EUS compared with endoscopy plus transabdominal US in the initial diagnostic evaluation of patients with upper abdominal pain

BACKGROUND

Primary upper endoscopy (EGD) and transabdominal US (TUS) are often performed in patients with upper abdominal pain.

OBJECTIVE

Primary: Determine whether the combination of EGD and EUS was equivalent to EGD plus TUS in the diagnostic evaluation of upper abdominal pain. Secondary: Compare EUS versus TUS in detecting abdominal lesions, and compare EGD by using an oblique-viewing echoendoscope versus the standard, forward-viewing endoscope in detecting mucosal lesions.

DESIGN

Prospective, paired design.

SETTING

Six academic endoscopy centers.

PATIENTS

This study involved patients with upper abdominal pain referred for endoscopy.

INTERVENTION

All patients had EGD, EUS, and TUS. The EGD was done using both an oblique-viewing echoendoscope and the standard, forward-viewing endoscope (randomized order) by two separate endoscopists in a blinded fashion, followed by EUS. TUS was performed within 4 weeks of EGD/EUS, also in a blinded fashion.

FOLLOW-UP

telephone interviews and chart reviews.

MAIN OUTCOME MEASUREMENTS

Diagnose possible etiology of upper abdominal pain and detect clinically significant lesions.

RESULTS

A diagnosis of the etiology of upper abdominal pain was made in 66 of 172 patients (38%). The diagnostic rate was 42 of 66 patients (64%) for EGD plus EUS versus 41 of 66 patients (62%) for EGD plus TUS, which was statistically equivalent (McNemar test; P = .27). One hundred ninety-eight lesions were diagnosed with either EUS or TUS. EUS was superior to TUS for visualizing the pancreas (P < .0001) and for diagnosing chronic pancreatitis (P = .03). Two biliary stones were detected only by EUS. Two hundred fifty-one mucosal lesions were similarly diagnosed with EGD with either the standard, forward-viewing endoscope or the oblique-viewing echoendoscope (kappa = 0.48 [95% CI, .43-.54]). EGD with the standard, forward-viewing endoscope was preferred for biopsies.

LIMITATIONS

No cost analysis.

CONCLUSION

The combination of EGD with EUS is equivalent to EGD plus TUS for diagnosing a potential etiology of upper abdominal pain. EUS is superior to TUS for detecting chronic pancreatitis. EGD combined with EUS should be considered in the first-line diagnostic evaluation of patients with upper abdominal pain.

Image analysis for classification of dysplasia in Barrett's esophagus using endoscopic optical coherence tomography

Barrett's esophagus (BE) and associated adenocarcinoma have emerged as a major health care problem. Endoscopic optical coherence tomography is a microscopic sub-surface imaging technology that has been shown to differentiate tissue layers of the gastrointestinal wall and identify dysplasia in the mucosa, and is proposed as a surveillance tool to aid in management of BE. In this work a computer-aided diagnosis (CAD) system has been demonstrated for classification of dysplasia in Barrett's esophagus using EOCT. The system is composed of four modules: region of interest segmentation, dysplasia-related image feature extraction, feature selection, and site classification and validation. Multiple feature extraction and classification methods were evaluated and the process of developing the CAD system is described in detail. Use of multiple EOCT images to classify a single site was also investigated. A total of 96 EOCT image-biopsy pairs (63 non-dysplastic, 26 low-grade and 7 high-grade dysplastic biopsy sites) from a previously described clinical study were analyzed using the CAD system, yielding an accuracy of 84% for classification of non-dysplastic vs. dysplastic BE tissue. The results motivate continued development of CAD to potentially enable EOCT surveillance of large surface areas of Barrett's mucosa to identify dysplasia.

In vivo characterization of pancreatic and lymph node tissue by using EUS spectrum analysis: a validation study

BACKGROUND

Quantitative spectral analysis of the radiofrequency (RF) signals that underlie grayscale EUS images can be used to provide additional, objective information about tissue state.

OBJECTIVE

Our purpose was to validate RF spectral analysis as a method to distinguish between (1) benign and malignant lymph nodes and (2) normal pancreas, chronic pancreatitis, and pancreatic cancer.

DESIGN AND SETTING

A prospective validation study of eligible patients was conducted to compare with pilot study RF data.

PATIENTS

Forty-three patients underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes (19 from a previous pilot study and 24 additional patients).

MAIN OUTCOME MEASUREMENTS

Midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were determined.

RESULTS

Discriminant analysis of mean pilot-study parameters was then performed to classify validation-study parameters. For benign versus malignant lymph nodes, midband fit and intercept (both with t test P < .058) provided classification with 67% accuracy and area under the receiver operating curve (AUC) of 0.86. For diseased versus normal pancreas, midband fit and correlation coefficient (both with analysis of variance P < .001) provided 93% accuracy and an AUC of 0.98. For pancreatic cancer versus chronic pancreatitis, the same parameters provided 77% accuracy and an AUC of 0.89. Results improved further when classification was performed with all data.

LIMITATIONS

Moderate sample size and spatial averaging inherent to the technique.

CONCLUSIONS

This study confirms that mean spectral parameters provide a noninvasive method to quantitatively discriminate benign and malignant lymph nodes as well as normal and diseased pancreas.

Characterization of pancreatic cancer and intra-abdominal lymph node malignancy using spectrum analysis of endoscopic ultrasound imaging

This study assessed the ability of spectral analysis of endoscopic ultrasound (EUS) RF signals acquired in humans in vivo to distinguish between (1) benign and malignant intraabdominal and mediastinal lymph nodes and (2) pancreatic cancer, chronic pancreatitis, and normal pancreas. Mean midband fit, slope, intercept, and correlation coefficient from a linear regression of the calibrated RF power spectra were computed over regions of interest defined by the endoscopist. Linear discriminant analysis was then performed to develop a classification of the resulting spectral parameters. For lymph nodes, classification based on the midband fit and intercept provided 67% sensitivity, 82% specificity, and 73% accuracy for malignant vs. benign nodes. For pancreas, classification based on midband fit and correlation coefficient provided 95% sensitivity, 93% specificity, and 93% accuracy for diseased vs. normal pancreas and 85% sensitivity, 71% specificity, and 85% accuracy for pancreatic cancer vs. chronic pancreatitis. These promising results suggest that mean spectral parameters can provide a non-invasive method to quantitatively characterize pancreatic cancer and lymph malignancy in vivo.

Squamous overgrowth is not a safety concern for photodynamic therapy for Barrett's esophagus with high-grade dysplasia

BACKGROUND & AIMS

Photodynamic therapy with porfimer sodium combined with acid suppression (PHOPDT) is used to treat patients with Barrett's esophagus (BE) with high-grade dysplasia (HGD). A 5-year phase 3 trial was conducted to determine the extent of squamous overgrowth of BE with HGD after PHOPDT.

METHODS

Squamous overgrowth was compared in patients with BE with HGD randomly assigned (2:1) to receive PHOPDT (n=138) or 20 mg omeprazole twice daily (n=70). Patients underwent 4-quadrant jumbo esophageal biopsies every 2 cm throughout the pretreatment length of BE until 4 consecutive quarterly follow-up results were negative for HGD and then biannually up to 5 years or treatment failure. Endoscopies were reviewed by blinded gastroenterology pathologists.

RESULTS

Histologic assessment of 33,658 biopsies showed no significant difference (P> .05) in squamous overgrowth between groups when compared per patient (30% vs 33%) or per biopsy (0.5% vs 1.3%), or when the average number of biopsies with squamous overgrowth were compared per patient (0.48 vs 0.66). The highest grade of neoplasia per endoscopy was not found exclusively beneath squamous mucosa in any patient.

CONCLUSIONS

No difference was observed in squamous overgrowth between patients given PHOPDT plus omeprazole compared with only omeprazole. Squamous overgrowth did not obscure the most advanced neoplasia in any patient. Treatment of HGD with PHOPDT in patients with BE does not present a long-term risk of failure to detect subsquamous dysplasia or carcinoma.

