A novel device to improve colon cleanliness during colonoscopy

BACKGROUND AND STUDY AIM

Effective colonoscopy depends on adequate visualization of the intestine, which might be ensured by intraprocedural use of a cleansing device. We investigated the performance of a novel endoscopic device with regard to cleanliness, safety, and tolerability during colonoscopy, compared with standard cleansing.

PATIENTS AND METHODS

At a single center, colonoscopy patients in whom the cecum was accessed and at least one bowel segment was inadequately cleansed were assigned to either use of a disposable catheter cleansing device (JetPrep), used through the endoscope working channel, or standard manual cleansing using a 50-ml syringe. The cleansing quality, for each segment and before and after irrigation, was recorded using a 4-point scale ranging from excellent (grade 1, no more than small bits of adherent feces) to poor (grade 4, large amount of fecal residue).

RESULTS

38 patients were included, 19 in each group. Reasons for referral included colorectal cancer screening (52 %), or blood loss (31 %). Each segment showed improvement after cleansing with JetPrep. Overall cleansing grade improved by a mean of 0.74 points (standard deviation [SD] 0.82) in the investigation group compared with 0.19 (0.40) in the control group (P < 0.0001), and right colon cleansing improved by 1.59 points (0.71) versus 0.31 (0.48) in the controls (P < 0.0001). There was no significant difference in procedure time between the groups. No adverse events or side effects were encountered.

CONCLUSIONS

The JetPrep disposable catheter device is safe and efficient for intraprocedural cleansing of a suboptimally prepared colon, allowing higher quality colonoscopy.

Herbal extract of gynostemma pentaphyllum decreases hepatic glucose output in type 2 diabetic goto-kakizaki rats

The aim of the study was to explore the effect of Gynostemma pentaphyllum (GP) extract on hepatic glucose output (HGO) in spontaneously type 2 diabetic Goto-Kakizaki (GK) rats treated orally with GP or placebo extract 1600 mg/kg daily, during three days or three weeks. The three-week treatment of GP, but not three-day treatment, significantly reduced plasma glucose (PG) levels from 9.8 ± 0.6 to 6.8 ± 0.4 mmol/L (p=0.027) in GK rats, whereas PG levels were not significantly decreased in the placebo rats. Glucose tolerance assessed by an intra-peritoneal glucose tolerance test was significantly improved in GP treated compared to placebo treated group (areas under the glucose curves, AUCs, from 0 to 120 min were 1150 ± 200 vs. 1761 ± 87 mmol/L; p=0.013). The glucose response in an intra-peritoneal pyruvate tolerance test from minute 15 to minute 120, the AUC (15-120) was significantly lower in the GP group (415.5 ± 68.0 vs. 641.5 ± 41.8 mmol/L; p<0.05). In liver perfusions, the AUCs for HGO during 18 min (0-18 min) were significantly decreased in GP treated rats compared with control rats (302.8 ± 36.5 vs. 423.5 ± 44.7 μmol, p<0.05). The three-week GP treatment significantly reduced the hepatic glycogen content, but not glycogen synthase activity compared to placebo group (p<0.007). In conclusion, three-week treatment of GP extract exerted anti-diabetic effect in GK rats, reducing plasma glucose levels and HGO, suggesting that GP improves the hepatic insulin sensitivity by suppressing gluconeogenesis.

Direct costs for care and glycaemic control in patients with type 2 diabetes in Sudan

The aim of this study was to estimate the contribution by type 2 diabetic patients in a low-income country from their own income in attempting to control the disease and to prevent chronic diabetes complications through good glycaemic control. Socio-economic and demographic data for study subjects were obtained from 822 adult diabetic patients attending public or private diabetic clinics in Khartoum State, Sudan. The average annual income of diabetic patients was estimated as USD 1.923. The direct cost of diabetes control was USD 175 per year. This included cost of drugs and ambulatory care, although drug supply was insufficient for 52% of the patients. Glycosylated hemoglobin as a measure of glycaemic control was determined to be unsatisfactory in 77% of patients. This gives an immediate indication that current practices in diabetes control in urban Sudan are not cost-effective. Patients attending private clinics had a higher income and cost of diabetes control than those attending public clinics. However, both groups had similar proportion of poor glycaemic control, which reflects the insufficient care given to diabetic patients, mainly due to deficient resources and inefficient utilization of what is scarcely available.

