Risk factors for surgery in patients with retention of endoscopic capsule

Objectives: Surgery is still the main means for removing retained endoscopic capsules. This study intended to evaluate risk factors for surgery in patients with capsule retention.

Materials and methods: The data of 5348 consecutive capsule endoscopy examinations were retrospectively analyzed. Cox regression analysis was used to evaluate risk factors.

Results: Seventy-seven patients (1.4%) had capsule retention. Spontaneous passage occurred in 16 patients, of which 14 were asymptomatic. Successful retrieval by double-balloon enteroscopy (DBE) was achieved in 14 patients, of which 11 did not need surgery during clinical follow-up. A total of 50 patients underwent surgery. The cumulative rates of surgery were 44.2%, 53.2%, 55.8%, 62.3% and 64.9% at 1, 3, 6, 12 and 60 months after capsule retention, respectively. Intestinal obstruction [hazard ratio (HR) 2.05, 95% confidence interval (CI) 1.12–3.76; p?=?.020] and overt small bowel bleeding (HR 2.01, 95%CI 1.08–3.71; p?=?.027) during capsule retention were independently associated with an increased risk for surgery. Specific treatment for primary disease (HR 0.22, 95%CI 0.07–0.74, p?=?.014) and successful endoscopic retrieval (HR 0.20, 95%CI 0.06–0.66; p?=?.008) were independently associated with a decreased risk for surgery.

Conclusions: For asymptomatic patients, specific medical treatment for primary disease can be maintained until the capsule spontaneously passes or symptoms appear. For patients with slight abdominal pain, DBE can be performed. For patients with intestinal obstruction or overt small bowel bleeding, early surgical consultation should be considered.     

Concordancia diagnóstica entre la videocápsula endoscópica y enteroscopia mono y de doble balón en la hemorragia de intestino delgado en un hospital de alta complejidad en Bogotá, Colombia

IntroductionVideo capsule endoscopy and balloon-assisted enteroscopy are complementary diagnostic methods in the study of small bowel bleeding, and different factors can affect their diagnostic yield.AimsTo define the level of agreement between video capsule endoscopy and enteroscopy in small bowel bleeding, according to the type of lesion, in a cohort of patients at a tertiary care referral center.Materials and methodsA retrospective study was conducted that included 428 capsule endoscopies performed within the time frame of 2011 and 2019 at our healthcare institution. Seventy-four video capsule endoscopies, followed by enteroscopy, in 71 patients suspected of presenting with small bowel bleeding, were analyzed.ResultsMean patient age was 63.9 ± 13.5 years and 42 patients were women. The two diagnostic procedures were performed. Overall diagnostic yield of positive findings between video capsule endoscopy and enteroscopy was 86.5% vs. 58.1%, respectively (p = 0.0527). Agreement between video capsule endoscopy and enteroscopy for positive pathologic findings was weak (Ik = 0.17, 95% CI: -0.0097-0.3543), but according to lesion type, it was good for inflammatory lesions (Ik = 0.71, 95% CI: 0.5182-0.9119) and moderate for angiectasias (Ik = 0.45, 95% CI: 0.2469-0.6538) and tumors (Ik = 0.40, 95% CI: 0.1217-0.6794). The results between the two methods differed in 38 patients (51.3%). There was complete intestinal capsule retention in one patient (1.4%) and active bleeding in 13 (17.6%).ConclusionsThe present study showed that the two techniques had a similar overall detection rate for small bowel lesions, but the type of lesion was the main factor that could modify diagnostic agreement.     

