Histomorphological differentiation of non-erosive reflux disease and functional heartburn in patients with PPI-refractory heartburn

BACKGROUND

Proton pump inhibitor (PPI)-refractory heartburn may be due to persistent gastro-oesophageal reflux, oesophageal hypersensitivity or functional heartburn (FH). The differentiation between non-erosive reflux disease (NERD) and FH may be very difficult. However, this differentiation is important for appropriate therapeutic management. Dilated intercellular spaces (DIS), papillary elongation (PE) and basal cell hyperplasia (BCH) can be all assessed by light microscopy. Whether these mucosal abnormalities allow the differentiation of NERD from FH in PPI-refractory patients is uncertain.

AIM

To assess histopathological findings by light microscopy in patients with refractory heartburn to differentiate NERD from FH.

METHODS

Sixty-two patients with PPI-refractory symptoms underwent EGD and MII-pH after pausing PPI medication for 2 weeks before investigation. Twenty-five subjects without upper gastrointestinal symptoms were included as controls. Symptom assessment was based on the reflux disease questionnaire (RDQ). Biopsies were taken 3-5 cm above the gastro-oesophageal junction. DIS, PE, BCH and infiltration of immune cells were evaluated and a sum score was calculated.

RESULTS

Based on endoscopy and MII-pH, GERD was diagnosed in 43 patients (NERD: 20; ERD: 23) and FH in 19 patients. There was no difference in symptoms between the groups. Each individual histopathological item was different between the groups (P < 0.0001). Between NERD and FH, the most significant difference was found for DIS and the histopathological sum score (P < 0.001).

CONCLUSIONS

These findings suggest that oesophageal biopsies are useful to differentiate NERD from FH. Increased DIS and a histological sum score are the most significant histopathological abnormalities in NERD as compared with FH.

Therapeutic and interventional endoscopy for gastrointestinal bleeding

INTRODUCTION

Gastrointestinal (GI) bleeding remains a common clinical problem encountered by every emergency room and trauma physician. Endoscopy remains the main approach to the diagnosis and therapy of GI bleeding.

OBJECTIVES

To present the modern endoscopic approach for GI bleeding.

METHODS

Narrative review based on our expertise and inclusion of classic articles dealing with interventional and therapeutic GI endoscopy.

RESULTS

GI hemorrhage is now classified as upper, middle, and lower GI bleeding. Upper GI bleeding is defined as hemorrhage originating from the oropharynx to the ligament of Treitz (or papilla of Vater), middle GI bleeding occurs distal to the papilla of Vater to the terminal ileum, and lower GI bleeding is defined as bleeding distal to the ileocecal valve, including the entire colon and anorectum. Endoscopic methods used to diagnosed and treat GI bleeding include esophagogastroduodenoscopy, duodenoscopy, capsule endoscopy, double- and single-balloon enteroscopy, spiral enteroscopy, and colonosocopy.

CONCLUSIONS

This is the first review paper dedicated to endoscopic therapy for bleeding involving any part of the luminal GI tract (i.e., esophagus, stomach, small bowel, and colon). Modern endoscopy permits the investigation and treatment of the majority of conditions affecting the entire hollow GI tract.

IL-17A and IL-17F gene expression is strongly induced in the mucosa of H. pylori-infected subjects from Kenya and Germany