Automated quantification of colonic crypt morphology using integrated microscopy and optical coherence tomography

Colonic crypt morphological patterns have shown a close correlation with histopathological diagnosis. Imaging technologies such as high-magnification chromoendoscopy and endoscopic optical coherence tomography (OCT) are capable of visualizing crypt morphology in vivo. We have imaged colonic tissue in vitro to simulate high-magnification chromoendoscopy and endoscopic OCT and demonstrate quantification of morphological features of colonic crypts using automated image analysis. 2-D microscopic images with methylene blue staining and correlated 3-D OCT volumes were segmented using marker-based watershed segmentation. 2-D and 3-D crypt morphological features were quantified. The accuracy of segmentation was validated, and measured features are in agreement with known crypt morphology. This work can enable studies to determine the clinical utility of high-magnification chromoendoscopy and endoscopic OCT, as well as studies to evaluate crypt morphology as a biomarker for colonic disease progression.

Artificial neural network as a predictive instrument in patients with acute nonvariceal upper gastrointestinal hemorrhage

BACKGROUND & AIMS

Triage of patients with acute upper gastrointestinal hemorrhage (UGIH) has traditionally required urgent upper endoscopy. The aim of this study is to evaluate the use of artificial neural network for nonendoscopic triage.

METHODS

A cohort of 387 patients was used to train (n = 194) and internally validate (n = 193) the neural network, which was then externally validated in 200 patients and compared with the clinical and complete Rockall score. Two outcome variables were assessed: major stigmata of recent hemorrhage and need for endoscopic therapy. Patient cohort data from 2 independent tertiary-care medical centers were prospectively collected. Adult patients hospitalized at both sites during the same time period with a primary diagnosis of acute nonvariceal UGIH.

RESULTS

In predicting the 2 measured outcomes, sensitivity of neural network was >80%, with high negative predictive values (92-96%) in both cohorts but with lower specificity in the external cohort. Both Rockall scores had adequate sensitivity (>80%) but poor specificity (<40%) at outcome prediction. Comparing areas under receiver operating characteristic curves, the clinical Rockall score was significantly inferior to neural network in both cohorts (</=0.65 vs. >/= 0.78), while in the external cohort, neural network performed similarly to the complete Rockall score (>/= 0.78).

CONCLUSIONS

In acute nonvariceal UGIH, artificial neural network (nonendoscopic triage) performed as well as the complete Rockall score (endoscopic triage) at predicting stigmata of recent hemorrhage and need for endoscopic therapy, even when tested in an external patient population.

EUS spectrum analysis for in vivo characterization of pancreatic and lymph node tissue: a pilot study

BACKGROUND

EUS is limited by variability in the examiner's subjective interpretation of B-scan images to differentiate among normal, inflammatory, and malignant tissue. By using information otherwise discarded by conventional EUS systems, quantitative spectral analysis of the raw radiofrequency (RF) signals underlying EUS images enables tissue to be characterized more objectively.

OBJECTIVE

Our purpose was to determine the feasibility of using spectral analysis of EUS data for characterization of pancreatic tissue and lymph nodes.

DESIGN AND SETTING

A pilot study of eligible patients was conducted to analyze the RF data obtained during EUS by using spectral parameters.

PATIENTS

Twenty-one subjects who underwent EUS of the esophagus, stomach, pancreas, and surrounding intra-abdominal and mediastinal lymph nodes.

MAIN OUTCOME MEASUREMENTS

Linear regression parameters of calibrated power spectra of the RF signals were tested to differentiate normal pancreas from chronic pancreatitis and from pancreatic cancer as well as benign from malignant-appearing lymph nodes.

RESULTS

The mean intercept, slope, and midband fit of the spectra differed significantly among normal pancreas, adenocarcinoma, and chronic pancreatitis when all were compared with each other (P < .01). On direct comparison, mean midband fit for adenocarcinoma differed significantly from that for chronic pancreatitis (P < .05). For lymph nodes, mean midband fit and intercept differed significantly between benign- and malignant-appearing lymph nodes (P < .01 and P < .05, respectively).

LIMITATIONS

Small sample population and spatial averaging inherent to this technique.

CONCLUSIONS

Mean spectral parameters in EUS imaging can provide a noninvasive method to discriminate normal from diseased pancreas and lymph nodes.

Five-year efficacy and safety of photodynamic therapy with Photofrin in Barrett's high-grade dysplasia

BACKGROUND

Barrett's esophagus (BE) with high-grade dysplasia (HGD) is a risk factor for development of esophageal carcinoma. Photodynamic therapy (PDT) with Photofrin (PHO) has been used to eliminate HGD in BE.

OBJECTIVE

Our purpose was to compare PHOPDT plus omeprazole with omeprazole only (OM).

DESIGN

Five-year follow-up of a randomized, multicenter, multinational, pathology-blinded HGD trial.

SETTING

30 sites in 4 countries.

PATIENTS

208.

INTERVENTIONS

Patients with BE and HGD were randomized (2:1) to PHOPDT (n=138) or OM (n=70) into a 2-year trial followed up for 3 more years. PHOPDT patients received 2 mg/kg PHO intravenously followed by endoscopic laser light exposure of Barrett's mucosa at a wavelength of 630 nm within 40 to 50 hours to a maximum of 3 courses at least 90 days apart. Both groups received 20 mg of OM twice daily. Pathologists at one center assessed biopsy specimens in a blinded fashion.

MAIN OUTCOME MEASUREMENT

HGD ablation status over 5 years of follow-up.

RESULTS

At 5 years PHOPDT was significantly more effective than OM in eliminating HGD (77% [106/138] vs 39% [27/70], P<.0001). A secondary outcome measure preventing progression to cancer showed a significant difference (P=.027) with about half the likelihood of cancer occurring in PHOPDT (21/138 [15%]) compared with OM (20/70 [29%]), with a significantly (P=.004) longer time to progression to cancer favoring PHOPDT.

LIMITATIONS

Not all patients were available for follow-up.

CONCLUSIONS

This 5-year randomized trial of BE patients with HGD demonstrates that PHOPDT is a clinically and statistically effective therapy in producing long-term ablation of HGD and reducing the potential impact of cancer compared with OM.

Postprocedure radiologist's interpretation of ERCP x-ray films: a prospective outcomes study

OBJECTIVE

To prospectively determine if the current practice of radiologists' interpretation of post-ERCP spot images sent by endoscopists resulted in discrepancies in interpretation, affected subsequent management of patients, and resulted in additional costs.

METHODS

A prospective analysis of 145 consecutive patients who underwent ERCP over the course of 4 months was performed. A separate endoscopist, not involved in the patient's care, reviewed the radiologist's report of the ERCP x-ray films to determine whether there was either concordance or discordance with the procedural findings. All patients' clinical courses were prospectively followed for a minimum of 6 months to determine whether clinical decision-making was affected by the radiologists' interpretation of the x-ray films. Secondarily, the cost of the current practice of postprocedure interpretation of ECRP radiographs was measured.

SETTING

This study took place at University Hospitals of Cleveland, which is a tertiary care facility.

RESULTS

In total, there were 61 (47%) discordant interpretations of 130 cholangiograms and 27 (38%) discordant interpretations of 72 pancreatograms, with an overall discordance between an endoscopist and a radiologist in 80 (55%) of the 145 cases. Clinical management was subsequently affected in 3 (2.1%) cases, all of which involved a discordant reading. In each of the 3 cases, further testing validated the gastroenterologist's initial findings at the time of the procedure. Radiologists were reimbursed $5395 for interpretation of ERCP x-ray films. Extrapolated over the course of a year, the reimbursement at this single tertiary care hospital would be greater than $16,000. Additional testing based on discordant reports resulted in $2510 of reimbursement for 3 patients.

LIMITATION

The limitation of this study is that it reflects data from only one academic institution.

CONCLUSIONS

Radiologists' interpretation of postprocedure ERCP films were inadequate, with a 47% discordance rate among cholangiograms and a 38% discordance rate among pancreatograms. The routine practice of postprocedure ERCP x-ray film interpretation by radiologists altered clinical practice in 2.1% of cases; subsequent care did not confirm radiologists' findings and imparted increased risk to the patients. This practice proved to be a misallocation of resources and should not be continued.

Pancreatic-stent placement for prevention of post-ERCP pancreatitis: a cost-effectiveness analysis

BACKGROUND

Controlled trials support pancreatic-stent placement as an effective intervention for the prevention of post-ERCP acute pancreatitis in high-risk patients.

OBJECTIVE

To perform a decision analysis to evaluate the most cost-effective strategy for preventing post-ERCP pancreatitis.

DESIGN

Cost-effectiveness analysis.

SETTING

Patients undergoing ERCP.