Prospective multicenter performance evaluation of the second-generation colon capsule compared with colonoscopy

BACKGROUND AND STUDY AIMS

A second-generation capsule endoscopy system, using the PillCam Colon 2, was developed to increase sensitivity for colorectal polyp detection compared with the first-generation system. The performance of this new system is reported.

PATIENTS AND METHODS

In a five-center feasibility study, second-generation capsule endoscopy was prospectively compared with conventional colonoscopy as gold standard for the detection of colorectal polyps and other colonic disease, in a cohort of patients scheduled for colonoscopy and having known or suspected colonic disease. Colonoscopy was independently performed within 10 hours after capsule ingestion. Capsule-positive but colonoscopy-negative cases were counted as false-positive.

RESULTS

104 patients (mean age 49.8 years) were enrolled; data from 98 were analyzed. Patient rate for polyps of any size was 44 %, 53 % of these patients having adenomas. No adverse events related to either procedure were reported. The capsule sensitivity for the detection of patients with polyps >or= 6 mm was 89 % (95 % confidence interval [CI] 70 - 97) and for those with polyps >or= 10 mm it was 88 % (95 %CI 56 - 98), with specificities of 76 % (95 %CI 72 - 78) and 89 % (95 %CI 86 - 90), respectively. Both polyps missed by colonoscopy and mismatch in polyp size by study definition lowered specificity. Overall colon cleanliness for capsule endoscopy was adequate in 78 % of patients (95 %CI 68 - 86).

CONCLUSIONS

The new second-generation colon capsule endoscopy is a safe and effective method for visualizing the colon and detecting colonic lesions. Sensitivity and specificity for detecting colorectal polyps appear to be very good, suggesting a potential for improved accuracy compared with the first-generation system. Further prospective and comparative studies are needed.

Detecting esophageal disease with second-generation capsule endoscopy: initial evaluation of the PillCam ESO 2

BACKGROUND AND STUDY AIM

Esophageal capsule endoscopy (ECE) provides an alternative, minimally invasive modality for evaluating the esophagus. This study evaluates the performance and test characteristics of a second-generation esophageal capsule endoscope, the PillCam ESO 2.

METHODS

Adults with known or suspected esophageal disease were included. Using the simplified ingestion procedure, each patient underwent capsule endoscopy with the PillCam ESO 2. Following ECE, esophagogastroduodenoscopy (EGD) was performed on the same day by an investigator who was blinded to the results of the ECE. In random order, capsule endoscopy videos were read and interpreted by the study investigator blinded to EGD results.

RESULTS

28 patients (19 men, 9 women; mean age 53.3 years) were included. In 82 % of the patients, at least 75 % of the Z line was visualized by the PillCam ESO 2. A per-lesion analysis demonstrated that the PillCam ESO 2 had definitive results in 30/43 lesions (69.8 %) and EGD in 29/43 (67.4 %), P value = 0.41. Compared with EGD for detecting suspected Barrett's esophagus and esophagitis, the PillCam ESO 2 had a sensitivity of 100 % and a specificity of 74 %, and a sensitivity of 80 % and a specificity of 87 %, respectively. The PillCam ESO 2 demonstrated 86 % agreement with EGD in describing the Z line (kappa statistic 0.68). The modified ingestion protocol provided excellent cleansing, with bubbles/saliva having no or only a minor effect on Z line images in 86 % of cases.

CONCLUSIONS

The PillCam ESO 2 demonstrated excellent visualization of the Z line. Compared with standard EGD, the PillCam ESO 2 had good test characteristics with high rates of detection of suspected Barrett's esophagus and esophagitis. This study provides indirect validation of the simplified ingestion procedure. The PillCam ESO 2 acquires high quality esophageal images, performs safely, and should be able to replace the current PillCam ESO.

Evaluation of the PillCam Colon capsule in the detection of colonic pathology: results of the first multicenter, prospective, comparative study

BACKGROUND AND STUDY AIMS

Population-based screening for colorectal cancer is widely recommended, with conventional colonoscopy considered to be the preferred diagnostic modality. However, compliance with screening colonoscopy is low and manpower capacity is limited. Capsule endoscopy might therefore represent a desirable alternative strategy.