Bacteremia with esophageal dilation

(GUMMI BEARS)Background: Antibiotic prophylaxis has been recommended for selected patients undergoing esophageal stricture dilation because of a reported high rate of bacteremia. The aim of this study was to determine the rate of bacteremia after esophageal dilatation in a large series and the source of the organisms recovered. Methods: Blood cultures and oral temperatures were obtained before esophageal dilation and at 5 and 30 minutes after dilation. Dilators were cultured immediately before dilation. Procedural data collected included type of dilation, number of passes, and presence of malignancy. Results: Of 100 procedures in 86 patients undergoing esophageal dilation, 22 (22%) were associated with a positive post-dilation blood culture. Bacteremia was more frequent with dilation of malignant strictures compared with benign strictures (9 of 17 [52.9%] vs. 13 of 83 [15.7%], respectively, p = 0.002) and with passage of multiple dilators compared with passage of a single dilator (16 of 46 [34.8%] versus 6 of 54 [11.1%], respectively, p = 0.007). Bacterial isolates from 22 positive blood cultures matched those from a dilator in only one episode (4.5%). Conclusion: The rate of bacteremia after esophageal dilation is 22% and is associated with dilation of malignant strictures or passage of multiple dilators. Organisms cultured from the blood are not transmitted from the dilator. (Gastrointest Endosc 1998;48:563-7.)     

Clinical outcomes of lumen-apposing metal stent in the management of benign gastrointestinal strictures: a systematic review and meta-analysis

Background and aims: Lumen-apposing metal stent (LAMS) have been considered as a viable alternative to treat benign gastrointestinal (GI) strictures. We aimed to determine the efficacy and safety of LAMS for benign GI strictures.

Methods: Medline, Embase, Cochrane, and PubMed databases were searched using the keywords ‘benign stricture’, ‘gastrointestinal stricture’, ‘lumen-apposing metal stent’ and related terms on December 2018. Articles were selected for review by two authors independently according to predefined inclusion criteria and exclusion criteria. A meta-analysis using a random effects model was performed.

Results: Six studies with a total of 144 patients were included in the final analysis (60 males, 41.7%). Overall, the pooled technical success rate was 98.3% [95% confidence interval (CI): 0.962–1.004], clinical success rate was 73.8% (95% CI: 0.563–0.912) and adverse events rate was 30.6% (95% CI: 0.187–0.425). The most common complication associated with LAMS for benign GI strictures was migration, and the pooled events rate was 10.9% (95% CI: 0.058–0.160). According to locations of stricture, subgroup analysis was performed in terms of clinical success [Esophagogastric: 63.9% (95% CI: 0.365–0.914); Gastroduodenal: 67.4% (95% CI: 0.421–0.927); Gastrojejunal: 78% (95% CI: 0.638–0.922); Pylorus: 77.6% (95% CI: 0.551–1.002); Colonic: 85.3% (95% CI: 0.515–1.191)].

Conclusions: Although the safety of LAMS placement in benign GI strictures is not very satisfactory, it is associated with a low migration rate. LAMS can achieve clinical symptom improvement or resolution in most patients with benign GI strictures, and it might be an alluring prospect for treating patients with this difficult condition.     

Effect of three bowel preparations on video-capsule endoscopy gastric and small-bowel transit time and completeness of the examination

Objective. Video capsule endoscopy fails to visualize the caecum in about 20% of patients. The aim of this study was to investigate the effect of different bowel preparations on video capsule endoscopy gastric- (GTT) and small-bowel transit time (SBTT) and the rate of caecal visualization. Material and methods. We retrospectively examined 186 consecutive capsule endoscopy videos undertaken over a 3-year period, excluding cases with diabetes mellitus or gastric surgery (n=28), cases with unknown bowel preparation and those with unreadable data CDs (n=27). Sixty-seven (36%) patients were prepared with a liquid diet (CL), 54 (29%) with sodium phosphate (PS) and 65 (35%) with polyethylene glycol (PEG). Two independent, experienced investigators examined the videos. Results. No difference was found in GTT among CL, PS and PEG preparations (25, 6.7–116.2 min, 34.75, 4.1–125 min, 35, 6.1–128.6 min, respectively, p=0.29). The caecum was visualized in 56/67 (83.6%), 44/54 (81.5%) and 53/65 (81.5%) patients who received CL, PS and PEG, respectively (p=0.9). In the cases where capsule endoscopy reached the caecum, no difference was observed in SBTT among patients that received CL, PS and PEG (264.4±85.9 min, 296.7±79.5 min, 291.3±84 min, respectively, p=0.11). Conclusions. Bowel preparations for capsule endoscopy do not have a significant effect on gastric and small-bowel video capsule transit time and the rate of caecum visualization.     