INTERVENTIONS

Three competing strategies were evaluated in a decision analysis model from a third-party-payer perspective in hypothetical patients undergoing ERCP. In strategy I, none of the patients had pancreatic-stent placement. Strategy II had only those patients identified to be at high risk for post-ERCP, and, in strategy III, all patients underwent prophylactic stent placement. Probabilities of developing post-ERCP pancreatitis and the risk reduction by placement of a pancreatic stent were obtained from published information. Cost estimates were obtained from Medicare reimbursement rates.

MAIN OUTCOME MEASUREMENTS

Incremental cost-effectiveness ratio (ICER) of different strategies.

RESULTS

Strategy I was the least-expensive strategy but yielded the least number of life years. Strategy II yielded the highest number of years of life, with an ICER of $11,766 per year of life saved, and strategy III was dominated by strategy II.

LIMITATIONS

Indirect costs and pharmacologic prophylaxis were not considered in this analysis.

CONCLUSIONS

Pancreatic-stent placement for the prevention of post-ERCP pancreatitis in high-risk patients is a cost-effective strategy.

Gastroesophageal reflux disease-associated esophagitis induces endogenous cytokine production leading to motor abnormalities

BACKGROUND & AIMS

Gastroesophageal reflux disease is a condition frequently associated with esophagitis and motor abnormalities. Recent evidence suggests that proinflammatory cytokines, such as interleukin (IL)-1beta and IL-6, may be implicated because they reduce esophageal muscle contractility, but these results derive from in vitro or animal models of esophagitis. This study used human esophageal cells and tissues to identify the cellular source of cytokines in human esophagitis investigate whether cytokines can be induced by gastric refluxate, and examine whether esophageal tissue- or cell-derived mediators affect muscle contractility.

METHODS

Endoscopic mucosal biopsy specimens were obtained from patients with and without esophagitis, organ-cultured, and undernatants were assessed for cytokine content. The cytokine profile of esophageal epithelial, fibroblast, and muscle cells was analyzed, and esophageal mucosa and cell products were tested in an esophageal circular muscle contraction assay.

RESULTS

The mucosa of esophagitis patients produced significantly greater amounts of IL-1beta and IL-6 compared with those of control patients. Cultured esophageal epithelial cells produced IL-6, as did fibroblasts and muscle cells. Epithelial cells exposed to buffered, but not denatured, gastric juice produced IL-6. Undernatants of mucosal biopsy cultures from esophagitis patients reduced esophageal muscle contraction, as did supernatants from esophageal epithelial cell cultures.

CONCLUSIONS

The human esophagus produces cytokines capable of reducing contractility of esophageal muscle cells. Exposure to gastric juice is sufficient to stimulate esophageal epithelial cells to produce IL-6, a cytokine able to alter esophageal contractility. These results indicate that classic cytokines are important mediators of the motor disturbances associated with human esophageal inflammation.

Gastrointestinal endoscopy: past and future

The former editor of Gastrointestinal Endoscopy reflects on the history of endoscopy, which reveals much about the mechanisms whereby innovation occurred, and attempts to forecast the future. Endoscopic technological development in most industrialised countries will be determined largely by various combinations of many external factors together with the further development of virtual imaging.

Computer-aided diagnosis of dysplasia in Barrett's esophagus using endoscopic optical coherence tomography

Barrett's esophagus (BE) and associated adenocarcinoma have emerged as a major health care problem over the last two decades. Because of the widespread use of endoscopy, BE is being recognized increasingly in all Western countries. In clinical trials of endoscopic optical coherence tomography (EOCT), we defined certain image features that appear to be characteristic of precancerous (dysplastic) mucosa: decreased scattering and disorganization in the microscopic morphology. The objective of the present work is to develop computer-aided diagnosis (CAD) algorithms that aid the detection of dysplasia in BE. The image dataset used in the present study was derived from a total of 405 EOCT images (13 patients) that were paired with highly correlated histologic sections of corresponding biopsies. Of these, 106 images were included in the study. The CAD algorithm used was based on a standard texture analysis method (center-symmetric auto-correlation). Using histology as the reference standard, this CAD algorithm had a sensitivity of 82%, specificity of 74%, and accuracy of 83%. CAD has the potential to quantify and standardize the diagnosis of dysplasia and allows high throughput image evaluation for EOCT screening applications. With further refinements, CAD could also improve the accuracy of EOCT identification of dysplasia in BE.

Endoscopic ultrasonography and prognosis of esophageal cancer

BACKGROUND & AIMS

Endoscopic ultrasonography (EUS) staging is used for management of esophageal cancer, but its effect on the outcome of patients is unknown. Our aim was to study the association of receipt of EUS and overall survival in a cohort of patients with esophageal cancer.

METHODS

All persons 65 years or older who were diagnosed with esophageal cancer between January 1994 and December 1999 in the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database were identified. Relevant demographic, cancer-specific information and EUS procedural information were extracted.

RESULTS

Two thousand eight hundred thirty patients with esophageal cancer (48% squamous cell cancer) were eligible for analysis. Only 303 (10.7%) patients underwent a EUS examination. Patients who had EUS evaluation were more likely to undergo esophageal resection (21.1% vs 14.7%, P = .01) and more likely to have received adjuvant therapy (11.2% vs 6.7%, P = .008). When adjusted for age at diagnosis, race, gender, comorbidity, histology, and tumor stage, receipt of EUS was associated with a reduced risk of death (relative hazard, 0.594; 95% confidence interval, 0.52-0.68; P = .001).

CONCLUSIONS

Undergoing EUS in patients with esophageal cancer is independently associated with improved survival, possibly because of improved stage-appropriate management such as use of adjuvant therapy and surgical resection.

Primary care physician attitudes toward endoscopic screening for GERD symptoms and unsedated esophagoscopy

BACKGROUND

Current guidelines recommend consideration of screening patients with chronic GERD for Barrett's esophagus (BE). Unsedated esophagoscopy (UE) is a less costly alternative to standard EGD for identifying BE. The aim of this study was to determine the indications for EGD referral, the barriers to screening, and the interest in performing UE.

METHODS

A one-page survey was mailed to a random sample of 500 family practitioners and 500 internists. This sample was obtained from the American Academy of Family Physicians and American Society of Internal Medicine (500 from each organization).

RESULTS

The overall response rate was 54%. The majority (78%) refer more than 50% of their GERD patients for EGD; however, 34% also refer more than 10% of their patients for barium studies. Primary care physicians cited alarm symptoms, refractory symptoms, and chronicity and severity of symptoms as the major indications for referral for EGD. Gender, age, obesity, and tobacco use were cited less frequently. Cost of endoscopy, poor patient acceptance, and lack of evidence were the most common reasons cited for not referring for EGD. A majority of respondents (62%) indicated that the availability of UE would increase referral for the procedure, and 52% would be willing to perform UE in their office.

CONCLUSIONS

Severe, refractory, and chronic symptoms are the primary reasons for endoscopic referral from primary care physicians who manage patients with GERD. Other risk factors for BE, such as gender and age, do not appear to be important determinants for endoscopic referral. Further evaluation of UE as a mechanism to increase screening for BE in primary care patients is merited.

Accuracy of endoscopic optical coherence tomography in the detection of dysplasia in Barrett's esophagus: a prospective, double-blinded study

BACKGROUND

Endoscopic optical coherence tomography (EOCT) is a high-resolution, cross-sectional tissue-imaging technique that provides microscopic morphologic information. EOCT should detect dysplasia in Barrett's epithelium, but this has not been established in a prospective blinded study. This study evaluated the accuracy of EOCT for the diagnosis and the exclusion of dysplasia in patients with Barrett's esophagus.

METHODS

A 2.4-mm diameter EOCT probe was modified for use with a cap-fitted, two-channel endoscope. Pairs of EOCT image streams and jumbo biopsy specimens were obtained. Endoscopy/EOCT procedures were performed by 4 endoscopists who separately reviewed the EOCT digital images for the absence or the presence of dysplasia (low grade, high grade, or cancer) for each biopsy specimen obtained. The endoscopists were blinded to the interpretation of the pathology. An experienced pathologist blinded to the endoscopic/EOCT findings evaluated each biopsy for the absence or the presence of dysplasia. The setting of the study was a major academic medical center. Adult patients with documented Barrett's esophagus greater than 2 cm were included in the study. The main outcome measurement was the accuracy of EOCT in the detection of dysplasia in patients with Barrett's esophagus.

