the cost calculation, a cost level could be presented for the hybrid DRGs formed.

CONCLUSION

Based on clearly defined structural, procedural and personnel requirements, services from suitable DRGs can be transferred to a hybrid DRG. Assigning services without the involvement of clinical experts seems extremely difficult. Case assignment based on arbitrary contextual factors increases complexity without demonstrably increasing the quality of the assignment and needs to be further developed. A cost analysis can be derived from the known inpatient costs and must serve as the basis for the 2025 Hybrid DRG catalog.

[A critical DRG-evaluation of cases with inflammatory bowel disease]

INTRODUCTION

Whether inpatients with inflammatory bowel disease (IBD) are reimbursed in a cost-covering manner in German hospitals has not yet been investigated. In this context, the present study analyses the reimbursement situation (cost-revenue comparison) of IBD in German hospitals with regard to the complexity of the disease and the type of care.

METHODS

For this retrospective study, anonymized case data, including cost data from the InEK calculation (§ 21-4 KHEntgG) of the DRG project of the German Society for Gastroenterology, Digestive and Metabolic Diseases (DGVS) from 2019, were available. 3385 cases with IBD the as main diagnosis from 49 hospitals were analyzed. To investigate the impact of disease complexity on reimbursement, different variables were analyzed, including gastroenterological complications, infections, the reason for admission, and additional charges. To investigate possible center effects, hospitals were grouped by type of care, mostly defined by the number of beds.

RESULTS

The present study shows that all types of care can be classified as not cost-covering on average. The under-recovery is, on average, 10% (296 € absolute under-recovery) and varies between the types of care. Cases with higher complexity show a higher cost under-recovery than cases with lower complexity. At the DRG level, the analyzed costs of the three most common IBD DRGs for inlier patients are higher than the InEK costs; however, the difference is not significant. Nonetheless, cases with the admission reason transfer of specific DRGs bear significantly higher costs.

DISCUSSION

Our results show that CED is not reimbursed in a cost-covering manner. This is due to inadequate reimbursement for gastroenterological complications, infections, specific procedures, and emergency and transfer cases. Transfer cases bear significantly higher costs.

Endoscopic ultrasound for structured surveillance after curative treatment of esophageal cancer

BACKGROUND

Structured surveillance after treatment of esophageal cancer is not established. Due to a paucity of data, no agreement exists on how surveillance should be performed. The main argument against intensive follow-up in esophageal cancer is that it may not lead to true survival advantage.

METHODS

Structured surveillance was performed in 42 patients after multimodal therapy with peri-operative chemotherapy (29) or definitive chemoradiotherapy (13) of esophageal cancer. The surveillance protocol included gastroscopy, endoscopic ultrasound, chest X-ray, abdominal ultrasound, and CEA measurement at regular intervals of up to five years. We analyzed relapse rate, time to relapse, localization of recurrence, diagnosis within or without structured surveillance, diagnostic method providing the first evidence of a relapse, treatment of recurrence, and outcome.

RESULTS

Median follow-up was 48 months; 18/42 patients suffered from tumor relapse, with 16 asymptomatic patients diagnosed within structured surveillance. Median time to recurrence was 9 months. Isolated local or locoregional recurrence occurred in 6, and isolated distant relapse in 9 patients. All patients with isolated locoregional recurrence were exclusively diagnosed with endoscopic ultrasound. Six patients received curatively intended therapy with surgery or chemoradiation, leading to long-lasting survival.

CONCLUSION

Structured surveillance offers the chance to identify limited and asymptomatic tumor relapse. Especially in cases of locoregional recurrence, long-lasting survival or even a cure can be achieved. Endoscopic ultrasound is the best method for the detection of locoregional tumor recurrence and should be an integral part of structured surveillance after curative treatment of esophageal cancer.

Sources of performance variability in deep learning-based polyp detection

PURPOSE

Validation metrics are a key prerequisite for the reliable tracking of scientific progress and for deciding on the potential clinical translation of methods. While recent initiatives aim to develop comprehensive theoretical frameworks for understanding metric-related pitfalls in image analysis problems, there is a lack of experimental evidence on the concrete effects of common and rare pitfalls on specific applications. We address this gap in the literature in the context of colon cancer screening.

METHODS

Our contribution is twofold. Firstly, we present the winning solution of the Endoscopy Computer Vision Challenge on colon cancer detection, conducted in conjunction with the IEEE International Symposium on Biomedical Imaging 2022. Secondly, we demonstrate the sensitivity of commonly used metrics to a range of hyperparameters as well as the consequences of poor metric choices.

RESULTS

Based on comprehensive validation studies performed with patient data from six clinical centers, we found all commonly applied object detection metrics to be subject to high inter-center variability. Furthermore, our results clearly demonstrate that the adaptation of standard hyperparameters used in the computer vision community does not generally lead to the clinically most plausible results. Finally, we present localization criteria that correspond well to clinical relevance.

CONCLUSION

We conclude from our study that (1) performance results in polyp detection are highly sensitive to various design choices, (2) common metric configurations do not reflect the clinical need and rely on suboptimal hyperparameters and (3) comparison of performance across datasets can be largely misleading. Our work could be a first step towards reconsidering common validation strategies in deep learning-based colonoscopy and beyond.

[Costs of potentially outpatient endoscopic procedures in cases with a 1-day hospital stay versus a longer stay]

INTRODUCTION

The transfer of patient care and medical interventions that was previously provided on an inpatient basis to outpatient settings is a stated goal of health politics. It is unclear to what extent costs of an endoscopic procedure and the disease severity depend on the duration of inpatient treatment. We therefore examined whether endoscopic services for cases with a one-day length of stay (VWD) are comparably expensive to cases with a longer VWD.

METHODS

Outpatient services were selected from the DGVS service catalog. Day cases with exactly one such gastroenterological endoscopic (GAEN) service were compared with cases with VWD>1 day regarding their patient clinical complexity levels (PCCL) and mean costs. Data from the DGVS-DRG project with §21-KHEntgG cost data from a total of 57 hospitals from 2018 and 2019 served as the basis. Endoscopic costs were taken from cost center group 8 of the InEK cost matrix and plausibility checked.