Helicobacter pylori infection is the major cause of gastritis. Immunologically, H. pylori gastritis is associated with an infiltration of immune cells into gastric mucosa and the upregulation of various cytokines. Here, we analysed the gene expression of IL-1- and IL-17-related cytokines in regard to H. pylori infection in 85 German and 51 Kenyan patients with reflux-related or dyspeptic symptoms, respectively. Degree of gastritis and density of colonization were assessed histologically in accordance with the updated Sydney classification. Gene expression levels of cytokines IL-1β, IL-8, IL-18, IL-33, IL-17A, IL-17F and IL-23 as well as IL-23R were analysed by real-time RT-PCR. In both populations, H. pylori-infected individuals had significant higher inflammatory scores for activity and chronicity than H. pylori-negative subjects (P values between 0.006 and <0.0001). IL-8 mRNA was induced up to 6-fold in H. pylori-infected patients (P < 0.05), while the expression levels of IL-1β, IL-18, IL-23, IL-33 and IL-23R did not differ with respect to the H. pylori status in both groups. Most strikingly, a significant induction of both IL-17A and IL-17F was noted in H. pylori-infected individuals of both ethnic groups. Almost all IL-17F-positive samples revealed co-expression of IL-17A (40/42, 95.2%). Analysing IL-17A and IL-17F transcript levels of these 40 'double-positive' samples, a highly significant positive correlation between both genes was identified (P < 0.001). Taken together, H. pylori infection leads to a strong upregulation of both IL-17A and IL-17F in the gastric mucosa suggesting a regulatory link between both genes.

Advanced diagnostic imaging in colonic disease

Advanced colonic imaging refers to the use of techniques such as high definition white light, standard white light with chromoendoscopy, virtual chromoendoscopy (narrow band imaging), autofluorescence imaging and endomicroscopy to evaluate the colonic mucosa. The main aims of both advanced colonic imaging are to enhance the mucosal detail and to allow a detailed view of the submucosal capillary pattern, thus potentially improving the detection of more pathological lesions. The mucosal surface of neoplastic and non-neoplastic growths develops into specific mucosal convolutions, also called "pit pattern". Neoplasia also leads to angiogenesis with its resulting vessel proliferation and disarray. Because both the pit pattern and the submucosal capillary network are disarranged in the presence of neoplasia it is compelling to hypothesize that advanced imaging methods will allow the endoscopist a better interrogation of lesions with a resulting increase in diagnostic sensitivity and specificity (i.e. differentiation of lesions). However, the current literature dealing with advanced endoscopic imaging of the colon is fraught with many controversial findings, with few experts vehemently supporting the use of most of these methods in routine clinical practice, whereas most practicing endoscopists still effuse to accept that this methods aid in the clinical routine. This review describes the concept of advanced endoscopic imaging. We conclude that advanced endoscopic imaging of the colon holds many promises, but with the exception of high definition white light endoscopy, at the present stage, there is no solid evidence to support the implementation of most advanced endoscopic methods in routine clinical practice.

A retrospective analysis of emergency double-balloon enteroscopy for small-bowel bleeding

Although the role of emergency esophagogastroduodenoscopy (EGD) and colonoscopy for upper and lower gastrointestinal bleeding (GIB) is well defined, there are no data on the concept of emergency double-balloon enteroscopy (DBE) for small-bowel bleeding. The aim of this study was to retrospectively evaluate the concept of emergency DBE in overt obscure GIB and assess its impact on patient management. A total of 17 emergency DBEs for overt obscure GIB were carried out in ten patients (six women, four men; mean age 68 years, range 35 - 83). The following diagnoses were made: actively bleeding Dieulafoy lesions of the small bowel, n = 2; bleeding tumors, n = 4 (carcinoids n = 2, adenocarcinoma n = 1, lipoma n = 1); bleeding angiodysplasias and/or large arteriovenous malformation (AVM), n = 2; multiple ulcers, n = 1; and no diagnosis, n = 1. Endoscopic therapies included argon plasma coagulation (n = 6), injection of epinephrine (n = 3), and use of fibrin glue (n = 1). It appears that emergency DBE is technically feasible, facilitates both diagnosis and therapy and enables management of patients with massive overt obscure GIB. This study is a first step in establishing the concept of emergency DBE for patients with suspected small-bowel bleeding.

