Endoscopic examination with the duodenoscope at ERCP: frequency of lesions and accuracy of detection

BACKGROUND: Little is known about the yield and accuracy of endoscopic examination with the duodenoscope after ERCP, and there appears to be no uniform standard of practice for endoscopic examination in this setting. METHODS: Over a 1-year period, all patients undergoing ERCP also underwent endoscopic examination of the duodenum, stomach, and esophagus with the duodenoscope upon completion of ERCP. Patients were then placed in the left lateral decubitus position and upper endoscopy was performed with a standard forward-viewing endoscope. The same investigator performed both endoscopic examinations. Patients were queried about prior ulcer disease, upper GI symptoms, and use of antisecretory medication as well as nonsteroidal anti-inflammatory drugs. RESULTS: During the 12-month study, 368 patients (mean age 53 years) underwent 474 procedures. The most frequent indication for ERCP was suspected choledocholithiasis (24%). Endoscopic examination was normal in 42% of patients, and the most frequent endoscopic finding was hiatal hernia (132 patients, 36%). The lesions most frequently missed with the duodenoscope were trauma at the upper esophageal sphincter (12 patients) and small benign gastric polyps (3 patients). Examination with the duodenoscope was superior to the forward-viewing endoscope for identification of Schatzki's ring. No carcinoma, gastric varices, or severe esophagitis were missed with the duodenoscope. CONCLUSIONS: Given the frequency of endoscopic lesions, a yield of positive findings similar to that obtained with the forward-viewing endoscope, and the ease of performing endoscopy with the duodenoscope, endoscopic examination of the esophagus, stomach, and duodenum with the duodenoscope should become standard practice after ERCP.     

Artificial intelligence in upper GI endoscopy ‐ current status,challenges and future promise

White‐light endoscopy with biopsy is the current gold standard modality for detecting and diagnosing upper gastrointestinal (GI) pathology. However, missed lesions remain a challenge. To overcome interobserver variability and learning curve issues, artificial intelligence (AI) has recently been introduced to assist endoscopists in the detection and diagnosis of upper GI neoplasia. In contrast to AI in colonoscopy, current AI studies for upper GI endoscopy are smaller pilot studies. Researchers currently lack large volume, well‐annotated, high‐quality datasets in gastric cancer, dysplasia in Barrett's esophagus and early esophageal squamous cell cancer. This review will look at the latest studies of AI in upper GI endoscopy, discuss some of the challenges facing researchers, and predict what the future may hold in this rapidly changing field.     

The value of endoscopy and endosonography in the diagnosis of the dysphagic patient

The value of endoscopy in dysphagia is limited in the diagnosis of motility disorders and small structures, webs, and hiatal hernias. Endoscopy is of special use for the clarification of an organic cause of dysphagia. Intraluminal tumors can be seen and in a high percentage of cases be definitely diagnosed by taking biopsies; a malignant degeneration in Barrett's esophagus is detectable by endoscopy in 89.1% of cases. Gastroesophageal reflux disease can be diagnosed on endoscopy as it leads to an endoscopically visible inflammatory reaction; however, normal findings on endoscopy cannot exclude reflux disease. Endoscopy is the method of choice in the diagnosis of nonreflux esophagitis, especiallyCandida and viral esophagitis. A further advantage of endoscopy is the fact that a microscopic diagnosis can be obtained and endoscopic treatment can be performed simultaneously. Submucosal or extramural lesions can be missed by endoscopy.Endosonography, the combination of endoscopy and ultrasonography (EUS) yields additional information in diagnosing submucosal and extramural lesions of the esophagus which is missed by other imaging procedures. One of the main advantages of EUS is the detection of small and submucosal lesions. The most important indication is the local staging of esophageal carcinomas; the accuracy of endosonography in determining the depth of infiltration ranges between 79% and 92%. The detection of paraesophageal lymph nodes is successful in 60%–82%, although EUS cannot differentiate benign from malignant lymph nodes. Submucosal tumors can be visualized by endosonography and their size, echopattern, and the layers of origin can be determined with high accuracy. Further indications for EUS are the exclusion of focal lesions in achalasia or peptic strictures.     