RESULTS

A total of 314 usable EOCT image stream/biopsy pairs were obtained in 33 patients. By using histology as the standard, the performance of EOCT was sensitivity, 68%; specificity, 82%; positive predictive value, 53%; negative predictive value, 89%; and diagnostic accuracy, 78%. Diagnostic accuracy for the 4 endoscopists ranged from 56% to 98%. Limitations of the study were the variability in endoscopists' accuracy rates, difficulty in real-time interpretation, and the need for refined criteria of dysplasia by EOCT imaging.

CONCLUSIONS

The current EOCT system has an accuracy of 78% for the detection of dysplasia in patients with Barrett's esophagus. EOCT could be used to target biopsies to areas of Barrett's epithelium with a higher probability for the presence of dysplasia. However, further modifications, including increased resolution and identification of further potential OCT characteristics of dysplasia, are needed before EOCT can be used clinically.

In vivo optical coherence tomography imaging of the pancreatic and biliary ductal system

BACKGROUND

In vivo optical coherence tomography (OCT) imaging has not yet been applied to the pancreatic ductal system. The aim of this study was to obtain in vivo OCT images of dog pancreatic and biliary ducts, and to correlate the images with histology.

METHODS

Images of dog pancreatic and biliary ducts were obtained by using an in vivo OCT probe introduced through the respective papillary orifices. Each duct was imaged in multiple locations, and the site of imaging was marked with injected India ink. After imaging, the dogs were euthanized, and the pancreaticobiliary system was harvested. Histologic cross sections were correlated with in vivo OCT images by measuring the structures seen on in vivo OCT images and correlating them with structures seen on corresponding histology slides that contained India ink.

OBSERVATIONS

Eighteen pairs of in vivo OCT images and histology slides from the bile duct and the pancreatic duct were obtained from 5 dogs. The entire duct wall could be visualized. A low reflective in vivo OCT layer corresponding to the epithelium could be discerned on many images. The bile duct showed a more complex architecture and had greater variations within the reflective OCT layers, possibly because of greater cellularity within the lamina propria. Nuclei within cells could not be identified, and structures adjacent to the ducts could not be imaged.

CONCLUSIONS

In vivo OCT is capable of imaging the pancreaticobiliary ductal system and of identifying the epithelial layer. Because of limited depth of imaging (320-845 micron), OCT is unlikely to serve the purpose of tumor staging.

The changing landscape of practice patterns regarding unsedated endoscopy and propofol use: a national Web survey

BACKGROUND

Lower reimbursements for endoscopic procedures and increasing demand for screening endoscopy over the past decade have spurred efforts to increase efficiency in the performance of endoscopic procedures. Two dichotomous approaches have emerged: (1) unsedated endoscopy and (2) propofol sedation. The aim was to determine national practice patterns of unsedated endoscopy and propofol sedation, and to assess endoscopists' attitudes toward unsedated screening with an electronic survey.

METHODS

A short survey was developed and then was converted to a Web-based format. All national members of the American Society for Gastrointestinal Endoscopy (ASGE) were invited via electronic mail (e-mail) to participate. Survey data were collected electronically.

RESULTS

Two e-mails elicited responses to the Web survey from 18% (724) of national ASGE members contacted, within 2 weeks. Of the respondents, 45% do not routinely offer unsedated EGD and colonoscopy, and only 15% of those respondents plan to incorporate unsedated endoscopy into their practice in the next year. Of the 55% who currently perform unsedated endoscopy, 85% do no more than 25 unsedated procedures per year. Lack of patient acceptance was the most common reason cited for not offering unsedated endoscopy. Most endoscopists felt that the availability of unsedated esophagoscopy or colonoscopy would not significantly increase screening for Barrett's esophagus or colonic polyps/colorectal cancer, respectively. Routine use of propofol sedation for EGD, colonoscopy, and ERCP/EUS was reported by 19%, 22%, and 19%, respectively. Community practitioners were more likely to use propofol than those at academic centers (p < 0.0002 for all). Of those not currently using propofol, 43% plan to incorporate it into their practice within the next year. Over 70% of respondents would themselves choose to be sedated for routine endoscopic procedures.

CONCLUSIONS

Electronic surveys allow for rapid distribution and data collection but suffer from a limited response rate. The survey suggests that unsedated endoscopy has limited acceptance in the United States, and, without a major intervention that affects endoscopists' attitudes, its use is not likely to increase significantly. Unsedated endoscopy will not have a great impact on endoscopic screening. In contrast, propofol sedation has already gained acceptance in the community, and the routine use of propofol in endoscopy units will likely increase in the future.

The yield of bleeding scans in acute lower gastrointestinal hemorrhage

GOALS/BACKGROUND

Previous studies have demonstrated low yield and conflicting results as to the ability of technetium-99m labeled red blood cell (TRBC) scintigraphy to accurately localize the site of bleeding in acute lower gastrointestinal hemorrhage. Our objective was to evaluate the accuracy of TRBC scintigraphy in clinical day-to-day practice at our institution and to determine predictors of a positive test.

METHODS

A retrospective medical records review of all patients who underwent TRBC scintigraphy over a 5-year period was conducted at a single academic medical center. The site of bleeding found on TRBC scintigraphy was correlated with the endoscopic, angiographic, surgical, and pathologic findings in each patient.

RESULTS

A total of 127 scans were performed in 115 patients. Forty-nine scans were positive (39%) and 78 were negative (61%). Forty-two patients had further evaluation after a positive scan, and the bleeding site was confirmed to be accurate in 20 of 42 patients (48%). A contradictory bleeding site was found in 5 of 49 positive scans (10%). Patients transfused greater than 2 units of packed red blood cells within 24 hours preceding the TRBC scan were twice as likely to have a positive scan (64%) than those transfused 2 units or less (32%) (P = 0.002). Multivariate analysis demonstrated that the number of units of blood transfused within 24 hours prior to the TRBC scan and the lowest recorded hematocrit were significantly different between patients with positive and negative scans. There was no difference in the rate of endoscopy between patients with a positive or negative scan result.

CONCLUSIONS

TRBC scintigraphy has a relatively low yield in the evaluation of acute lower gastrointestinal bleeding. Objective selection criteria such as number of units of packed red blood cells transfused prior to obtaining the scan may increase the overall yield.

Correlation of endoscopic optical coherence tomography with histology in the lower-GI tract

BACKGROUND

Optical coherence tomography (OCT), a noninvasive optical imaging technique, provides high-resolution cross-sectional images of tissue microstructure. We developed a system for real-time endoscopic OCT (EOCT) of the human GI tract. During clinical trials, the structure of mucosa and submucosa, glands, blood vessels, pits, villi, and crypts was observed in a range of GI organs. Although EOCT images are thought to accurately depict actual histologic features, there are few data to support this assumption. Therefore, the present study correlated images acquired with an EOCT imaging system in vitro to corresponding histologic sections.

METHODS

EOCT images were obtained of fresh specimens of ileum, colon, and rectum that then were fixed in formalin and were processed for microscopic evaluation by using standard methods. The thickness of mucosa and of submucosa was determined for both EOCT images and histologic slides.

RESULTS

The first hyper-reflective layer in the EOCT images was identified as mucosa. A close correlation (R 2=0.84) was observed between EOCT and histology. Furthermore, the submucosa and the muscularis propria could be identified as the next deepest hyporeflective band and a hyper-reflective layer, respectively, in EOCT images. The submucosa was found to be more compressible than mucosa, and its EOCT appearance was dependent on its content of adipose tissue.

CONCLUSIONS

EOCT provides images that precisely correlate with the histologic structure of the mucosa and the submucosa of the GI tract.

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUND

Impaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication.

METHODS

Two reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated.

RESULTS

Five trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement.

CONCLUSIONS

Prophylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.

An international survey of the clinical practice of EUS

BACKGROUND

No comparative information exists regarding clinical variations in EUS practice patterns among American and international endosonographers.

METHODS

Eligible attendees of the XIIIth International Symposium on EUS, October 4-6 2002, New York, New York, were asked to complete a 2-page survey questionnaire on clinical practice of EUS.