Effects of anti-inflammatory therapy on bursting pressure of colonic anastomosis in murine dextran sulfate sodium induced colitis

Abstract

Background: In suspected Crohn’s disease (CD), non-diagnostic ileocolonoscopies are often followed by small bowel capsule endoscopy (SBCE). Adequate pre-selection of patients for SBCE is a key to optimize allocation of resources. We aimed to establish a rational approach for the CD diagnostic workflow, based on biochemical profile of patients with suspected CD, targeting an optimization of patients’ selection for SBCE.

Methods: Multicenter cohort study includes consecutive patients with suspected undergoing SBCE after non-diagnostic ileocolonoscopy. Minimum follow-up period after the capsule enteroscopy was six months. The outcome was confirmation of CD diagnosis. Univariate analysis and logistic regression were performed.

Results: In included 220 patients, 62.3% of women were with a mean age of 41?years [26–54]. A confirmed diagnosis of CD was established in 98 patients (44.5%). The initial univariate analysis identified variables above the threshold of marginal statistical association toward CD diagnosis (p?p?=?.128) and low serum Iron (OR 0.990 p?=?.025) as the independent variables with consistent correlation with CD diagnosis. Those two variables present a suitable discriminative power (AUC?=?0.669, p?Conclusion: In suspected CD, low serum iron and elevated CRP had a statistically significant association with CD diagnosis, being helpful to identify patients with higher CD probability before SBCE. However, the lack of a proper validation of the model leads us to currently recommend SBCE to all patients with suspected CD and negative ileocolonoscopy, as no specific biochemical profile can be used to confidently exclude small bowel CD.     

The prevalence of adverse events associated with double-balloon enteroscopy from a single-centre dataset in Japan

BackgroundThere are few comprehensive reports detailing the prevalence of major adverse events associated with a double-balloon enteroscopy procedure.MethodsWe retrospectively investigated the prevalence of major adverse events in 538 patients (262 males and 276 females; median age, 65 years; age range, 12–95 years) who underwent double-balloon enteroscopy at our Institution between April 2008 and October 2011.ResultsOf the 17 adverse events recorded (3.2%), acute pancreatitis (n = 5; 0.9%) occurred during both diagnostic (n = 3) and therapeutic (n = 2) anterograde double-balloon enteroscopy, and all of them were treated conservatively. For these cases, the average duration of the examination was 135 min, which was longer than for the other patients (97 min) (P = 0.046). Intestinal bleeding (1.3%) was observed in 6 cases after endoscopic polypectomy and in 1 case following a biopsy procedure during a diagnostic double-balloon enteroscopy. The prevalence rates of intestinal perforation and other complications were 0.2% and 0.7%, respectively.ConclusionsThe rate of adverse events associated with double-balloon enteroscopy was high compared to that associated with conventional upper/lower gastrointestinal endoscopy (0.042%/0.078%). The occurrence of acute pancreatitis may be significantly dependent on the duration of double-balloon enteroscopy examination.     

Treatment of small-bowel diaphragm disease by using double-balloon enteroscopy

BACKGROUND: Double-balloon enteroscopy is a new technique that allows endoscopic therapy throughout the entire length of the small bowel. Diaphragm disease, characterized by thin septa that narrow the small-bowel lumen, is traditionally treated surgically by segmental resection. OBJECTIVE: To report successful endoscopic treatment of diaphragm disease by double-balloon enteroscopy. PATIENTS: Three patients. DESIGN: Case report. INTERVENTIONS: Double-balloon enteroscopy and stricture balloon dilation. RESULTS: We report, for the first time, 3 cases in which diaphragm strictures were successfully treated during double-balloon enteroscopy. In 2 cases, a retained capsule endoscope was removed by the retrograde approach after stricture dilation. LIMITATIONS: Small number of patients and brief length of patient follow up. CONCLUSION: Double-balloon enteroscopy may be used to treat patients with diaphragm disease, thus avoiding potentially complicated surgery.     