PATIENTS AND METHODS

The PillCam Colon capsule endoscope was prospectively tested in a multicenter setting. The indications for endoscopy in the enrolled patients included colorectal cancer screening (43 %), postpolypectomy surveillance (26 %), and lower gastrointestinal signs and symptoms (31 %). Study subjects underwent colon preparation and then ingested the capsule on the morning of the examination, with conventional colonoscopy being performed the same day. The PillCam Colon capsule findings were reviewed by three experts in capsule endoscopy who were blinded to the conventional colonoscopy findings.

RESULTS

A total of 91 subjects were enrolled in three Israeli centers (55 men, 36 women; mean age 57), and the results were evaluable in 84 cases. The capsule was excreted within 10 hours in 74 % of the patients and reached the rectosigmoid colon in the other 16 %. Of the 84 evaluable patients, 20 (24 %) had significant findings, defined as at least one polyp of 6 mm or more in size or three or more polyps of any size: 14/20 (70 %) were identified with the capsule and 16/20 (80 %) were identified by conventional colonoscopy. Polyps of any size were found in 45 patients, 34/45 (76 %) found by the capsule and 36/45 (80 %) by conventional colonoscopy. In comparison with conventional colonoscopy, false-positive findings on PillCam Colon capsule examination were recorded in 15/45 cases (33 %). There were no adverse events related to the capsule endoscopy.

CONCLUSIONS

PillCam Colon capsule endoscopy appears to be a promising new modality for colonic evaluation. Further improvements in the procedure will probably increase capsule examination completion and polyp detection rates. Additional studies are needed to evaluate the accuracy of PillCam Colon endoscopy in other patient populations with different prevalence levels of colonic disease.

The accuracy of PillCam ESO capsule endoscopy versus conventional upper endoscopy for the diagnosis of esophageal varices: a prospective three-center pilot study

BACKGROUND AND STUDY AIMS

Variceal bleeding is a major complication of cirrhosis, and is associated with a 20 % mortality at 6 weeks. Current international guidelines recommend that patients with cirrhosis are screened by conventional upper endoscopy (esophagogastroduodenoscopy, EGD) in order to detect esophageal varices. The recently developed PillCam ESO esophageal capsule endoscope has been shown to be an accurate diagnostic tool in the investigation of patients with gastroesophageal reflux and Barrett's esophagus. We compared the PillCam ESO capsule endoscope with EGD for the detection of esophagogastric varices and portal hypertensive gastropathy in patients with cirrhosis.

PATIENTS AND METHODS

A pilot trial was conducted at three sites. Patients with cirrhosis who were undergoing clinically indicated EGD for screening or surveillance for esophageal varices underwent a PillCam ESO study followed by an EGD within 48 hours. Capsule videos were assessed by an investigator who was blinded to the patient's medical history and EGD findings.

RESULTS

A total of 23 of the 32 enrolled patients were found to have esophageal varices at both EGD and PillCam ESO endoscopy. In one patient PillCam ESO detected small varices that were not seen at EGD. The overall concordance between PillCam ESO and EGD was 96.9 % for the diagnosis of esophageal varices and 90.6 % for the diagnosis of portal hypertensive gastropathy. There were no adverse events related to PillCam ESO endoscopy.

CONCLUSIONS

In a high-prevalence population, PillCam ESO may represent an accurate noninvasive alternative to EGD for the detection of esophageal varices and portal hypertensive gastropathy. A large-scale trial is underway to validate and expand these findings.

Outcome and early complications of ERCP: a prospective single center study

BACKGROUND/AIMS

ERCP has been used since 1968 both as a diagnostic and as a therapeutic procedure. In the last ten years several less invasive imaging methods have developed which allow visualization of bile ducts and pancreatic ducts; therefore ERCP has become mainly a therapeutic tool. The aim of the study was to prospectively evaluate the early outcome of ERCP when used essentially as a therapeutic tool.

METHODOLOGY

All patients referred to our unit between April 1 1998 and March 31 2000 were included in the study. The indication for the procedure, number of cannulations, duration of procedure, performance of endoscopic sphinterotomy or pre-cut, insertion of stent and the final outcome were recorded. All patients were visited (in-patients) or contacted by phone (outpatients) 24 hours and one week after the procedure. If a complication occurred the patient was followed until it was resolved.