RESULTS

A total of 191 of 391 eligible attendees (48.9%) participated in the survey (110 from the United States, 81 from 30 different countries). The mean age of participants was 40.5 (10.6) years, and 171 (89.5%) were men. A total of 102 endosonographers (53.4%) were in academic practice. The majority (150, 78.5%) also performed ERCP. Seventy-eight (40.8%) had performed EUS for more than 5 years and 21 (11%) for less than 1 year. Only 36 (18.8%) had more than 6 months of dedicated hands-on EUS training, and more than a third of the respondents learned to perform EUS by observing others or they were self-taught. Compared with respondents from the United States, relatively fewer international respondents were performing open-access EUS, pancreatobiliary EUS procedures, and interventions such as EUS-guided FNA and celiac plexus neuralysis.

CONCLUSIONS

This survey provides insight into the status of EUS as practiced in the United States and internationally. Although it appears that over the last decade EUS has become disseminated fairly uniformly on a global basis, a lack of consistent training standards and also inadequate opportunities for EUS training remain important areas of concern.

Does prophylactic pancreatic stent placement reduce the risk of post-ERCP acute pancreatitis? A meta-analysis of controlled trials

BACKGROUND

Impaired drainage of the pancreatic duct is one of the possible triggers for post-ERCP acute pancreatitis. The aim of this meta-analysis was to determine whether temporary stent placement across the main pancreatic-duct orifice lowers the frequency of post-ERCP acute pancreatitis in patients at high risk for this complication.

METHODS

Two reviewers systematically identified prospective studies that (1) compared the risk of post-ERCP acute pancreatitis in patients with pancreatic stent placement vs. no stent placement and (2) included patients at high risk of developing this complication. Studies were assessed for methodologic quality and variations in execution and design. Frequency and severity of post-ERCP acute pancreatitis were the primary outcomes evaluated.

RESULTS

Five trials involving 481 patients were selected. Of the 481, 55 (11.4%) patients developed pancreatitis after ERCP. Patients in the no stent group had 3-fold higher odds of developing pancreatitis compared with the stent group (15.5% vs. 5.8%; OR 3.2: 95% CI[1.6, 6.4]). Number needed to treat analysis showed that one in every 10 patients (95% CI[6,18]) could be expected to benefit from pancreatic-duct stent placement.

CONCLUSIONS

Prophylactic temporary stent placement across the main pancreatic-duct orifice reduces the risk of post-ERCP acute pancreatitis in patients at risk for developing this complication.

Acute pancreatitis after EUS-guided FNA of solid pancreatic masses: a pooled analysis from EUS centers in the United States

BACKGROUND

The aim of this study was to determine the frequency and the severity of pancreatitis after EUS-guided FNA of solid pancreatic masses. A survey of centers that offer training in EUS in the United States was conducted.

METHODS

A list of centers in which training in EUS is offered was obtained from the Web site of the American Society for Gastrointestinal Endoscopy. Designated program directors were contacted via e-mail. The information requested included the number of EUS-guided FNA procedures performed for solid pancreatic masses, the number of cases of post-procedure pancreatitis, and the method for tracking complications. For each episode of pancreatitis, technical details were obtained about the procedure, including the location of the mass, the type of fine needle used, the number of needle passes, and the nature of the lesion.

RESULTS

Nineteen of the 27 programs contacted returned the questionnaire (70%). In total, 4909 EUS-guided FNAs of solid pancreatic masses were performed in these 19 centers over a mean of 4 years (range 11 months to 9 years). Pancreatitis occurred after 14 (0.29%): 95% CI[0.16, 0.48] procedures. At two centers in which data on complications were prospectively collected, the frequency of acute pancreatitis was 0.64%, suggesting that the frequency of pancreatitis in the retrospective cohort (0.26%) was under-reported (p=0.22). The odds that cases of pancreatitis would be reported were 2.45 greater for the prospective compared with the retrospective cohort (95% CI[0.55, 10.98]). The median duration of hospitalization for treatment of pancreatitis was 3 days (range 1-21 days). The pancreatitis was classified as mild in 10 cases, moderate in 3, and severe in one; one death (proximate cause, pulmonary embolism) occurred after the development of pancreatitis in a patient with multiple comorbid conditions.

CONCLUSIONS

EUS-guided FNA of solid pancreatic masses is infrequently associated with acute pancreatitis. The procedure appears to be safe when performed by experienced endosonographers. The frequency of post EUS-guided FNA pancreatitis may be underestimated by retrospective analysis.

Computed tomographic colonography (virtual colonoscopy): a multicenter comparison with standard colonoscopy for detection of colorectal neoplasia

CONTEXT

Conventional colonoscopy is the best available method for detection of colorectal cancer; however, it is invasive and not without risk. Computed tomographic colonography (CTC), also known as virtual colonoscopy, has been reported to be reasonably accurate in the diagnosis of colorectal neoplasia in studies performed at expert centers.

OBJECTIVE

To assess the accuracy of CTC in a large number of participants across multiple centers.

DESIGN, SETTING, AND PARTICIPANTS

A nonrandomized, evaluator-blinded, noninferiority study design of 615 participants aged 50 years or older who were referred for routine, clinically indicated colonoscopy in 9 major hospital centers between April 17, 2000, and October 3, 2001. The CTC was performed by using multislice scanners immediately before standard colonoscopy; findings at colonoscopy were reported before and after segmental unblinding to the CTC results.

MAIN OUTCOME MEASURES

The sensitivity and specificity of CTC and conventional colonoscopy in detecting participants with lesions sized at least 6 mm. Secondary outcomes included detection of all lesions, detection of advanced lesions, possible technical confounders, participant preferences, and evidence for increasing accuracy with experience.

RESULTS

A total of 827 lesions were detected in 308 of 600 participants who underwent both procedures; 104 participants had lesions sized at least 6 mm. The sensitivity of CTC for detecting participants with 1 or more lesions sized at least 6 mm was 39.0% (95% confidence interval [CI], 29.6%-48.4%) and for lesions sized at least 10 mm, it was 55.0% (95% CI, 39.9%-70.0%). These results were significantly lower than those for conventional colonoscopy, with sensitivities of 99.0% (95% CI, 97.1%->99.9%) and 100%, respectively. A total of 496 participants were without any lesion sized at least 6 mm. The specificity of CTC and conventional colonoscopy for detecting participants without any lesion sized at least 6 mm was 90.5% (95% CI, 87.9%-93.1%) and 100%, respectively, and without lesions sized at least 10 mm, 96.0% (95% CI, 94.3%-97.6%) and 100%, respectively. Computed tomographic colonography missed 2 of 8 cancers. The accuracy of CTC varied considerably between centers and did not improve as the study progressed. Participants expressed no clear preference for either technique.

CONCLUSIONS

Computed tomographic colonography by these methods is not yet ready for widespread clinical application. Techniques and training need to be improved.

Sphincter of Oddi manometry does not predispose to post-ERCP acute pancreatitis

BACKGROUND

Sphincter of Oddi manometry is helpful in selecting patients with sphincter of Oddi dysfunction who will respond to sphincterotomy. However, studies have shown that sphincter of Oddi manometry is associated with a high risk of post-procedure pancreatitis. The primary objective of this study was to evaluate the safety of sphincter of Oddi manometry in patients with sphincter of 2Oddi dysfunction. The secondary objective was to determine the risk factors for post-ERCP pancreatitis in patients with sphincter of Oddi dysfunction.

METHODS

Data were collected retrospectively for 268 patients who had elective ERCP performed at 3 tertiary care medical centers between 1996 and 2000. Consecutive patients with suspected sphincter of Oddi dysfunction formed the case group; the control group consisted of patients with bile duct stone. The case group was further subclassified into group A, patients who underwent sphincter of Oddi manometry followed by immediate ERCP, and group B, patients who had ERCP without manometry. The rate of post-ERCP acute pancreatitis was compared between case and control groups.

RESULTS

Twenty-seven percent of patients in the case group with suspected sphincter of Oddi dysfunction developed acute pancreatitis compared with 3.2% of patients in the control group with bile duct stone (p<0.001). There was no significant difference in the rate of acute pancreatitis in patients with sphincter of Oddi dysfunction who underwent sphincter of Oddi manometry and ERCP compared with patients with sphincter of Oddi dysfunction who had ERCP without sphincter of Oddi manometry (odds ratio 0.72: 95% CI[0.08, 9.2]). Multivariable logistic regression analysis showed that biliary sphincterotomy (p=0.006) and pancreatography (p=0.03) were independent predictors of acute pancreatitis.

CONCLUSIONS

Patients with suspected sphincter of Oddi dysfunction are at higher risk of post-ERCP acute pancreatitis. Sphincter of Oddi manometry by itself does not appear to predispose to this complication.