上消化道胶囊内镜发展与创新北大核心CSCD

上消化道疾病高发,传统插管式胃镜是检查上消化道疾病最常用的检查方法和"金标准"。为了更舒适无创的检查上消化道黏膜,多项研究提出了上消化道胶囊内镜的概念,但是由于上消化道各部位解剖与生理结构的差异,目前可以使用的胶囊内镜如单纯被动式、磁控式、线控式、磁控联合线控式以及侧视胶囊内镜都存在一定的局限性,无法实现对上消化道整体黏膜情况的观察。文章试图通过介绍适用于食管、胃以及十二指肠检测的胶囊内镜,分析各内镜的诊断效能及其不足,探讨未来上消化道胶囊内镜可能的发展方向。     

Pharyngoesophageal interrelationships: observations and working concepts

Simultaneous disorders of the pharynx and esophagus are so frequent that the complete swallowing chain should be examined in all patients with dysphagia. Data are presented to support the concept that such simultaneous disorders represent related phenomena; the mechanism involves changes in cricopharyngeal function seen radiographically as cricopharyngeal prominence. If neurologic disease has been excluded, cricopharyngeal prominence may be the clue to esophageal disease. When cricopharyngeal prominence is found during dynamic imaging of the pharynx, intensive examination of the esophagus and a search for signs of compensation or decompensation in the pharynx should be undertaken.     

外套管辅助内镜下黏膜切除术在治疗食管上段胃黏膜异位症中的价值探讨

目的探讨外套管辅助内镜直视下黏膜切除术治疗食管上段胃黏膜异位症的临床价值。方法选择经内镜检查和病理证实为食管上段胃黏膜异位症并伴有局部症状的患者53例进行内镜治疗,将外套管套在内镜外,随内镜一起插入患者食管内,将内镜退至外套管内,边退外套管边观察,见外套管头部刚好退至病变部位口侧,固定外套管,行内镜下黏膜切除术。术后随访观察疗效。结果53例患者采用一次性切除者45例,2次切除者5例,3次切除者3例。平均每例所需时间为6．5min（4．5～7．5min）,内镜下完全切除率达100％。术后3个月随访时43例症状消失,占81.1％：6个月随访时45例症状消失,占85％。内镜及活检病理均未见复发。无食管狭窄、穿孔及心肺意外等并发症。结论食管上段胃黏膜异位症合并局部症状者,采用外套管辅助固定内镜直视下黏膜切除具有手术简便、仓Ⅱ伤小、恢复快、疗效确切的特点。     

Accuracy of esophagoscopy performed by a non-physician endoscopist with a 4-mm diameter battery-powered endoscope

BACKGROUND: A cost-effective technique is needed for screening of a broad population at risk for esophageal cancer. A solution would be to have non-physician endoscopists perform esophagoscopy with small-caliber battery-powered endoscopes. METHODS: In a prospective blinded study, the diagnostic accuracy of sedated esophagoscopy performed by a trained nurse practitioner with a battery-powered 4-mm diameter endoscope was compared with that for a sedated standard video-endoscopy performed by a gastroenterologist. Patients were recruited to undergo peroral esophagoscopy by the nurse practitioner followed by sedated standard endoscopy by the supervising gastroenterologist, each blinded to the findings of the other. Major esophageal findings of nurse practitioner and gastroenterologist were compared. RESULTS: Findings in 40 patients were analyzed. In 4 patients both endoscopists could not assess the presence or absence of columnar-lined esophagus because of severe erosive esophagitis (n = 3) or severe candida-esophagitis (n = 1). By using sedated standard endoscopy as the standard, on a per finding basis, esophagoscopy by the nurse practitioner had a sensitivity for columnar-lined esophagus of 89%: 95% CI [75%, 97%] and specificity of 96%: 95% CI [84%, 99%]. The missed columnar epithelium was a 3 x 3-mm island. For all lesions, the sensitivity of endoscopy performed by the nurse practitioner with the battery-powered endoscope was 75%: 95% CI [67%, 82%] and specificity 98%: 95% CI [96%, 99%]. The nurse practitioner missed all of 4 rings (3 considered clinically irrelevant). CONCLUSION: Esophagoscopy with a battery-powered 4-mm diameter endoscope by a non-physician endoscopist is feasible and accurate in detecting esophageal pathologies. It may be an efficient screening method for the detection of columnar-lined esophagus. There was a distinct underestimate of the presence of esophageal rings.     