Patient-oriented education and visual-aid intervention are inadequate to identify patients with potential capsule retention: a prospective randomized study

Background/aims: The key procedure-related risk with video capsule endoscopy (VCE) is capsule retention, which should be suspected in patients who have not reported capsule passage. The study aims were to determine the frequency of capsule passage visualization and the difference in self-reporting of capsule passage between patients who receive patient-oriented education (POE) and patients who receive POE and a visual aid intervention in the form of a wrist band (WB).

Methods: This was a prospective randomized study that enrolled patients undergoing VCE. Patients were randomly assigned to a POE group versus a POE and WB group. POE consisted of verbal education and an information booklet. Both groups received instructions to notify the study team regarding capsule passage.

Results: Sixty patients (mean age 57?±?18 years; 61% female) were included. A total of 57 patients were included in the analysis (3 lost to follow-up; 28 in POE group; 29 in WB group). Capsule passage status was reported by 68% without significant difference between POE and WB groups (72% vs. 64%; p?=?.51). Capsule passage status was obtained from all 57 patients with the addition of a proactive follow-up. Only 56% (n?=?32) reported visualizing capsule passage. Of the remaining patients who did not visualize capsule passage, 60% (n?=?15) reported on this without significant difference between the POE and WB groups (p?=?.23).

Conclusions: Lack of visualization of capsule passage is a poor indicator of retention. Self-reporting of VCE passage status is suboptimal and the addition of a visual aid did not improve this parameter.     

A comparison between capsule endoscopy and double balloon enteroscopy using propensity score-matching analysis in patients with previous obscure gastrointestinal bleeding

Background: Recently, diagnosis of obscure gastrointestinal bleeding (OGIB) has improved greatly due to introduction of capsule endoscopy (CE) and double balloon enteroscopy (DBE). However, the efficacy of CE over DBE in patients with previous OGIB remains unclear. This study aimed to compare, in terms of diagnostic yield, the efficacy of DBE with that of CE in patients with previous OGIB.

Patients and methods: We enrolled 223 consecutive patients with previous OGIB who were treated between May 2007 and March 2012. We retrospectively evaluated the respective diagnostic yields of CE and DBE in patients with previous OGIB using propensity score-matching analysis. We compared the diagnostic yield of CE with that of DBE.

Results: The diagnostic yields were 41.9% in DBE group and 11.6% in CE group, respectively (p?<?.01). On logistic regression analysis, DBE was significantly superior to CE after matching (Odds ratio [OR], 4.25; 95% confidence interval [CI], 1.43–12.6; p?<?.01), even after adjustment for propensity score (OR, 5.65; 95% CI, 1.56?20.5; p?<?.01).

Conclusions: Our results indicate that DBE might be more useful and perhaps safer than CE in achieving a positive diagnosis in patients with previous OGIB.     

Enteroscopy for the early detection of small bowel tumours in at-risk celiac patients

BackgroundA subset of celiac patients shows a high risk for small bowel malignancies.AimsTo select celiac patients considered at risk and evaluate the diagnostic yield of enteroscopy in this context.MethodsCeliac patients were enrolled from a tertiary referral centre during the period June 2011–June 2013, based on the following criteria: (i) patients diagnosed when aged 50+ and with poor response to gluten-free dieting; (ii) low dietary compliance; (iii) alarm symptoms. The patients underwent small bowel capsule endoscopy and/or double-balloon enteroscopy. Control populations were represented by the 165 non-celiac patients undergoing capsule endoscopy for obscure gastrointestinal bleeding, and the 815,362-strong population of the Italian province of Varese as a registered cohort.ResultsFifty-three patients (19% males, mean age 43.6 ± 17.4 years) were evaluated. Two jejunal adenocarcinomas and one ileal neuro-endocrine tumour were diagnosed by enteroscopy (the diagnostic yield for malignancies in the selected population being 5.7%). In the non-celiac controls the detection rate of small bowel tumours by capsule endoscopy was 0.6% (P = 0.04). When compared to the registered population, the relative risk for intestinal malignancy was 1282 (95% CI, 407–4033; P < 0.0001).ConclusionsCapsule endoscopy and double-balloon enteroscopy can be considered for early disease management of a subset of celiac patients.     