Double-balloon enteroscopy-assisted virtual chromoendoscopy for small-bowel disorders: a case series

The Fujinon intelligent color enhancement (FICE) system is a new, virtual chromoendoscopy technique that enhances mucosal visibility. The aim of this study was to assess the utility of double-balloon enteroscopy (DBE) with FICE technology (EPX-4400 processor, Japan) for the characterization of various small-bowel diseases. Overall, a total of 574 endoscopic pictures were obtained and analyzed. FICE was found to be a helpful method for the evaluation of adenomatous small-bowel polyps and angiodysplasias. Its use for the characterization of celiac and Crohn's disease appears to be limited. Overall, FICE may become a useful method that aids in characterization and provides new insights to small-bowel pathologies.

[Catheter-free pH-metry using the Bravo capsule versus standard pH-metry in patients with non-erosive reflux disease (NERD)]

BACKGROUND

pH-monitoring is considered the gold standard for the detection of acid reflux in patients with non-erosive reflux disease (NERD). Preliminary pH studies performed over periods longer than 24 hours have shown that in up to one-third of subjects abnormal pH exposure is detected only on the second day of monitoring. Therefore, pH-monitoring during 48 hours may yield more information about pathological acid reflux in patients being investigated for NERD.

AIM

The aim of this study was to compare conventional 24-hour pH-monitoring with the new wireless 48-hour Bravo pH-monitoring in patients with NERD.

PATIENTS AND METHODS

Patients with typical reflux symptoms, a positive reflux disease questionnaire and negative endoscopy (NERD) and without any form of acid suppressive therapy were included in this prospective study. The patients were divided into two groups: group A for conventional 24-hour pH-monitoring and group B for wireless 48-h Bravo pH-monitoring.

RESULTS

76 patients with a diagnosis of NERD based on a positive RDQ questionnaire and negative endoscopy were included. (47 woman, 29 men, median age: 49 years). 54 underwent conventional pH-monitoring and 22 underwent 48-h pH-monitoring with the new wireless BRAVO system. The overall incidence of acid reflux was 55 % in patients with NERD. Acid reflux was detected less frequently when using Bravo as compared to conventional pH-monitoring. In addition, the Bravo pH-metry showed a large day-to-day variability.

CONCLUSIONS

Prolonged pH-monitoring over a period longer than 24 hours did not improve the detection of acid reflux in patients with NERD. Thus, it appears that the Bravo pH-metry does not offer an advantage over standard pH-metry in the daily clinical practice.

Incidence of bleeding lesions within reach of conventional upper and lower endoscopes in patients undergoing double-balloon enteroscopy for obscure gastrointestinal bleeding

BACKGROUND

Double-balloon enteroscopy (DBE) is a useful method for evaluation of obscure gastrointestinal bleeding (OGIB).

AIM

To determine the incidence of lesions within reach of conventional upper and lower endoscopes as the cause of OGIB in patients referred for DBE.

METHODS

All patients undergoing DBE for OGIB during a 3.5-year period at a university hospital were studied. OGIB was defined according to American Gastroenterological Association (AGA) guidelines.

RESULTS

One hundred and forty-three DBEs were performed in 107 patients for obscure overt (n=85) and obscure occult (n=22) GIB. Lesions outside the SB as possible sources of GIB were found in 51 patients (47.6%) and a definite source of bleeding outside the small bowel (SB) was detected in 26 patients (24.3%). Lesions considered to explain a definite source of GIB were: gastric ulcer (n=3), duodenal ulcer (n=3), Cameron's lesions (n=2), gastric antral vascular ectasias (n=4), radiation proctitis (n=1), radiation ileitis (n=2), duodenal angiodysplasias (n=1), haemorrhoids with stigmata of recent bleed (n=1), colon angiodysplasias (n=3), colon diverticulosis (n=3), colonic Crohn's disease (n=1), anastomotic ulcers (n=1).

CONCLUSIONS

The frequency of non-SB lesions definitely explaining the source of GIB in patients referred for DBE was 24.3%. Therefore, repeat esophago-gastroduodenoscopy (EGD) and ileocolonoscopy should be taken into consideration before DBE.