Success and shortcomings of a clinical care pathway in the management of acute nonvariceal upper gastrointestinal bleeding

OBJECTIVES

Acute nonvariceal upper gastrointestinal (GI) bleeding is the most common medical emergency encountered by gastroenterologists resulting in high patient morbidity and cost. We sought to establish if a GI bleeding clinical care pathway could improve the quality and cost effectiveness of inpatient medical care.

METHODS

A disease management program for acute upper GI bleeding was established. Length of stay, time to endoscopy, utilization of potentially unnecessary radiological tests, acid suppression, and cost of care were compared between patients pre- and postinitiation of GI bleeding pathway guidelines.

RESULTS

The instituted GI bleeding management program significantly reduced the use of intravenous H2-blockade from 65.3% to 47.7% (p = 0.002). The use of radiological tests, time to endoscopy, and length of hospital of stay were unchanged. There was a trend toward a reduction in total cost and variable direct cost per patient admitted with acute upper GI bleeding, from $5,381 to $4,627 and from $2,269 to $1,952, respectively.

CONCLUSION

A clinical care pathway may affect the management of acute upper GI bleeding and reduce costs. However, there are significant limitations and barriers to the overall effectiveness of such a pathway in actual clinical practice.

Endoscopic management of adenoma of the major duodenal papilla

BACKGROUND

It is well established that adenoma of the major duodenal papilla has a potential for malignant transformation. Standard treatment has been surgical (duodenotomy/local resection, pancreaticoduodenectomy). Endoscopic management is described, but there is no established consensus regarding the approach to papillectomy or the need for surveillance. This study describes endoscopic management and long-term follow-up of papillary tumors by 4 groups of expert pancreaticobiliary endoscopists.

METHODS

Consecutive patients with papillary tumors referred to 4 pancreaticobiliary endoscopy centers for evaluation for endoscopic papillectomy were reviewed. For each patient, an extensive questionnaire was completed, which included 19 preoperative and 15 postoperative data points. A total of 103 patients (53 women, 50 men, age range 24-93) who underwent attempted endoscopic resection were included. Of these, 72 had sporadic adenoma, and the remaining patients had familial adenomatous polyposis, including Gardner's variant. Presenting symptoms were jaundice/cholangitis/pain (n=59), pancreatitis (n=18), and bleeding (n=12). Twenty-six patients were asymptomatic.

RESULTS

Endoscopic treatment was successful, long term, in 83 patients (80%) and failed (initial failure or recurrent tumor) in 20 (20%) patients. Success was significantly associated with older age (54.7 [16.6] vs. 46.6 [21.7] years; p=0.08) and smaller lesions (21.1 [8.3] vs. 29.7 [7.2] mm; p<0.0001). Success rate was higher for sporadic lesions compared with genetically determined lesions (63 of 72 [86%] vs. 20 of 31 [67%]; p=0.02). There were 10 initial failures, which was more common for sporadic lesions (7 of 10). The overall success rate for papillectomy was similar in patients who had adjuvant thermal ablation (81%) compared with those who did not (78%). However, recurrence (n=10) was more common in the former group (9 of 10, [90%]; p=0.22). Complications (n=10) included acute pancreatitis (n=5), bleeding (n=2), and late papillary stenosis (n=3). Acute pancreatitis was more common in patients who did not have pancreatic duct stents placed (17% vs. 3.3%). Papillary stenosis was more frequent without short-term pancreatic duct stent placement (15.4% vs. 1.1%), although the difference was not statistically significant, because this complication was infrequent.

CONCLUSIONS

Endoscopic treatment of papillary adenoma in selected patients appears to be highly successful. The majority can undergo complete resection after ERCP. In expert hands, complications are infrequent and may be avoided by routine placement of a pancreatic duct stent.

Long-term follow-up of patients with clinically indeterminate suspicion of pancreatic cancer and normal EUS

BACKGROUND

EUS often is performed because of a clinical suspicion of pancreatic cancer when the results of other noninvasive diagnostic tests are indeterminate. The aim of this study was to determine the true negative predictive value of a normal EUS in a cohort of patients with an indeterminate suspicion of pancreatic cancer by obtaining long-term follow-up information.

METHODS

Patients referred for EUS of the pancreas for the following indications were identified: elevated carbohydrate-associated antigen (CA 19-9) without other definitive evidence of pancreatic cancer, subtle abnormalities on CT of the pancreas, and unexplained abdominal pain and/or weight loss. Endoscopy procedure reports, as well as inpatient and outpatient records were obtained. In addition, referring physicians, as well as patients, were contacted to acquire adequate follow-up information.

RESULTS

A total of 80 patients were included in the study. Follow-up of at least 6 months was obtained for 76 (95%) patients (mean follow-up 23.9 months). No patient with a normal EUS of the pancreas developed pancreatic cancer or required pancreatic surgery during the follow-up period. One patient in whom a diagnosis of chronic pancreatitis was made by EUS subsequently was found to have pancreatic cancer at surgery.

CONCLUSIONS

A normal EUS of the pancreas in the setting of subtle radiologic findings, serologic abnormalities, and/or nonspecific symptoms definitively rules out the presence of pancreatic cancer.

Prediction of outcome in acute lower-gastrointestinal haemorrhage based on an artificial neural network: internal and external validation of a predictive model

BACKGROUND

Models based on artificial neural networks (ANN) are useful in predicting outcome of various disorders. There is currently no useful predictive model for risk assessment in acute lower-gastrointestinal haemorrhage. We investigated whether ANN models using information available during triage could predict clinical outcome in patients with this disorder.

METHODS

ANN and multiple-logistic-regression (MLR) models were constructed from non-endoscopic data of patients admitted with acute lower-gastrointestinal haemorrhage. The performance of ANN in classifying patients into high-risk and low-risk groups was compared with that of another validated scoring system (BLEED), with the outcome variables recurrent bleeding, death, and therapeutic interventions for control of haemorrhage. The ANN models were trained with data from patients admitted to the primary institution during the first 12 months (n=120) and then internally validated with data from patients admitted to the same institution during the next 6 months (n=70). The ANN models were then externally validated and direct comparison made with MLR in patients admitted to an independent institution in another US state (n=142).

FINDINGS

Clinical features were similar for training and validation groups. The predictive accuracy of ANN was significantly better than that of BLEED (predictive accuracy in internal validation group for death 87% vs 21%; for recurrent bleeding 89% vs 41%; and for intervention 96% vs 46%) and similar to MLR. During external validation, ANN performed well in predicting death (97%), recurrent bleeding (93%), and need for intervention (94%), and it was superior to MLR (70%, 73%, and 70%, respectively).

INTERPRETATION

ANN can accurately predict the outcome for patients presenting with acute lower-gastrointestinal haemorrhage and may be generally useful for the risk stratification of these patients.

Criteria for the diagnosis of dysplasia by endoscopic optical coherence tomography

BACKGROUND

Endoscopic optical coherence tomography provides images of the GI mucosa and submucosa in microscopic detail. It is unknown whether endoscopic optical coherence tomography can reliably detect dysplasia. Colon polyps were used as a model to determine whether dysplasia in GI tissue has characteristic optical coherence tomography imaging features.

METHODS

Endoscopic optical coherence tomography images of colon polyps and normal colon tissue were obtained at colonoscopy. In real time, endoscopists compared tissue organization and light scattering for polyps and normal mucosa with endoscopic optical coherence tomography. Imaged polyps were removed and evaluated histopathologically. Organization and light scattering, as assessed by endoscopic optical coherence tomography at colonoscopy, were compared for adenomas versus hyperplastic polyps. A computer program also quantified and compared the degree of light scattering for hyperplastic polyps and adenomas.

RESULTS

A total of 44 polyps were imaged in 24 patients (30 adenomas, 14 hyperplastic polyps). Endoscopic optical coherence tomography images of adenomas had significantly less structure (p = 0.0005) and scattered light to a lesser degree than hyperplastic polyps (p = 0.0007). Hyperplastic polyps were significantly closer in organization (p = 0.0003) and light scattering (p = 0.0006) to normal mucosa as compared with adenomas. By digital image analysis, the light-scattering property of hyperplastic polyps was closer to normal mucosa compared with adenomas (14.86 vs. 45.81; p = 0.0001).