RESULTS

722 ERCP procedures were performed on 534 patients (59% females), mean age 63.4 years (range 3 to 98 years). The procedure was performed with a therapeutic intention in 95% of cases because of suspicion of: cholelithiasis (58%), tumor of pancreas/bile ducts (30%), post-cholecystectomy bile leak or bile duct stenosis (6%) or treatment of chronic pancreatitis (1%). The overall success rate of selective duct cannulation was 92%. Endoscopic sphincterotomy was performed in 375 procedures (52%), pre-cut in 152 (21%) and stent inserted in 180 (25%). Among the 701 procedures with complete information 76 complications occurred in 73 patients (10.8%): pancreatitis 4.3%, perforation 1.3%, sepsis 3.7%, bleeding 1.4%. Most of the complications (63/701, 9%) were mild to moderate. Procedure-related mortality was 0.6% due to perforation (1 patient), and sepsis (3 patients). The main factors influencing the complication rate were the difficulty of the examination, performance of an invasive procedure or the operator.

CONCLUSIONS

In the era of therapeutic ERCP, the risk of severe complication from the procedure is low--1.8% (including a mortality rate of 0.6%) when using the appropriate technique in experienced and skilled hands.

A novel diagnostic tool for detecting oesophageal pathology: the PillCam oesophageal video capsule

BACKGROUND

Gastro-oesophageal reflux disease is a common entity. Erosive oesophagitis, ulcers and Barrett's oesophagus, which is found in up to 10% of gastro-oesophageal reflux disease patients, characterize severe gastro-oesophageal reflux disease. Patients with Barrett's oesophagus have 0.5% per patient-year risk of developing oesophageal adenocarcinoma. Currently, it appears that a minority of those at risk for Barrett's oesophagus undergo screening in part because of the costs associated with endoscopy as well as risks of sedation. A new ingestible PillCam oesophageal capsule developed may offer an alternative office-based approach to visualize the oesophagus without sedation.

AIM

To compare the oesophageal capsule to conventional upper endoscopy for detection of oesophageal pathologies.

METHODS

A newly developed capsule, which acquires video images from both ends of the device at a 4 frame/s rate, was ingested by 17 fasting patients with suspected oesophageal disorders. An ingestion procedure aimed to lengthen capsule transit time in the oesophagus was utilized. Subsequently, a standard upper endoscopy was carried out. The investigator interpreting the capsule findings was blinded to the endoscopy results and vice versa. Patients with dysphagia, known Zenker's diverticulum, intestinal obstruction, cardiac pacemaker or pregnancy were excluded.

RESULTS

Twelve of the 17 patients examined had oesophageal findings using the endoscope as the gold standard. Capsule endoscopy identified oesophageal pathology in all 12 of these patients and an additional pathology in one patient that was missed during endoscopy. For the purpose of this study, this finding was regarded as a false-positive. The mean oesophageal passage time was 189 +/- 280 s. The positive predictive value of the oesophageal capsule for any oesophageal pathology was 92% and the negative predictive value was 100%. Oesophageal capsule sensitivity was 100% and specificity 80%. There were neither swallowing difficulties nor complications subsequent to ingestion in any subjects. Seventy-three percentage of patients preferred the oesophageal capsule procedure on conventional endoscopy. Only one patient preferred oesophagogastroduodenoscopy.

CONCLUSIONS

This pilot study has shown that oesophageal capsule endoscopy is an accurate, convenient, safe and well-tolerated method to screen patients for significant oesophageal disorders. No sedation is required, which may allow simple, office-based screening and assessment. Further, large-scale studies are necessary to more fully assess this novel diagnostic tool.

Wireless capsule video endoscopy compared to barium follow-through and computerised tomography in patients with suspected Crohn's disease--final report

BACKGROUND

Wireless capsule endoscopy is a superior diagnostic tool to barium small bowel follow-through and enteroscopy in diagnosing patients with occult blood loss.

AIM

To compare capsule endoscopy with barium follow-through and entero-computerised tomography in patients with suspected Crohn's disease.