Management of infected and sterile pancreatic necrosis by programmed endoscopic necrosectomy

INTRODUCTION

Necrosectomy is the gold standard treatment for infected pancreatic necrosis (IPN). A percutaneous and endoscopic approach has been accepted in selected cases. Endoscopic drainage (ED) of IPN can be performed by using transpapillary or transmural procedures, or a combination of both with or without endoscopic ultrasound.

AIMS

The aim of this study was to determine the indications, complications, success rate, and the importance of assessment of main pancreatic duct integrity by endoscopic retrograde pancreatography (ERP) in patients with IPN.

METHODS

Records of all patients who underwent endoscopic necrosectomy from January 2002 to December 2007 at Rio de Janeiro Federal University Hospital were reviewed. A total of 56 patients were included. ED was performed using daily transmural and transpapillary drainage. A diagnostic pancreatogram (ERP) to search for communications between the pancreatic duct and the collection were performed in all cases and in cases where communication existed. A pre-cut needle knife was used to puncture the cyst wall, aspirate the content and then enter at the cyst cavity (contrast was injected to ensure opacification of the cyst and subsequent drainage). Sphincterotomy catheter or balloons were used to enlarge and ensure a wide cystoenterostomy. All patients were followed with computerized tomography scans or ultrasound to ensure clinical resolution. Mean follow-up was 21 months.

RESULTS

49/56 patients could be successfully treated. ED was successful in 49 patients (87%) and in 3 (13%) it failed. Mean follow-up was 21 months. During this period, there were 2 (10.5%) pseudocyst recurrences and only 1 (5.2%) recurrence of new episodes of pancreatic necrosis, and all were managed clinically and/or endoscopically. No mortality was related to the procedure.

CONCLUSION

ED with daily necrosectomy is a useful method to remove infected and sterile pancreatic necrosis.

[Handling of the gastroesophageal reflux disease (GERD) during pregnancy--a review]

Gastroesophageal reflux disease (GERD) is common during pregnancy. The pathogenesis is a decrease in lower oesophageal sphincter pressure caused by female sex hormones, especially progesterone. The most common symptom of GERD is heartburn. Nevertheless, serious reflux complications during pregnancy are rare. In contrast to non-pregnant patients, GERD during pregnancy should be managed with a step-up algorithm beginning with lifestyle modifications and dietary changes. Antacids or sucralfate are considered the first-line on-demand drug therapy. If symptoms persist, any of the histamine-2-receptor antagonists can be used. Proton pump inhibitors are reserved for women with intractable symptoms or complicated reflux disease. Usually, heartburn during pregnancy resolves soon after delivery but little is known about the late sequelae or, respectively, an influence on subsequent pregnancies. Accordingly a prospective study (longitudinal cohort analysis) is currently underway.

[Eosinophilic esophagitis--pathogenesis, clinical presentation and therapeutic management]

Eosinophilic esophagitis (EE) is a relatively new, chronic, TH 2-type allergic inflammation of the esophagus. EE occurs more frequently in men. Allergic diseases such as asthma or atopic dermatitis are present in 50-70 % of patients or their relatives. In adults, the most common presenting symptom of EE is dysphagia, with or without food bolus impaction. Endoscopic findings of EE include mucosal furrows, corrugated or concentric rings or ridges in the esophagus ("feline esophagus"), with or without tiny whitish exudates. The diagnosis is confirmed by the observation of high counts of eosinophils in the esophageal epithelium (at least 24 /HPF). The cornerstones of medical therapy are either topical or systemic corticosteroids. Additional therapies included leukotriene receptor antagonists (montelukast) and IL-5 blockers (Mepolizumab). Complications of EE such as esophageal strictures should be carefully dilated using either bougies or a balloon. Currently it is still not known whether the late complications of EE can be prevented by the use of anti-inflammatory agents and this can only be demonstrated through further long-term follow-up studies.