CONCLUSIONS

Real-time endoscopic optical coherence tomography imaging differentiated adenomas, hyperplastic polyps, and normal colon tissue. By using the colon adenoma as a model, the endoscopic optical coherence tomography characteristics of dysplasia are loss of tissue organization and reduced light scattering.

Clinical utility of intraductal US for evaluation of choledocholithiasis

BACKGROUND

Intraductal US can improve the diagnostic accuracy of cholangiography performed under C-arm fluoroscopy in patients with suspected choledocholithiasis. This study aimed to determine the clinical utility of intraductal US for patient management.

METHODS

Patients with suspected choledocholithiasis undergoing ERCP with a C-arm fluoroscope at two tertiary academic medical centers were enrolled. After initial cholangiography, findings and decisions concerning the need for further interventions were recorded. Intraductal US (20 MHz) was then selectively performed in patients with equivocal cholangiography or those without cholangiographic evidence of bile duct stones. Intraductal US was also performed after endoscopic sphincterotomy and stone extraction to confirm bile duct clearance.

RESULTS

Fifty-two patients (28 men, 24 women) were enrolled and intraductal US was selectively performed in 35 (64%). Of the 21 patients with normal cholangiography, 8 (38%) had stones or sludge by intraductal US. Endoscopic sphincterotomy was performed as a direct result of intraductal US in these 8 and the findings were confirmed in 7. In the 14 patients in whom cholangiography demonstrated small (<5 mm) or round filling defects, intraductal US concurred in 9 and found air bubble/no stone in 5. Sphincterotomy was avoided in these 5 patients. Overall, intraductal US led to a change in clinical management in 13 of 35 patients (37%) in whom it was performed.

CONCLUSIONS

Selective use of intraductal US affects the clinical management of a large proportion of patients who undergo C-arm fluoroscopy-guided ERCP for suspected bile duct stones.

Prospective evaluation of 4-mm diameter endoscopes for esophagoscopy in sedated and unsedated patients

BACKGROUND

Unsedated esophagoscopy with small-diameter endoscopes is generally well tolerated but of limited sensitivity for the diagnosis of esophageal mucosal disease. This study evaluated the sensitivity of esophagoscopy performed with new 4-mm diameter prototype battery-powered and video endoscopes. Patient tolerance for an unsedated examination with the 4-mm endoscopes was assessed and the performance characteristics of the battery-powered and video 4-mm endoscopes were compared.

METHODS

Patients referred for EGD were recruited to undergo an additional examination with a 4-mm endoscope. A prototype 60-cm long, 4-mm diameter battery-powered fiberoptic esophagoscope was used in the first 24 patients and a prototype 60-cm long, 4-mm diameter video esophagoscope in the next 27 patients. Examiners who were unaware of patient history and procedure indications recorded esophageal findings, ease of intubation, optical quality (5-point visual scale), and time for examination of the esophagus and then recorded esophageal findings after the standard EGD.

RESULTS

The sensitivity, specificity, and accuracy for identification of Barrett's esophagus was 100%; overall sensitivity, accuracy, and specificity for detecting esophageal lesions were, respectively, 91%, 98%, and 99%. Patient tolerance (assessed by symptom scores for choking, pain, and discomfort) and acceptability of unsedated esophagoscopy with the 4-mm diameter instruments were significantly better than in a historical group of patients examined with a 3-mm diameter endoscope. The optical quality of video endoscope was rated as superior to that of battery-powered endoscope, and esophageal examination was performed significantly quicker with the video versus the battery-powered endoscope (68 vs. 137 seconds; p = 0.001).

CONCLUSIONS

Unsedated esophagoscopy with 4-mm diameter endoscopes may be an alternative to EGD for screening for Barrett's esophagus. Given the current state of endoscopic technology, a minimum diameter of 4 mm is required for satisfactory esophageal imaging.

Effectiveness of open-access endoscopy in routine primary-care practice

BACKGROUND

Direct referral of patients for endoscopic procedures without prior consultation (open-access endoscopy) has become commonplace. However, the effect of open-access endoscopy on the care of patients in routine clinical practice has not been studied.

METHODS

The impact of open-access endoscopy was examined in 168 consecutive patients referred from 8 primary-care practices to our tertiary hospital-based endoscopy center. The effectiveness of open-access endoscopy was assessed by review of office medical records at the primary-care practice sites for a minimum follow-up period of 6 months. Outcome measures evaluated included postprocedure communication between primary-care physician and patient, primary-care physician adherence to postprocedure recommendations, and the need for subsequent diagnostic evaluation and/or consultation.

RESULTS

The mean age of the 168 patients was 60 years; 56 (33%) underwent EGD and 112 (67%) had colonoscopy; 65% were from hospital-based practices and 35% from community practices. The indication(s) for 77% of the procedures met American Society for Gastrointestinal Endoscopy guidelines for the appropriate use of endoscopy. An office follow-up was noted for 82% of patients after the open-access procedure. Discussion of results was documented in 61% of the patient charts. Compliance with diagnostic and therapeutic recommendations was documented, respectively, in 75% and 90% of patient charts. A follow-up GI consultation was requested for only 7% of the patients.

CONCLUSION

Open-access endoscopy in the primary-care setting is effective to the extent that subsequent GI consultations are rare and the level of compliance with endoscopist recommendations is high. However, documentation of communication of the results of endoscopy with the patient can be improved.

Endoscopic retrograde cholangiopancreatography in children and adolescents

OBJECTIVES

Endoscopic retrograde cholangiopancreatography (ERCP) is becoming a more frequently used diagnostic and therapeutic tool in children. We sought to determine the indications, feasibility, safety, and effect on patient management of ERCP in pediatric patients of varying age.

METHODS

All ERCPs performed during a 4-year period in patients aged 18 years or less at an academic hospital were retrospectively reviewed. The indications, type of anesthesia administered, type of duodenoscope used, diagnostic findings, therapeutic interventions, complication rate, and effect on management were compared between children (age 0-12 years) and adolescents (age 13-18 years).

RESULTS

A total of 53 procedures were performed in 43 patients whose median age was 13.5 years. ERCP was successful in 50 of 53 cases (94%) with a complication rate of 6%. Endoscopic therapy was provided in 24 of 53 cases (45%). Compared with adolescents (n = 28), children (n = 25) were more likely to receive general anesthesia (96% vs. 29%; P < 0.001) and undergo ERCP with a pediatric duodenoscope (0% vs. 40%). ERCP affected management in 73% of cases, equally in both groups.

CONCLUSION

ERCP is a successful and safe diagnostic and therapeutic modality in a variety of pancreatobiliary disorders that directly affects management in children of all ages.

Endoscopic ultrasound-guided fine needle aspiration in the diagnosis of mediastinal masses of unknown origin

OBJECTIVES

The ability of endosonography to diagnose a variety of gastrointestinal pathology has been significantly advanced with the introduction of endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) biopsy. EUS-FNA technology can also be applied to the evaluation of non-GI disorders. The role of EUS-FNA to establish the diagnosis of unexplained mediastinal masses has not been previously described. The aim of this study was to determine the diagnostic accuracy, impact on subsequent workup, and role of EUS-FNA in treating mediastinal masses of unknown cause.

METHODS

A total of 26 patients (15 men and 11 women, mean age 61 yr, range 39-77 yr) underwent EUS-FNA in patients presenting with unexplained mediastinal masses at four tertiary referral centers. Presenting symptoms included: chest pain (10 patients), dysphagia (eight), cough (seven), fever (six), night sweats (three), and no symptoms/abnormal x-ray (five patients). Five of 26 patients had prior history of cancer (three lung, one tracheal, and one esophageal).

RESULTS

Final diagnosis using EUS-FNA, surgery, autopsy, other diagnostic study, or long-term follow-up was available in all patients. EUS-FNA results were classified under three disease categories: 1) infectious, 2) benign/ inflammatory, and 3) malignant. Final diagnosis included infectious in five patents, benign/inflammatory in nine, and malignant in 12. EUS-FNA was successful in 21 of 26 patients (81%) for all disease categories (infectious 60%, benign/inflammatory 78%, and malignant 92%). EUS-FNA was successful in directing subsequent workup in 77% (20 of 26) and therapy in 73% (19 of 26). Mean EUS-FNA passes for adequate tissue sampling was lower of nonmalignant disease categories (3.0 and 3.4) versus malignant disease (4.4). No complications were seen during the course of this study.