RESULTS

A total of 122,514 cases with exactly one GAEN service were identified. Statistically equal costs were shown in 30 of 47 service groups. In 10 groups, the cost difference was not relevant (<10%). Cost differences >10% existed only for EGD with variceal therapy, insertion of a self-expanding prosthesis, dilatation/bougienage/exchange with PTC/PTCD in place, non-extensive ERCP, endoscopic ultrasound in the upper gastrointestinal tract, and colonoscopy with submucosal or full thickness resection, or foreign object removal. PCCL differed in all but one group.

CONCLUSION

Gastroenterology endoscopy services provided as part of inpatient care but potentially performable on an outpatient basis are predominantly equally expensive for day cases as for patients with a length of stay greater than one day. The disease severity is lower. Calculated §21-KHEntgG cost data thus form a reliable basis for the calculation of appropriate reimbursement for hospital services to be provided as outpatient services under the AOP in the future.

Bile duct tissue acquisition by cholangioscopy-guided cryobiopsy technique: first-in-human application

Video 1Case description and video in cholangioscopic view demonstrating bile duct tissue acquisition by cholangioscopy-guided cryobiopsy technique.

Capsule Retention in Crohn's Disease: A Meta-analysis

BACKGROUND

The main factor that limits wider utilization of capsule endoscopy (CE) in Crohn's disease (CD) is the potential risk of retention. The aim of this systematic review was to evaluate capsule retention rates in adult and pediatric CD and determine if retention risk is reduced in established CD (ECD) with patency capsule (PC) or magnetic resonance/computed tomography (MR/CT) enterography.

METHODS

Studies of CD patients undergoing CE that reported retention were identified. Pooled estimates for retention rates and relative risk in ECD to suspected CD (SCD) were calculated. All hypothesis tests were 2-sided; statistical significance was set at a P value of <0.05.

RESULTS

In the overall CD cohort, retention rates were 3.32% (95% confidence interval [CI], 2.62%-4.2%): 4.63% (95% CI, 3.42%-6.25%) and 2.35% (95% CI, 1.31%-4.19%) in ECD and SCD, respectively. Retention rates were 3.49% (95% CI, 2.73%-4.46%) and 1.64% (95% CI, 0.68%-3.89%) in adult and pediatric CD, respectively. Retention risk in adult ECD was 3.4 times higher than SCD, but there was no difference in retention risk in pediatric ECD compared with SCD. Retention rates in ECD were decreased after patency capsule (2.88%; 95% CI, 1.74%-4.74%) and MR/CT enterography (2.32%; 95% CI, 0.87%-6.03%).

CONCLUSIONS

In comparison with older literature, this meta-analysis demonstrates lower CE retention rates in SCD and ECD. Retention rates in pediatric CD were lower than in adult CD. Retention rates in adult ECD were higher than SCD, but there were no differences between pediatric ECD and SCD. Retention rates in ECD were lower after negative PC or MR/CT enterography.

Time-saving polyp detection in colon capsule endoscopy: evaluation of a novel software algorithm

BACKGROUND

Colon capsule endoscopy (CCE) is a reliable method to detect colonic polyps in the well-prepared colon. As CCE evaluation can be time consuming, a new software algorithm might aid in reducing evaluation time.

OBJECTIVES

The aim of the study was to evaluate whether it is feasible to reliably detect colon polyps in CCE videos with a new software algorithm the "collage mode" (Rapid 8 Software, Covidien/Medtronic®).

METHODS

Twenty-nine CCE videos were randomly presented to three experienced and to three inexperienced investigators. Videos were evaluated by applying the collage mode. Investigation time was documented and the results (≥one polyp vs. no polyp) were compared with the findings of two highly experienced central readers who read the CCE videos in the standard mode beforehand.

RESULTS

It took a median time of 9.8, 3.5, and 7.5 vs. 4.3, 4.6 and 12.5 min for experienced vs. inexperienced investigators to review the CCE videos. For detecting ≥one polyp vs. no polyp, sensitivity of 93.3%, 73.3%, and 93.3% was observed for the experienced and sensitivity of 46.7%, 33.3%, and 93.3% for the inexperienced CCE readers.

CONCLUSION

Collage mode might allow for a quick review of CCE videos with a high polyp detection rate for experienced CCE readers. Future prospective studies should include CCE collage mode for rapid polyp detection to further prove the feasibility of practical colon polyp detection by CCE and possibly support the role of CCE as a screening tool in CRC prevention.

Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial

BACKGROUND AND AIMS

Treatment of anastomotic biliary strictures (ABSs) after orthotopic liver transplantation by endoscopic insertion of multiple plastic stents (MPSs) is well established. The use of covered self-expandable metal stents (cSEMSs) for this indication is less investigated.

METHODS

In an open-label, multicenter, randomized trial, patients with confirmed ABSs were randomly assigned 1:1 to receive either an MPS or a cSEMS. The primary endpoint was the number of endoscopic interventions until ABS resolution. Secondary endpoints were frequency of adverse events, treatment success rates, and time to treatment success and recurrence of ABS during follow-up of at least 1 year.

RESULTS

Fifty-eight patients were included between 2012 and 2015, and 48 patients completed follow-up. Patients receiving MPS (n = 24) underwent a median of 4 (range, 3-12) endoscopic retrograde cholangiography examinations, whereas those in the cSEMS group (n = 24) underwent a median of 2 (range, 2-12) sessions until ABS resolution (P < .001). A median of 8 (range, 2-32) stents was used until ABS resolution within the MPS group and 1 (range, 1-24) in the cSEMS group (P < .0001). cSEMS migration occurred in 8 (33.3%) patients. Treatment duration did not differ significantly. Initial treatment success rates were high with 23 (95.8%) in the MPS group and 24 (100%) for cSEMSs (P = 1). Five (20.8%) patients in both groups showed stricture recurrence after a median follow-up of 500 days (range, 48-1317 days).

CONCLUSIONS

cSEMSs for treatment of ABSs needed less endoscopic interventions to achieve similar efficacy as MPS and might become a new treatment standard. However, the optimal duration of cSEMS therapy and cost-efficacy have to be evaluated. (Clinical trial registration number: NCT01393067.).

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project]

Background In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methods To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Results Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussion For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Pan-intestinal capsule endoscopy in patients with postoperative Crohn's disease: a pilot study

BACKGROUND

Patients are at increased risk of disease recurrence after surgical treatment of Crohn's disease. Endoscopic detection of postoperative, ileo-colonic inflammation is well established, but the potential of pan-intestinal endoscopy is yet unknown.