Enteroscopy

Wireless capsule endoscopy and double-balloon endoscopy are new methods of enteroscopy that have been introduced in recent years. Wireless capsule endoscopy is an epoch-making examination method that makes possible an endoscopic imaging examination of the entire small intestine without discomfort and without confining patients to a medical facility. Although it is expected to be useful as an initial examination for finding diseases of the small intestine, it cannot be used for biopsy or treatment. One risk associated with the capsule endoscopy technique is entrapment by strictures. Double-balloon endoscopy is based on a new insertion technique in which two balloons, one at the distal end of the endoscope and the other at the distal end of an overtube, are operated in combination, and the endoscope is inserted while simultaneously shortening the intestine. It can be inserted through either the mouth or the anus, allowing the observation of the entire gastrointestinal tract. It features excellent maneuverability even in the distal small intestine, and enables back-and-forth observation, biopsy, and endoscopic treatment at any given site. These two new enteroscopy techniques are expected to lead to innovations in how diseases of the small intestine are approached.     

Practical gastrointestinal investigation of iron deficiency anaemia

Introduction: About 10% of oesophagogastroduodenoscopies (OGDs) and colonoscopies are done for investigation of iron deficiency anemia (IDA) . Much of the existing guidance on investigation of IDA predates CRC screening, which has driven significant improvements in colonoscopy quality and completion rates, as well as a reduction in Helicobacter pylori prevalence and increase in PPI usage, and therefore probably needs re-consideration. New investigations, e.g. CT colonography, enteroscopy and capsule endoscopy have also been introduced.

Areas covered: This review updates the approach to practical investigation of IDA. Medline was searched using the terms iron deficiency AND anemia AND/OR gastroscopy, colonoscopy, capsule and enteroscopy, together with review of recent relevant published abstracts on the topic.

Expert commentary: Gastrointestinal pathology is now a more common cause of IDA than upper GI causes, reflecting better colonoscopy accuracy and completion rates as well as changing disease patterns, and carcinomas are more likely cause IDA than benign adenomas. Increasing use of antiplatelet and anticoagulants is driving greater presentation of IDA. Capsule endoscopy, enteroscopy and CT colonography are increasingly used. Fecal occult blood testing may be a useful simple screening method in the frail, as a negative test can avoid the need for invasive tests.     

Development of psoriasis in IBD patients under TNF-antagonist therapy is associated neither with anti-TNF-antagonist antibodies nor trough levels

Background: The cause of anti-TNF-induced psoriasis is still unknown.

Objective: We aimed to evaluate if the appearance of psoriasis under anti-TNF therapy is associated with anti-TNF antibody levels and TNF-antagonist trough levels.

Methods: In this case-control study we identified 23 patients (21 with Crohn’s disease [CD], two with ulcerative colitis [UC]) who developed psoriasis under infliximab (IFX, n?=?20), adalimumab (ADA, n?=?2), and certolizumab pegol (CZP, n=?1) and compared them regarding the anti-TNF-antagonist antibody levels with 85 IBD patients (72 with CD, 13 with UC) on anti-TNF therapy without psoriasis.

Results: Median disease duration was not different between the two groups (7 years in the group with psoriasis under TNF-antagonists vs. 10 years in the control group, p?=?0.072). No patient from the psoriasis group had antibodies against TNF-antagonists compared to 10.6% in the control group (p?=?0.103). No difference was found in IFX trough levels in the group of patients with psoriasis compared to the control group (2.6?μg/mL [IQR 0.9–5.5] vs. 3.4?μg/mL [IQR 1.4–8.1], p?=?0.573). TNF-antagonist therapy could be continued in 91.3% of patients with TNF-antagonist related psoriasis and most patients responded to topical therapies.

Conclusion: Anti-TNF-induced psoriasis seems to be independent of anti-TNF antibodies and trough levels. Interruption of Anti-TNF therapy is rarely necessary.     