SUBJECTS AND METHODS

Thirty-five patients with suspected Crohn's disease underwent the three examinations. The radiologist and gastroenterologist were blinded to each other's results. In cases of discrepancy, colonoscopy and ileoscopy were performed.

RESULTS

Thirty-five patients (22 males), mean age 28.4 years, were included. Eighty-eight percent had abdominal pain, 83% had diarrhoea and 69% had weight loss. The diagnostic yield of capsule endoscopy was 77% versus 23% and 20% of barium and computerised tomography examinations, respectively (P < 0.05). The capsule detected all of the lesions diagnosed by barium follow-through and entero-computerised tomography.

CONCLUSIONS

Capsule endoscopy is a superior and more sensitive diagnostic tool than barium follow-through and entero-computerised tomography in patients with suspected Crohn's disease.

Natural beta-carotene for the prevention of post-ERCP pancreatitis

OBJECTIVE

Endoscopic retrograde cholangiopancreatography (ERCP) is a commonly used procedure. Pancreatitis is its most common complication. As the injury may be mediated by oxidative stress, it could be ameliorated by antioxidants.

METHODS

We conducted a double-blind trial, giving the patients a single dose of natural beta-carotene or placebo, 12 hours prior to procedure, and monitoring them for 24 hours post-procedure for procedure complications, antioxidant levels, and plasma oxidation.

RESULTS

The overall incidence of acute pancreatitis according to our definition was 9.6%. The incidence of pancreatitis was not significantly different between the beta-carotene group (10%) and the placebo group (9.4%). Four patients in the placebo group had severe pancreatitis (2.22%), but none in the beta-carotene group. This difference is statistically significant.

CONCLUSION

We did not see a reduction in the incidence of post-ERCP pancreatitis, but there may be some protective effect of treatment with beta-carotene regarding the severity of disease.

[Undiagnosed celiac disease in adults unmasked by endoscopy]

BACKGROUND

Celiac disease may be present in many patterns other than the classical manifestations of diarrhea and malabsorption. The prevalence of celiac disease is greater than usually reported as mild cases are often undiagnosed. Diagnosing celiac disease may have major health significance.

AIMS

The aim of our study was to determine the prevalence of celiac disease in adults appearing for endoscopy with abdominal pain, in an open access setting.

METHODS

Two hundred and seventy consecutive, non-selected adult patients undergoing upper endoscopy for abdominal pain were included in the study. Three biopsies were routinely taken from the second part of the duodenum. In those cases with flattened villi on histology, antiendomysial antibody (AEA) was tested.

RESULTS

The prevalence of celiac disease among Israeli patients undergoing endoscopy for abdominal pain was high (1:23), greater than its highest reported prevalence in general populations (1:200-300).

CONCLUSIONS

Routine small bowel biopsies should be considered in patients undergoing upper endoscopy for otherwise unexplained pain.

The epidemiology of hepatitis A infection in Palestine: a universal vaccination programme is not yet needed

In Palestine, there has been an increase in the reported incidence of acute hepatitis A virus (HAV) infection since 1995. Since overt clinical disease occurs only among adults, questions were raised whether or not a shift in the epidemiology of HAV has occurred. This is generally characterized by a decrease in the overall incidence rate and a shifting in the mean age of infection towards adolescence and early adulthood. The need for a vaccination programme is being discussed. To resolve this issue, we examined the prevalence of anti-HAV in a representative sample of 396 school children in the Gaza Strip. The prevalence of anti-HAV was 93.7% (95% CI: 91.3, 96.1%). Stratifying the prevalence by age showed that 87.8% (95% CI: 78.6, 97%) were HAV antibody positive by the age of 6. By the age of 14, almost 98% (95% CI: 92.7, 100%) were HAV antibody positive. This means that the majority of HAV infection is still taking place in early childhood, when it is usually asymptomatic and of little clinical significance. The results refuted the shifting epidemiology theory and we recommend that a vaccination programme against HAV infection is not yet needed. Alternative explanations for the increase in reported cases are discussed.