CONCLUSIONS

EUS-FNA in patients presenting with idiopathic mediastinal masses establishes the diagnosis in the vast majority of cases, particularly for those with malignant disease. The emergence of transesophageal EUS-FNA of the mediastinum provides the ability to alter subsequent workup and therapy, obviating the need for more invasive diagnostic studies such as thoracotomy.

Familial aggregation of Barrett's oesophagus, oesophageal adenocarcinoma, and oesophagogastric junctional adenocarcinoma in Caucasian adults

BACKGROUND

Although familial clusters of Barrett's oesophagus and oesophageal adenocarcinoma have been reported, a familial predisposition to these diseases has not been systematically investigated.

AIMS

To determine whether Barrett's oesophagus and oesophageal (or oesophagogastric junctional) adenocarcinoma aggregate in families.

PATIENTS AND METHODS

A structured questionnaire eliciting details on reflux symptoms, exposure history, and family history was given to Caucasian case (n=58) subjects with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma, and to Caucasian control (n=106) subjects with symptomatic gastro-oesophageal reflux disease without Barrett's oesophagus. Reported diagnoses of family members were confirmed by review of medical records.

RESULTS

The presence of a positive family history (that is, first or second degree relative with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma) was significantly higher among case subjects compared with controls (24% v 5%; p<0.005). Case subjects were more likely to be older (p<0.001) and male (74% v 43% male; p<0.0005) compared with control subjects. In a multivariate logistic regression analysis, family history was independently associated with the presence of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma (odds ratio 12.23, 95% confidence interval 3.34-44.76) after adjusting for age, sex, and the presence of obesity 10 or more years prior to study enrollment.

CONCLUSIONS

Individuals with Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma are more likely to have a positive family history of Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma than individuals without Barrett's oesophagus, oesophageal adenocarcinoma, or oesophagogastric junctional adenocarcinoma. A positive family history should be considered when making decisions about screening endoscopy in patients with symptoms of gastro-oesophageal reflux.

EUS-guided fine needle aspiration of idiopathic abdominal masses

BACKGROUND

EUS-guided fine needle aspiration (EUS-FNA) has significantly increased the diagnostic capability of EUS. FNA can also be helpful in the diagnosis of non-GI disorders. The role of EUS-FNA in the diagnosis of idiopathic abdominal masses has not been determined. This study evaluated the diagnostic accuracy of EUS-FNA of abdominal masses of unknown cause and its impact on subsequent evaluation and therapy.

METHODS

Thirty-four patients from 5 tertiary referral centers (21 women, 13 men; mean age 54 years, range 27-72 years) with idiopathic abdominal masses underwent EUS-FNA. Presenting symptoms included the following: pain (29 patients), weight loss (15), altered bowel habits (7), nausea/vomiting (6), abnormal liver function tests (4), palpable mass (4), and urinary retention (1). Four patients had a history of intra-abdominal cancer (2 cervical, 1 ovarian, 1 colon). A final diagnosis by EUS-FNA, surgery, autopsy, or long-term follow-up was available in all patients. Abdominal masses were classified into 3 disease categories: infectious, benign/inflammatory, and malignant.

RESULTS

Final diagnosis included infectious (5), benign/inflammatory (6), and malignant (23) abdominal mass. Overall, EUS-FNA established a tissue diagnosis in 29 of 34 patients (85%) in all 3 categories (infectious, 80%; benign/inflammatory, 67%; malignant, 91%). EUS-FNA was instrumental in directing subsequent evaluation in 29 patients (85%) and therapy in 26 (77%). The number of fine needle passes for adequate tissue sampling was lower for nonmalignant (2.2-3.2) versus malignant diseases (4.6). One complication occurred (perirectal abscess) and was treated successfully with antibiotics.

CONCLUSIONS

EUS-FNA of idiopathic abdominal masses is safe and accurate and helps to guide subsequent evaluation and therapy in the majority of patients. The most common and promising area seems to be EUS-FNA of malignant abdominal masses. Transluminal EUS-FNA provides minimally invasive tissue sampling and obviates the need for exploratory laparotomy.

Patient tolerance and acceptance of unsedated ultrathin esophagoscopy

BACKGROUND

Unsedated endoscopy has not gained wide acceptance in the United States. Factors that may predict tolerance and acceptance of unsedated endoscopy are ill defined.

METHODS

Outpatients referred for standard EGD were recruited to undergo unsedated ultrathin esophagoscopy (UUE) with a new 3.1-mm battery-powered esophagoscope before sedated EGD. They rated preprocedure and postprocedure anxiety levels with the Profile of Mood States Tension/Anxiety subscale (POMS-SF T/A). They also rated symptoms and overall acceptability and listed procedural preference between EGD and UUE. Patients who refused UUE noted a reason for refusal and also completed the anxiety questionnaire.

RESULTS

Fifty-two of 98 patients recruited agreed to participate, and underwent both UUE and EGD. Patients who refused UUE were significantly more anxious (mean anxiety score, 8.2 vs. 4.5, p < 0.005). Participants reported no significant difference between preprocedural (4.6 vs. 5.3) or postprocedural (3.5 vs. 2.6) anxiety for UUE versus standard EGD. After undergoing both procedures, only 46% stated they would prefer UUE to EGD in the future. Patients who chose the peroral approach were more likely to prefer UUE than those who chose the transnasal approach (58% vs. 23%, p = 0.02).

CONCLUSIONS

Patient acceptance of unsedated endoscopy even with an ultrathin instrument is limited. Anxiety assessment by the POMS-SF T/A can identify patients willing to undergo UUE. Patients who choose transoral UUE may be more willing to repeat the procedure.

Correlation of EUS measurement with pathologic assessment of neoadjuvant therapy response in esophageal carcinoma

BACKGROUND

EUS-measured reduction in tumor size after neoadjuvant therapy has previously been correlated with downstaging and improved survival in patients with esophageal cancer. The aim of this study was to determine whether tumor changes measured by EUS correspond to pathologically assessed chemoradiotherapy-induced tumor regression.

METHODS

Forty-one patients with esophageal cancer treated with combined modality treatment were studied. After initial EUS, patients completed a cisplatin/carboplatinum, 5-fluorouracil, and radiotherapy regimen and underwent repeat EUS before resection. A positive response on EUS was defined as a 50% reduction in maximal tumor cross-sectional area. Chemoradiotherapy-induced tumor regression was assessed in resection specimens by using a previously defined pathologic scoring system based on the extent of tumor proliferation into adjacent fibrosis.

RESULTS

Pathologic tumor regression was present in 23, indeterminate in 5, and minimal or absent in 13 patients. EUS measured a positive response in 20 of 23 (87%) patients with CRT-induced tumor regression and a negative response in 10 of 13 (77%) patients with absent tumor regression (p < 0.001). EUS had a positive predictive value of 80% for pathologic tumor regression.

CONCLUSIONS

Measurement of tumor size by EUS is a reliable clinical method for assessing pathologic tumor regression before surgery.

Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients

BACKGROUND

Esophagoscopy with a portable battery-powered endoscope could provide a safe, inexpensive, and minimally invasive way to screen for Barrett's esophagus or esophageal varices. The use of such an instrument in an unsedated fashion has not been previously evaluated.

METHODS

Patients referred for an EGD were recruited to undergo an additional examination with the battery-powered endoscope before EGD. In phase 1, (n = 42) patients received conscious sedation before the battery-powered endoscopic examination. In phase 2, (n = 56) patients were not sedated and were given the option of a peroral (n = 43) or transnasal (n = 13) endoscopy. Examiners were blinded to patient history and procedure indications. Esophageal findings, ease of intubation, optical quality, and patient comfort for the battery-powered endoscope and standard EGD were recorded by the endoscopist.

RESULTS

Ninety-eight patients (60 men, 38 women, mean age 53 years) were recruited. The sensitivity for detecting Barrett's esophagus, esophageal tumors, and esophageal varices was 54.5%, 66.7%, and 80%, respectively. Ease of intubation and patient comfort as perceived by the endoscopist were not significantly different between the battery-powered endoscope and EGD. Optical quality was ranked as less than 4 (on a 5-point scale with 5 = standard EGD and 1 = poor) in 42% of battery-powered endoscopic examinations. There were no complications.

CONCLUSION

The accuracy of esophageal examination with a 3.1-mm endoscope is substantially inferior to standard EGD. Thus, the battery-powered endoscope would not be useful for screening patients for Barrett's esophagus or varices unless improvements in optical quality and visualization are made.