Incidence, clinical management and outcomes of esophageal perforations after endoscopic dilatation

BACKGROUND

Esophageal dilatation is performed for the treatment of anatomic and sometimes functional narrowing of the esophageal lumen caused by a variety of benign and malignant conditions. Esophageal perforation is the major complication associated with endoscopic dilatation.

AIM

The object of this study was to assess the incidence of perforation, management and outcomes after endoscopic esophageal dilatation.

METHODS

All patients who underwent endoscopic esophageal dilatation at our institution from June 2001 to December 2006 were identified. Data were obtained by searching our prospectively collected electronic database (MEDOS AG, Langenselbold, Germany), which includes all endoscopic reports as well as discharge summaries of patients who have undergone endoscopy in our department.

RESULTS

248 patients (148 male, 100 female, mean age 58 years, range 14-87 years) underwent 365 esophageal dilatations: 74 pneumatic balloon dilatations for achalasia, 79 balloon dilatations for other reasons such as tumors, peptic stenosis, or post-radiotherapy stenosis and 212 dilatations with Savary bougies. The overall incidence of perforation based on the number of procedures was 2.2% (8 perforations/365 procedures) and 3.2% (8/248 patients) based on the number of patients. The perforation rate was 1.9% for bougie dilatation, 0% for balloon dilatation and 5-4% for pneumatic balloon dilatation for achalasia. Five patients were treated surgically and 3 patients were managed conservatively. The mean hospital stay was 14 days (7-33 days). One patient in whom the perforation was recognized 16 days after the dilatation died.

CONCLUSIONS

Endoscopic esophageal dilatation is a safe procedure for the palliation of malignant strictures, for the management of benign strictures as well as for the therapy of achalasia. The perforation rate after these procedures is low. Early recognition of the perforation is associated with a good outcome. Small perforations can be treated conservatively.

Characterization of yellow plaques found in the small bowel during double-balloon enteroscopy

BACKGROUND AND STUDY AIMS

The aim of this study was to characterize yellow (or whitish) plaques of the small bowel that were found during double-balloon enteroscopy (DBE) performed for small-bowel evaluation.

PATIENTS AND METHODS

Patients who were being evaluated for small-bowel pathology at our institution (for a variety of indications) were included in the study. In 16 patients, DBE revealed yellow or whitish submucosal plaques, defined as small, raised, submucosal lesions that were well circumscribed and covered by normal-appearing small-bowel mucosa. Biopsy tissue obtained during the procedures was stained with hematoxylin and eosin and with periodic acid-Schiff stain, and was subjected to immunochemical testing using endothelial markers (anti-CD31 and anti-CD34).

RESULTS

These 16 patients were identified out of a total of 150 DBE procedures performed in 120 patients (eight men, eight women; mean age 62, range 33 - 78). The lesions were mostly single (range 1 to > 5 lesions), ranging in size from 2 mm to 15 mm, and were slightly raised (from 1 mm to 2 mm). In four cases the plaques could not be biopsied because the patient had a coagulation disorder or because the DBE was being performed to investigate severe acute bleeding. In the other 12 patients, a characteristic white-yellow liquid exudated from the biopsy site in 80 % of lesions, and these 12 patients were shown to have lymphangiectasias. No association with an infiltrative disorder could be detected.

CONCLUSIONS

Yellow and white submucosal plaques are found in up to 13 % of patients undergoing DBE. They are most likely to be lymphangiectasias and are a normal anatomical variant. They do not require further work-up.

[Diagnosis and therapy of HIV associated esophagitis--HIV and esophagitis]

Diseases of the gastrointestinal tract are one of the most common complication of the acquired immunodeficiency syndrome (AIDS). Although there have been advances in the diagnosis and therapy of GI diseases in AIDS, currently, the diagnosis of and therapy for such opportunistic diseases still represent a challenge. The following article focuses on the diagnostic approach, differential diagnosis of and therapy for opportunistic esophageal diseases in AIDS.