Endoscopic spray cryotherapy: a new technique for mucosal ablation in the esophagus.

BACKGROUND: A simple and safe method for controlled ablation of esophageal mucosa is not currently available. Therefore, an endoscopic cryotherapy device was developed and its efficacy and safety were assessed in a swine model. METHODS: The device consists of a cryogenic system that delivers cold nitrogen gas via a catheter introduced into the esophagus through the accessory channel of an upper GI endoscope. Esophagoscopy was performed in 20 swine under conscious sedation, and cold nitrogen gas was sprayed on the distal 2 to 3 cm of the esophagus under direct visualization. RESULTS: Freezing of the esophageal mucosa was evidenced by the appearance of a white "cryoburn" with sharply demarcated margins. Hemicircumferential to circumferential freezing of the distal esophagus was achieved in 20 swine by varying the duration of cryoburn from 10 to 60 seconds. Mucosal ablation was noted 2 to 7 days after treatment in 95% of the swine. Complications included 3 esophageal strictures and 1 aspiration pneumonia. CONCLUSIONS: Cryotherapy performed by spraying liquid nitrogen at upper GI endoscopy is a simple technique capable of inducing controlled superficial mucosal necrosis with complete healing in the esophagus. This method warrants further evaluation as a treatment for esophageal lesions including Barrett's esophagus.     

Esophageal motility disorders in HIV patients

Opportunistic esophageal infections (Candida, cytomegalovirus, herpes simplex virus) and idiophatic esophageal ulcerations are commonly found in HIV patients. However, motility disorders of the esophagus have seldom been investigated in this population. The aim of this prospective study was to determine the presence of motility disorders in HIV patients with esophageal symptoms (with or without associated lesions detected by endoscopy) and in HIV patients without esophageal symptoms and normal esophagoscopy. Eigthteen consecutive HIV patients (10 male, 8 female, ages 20–44 years, mean age 33.5; 8 HIV positive and 10 AIDS) were studied prospectively. Nine patients complained of esophageal symptoms, e.g, dysphagia/odynophagia (group 1) and 9 had symptoms not related to esophageal disease, such as diarrhea, abdominal pain, or gastrointestinal bleeding (group 2). All patients underwent upper endoscopy; mucosal biopsies were taken when macroscopic esophageal lesions were identified or when the patients were symptomatic even if the esophageal mucosa was normal. Esophageal manometry was performed in the 18 patients, using a 4-channel water-perfused system according to a standardized technique. Sixteen of the 18 patients (88.8%) had baseline manometric abnormalities. In group 1, 8/9 patients had esophageal motility disorders: nutcracker esophagus in 1, hypertensive lower esophageal sphincter (LES) with incomplete relaxation in 2, nonspecific esophageal motility disorders (NEMD) in 3, diffuse esophageal spasm in 1, esophageal hypocontraction with low LES pressure in 1. Six of these 9 patients had lesions detected by endoscopy: CMV ulcers in 2, idiopathic ulcers in 1, candidiasis in 1, idiopathic ulcer + candidiasis in 1, nonspecific esophagitis in 1; and 3/9 had normal endoscopy and normal esophageal biopsies. In group 2, 8/9 patients had abnormal motility: hypertensive LES with incomplete relaxation in 1, nutcracker esophagus in 2, esophageal hypocontraction in 3, and NEMD in 2. All these patients had a normal esophageal mucosa at endoscopy. In conclusion, our findings suggest that HIV patients have esophageal motility disorders independent of esophageal symptoms and/or the presence of mucosal esophageal lesions.     