Morbidity and risk factors of diarrheal diseases among under-five children in rural Upper Egypt

Diarrhea is a leading cause of mortality and morbidity in developing countries. In Egypt, researchers have traditionally been targeting diarrhea-related mortality. This study is an attempt to portray the morbidity and risk factors of diarrhea among children under 5 years old (under-fives) in rural Upper Egypt. The incidence of diarrhea in the 6 months before the study was determined among 1025 under-fives in six sentinel sites by interviewing mothers or caretakers. The association between diarrhea and a set of risk variables was examined using a multivariate logistic regression model. Variables that appeared to have a significant predictive power were then included in a forward wald stepwise logit analysis model to estimate statistical functions which best predict the diarrheal morbidity. The incidence rate of diarrhea was found to be 3.6 episodes per child semiannually and the point prevalence was 19.5 per cent. The average duration of current episodes was 4.8 +/- 3.7 days; 33.6 per cent of children had had diarrhea more than three times (recurrent diarrhea). Four variables were found to have a significant association with recurrent diarrhea. The logit coefficients and their significance levels indicated that, in order of contribution to risk prediction, the variables ranked as follows: household meat consumption, mother's age at the time of birth of the child, child's age, and father's illiteracy. A total of 74.8 per cent of overall children were correctly predicted by these risk factors, a figure which indicates the goodness of fit of the model. It is concluded that the diarrheal morbidity is still unacceptably high in rural Upper Egypt. More interventions are needed to control for specific risk factors.

Transient radiological and colonoscopic features of inflammatory bowel disease in a patient with severe Salmonella gastroenteritis

Salmonella is the most commonly reported cause of food-borne outbreaks of gastroenteritis. We report a case of a severe and toxic form of enteritis caused by Salmonella enteritidis. Findings of colonoscopy, an upper G1 tract series, and small bowel follow-through were consistent with those of inflammatory bowel disease, but the enteritis was self-limited, and the patient recovered after supportive treatment only and has remained well.

Failure of cefonicid prophylaxis for infectious complications related to endoscopic retrograde cholangiopancreatography

We performed a controlled study to evaluate the role of cefonicid in preventing infectious complications related to retrograde cholangiopancreatography (ERCP). Consecutive patients were randomized to receive prophylaxis with cefonicid (1 g intravenously) 1 hour before the procedure or to be untreated controls. During a 26-month period, 179 ERCPs, including 93 therapeutic procedures, were performed on 164 patients. Prophylaxis was administered before 88 procedures (49%). The rate of bacteremia among treated patients was similar to that among controls (3% vs. 2%, respectively; P = .4). The rate of cholangitis was also similar among both groups (8% vs. 2%, respectively; P = .07). There were no episodes of sepsis, and none of the patients died. The rate of bacteremia was also similar among patients undergoing diagnostic procedures and patients undergoing therapeutic procedures, but all cases of cholangitis occurred in the latter group (0 vs. 10%, respectively; P = .002). Nevertheless, the rate of cholangitis was not significantly changed by the use of prophylaxis (14% among treated patients vs. 5% among controls, P = .12). Therefore, infectious complications could not be prevented by cefonicid prophylaxis.

Lack of suppression of insulin secretion by hyperinsulinemia in a patient with an insulinoma

The regulation of insulin secretion in patients with insulinoma is known to be abnormal. For example, physiological and pharmacological stimuli often fail to stimulate insulin in such patients. Recently, insulin has been found to inhibit its own secretion in normal subjects. To determine if insulin has this effect in patients with insulinoma, we infused insulin at rates of 1 and 10 mU/kg X min in such a patient and in eight normal subjects. Euglycemia was maintained by the euglycemic glucose clamp technique, and endogenous insulin secretion was estimated by measuring plasma C-peptide levels. In the normal subjects, plasma C-peptide declined from 1.60 +/- 0.22 (+/- SEM) to 1.16 +/- 0.17 and 0.82 +/- 0.11 ng/ml during the low and high dose insulin infusions, respectively, indicating 27% (P less than 0.01) and 48% (P less than 0.001) decreases in endogenous insulin secretion at moderately elevated and extremely elevated insulin levels, respectively. In the insulinoma patient, plasma C-peptide was 2.6 ng/ml basally, did not change during the low dose insulin infusion, and rose to 3.4 ng/ml during the high dose insulin infusion. We conclude that the feedback regulation of insulin secretion by insulin that occurs in normal subjects is absent in insulinoma patients. This finding could have pathophysiological and possibly diagnostic significance.