Perforation from endoscopic small bowel biopsy.

Two patients, having undergone an apparently straightforward endoscopy with small bowel biopsy, developed a perforation. One, who proved to have normal small bowel mucosa, needed laparotomy and suturing of the duodenal perforation. The other, who had coeliac disease, settled with conservative management.     

Gastrointestinal hemorrhage from ileal leiomyoma: utility of the complete reflux small bowel examination.

A case of recurrent gastrointestinal hemorrhage with nondiagnostic conventional barium X-ray and endoscopic studies is described. A complete reflux small bowel examination clearly demonstrated an ilial leiomyoma. Details of the methodology of the reflux small bowel are reviewed.     

An interesting coexistence: small bowel volvulus and small bowel diverticulosis.

Acquired (non-Meckel's) jejuno-ileal diverticular disease is uncommon, and most surgeons have limited, if any, experience with this condition. We present an interesting case with coexistence of small bowel diverticulum and small bowel volvulus with massive abdominal distension, in which the patient had a history of abdominal distension without abdominal pain over a five-year period. A brief discussion of the common clinical features is given and the principles of treatment of jejuno-ileal diverticular disease and small bowel volvulus are presented. A 29-year- old man with no history of laparotomy was admitted with abdominal distension and abdominal compartment syndrome symptoms. An emergency laparotomy revealed 180 degree clockwise volvulus of the multiple diverticula-bearing terminal ileum. There was no diverticulum in other sites of the small intestine and colon. Additionally, there was neither adhesion nor any congenital anomalies at the other sites of the gastrointestinal system. The viability of the intestine was normal but the diameter of the ileum was extremely enlarged (approximately 20 cm). In addition, the bowel wall was also hypertrophied. The rotated and enormously enlarged diverticula-bearing small intestine was removed with cecum, and ileocolostomy was performed. The patient was discharged uneventfully from hospital on the eighth postoperative day. After the operation, all symptoms of the patient disappeared. Small bowel obstruction is a common cause of emergency surgical admission. Awareness of the fact that volvulus of the diverticula-bearing segment of the jejuno- ileum is a rare cause of small bowel obstruction may lead to earlier and prompt diagnosis and treatment.     

Comparison of suction capsule and endoscopic biopsy of small bowel mucosa

Small bowel mucosal biopsy specimens were studied in 52 consecutive patients. Twenty-six patients underwent biopsy by a suction capsule and 16 patients by endoscopy using an 8-mm forceps. Additionally, 10 patients were asked to undergo biopsy by both techniques in the same morning. Material was obtained in 81% of attempts by suction and 100% by endoscopy. Tissue obtained was excellent in 58%, good in 28%, and poor in 14% of suction biopsy specimens. Corresponding grades for endoscopy were 65%, 31%, and 4%. The frequency of abnormal findings was not different by either technique. In the 10 patients who had both procedures, mean time to completion was 43 min by suction and 12 min by endoscopy. Intravenous premedication was used in endoscopy, and patient comfort was judged as excellent in 60% with endoscopy, whereas 60% judged suction biopsy as very uncomfortable. The mean fluoroscopy time of 3.9 min necessary for suction biopsy was eliminated with endoscopy. Biopsy with an 8-mm forceps through the endoscope is the preferred way to obtain tissue from the proximal small bowel.     

The utility of capsule endoscopy small bowel surveillance in patients with polyposis

BACKGROUND: Small intestinal (SI) surveillance is recommended for polyposis patients. The utility and safety of capsule endoscopy (CE) for surveillance of SI neoplasia in patients with familial adenomatous polyposis (FAP) and Peutz-Jeghers syndrome (PJS) is unknown. METHODS: CE was offered to consecutive FAP and PJS patients due for routine upper endoscopic surveillance. The prevalence, location (jejunum, ileum), size (1-5 mm, 6-10 mm, >10 mm) and number (1-5, 6-12, >20) of polyps detected by CE was assessed. RESULTS: 19 subjects (15 FAP/4 PJS) with a mean age of 43 were included. All subjects had previous intestinal surgery. No complications occurred with CE. CE in FAP: 9/15 (60%) of subjects with FAP had SI polyps. The prevalence of SI polyps was related to the duodenal polyposis stage and subject age. The location, size and number of polyps progressed as duodenal polyposis stage advanced. CE in PJS: 3/4 (75%) of subjects with PJS had SI polyps. The polyps were diffuse in 2/4 and only in the ileum in one subject. CE findings led to laparotomy with intra-operative endoscopic polypectomy in two PJS patients. CONCLUSION: SI polyps are common in FAP but their importance is unknown. CE should be performed in FAP patients with stage III and IV duodenal disease. Clinically significant polyps are commonly detected by CE in PJS and lead to change in management in 50% of PJS subjects. CE should replace radiographic SI surveillance for PJS patients. CE is safe in polyposis patients who have undergone major intestinal surgery.     

Role of colonoscopy in the diagnostic work-up of bowel endometriosis

AIM:To evaluate the accuracy of colonoscopy for the prediction of intestinal involvement in deep pelvic endometriosis.METHODS:This prospective observational study was performed between September 2011 and July 2014.Only women with both a clinical and imaging diagnosis of deep pelvic endometriosis were included.The study was approved by the local ethics committee and written informed consent was obtained in all cases.Both colonoscopy and laparoscopy were performed by expert surgeons with a high level of expertise with these techniques.Laparoscopy was performed within4 wk of colonoscopic examination.All hypothetical colonoscopy findings(eccentric wall thickening with or without surface nodularities and polypoid lesions with or without surface nodularities of endometriosis)were compared with laparoscopic and histological findings.We calculated the sensitivity,specificity,positive predictive value and negative predictive value for the presence of colonoscopic findings of intestinal endometriosis.RESULTS:A total of 174 consecutive women aged between 21-42 years with a diagnosis of deep pelvic endometriosis who underwent colonoscopy andsurgical intervention were included in our analysis.In 76 of the women(43.6%),intestinal endometrial implants were found at surgery and histopathological examination.Specifically,38 of the 76 lesions(50%)were characterized by the presence of serosal bowel nodules;28 of the 76 lesions(36.8%)reached the muscularis layer;8 of the 76 lesions(10.5%)reached the submucosa;and 2 of the 76 lesions(2.6%)reached the mucosa.Colonoscopic findings suggestive of intestinal endometriosis were detected in 7 of the174(4%)examinations.Colonoscopy failed to diagnose intestinal endometriosis in 70 of the 76 women(92.1%).A colonoscopic diagnosis of endometriosis was obtained in all cases of mucosal involvement,in 3of 8 cases(37.5%)of submucosal involvement,in no cases of muscularis layer involvement and in 1 of 38cases(2.6%)of serosa involvement.The sensitivity,specificity,positive predictive and negative predictive values of colonoscopy for the diagnosis of intestinal endometriosis were 7%,98%,85%and 58%,respectively.CONCLUSION:Being an invasive procedure,colonoscopy should not be routinely performed in the diagnostic work-up of bowel endometriosis.