METHODS

This prospective multicenter pilot study assessed the value of pan-intestinal capsule endoscopy using a colon capsule endoscope for the detection of inflammatory recurrence of Crohn´s disease. Patients who had been operatively treated for Crohn´s disease were included. Colon capsule endoscopy was performed 4-8 weeks (d1) and 4-8 months (d2) postoperatively together with ileo-colonoscopy at d2 using a modified Ruttgeerts index for evaluating disease activity.

RESULTS

Twenty-two patients were included into this study. At d1, significant disease activity (Ruttgeerts index ≥2) was detected in 3/16 (19%) of the patients. At d2, half of the patients (6/12) showed active disease, whereas ileo-colonoscopy revealed significant inflammation in 5/15 (33%). All patients rated as having active disease by ileo-colonoscopy had been revealed by PICE as well. These findings influenced the medical treatment in every case.

CONCLUSION

Pan-intestinal capsule endoscopy seems to be feasible in the postoperative surveillance of Crohn's disease. Disease activity is reliably detected. Especially, the findings in the small bowl might be a significant advantage in comparison to ileo-colonoscopy, as they can have significant impact on clinical management. Further studies with a larger number of patients are needed to confirm these findings and might lead to a replacement of the flexible ileo-colonoscopy with pan-intestinal capsule endoscopy in this indication in the future.

Direct retrograde cholangioscopy with a new prototype double-bending cholangioscope

BACKGROUND AND STUDY AIMS

Direct retrograde cholangioscopy (DRC) enables high quality video imaging of the bile ducts and allows intraductal treatment with optical control. We evaluated the feasibility, success, and complications of a new third-generation prototype cholangioscope.

PATIENTS AND METHODS

All consecutive patients from two tertiary endoscopy centers who had undergone DRC with the prototype were included. Indications for DRC were: evaluation of indeterminate strictures, filling defects, and complex bile duct stones. Technical success was investigated in terms of indication and treatment performed. All adverse events were recorded.

RESULTS

DRC with the prototype was performed in 74 patients. Therapeutic interventions included laser or electrohydraulic lithotripsy and stone removal, among others. The papilla was entered in 72/74 patients (97 %). The targeted bile duct segment was reached in 62 /74 patients (84 %), with an anchoring balloon catheter needed in 21/74 (28 %). Mean investigation time was 21 minutes (15 - 27 minutes)

CONCLUSIONS

DRC using the prototype is feasible, safe, and attains access to the bile ducts in almost all patients, with less need of an anchoring balloon catheter compared with the standard technique and short investigation and fluoroscopy times.

Intraductal biopsies in indeterminate biliary stricture: Evaluation of histopathological criteria in fluoroscopy- vs. cholangioscopy guided technique

BACKGROUND

Differentiating malignancy from benign disease in indeterminate biliary stricture by imaging modalities is limited. Definite diagnosis relies on histopathological diagnosis.

AIMS

To assess accuracy of histopathological diagnosis of fluoroscopy-guided vs. cholangioscopy-directed intraductal biopsies in indeterminate biliary stricture.

METHODS

All patients with indeterminate biliary stricture and fluoroscopically (n=68) or cholangioscopy-directed (working channel 2mm, n=38) biopsies were included. Histopathological results of biopsies were classified into inflammatory lesion (class 1), dysplasia/intraepithelial neoplasia (class 2) and malignancy (class 3) and results as well as macroscopic diagnosis were compared with final diagnosis.

RESULTS

Sensitivity and specificity of fluoroscopy-guided vs. cholangioscopy-directed biopsies were 22.9% and 100% vs. 25.0% and 100% for class 1+2 vs. class 3 lesions, respectively. Sensitivity for class 1 vs. class 2+3 lesions was 45.7% (p=0.044) vs. 58.3% (p=0.214) for fluoroscopy-guided vs. cholangioscopy-directed biopsies, respectively, while specificity was 100% in both. There was no difference in size of the obtained sample (p=0.992). True positive diagnosis rate increased with the number of biopsies taken (p=0.028).

CONCLUSION

Fluoroscopy-guided and cholangioscopy-directed intraductal biopsies are equally limited in establishing the diagnosis of malignancy in indeterminate biliary stricture. Categorizing dysplasia or intraepithelial neoplasia as malignancy increases sensitivity without decrease in specificity. By taking more biopsies, diagnostic yield is increased.

[New methods for endoscopic hemostasis: focus on non-variceal gastrointestinal bleeding]

Gastrointestinal bleeding is a frequent emergency in daily clinical practice of a gastroenterologist. While incidence and mortality of gastrointestinal bleeding are decreasing in many countries, numbers of endoscopic procedures are increasing. Endoscopic therapy of non-variceal gastrointestinal bleeding is still mainly based on "classical" procedures like injection of vasoactive drugs (i. e. epinephrine) or blood derivates, application of through-the-scope hemoclips (TTSC), Argon plasma coagulation and bipolar coagulation. However, in the last years new endoscopic techniques especially for non-variceal gastrointestinal bleedings have become available and enriched our endoscopic equipment. For example, over-the-scope clips (OTSCs) surpass the size of TTSCs and have been successfully established for treatment of gastrointestinal bleeding and leak closure of fistulas and perforations. In addition, hemostatic powders were shown to achieve primary hemostasis in several cases of gastrointestinal bleeding. Besides a brief overview of "classical" endoscopic procedures for hemostasis of non-variceal gastrointestinal bleeding, this review focuses on new epidemiological data and uprising methods for endoscopic hemostasis.

A Simple Evaluation Tool (ET-CET) Indicates Increase of Diagnostic Skills From Small Bowel Capsule Endoscopy Training Courses: A Prospective Observational European Multicenter Study

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n = 2), Italy (n = 2), Germany (n = 2), Finland (n = 1), and nationally in Germany (n = 10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P < 0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P < 0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P < 0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P < 0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

Endoscopic findings in patients with eosinophilic esophagitis

BACKGROUND

Endoscopy has a key role in establishing the diagnosis of eosinophilic esophagitis (EoE), but endoscopic features of EoE might not be well known.