Significance of endoscopic deep small bowel evaluation using balloon-assisted enteroscopy for Crohn’s disease in clinical remission

Background

Small bowel lesions of Crohn’s disease (CD) are known to be associated with a poor prognosis; however, endoscopic healing leads to favorable patients’ outcome. The aim of this study was to clarify the clinical impact of assessing deep small bowel lesions (DSB) using balloon-assisted enteroscopy (BAE) on CD patients in clinical remission.

Methods

From January 2012 to July 2018, a total of 100 CD patients in clinical remission were enrolled to undergo trans-anal enteroscopy using single-balloon enteroscope. Endoscopic evaluations at the terminal ileum (TI) were performed using a partial Simple Endoscopic Score for CD (pSES-CD). Endoscopic evaluations at the DSB used a modified partial SES-CD (mpSES-CD). We evaluated the factors associated with relapse, and the correlation of endoscopic score between the TI and DSB. For this study, relapse was defined as hospitalization within a year from enteroscopy.

Results

30 patients (30.0%) relapsed within a year from enteroscopy. Multivariate logistic regression analysis revealed that the Harvey–Bradshaw Index (OR 1.77, 95% CI 1.18–2.65; p = 0.003) and an mpSES-CD at DSB (OR 3.10, 95% CI 1.86–5.15; p = 0.001) were independent predictors for relapse, whereas a SES-CD at the TI did not exhibit independence. There was a significant correlation trend between the relapse rate and greater than 5 points of an mpSES-CD at DSB; however, there was no correlation between the relapse rate and pSES-CD at the TI.

Conclusion

Even when Crohn's disease is in remission, it is important to evaluate DSB using BAE to assess endoscopic mucosal healing.

     

Results of laparoscopic splenectomy for treatment of malignant conditions

BackgroundLaparoscopic splenectomy (LS) is widely accepted for treatment of benign diseases, but there are few reports of its use in cases of haematological malignancy. In addition, comparative studies with open operation are lacking. Malignant haematological diseases have specific clinical features-notably splenomegaly and impaired general health-which can impact on the immediate outcome after LS. The immediate outcome of LS comparing benign with malignant diagnoses has been analysed in a prospective series of 137 operations.Patients and methodsBetween February 1993 and April 2000, 137 patients with a wide range of splenic disorders received LS. Clinical data and immediate outcome were prospectively recorded,and age, diagnosis, operation time, perioperative transfusion requirement, spleen weight, conversion rate, accessory incision, hospital stay and complications were analysed.ResultsThe series included 100 benign cases and 37 suspected malignancies. In patients with malignant diseases the mean age was greater (37 years [3–85] vs 60 years [27–82], p<0.0l), LS took longer (138 min [60–400] vs 161 min [75–300], p<0.05) and an accessory incision for spleen retrieval was required more frequently (18% vs 93%, p<0.0l) because the spleen was larger (279 g [60–1640] vs 1210 g [248–3100], p <0.01). However, the rate of conversion to open operation (5% vs 14%), postoperative morbidity rate (13% vs 22%) and transfusion requirement (15% vs 26%) did not differ between benign and malignant cases. Hospital stay was longer in malignant cases (3.7 days [2–14] vs 5 days [2–14], p<0.05).ConclusionLS is a safe procedure in patients with malignant disease requiring splenectomy in spite of the longer operative time and the higher conversion rate.     

Impact of aging on immature platelet count and its relationship with coronary artery disease

Abstract

Despite the fact that elderly patients represent a prevalent and challenging population in the current practice, few data exist on the impact of platelet parameters on cardiovascular risk in these patients. Therefore, the aim of the present study was to evaluate the impact of age on the immature platelet count (IPC) and their relationship with CAD. We included a total of 2236 consecutive patients undergoing coronary angiography in a single center. Elderly patients (age ≥ 75 years) were 756 (33.7%). IPC was measured at admission. Elderly patients were more often females (p < .001), with lower BMI and prevalence of smokers (p < .001), and a more complex cardiovascular risk profile and coronary disease (p = .02). Platelet count decreased with aging (p = .05), whereas no difference in the mean IPC was found between patients < or ≥75 years. In fact, advanced age did not emerge as an independent predictor of IPC above III tertile (≥8.6*10^6/ml), (adjusted OR[95%CI] = 0.97[0.78–1.21], p = .79). When considering elderly patients according to tertiles values of IPC (<5.1,5.1–8.59; ≥8.6*10^6/ml), we found no impact of IPC on the prevalence of CAD (81.1% vs 84.5% vs 81.5%, p = .92; adjusted OR[95%CI] = 1.08[0.67–1.72], p = .75) and its extent (37.7% vs 34.5% vs 40.2%, p = .57; adjusted OR[95%CI] = 1.22[0.85–1.73], p = .28). However, we observed a higher rate of calcified and type C lesions in elderly patients with higher IPC (p = .03 and p < .001, respectively). Therefore, advanced age is not associated with higher immature platelet count and the prevalence and severity of CAD. Moreover, IPC does not contribute to explain the higher prevalence and extent of coronary artery disease observed in elderly patients.     

ORBIT score: an useful predictor of small bowel rebleeding in patients under chronic anticoagulation

Background and study aims: Available scoring systems to assess the risk for major bleeding in patients on chronic anticoagulation seem inadequate in predicting higher diagnostic yields of small bowel capsule endoscopy (SBCE) or higher rebleeding rates in patients with suspected small bowel bleeding. The aim of this study was to evaluate the ability of the new ORBIT score in predicting positive findings of SBCE or higher rebleeding rates in chronically anticoagulated patients with suspected small bowel bleeding.

Patients and methods: Retrospective analysis of 570 patients who consecutively underwent SBCE for the study of suspected small bowel bleeding. For each of the 67 patients who were on chronic anticoagulation, ORBIT score (Older age, Reduced hemoglobin/hematocrit, Bleeding history, Insufficient kidney function and Treatment with antiplatelets) was calculated. Patients were classified as high-risk (ORBIT score?≥4) or low/intermediate-risk (ORBIT score?<4). Data on SBCE findings, diagnostic yield and rebleeding were compared between groups.

Results: When ORBIT score was calculated, 41 and 26 patients were classified as low/intermediate-risk and high-risk, respectively. When low/intermediate-risk and high-risk groups were compared, no differences were found in the diagnostic yield of SBCE (39.0% vs. 23.1%; p?=?.176). However, in high-risk patients, rebleeding was significantly more common than in low/intermediate-risk patients (80.0% vs. 36.6%; p?=?.003).

Conclusions: In patients presenting with suspected small bowel bleeding and on chronic anticoagulation, the new ORBIT score seems promising in identifying those with a higher risk of rebleeding, in whom a closer follow-up and a more aggressive diagnostic and therapeutic strategy is advisable.     

Individual probe based confocal laser endomicroscopy criteria in the analysis of indeterminate biliary strictures

Abstract

Objectives: Evaluation of indeterminate biliary strictures remains challenging due to limited sensitivity of endoscopic tissue sampling. Biliary probe-based confocal laser endomicroscopy (pCLE) has shown promise to detect and exclude neoplasia. However, knowledge of whether individual inflammatory criteria are more prevalent in neoplasia compared to benign strictures is limited. The objective of this work is to improve diagnosis of neoplastic and inflammatory conditions using pCLE.

Materials and methods: The charts of all patients who underwent pCLE at a single referral center between 2009 and 2015 were reviewed. ERCP reports were reviewed for eleven Miami and Paris criteria. Primary outcome was the identification of neoplasia by histopathology (defined as high-grade dysplasia and/or adenocarcinoma). To model predictors of neoplasia, we fit a binary regression model incorporating data from pCLE operating criteria, pCLE impression, and PSC status.

Results: 97 patients were identified. In the 27 patients with neoplasia, there was increasing number of Miami malignant criteria (Pearson r?=?0.512, p?p?p?Conclusions: Presence of malignant criteria and absence of certain inflammatory criteria are more prevalent in patients with neoplasia. Our model, which weights individual imaging components, shows impressive sensitivity and specificity over prior prognostic efforts. Prospective studies will be required to evaluate this model.