METHODS

All patients aged 18 or older who were diagnosed with EoE from 2008 to 2013 were systematically identified retrospectively and findings at esophago-gastro-duodenoscopy (EGD) were reviewed by two experienced endoscopists through a query of the university hospital database. Patients in whom biopsies from the esophagus were lacking or inadequate for histopathological examination were excluded.

RESULTS

23 patients (17 male, 6 female) were included into the study (median age: 38 years, range: 19 to 71 years). Patients presented with the following symptoms: 12 (52 %) had bolus obstruction and 18 (78 %) dysphagia and/or chest pain. At EGD, 22 of 23 (96 %) patients were observed with at least one endoscopic feature of EoE, i. e., mucosal edema (52 %), longitudinal furrows (57 %), vertical furrows (48 %), or crêpe paper esophagus (52 %).

CONCLUSIONS

Typical endoscopic features were present in most patients in whom EoE was diagnosed. Recognizing typical characteristics of EoE is substantial for establishing the diagnosis and for taking biopsies.

Indication for 'Over the scope' (OTS)-clip vs. covered self-expanding metal stent (cSEMS) is unequal in upper gastrointestinal leakage: results from a retrospective head-to-head comparison

Background

Intestinal perforation or leakage increases morbidity and mortality of surgical and endoscopic interventions. We identified criteria for use of full-covered, extractable self-expanding metal stents (cSEMS) vs. ‘Over the scope’-clips (OTSC) for leak closure.

Methods

Patients who underwent endoscopic treatment for postoperative leakage, endoscopic perforation, or spontaneous rupture of the upper gastrointestinal tract between 2006 and 2013 were identified at four tertiary endoscopic centers. Technical success, outcome (e.g. duration of hospitalization, in-hospital mortality), and complications were assessed and analyzed with respect to etiology, size and location of leakage.

Results

Of 106 patients (male: 75 (71%), female: 31 (29%); age (mean ± SD): 62.5 ± 1.3 years, 72 (69%) were treated by cSEMS and 34 (31%) by OTSC. For cSEMS vs. OTSC, mean treatment duration was 41.1 vs. 25 days, p<0.001, leakage size 10 (1-50) vs. 5 (1-30) mm (median (range)), and complications were observed in 68% vs. 8.8%, p<0.001, respectively. Clinical success for primary interventional treatment was observed in 29/72 (40%) vs. 24/34 (70%, p = 0.006), and clinical success at the end of follow-up was 46/72 (64%) vs. 29/34 (85%) for patients treated by cSEMS vs. OTSC; p = 0.04.

Conclusion

OTSC is preferred in small-sized lesions and in perforation caused by endoscopic interventions, cSEMS in patients with concomitant local infection or abscess. cSEMS is associated with a higher frequency of complications. Therefore, OTSC might be preferred if technically feasible. Indication criteria for cSEMS vs. OTSC vary and might impede design of randomized studies.

A novel, stiff-shaft, flexible-tip guidewire for cannulation of biliary stricture during endoscopic retrograde cholangiopancreatography: a randomized trial

BACKGROUND AND STUDY AIMS

During endoscopic retrograde cholangiopancreatography (ERCP), a guidewire is used to cannulate biliary strictures and allow for therapeutic interventions. The aim of this study was to assess the success of stricture cannulation using a combination of a flexible guidewire and a stable nitinol wire vs. a novel, single, stiff-shaft, flexible-tip guidewire.

PATIENTS AND METHODS

Consecutive patients who were scheduled for ERCP for biliary obstruction were randomized to undergo the procedure with either a 260-cm long, angled-tip hydrophilic wire in combination with a nitinol wire as required (standard group), or a novel, 270-cm guidewire featuring a hyperflexible, hydrophilic tip with a stiff shaft (novel group). At unsuccessful negotiation of the stricture, patients in the standard group were switched to the novel guidewire and vice versa ("crossover"). Successful cannulation (primary success: as assigned; final success: after "crossover"), procedure time, and total number of wires needed per procedure were compared.

RESULTS

A total of 222 patients were randomized and 197 were included in the study (97 in the standard group and 100 in the novel group). The primary success rate was significantly higher in the novel group (94/100, 94 %) compared with the standard group (77/97, 79 %; P = 0.00041), and final success was similar. Mean time (median, interquartile range) to stricture cannulation was 11.2 minutes (6.3, 3.7 - 14.6) in the standard group and 8.1 minutes (2.5, 0.9 - 7.7) in the novel group (P < 0.0001). The mean total procedure time was 31.2 minutes (24.6, 16.5 - 40.8) vs. 24.3 minutes (16.9, 10.0 - 31.5), respectively (P = 0.0011). There were no complications observed with either of the guidewires.

CONCLUSIONS

A guidewire that features a flexible tip with a stable shaft could replace the use of a combination of flexible and stable guidewires and increase the success rate of stricture cannulation while decreasing the procedure time.ClinicalTrials.gov Identifier: NCT 01382680.

The capsule endoscopy "suspected blood indicator" (SBI) for detection of active small bowel bleeding: no active bleeding in case of negative SBI

OBJECTIVE

Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The "suspected blood indicator" (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding.

METHODS

This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC).

RESULTS

In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%).

CONCLUSION

The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

A multicenter study on the role of direct retrograde cholangioscopy in patients with inconclusive endoscopic retrograde cholangiography

BACKGROUND AND STUDY AIMS

Direct retrograde cholangioscopy (DRC) may improve the diagnostic and therapeutic yield of endoscopic retrograde cholangiography (ERC) but safety, feasibility, and outcome are unknown.

PATIENTS AND METHODS

All consecutive patients who underwent DRC at three tertiary endoscopy centers for inconclusive findings at ERC were included in this retrospective analysis. Ultraslim endoscopes (FujiFilm EG 530NP; Olympus GIF XP180; GIF N180) were used by the peroral route for intubating all accessible bile ducts. Success rate, usefulness in diagnosis and therapy, and safety of DRC were assessed in terms of technical and clinical parameters and therapeutic vs. diagnostic indication.

RESULTS

DRC was performed in 130 cases (89 patients). CO2 insufflation and an anchoring balloon were used in 66.9% and 97.7% of cases, respectively. Intubation of the papilla was successful in 115 of 130 (88.5%) cases, and the aim of the DRC investigation was accomplished in 105 cases (80.8%). DRC-guided biopsies were taken in 53 cases (40.8%), and a therapeutic intervention was performed in 32 cases (24.6%). The initial diagnosis was revised by DRC in 18 of 69 patients (26.1%) with indeterminate biliary stricture. Complications were observed in 10 cases (7.7%), including cholangitis (n=2; 1.5%), bleeding (n=2; 1.5%), and pain, hypoxia, bradyarrhythmia, air embolism, and perforation of an intrahepatic and an extrahepatic bile duct (1 each; 0.8%). There was no mortality associated with DRC.

CONCLUSIONS

DRC was successfully performed for the diagnosis and treatment of biliary disease that had eluded diagnosis with conventional ERC. DRC impacted on clinical decision making. The complication rate was low and similar to other cholangioscopy techniques.

Health care for osteoporosis in inflammatory bowel disease: unmet needs in care of male patients?

BACKGROUND AND AIMS

Osteoporosis is a frequent complication of inflammatory bowel disease (IBD). It may be related to IBD itself or to its therapy. In this study, the quality of care regarding diagnosis and treatment of osteoporosis was examined.

METHODS

In this retrospective, monocentric study 293 consecutive patients with IBD (98 ulcerative colitis, 195 Crohn's disease) were included. Information on age, gender, weight, nicotine abuse, course, disease pattern and medication was assessed, results of dual X-ray absorptiometry (DEXA-scan) were evaluated.

RESULTS

DEXA-scan was performed in 174 patients (59 male, 115 female). Bone mineral density (BMD) was impaired in 38.5% of these patients. Male patients were diagnosed more often with osteopenia or osteoporosis than females (55.9% vs. 29.6%, p=0.03) and had a risk of bone disease comparable to postmenopausal women. Additionally, duration of corticosteroid treatment and IBD were identified as risk factors for osteoporosis. Follow up DEXA-scan demonstrated an overall deterioration of BMD in patients with normal baseline results.

CONCLUSIONS

While in general, women are considered at higher risk for osteoporosis, male patients had a higher risk of impaired BMD, especially when under treatment with corticosteroids. The high incidence of reduced BMD supports the recommendation to screen patients with IBD at an early stage of disease, although a possible bias has to be considered for patients at a tertial referral centre for IBD. Patients with normal baseline DEXA-scan were still at risk to develop bone disease and it seems advisable to monitor patients with IBD for reduced BMD continually.

Self-expandable metal stent for malignant colonic obstruction: outcome in proximal vs. left sided tumor localization

INTRODUCTION

The aim of this study was to evaluate the outcome of through-the-scope (TTS) implanted self-expanding metal stent (SEMS) comparing left-sided vs. proximal placement with regard to complications and outcome in palliation of malignant colorectal obstruction.

MATERIAL AND METHODS

All patients were consecutively retrospectively enrolled to this study between January 2009 and February 2012 due to impending or prevalent complete malignant colorectal obstruction. TTS applicable uncovered nitinol SEMS with unique flexible properties were used (Taewoong Medical, South Korea). Left-sided obstruction (aboral from the left flexure) was compared to proximal (from the ileo-cecal valve to the left flexure) localization. All patients have been discussed in the interdisciplinary tumor conference and the recommendation to treat by endoscopic stent placement was given in consensus.

RESULTS

A total of 15 patients was enrolled to this study (10 male and 5 female; mean age 68.3 ± 15.4 years, range 48 - 94), five patients with obstructions located in the proximal hemicolon whereas ten patients had a left-sided malignancy. Technical success was achieved in all cases and there was no early complication noticed. Three late complications included tumor overgrowth (n = 1), stent occlusion (1), and dislocation (1). Stent-in-stent insertion achieved, again, clinical success. The site of SEMS implantation (proximal vs. left colon) had no impact on patient outcome or complication rate. SEMS patency duration was 269.8 ± 175.2 days (range 30 - 570) and mean survival of the patients was 305.1 ± 279.3 days (range 16 - 990).

CONCLUSION

TTS application of flexible, non-covered SEMS seems to be safe and effective for palliation of malignant colorectal obstruction independent of localization of the tumor in the colon.

Long-term follow-up of endoscopic therapy for stenosis of the biliobiliary anastomosis associated with orthotopic liver transplantation

Endoscopic treatment for stenosis of an anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but the long-term outcomes and the risk factors for recurrence are unknown. All 374 patients who underwent OLT at Frankfurt University Hospital were screened for the occurrence of ABSs. ABSs were treated via the endoscopic insertion of a plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of the two (57.4%). The mean follow-up time was 151 weeks, and the mean survival time was 3.4 years. ABSs were observed in 47 patients (12.6%). The mean time from OLT to an ABS was 16.25 months (median = 3.25 months). The cumulative incidence rates for ABSs were 0.09 after 12 months, 0.10/24 m. and 0.11/36 m. In 12 cases (25.5%), ABSs were observed more than 12 months after OLT. ABSs recurred in 16 of the 47 patients (34%). The occurrence of an ABS 6 weeks or more after OLT was a significant predictor of ABS recurrence [P = 0.04, hazard ratio (HR) = 0.235]. There was a trend of hepatitis C virus (HCV) infections being predominant in patients experiencing ABS recurrence (30% for HCV etiology versus 4% for non-HCV etiology) in comparison with patients not experiencing recurrence (36% for HCV etiology versus 30% for non-HCV etiology, P > 0.05). The severity of the initial stricture predicted ABS recurrence (P = 0.046, HR = 2.78), but it did not influence overall survival. The long-term resolution of ABSs was observed in 45 of the 47 patients (95.7%), and ABS recurrence was treated with another attempt (n = 16 or 34%) or 2 more attempts (n = 1) at endoscopic treatment. In conclusion, the long-term success of the endoscopic treatment of ABSs is highly probable if recurrent strictures are again treated endoscopically. ABSs might occur late (>36 months) after OLT, and lifelong follow-up is essential for identifying OLT patients with ABSs.

Long-term follow-up of endoscopic therapy in stenosis of the bilio-biliary anastomosis associated with orthotopic liver transplantation

BACKGROUND: Endoscopic treatment of stenosis of the anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but long term outcome and risk factors for recurrence are unknown. METHODS: All 374 patients who underwent OLT at Frankfurt University hospital were screened for occurrence of ABS. ABS was treated by endoscopic insertion of plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of both (57.4%). Long-term outcome and risk factors for occurrence and recurrence of ABS was determined through competing risk analysis. Mean follow-up time was 151 weeks and mean survival was 3.4 years. RESULTS: ABS was observed in 47 patients (12.6%). Mean (median) time from OLT to ABS was 16.3 months (3.3 months). Cumulative incidence rates of ABS were 0.09 after 12 months, 0.10 after 24 months and 0.11 after 36 months. In 12 cases (25.5%), ABS was observed later than 12 months after OLT. ABS recurred in 14 of 47 (29%). Ocurrence of ABS more than six weeks after OLT was a significant predictor of ABS recurrence (p=0.04, H.R. 0.235). There was a trend of HCV infection to be predominant in patients with recurrence of ABS (30% HCV vs. 4% non-HCV) in comparison to patients with non-recurrence (HCV 36%, non-HCV 30%); p > 0.05. Severity of initial stricture predicted recurrence of ABS (p = 0.046, HR=2.78), but did not influence overall survival. Long-term resolution of ABS was observed in 45 of 47 patients (95.7%), recurrence of ABS was treated with a second (n= 16, 34%), or a third endoscopic treatment attempt (1). CONCLUSION: Long-term success of endoscopic treatment of ABS is highly probable if recurrent strictures are again treated endoscopically. ABS might occur late (>36 months) after OLT and life-long follow-up is essential in OLT patients to identify patients with ABS. © 2013 American Association for the Study of Liver Diseases.

[Diagnosis of intestinal metastases from malignant melanoma]

The small bowel harbors metastases of malignant melanoma in 5 % to 72 %, dependent on tumor stage and evidence of intestinal blood loss. Capsule endoscopy is sensitive in detecting small bowel metastasis. Computed tomography, magnetic resonance imaging, and PET-CT demonstrate extraintestinal intraabdominal metastases. Melanoma patients with signs of intestinal blood loss should be endoscopically investigated, including small bowel endoscopy. Selected patients in advanced tumor stage should also undergo small bowel endoscopy to plan a treatment strategy. A resection of intestinal metastases can improve the prognosis, if all metastases are removed.

Interventional balloon-enteroscopy

Balloon assisted enteroscopy (BE) expands greatly the therapeutic options in interventional endoscopy; bleeding sites, strictures, polyps, and other small bowel lesions are increasingly been treated by use of BE in the last 10 years. Treatment options for small bowel bleeding include Argon plasma coagulation (APC), injection therapy, and application of TTS metal clips, and thereby bleeding is stopped in most cases. Dilating symptomatic strictures, resecting polyps as seen in Peutz-Jeghers syndrome (PJS), and removing foreign bodies, BE carries most endoscopic treatment techniques to the small bowel. Another new indication field for BE are interventions at the biliary system in patients with surgically modified anatomy such as Roux-Y anastomosis. This review offers a full overview on indications of BE and refers to the practical use of the method for all endoscopic interventions.

Peroral cholangioscopy for diagnosis and therapy of biliary tract disease using an ultra-slim gastroscope

High-resolution video cholangioscopy is expected to improve diagnostic validity for diseases of the biliary tract. We report our experience in using an ultra-slim gastroscope for diagnosis and treatment of biliary tract disease. Cholangioscopy was attempted in 25 cases (22 patients) and succeeded in 22 cases (success rate 88%; 19 patients). Cholangiocellular carcinoma (CCC) was diagnosed by cholangioscopy in five of 10 cases (histopathologically confirmed in four), or ruled out in five. Cholangioscopy was used to detect stones in mega-choledochus (n=3), to clarify the postoperative condition of the bile ducts (n=2), to diagnose bile duct varices (n=1), and to release a dislodged self-expanding metal stent (n=1), and others. Argon plasma coagulation was successfully completed in a patient with mucin-producing adenomatosis of the bile ducts. One case of non-fatal air embolism occurred before replacing air with CO2 insufflation. In summary, peroral cholangioscopy with an ultra-slim gastroscope is feasible and helpful in selected patients, improving diagnostic validity, and offering new therapeutic interventions. This technique should only be performed using CO2 insufflation.

Benefit of a clipping device in use in intestinal bleeding and intestinal leakage

BACKGROUND

The over-the-scope clip (OTSC) system was first used to close the access route in natural orifice transluminal endoscopic surgery and is increasingly used for other indications.

OBJECTIVE

We analyzed the use of the OTSC in intestinal bleeding and in closure of GI tract leaks.

DESIGN

Analysis of a consecutive series of patients.

SETTING

University hospital.

PATIENTS

Nineteen patients (group A: closure of GI leak site, n = 12; group B: complex GI bleeding, n = 7) were retrospectively enrolled in this study. We analyzed outcome and follow-up (6-68 weeks; group A: mean 37 weeks, standard deviation 24) in terms of treatment success (closure of the GI tract leak/durable hemostasis).

INTERVENTION

Endoscopic application of OTSCs.

MAIN OUTCOME MEASUREMENTS

Resolution of leaks, closure of fistula (group A), or stopping bleeding (group B).

RESULTS

In group A, durable closure was achieved in 8 of 12 patients. Sealing a postoperative/postinterventional leak was successful in 6 patients and failed in 3. A gastrocutaneous fistula was primarily closed successfully in 2 patients, but recurred in 1 of these patients. A gastric wall dehiscence in necrotizing pancreatitis was successfully closed in another patient. Group B patients had previous endoscopic treatment failure in 4 of 7 patients (through-the-scope clips, injection of Suprarenin or fibrin glue, others) and were deemed not treatable by through-the-scope clips in 3 of 7 patients. The primary success rate was 100% (7 of 7 patients); durable hemostasis was achieved in 4 of 7 patients, whereas surgery or angiography was necessary in the remaining patients.

LIMITATIONS

Retrospective analysis.

CONCLUSIONS

Leaks and fistulae are reliably closed with OTSCs in tissue flexible enough to be sucked into the attached cap (eg, in lesions caused <1 week before). GI bleeding may be stopped by OTSCs with reliable transient hemostasis, but durable hemostasis is less frequent.

Algorithm for detection of small-bowel metastasis in malignant melanoma of the skin

BACKGROUND AND STUDY AIM

The aim of this study was to develop an algorithm to detect small-bowel metastasis (SBM) of melanoma by sequential laboratory parameters and pan-intestinal endoscopy (PIE) including video capsule endoscopy (VCE).

PATIENTS AND METHODS

A total of 390 melanoma patients (AJCC stage I/II/III/IV, 140/80/121/49) were screened for signs of intestinal blood loss (fecal occult blood test [FOBT] or overt bleeding) in an open, multicenter, prospective study, and those who were positive underwent PIE. Independent of the presence of intestinal bleeding, all stage IV patients were offered PIE. Follow-up was obtained in 357 patients (91.5 %) for a median of 16 months. We undertook to identify possible associations between SBM and clinical and laboratory data. Survival data were analyzed with regard to clinical and laboratory data and small-bowel findings.

RESULTS

Intestinal blood loss was suspected in 49 of 390 patients (12.6 %), 38 of whom (77.6 %) agreed to undergo endoscopy. In 10 patients, SBM was detected by VCE (intention-to-diagnose, 20.4 %; AJCC III, n = 2; AJCC IV, n = 8). The SBM was resected in five patients. Total detection rates of SBM were 14 of 49 patients in stage IV (28.6 %, intention-to-diagnose), 2 of 121 in stage III (1.7 %), and 0 in stage I/II. In FOBT-positive patients, SBM detection rates were 72.7 %, 14.3 %, and 0 % in tumor stages IV, III, and I/II, respectively. Positive FOBT proved to be an independent negative prognostic factor for total survival in stage III and IV melanoma.

CONCLUSIONS

SBMs are frequent in advanced melanoma. In stage III patients, screening for intestinal blood loss by PIE may help to identify SBMs. In stage IV, indication for PIE should depend on the individual consequences of detecting SBM, but not on bleeding symptoms alone.

[Endoscopic-retrograde cholangiopancreatography in patients with surgical modification of anatomy]

Endoscopic retrograde cholangiopancreatography (ERCP) is an essential element in treating disease of the bilio-pancreatic system. In some patients, access to the bile ducts is limited due to operatively altered anatomy. The aim of this review is to illustrate the endoscopic procedure in these patients. We present the available evidence and comment on our approach to ERCP in patients with surgical modification of anatomy. In conclusion, conventional side-viewing or forward-viewing endoscopes allow one to access the biliary system in most patients with Billroth-II or partial pancreaticoduodenectomy. By use of balloon enteroscopy, biliary intervention in spite of surgical reconstruction with a long limb - such as Roux-en-Y gastrojejunostomy or hepaticojejunostomy and gastric bypass for obesity - has become feasible in many cases. Adaption of accessory devices to balloon-assisted enteroscopes permits therapeutic interventions in these patients.

Minimizing procedural cost in diagnosing small bowel bleeding: comparison of a strategy based on initial capsule endoscopy versus initial double-balloon enteroscopy

INTRODUCTION

Capsule endoscopy (CE) and double-balloon enteroscopy (DBE) detect small bowel bleeding with equal diagnostic yield. We aimed to detect factors that influence procedural cost of CE and DBE in diagnosing and treating small bowel bleeding, and to compare them with reimbursement.

METHODS

A cost model analysed procedural cost for diagnostic CE versus diagnostic, unidirectional DBE(scenario 1) and CE plus directed therapeutic DBE(positive findings in CE) versus unidirectional diagnostic plus therapeutic DBE (scenario 2). The frequency of investigations per annum (p.a.) at which cost per procedure is equalized (break-even point) was determined for CE versus DBE. A retrospectively collected cohort of patients was used to validate the cost model and to compare procedural costs with reimbursement (German diagnosis related groups, G-DRG).

RESULTS

The break-even point at which cost per procedure is equalized for CE versus DBE was reached at 100 procedures p.a. in scenario 1 and 79 in scenario 2 for a rate of therapeutic enteroscopy of 14%, and 27 for a therapeutic enteroscopy rate of 30%. Personnel cost, procedure time,procedures p.a. and the rate of therapeutic enteroscopy had a major influence on procedural cost. In this patient cohort, the 'CE-first' and the 'DBE-first' strategies produced procedural costs of pound sterling 830 and pound sterling 1,076 per patient to attain a diagnosis, and pound sterling 1,042 versus pound sterling 1,181 to achieve therapeutic enteroscopy, respectively. For this cohort, potential reimbursement was pound sterling 2,320 and pound sterling 3,047 for the 'CE-first' and the 'DBE-first' strategies, respectively (G-DRG).

CONCLUSION

Workflow management of CE versus DBE should consider frequency of investigations p.a. and probability for therapeutic enteroscopy to minimize procedural costs. The cost of DBE increases with less frequent or time-consuming investigations; CE is more robust with regard to these factors. From a third-party payer perspective, a strategy incorporating CE seems to minimize costs in G-DRG.

[Small bowel diverticula - unknown disease]

Diverticula of the small bowel are quite frequent (about 5 %), but being a differential diagnosis of abdominal complaints they may still be underdiagnosed. One reason for the low level of suspicion for a complication of small bowel diverticula might be that the small bowel was out of the gastroenterologists' focus until recently when small bowel endoscopy became available as a reliable and practical diagnostic tool. Diverticula of the jejunum and the ileum may lead to diverticulitis, abscess, obstruction, bleeding, and perforation. Small intestinal bacterial overgrowth syndrome due to small bowel diverticula is a common complication and involves meteorism and malassimilation syndrome. Meckel's diverticulum sometimes provokes bleeding even in the young adult and resection of the diverticulum is clearly indicated. Contrariwise, incidental detection of a Meckel's diverticulum during abdominal laparotomy does not necessarily imply resection of the diverticulum. The juxtapapillary duodenal diverticula appear to be a risk factor for gallbladder stones, bile duct stones, and their recurrence. Moreover, the complication rate of endoscopic interventions of the bile system might be increased. In this review, we highlight the historical background of small bowel diverticular disease, present the epidemiological and pathophysiological implications and provide information on the diagnostic modalities that are available. Diseases of the primary acquired and congential small bowel diverticula are described in detail.

Role of small-bowel endoscopy in the management of patients with inflammatory bowel disease: an international OMED-ECCO consensus

Crohn's disease and ulcerative colitis are lifelong diseases seen predominantly in the developed countries of the world. Whereas ulcerative colitis is a chronic inflammatory condition causing diffuse and continuous mucosal inflammation of the colon, Crohn's disease is a heterogeneous entity comprised of several different phenotypes, but can affect the entire gastrointestinal tract. A change in diagnosis from Crohn's disease to ulcerative colitis during the first year of illness occurs in about 10 % - 15 % of cases. Inflammatory bowel disease (IBD) restricted to the colon that cannot be characterized as either ulcerative colitis or Crohn's disease is termed IBD-unclassified (IBDU). The advent of capsule and both single- and double-balloon-assisted enteroscopy is revolutionizing small-bowel imaging and has major implications for diagnosis, classification, therapeutic decision making and outcomes in the management of IBD. The role of these investigations in the diagnosis and management of IBD, however, is unclear. This document sets out the current Consensus reached by a group of international experts in the fields of endoscopy and IBD at a meeting held in Brussels, 12-13th December 2008, organised jointly by the European Crohn's and Colitis Organisation (ECCO) and the Organisation Mondiale d'Endoscopie Digestive (OMED). The Consensus is grouped into seven sections: definitions and diagnosis; suspected Crohn's disease; established Crohn's disease; IBDU; ulcerative colitis (including ileal pouch-anal anastomosis [IPAA]); paediatric practice; and complications and unresolved questions. Consensus guideline statements are followed by comments on the evidence and opinion. Statements are intended to be read in context with qualifying comments and not read in isolation.

[Tonsillar actinomycosis as a rare cause of oral malodor. Diagnosis beyond a gastroenterologist's nose]

BACKGROUND

Up to 30% of patients seen by dentists suffer from oral malodor. Part of them report serious distress and a sometimes paradoxical discrepancy in subjective and objective perception of symptoms. Less often, patients with oral malodor are primarily seen by general practitioners and specialists like gastroenterologists or ear, nose and throat (ENT) doctors. Correct characterization of the underlying disease and an adequate diagnosis are made most successfully through interdisciplinary cooperation.

CASE REPORT

The case of a 43-year-old female patient is reported who presented with persistent oral malodor for > 1 year in the authors' outpatient department. Extensive diagnostic tests performed by various doctors in the past had not led to an adequate diagnosis and treatment. Clinical and laboratory examination in the authors' hospital showed normal findings apart from suspicion of chronic tonsillitis, confirmed by an ENT specialist. Therefore, tonsillectomy was performed. Histopathology revealed chronic tonsillitis with tonsillar actinomycosis but no other disease. 6 months after tonsillectomy the patient presented asymptomatic and comfortable. Oral malodor was no longer detectable.

CONCLUSION

Oral malodor has a broad differential diagnosis including chronic tonsillitis caused by Actinomyces species and concomitant anaerobic bacteria able to produce volatile sulphur compounds and other putrefactive molecules. Therapeutic gold standard in symptomatic disease is tonsillectomy, lacking comparative studies on the success rates of conservative antibiotic therapy, e.g., with aminopenicillins plus beta-lactamase inhibitor for several weeks or months. This case presentation illustrates that anticipated internal disease with an agonizing and prolonged cause of disease could be solved by tonsillectomy.

Course of Crohn's disease prior to establishment of the diagnosis

BACKGROUND

The course of Crohn's disease prior to the establishment of the diagnosis is widely unknown. Therefore, we instigated a survey amongst newly diagnosed patients.

PATIENTS AND METHODS

Patients diagnosed with CD less than 12 months before enrollment were included. Data on demography, social status, time interval to diagnosis, symptoms, and health care service use were collected in a retrospective, web-based, census. Patients were contacted in cooperation with two organizations: a German patients' organization (Deutsche Morbus Crohn/Colitis ulcerosa Vereinigung e.V. [DCCV]) and a professional organization of German gastroenterologists (Berufsverband der Niedergelassenen Gastroenterologen Deutschlands e.V. [bng]). Study participation was anonymous by use of a transaction number.

RESULTS

The median interval period between onset of first symptoms and diagnosis was 13 months. During this time, participants reported having five doctor consultations on average, with 44% of them having a mean of 1.5 hospitalizations. 65% were unfit for work with a 14 day median (2 to 480 days) due to their symptoms. A mean (+/-SD) of 8.6 (+/-7.1) diagnostic tests were performed before the diagnosis was established. Overall health state was judged as temporarily bad or very bad by 84% of the participants. Age at diagnosis, characteristic symptoms, and localization of the disease for the participants did not differ from previously reported international data.

DISCUSSION

This web-based survey shows a substantial time interval of over one year until diagnosis of Crohn's disease amongst the study participants. This period is characterized by both psychological stress and impaired ability to work.

Diagnosis of small bowel Crohn's disease: a prospective comparison of capsule endoscopy with magnetic resonance imaging and fluoroscopic enteroclysis

BACKGROUND AND AIMS

The diagnostic yield of capsule endoscopy (CE) compared with magnetic resonance imaging (MRI) in small bowel Crohn's disease is not well established. We prospectively investigated CE, MRI, and double contrast fluoroscopy in patients with suspected small bowel Crohn's disease.

METHODS

Fifty two consecutive patients (39 females, 13 males) were investigated by MRI, fluoroscopy and--if bowel obstruction could be excluded--by CE. In 25, Crohn's disease was newly suspected while the diagnosis of Crohn's disease (non-small bowel) had been previously established in 27.

RESULTS

Small bowel Crohn's disease was diagnosed in 41 of 52 patients (79%). CE was not accomplished in 14 patients due to bowel strictures. Of the remaining 27 patients, CE, MRI, and fluoroscopy detected small bowel Crohn's disease in 25 (93%), 21 (78%), and 7 (of 21; 33%) cases, respectively. CE was the only diagnostic tool in four patients. CE was slightly more sensitive than MRI (12 v 10 of 13 in suspected Crohn's disease and 13 v 11 of 14 in established Crohn's disease). MRI detected inflammatory conglomerates and enteric fistulae in three and two cases, respectively.

CONCLUSION

CE and MRI are complementary methods for diagnosing small bowel Crohn's disease. CE is capable of detecting limited mucosal lesions that may be missed by MRI, but awareness of bowel obstruction is mandatory. In contrast, MRI is helpful in identifying transmural Crohn's disease and extraluminal lesions, and may exclude strictures.