Primary cricopharyngeal dysfunction: Treatment with balloon catheter dilatation

BACKGROUND: Primary cricopharyngeal dysfunction (PCD) is a rare, idiopathic, functional disorder of the upper esophageal sphincter, characterized by dysphagia, frequent aspiration, and functional narrowing at the level of the upper esophageal sphincter. METHODS: Five of 29 patients with oropharyngeal dysphagia were found to have PCD. Patients presented with severe dysphagia and predisposition to aspiration. Radiography demonstrated narrowing at the level of the upper esophageal sphincter and aspiration. An endoscope could be introduced into the esophagus in only 2 patients before dilation. OBSERVATIONS: In contrast to organic stenoses, these functional upper esophageal sphincter stenoses were dilated without difficulty with a balloon catheter. After low-pressure (1.5-2 atm) progressive balloon dilation (to 20 mm), superficial mucosal injury was observed only in one patient. After dilatation, symptoms resolved and barium swallow demonstrated normal passage through the upper esophageal sphincter. During a mean follow-up of 21 months (7-33), redilation was necessary in only 1 case. CONCLUSIONS: Balloon catheter dilatation of PCD is minimally invasive and provides both important diagnostic information and effective therapy. It should be the first choice of therapy for PCD.     

Fiberoptic endoscopic diagnosis and treatment of a congenital esophageal diaphragm

Summary A 9-month-old infant suffering from dysphagia to solids presented with esophageal bolus obstruction. Using an adult fiberoptic esophagoscope, a congenital web was found at the junction of the middle and distal thirds of the esophagus. Previous direct rigid esophagoscopy and roentgenologic examination had not visualized the web. The web was successfully ruptured and dilated by inserting a guide wire under fiberscopic control and then inserting metal olives, followed later by blind mercury bougienage. This report illustrates the use of adult fiberoptic instruments for diagnosis and treatment in pediatric patients.     

Endoscopic dilatation and surgical myectomy of symptomatic cervical esophageal webs

During a 10-year period a cervical esophageal web or stricture was diagnosed at rigid endoscopy in 57 patients. Of these patients 72% had restricted their dietary habits because of their symptoms of dysphagia. Cineradiography of the pharynx had revealed abnormalities in 90% of the patients. Dilatation of the webs was performed with semisolid bougies, the endoscope itself, or with balloon inflation. Twelve patients were treated by myectomy of the cricopharyngeal muscle because of unsatisfactory results from the dilatation treatment. Cineradiographic outcome and improvement in dietary habits as a result of the treatment are reported.     

Multicentric tumor of the esophagus and its clinical significance; case report and review of the literature

Simultaneous occurrence of the esophageal tumor at multiple sites in a single patient is unusual. Here in, we described a patient had three separate tumoral nodules with ulceration of the esophagus. Thorax CT scan, X-ray and endoscopy revealed the only two tumoral lesion at the lower esophagus. But, the other tumoral lesion at the upper part of the esophagus was detected at operation and histopathologic examination. The aspect of treatment was changed according to this new condition during the operation. We discussed the multicentric tumoral lesions of the esophagus in view of the literature.     

Update on endoscopic diagnosis, management and surveillance strategies of esophageal diseases

In the last few decades, upper gastrointestinal endoscopy has become the most complementary test for investigation of esophageal diseases. Its accessibility and safety guarantee wide clinical utilization in patients with suspected benign and malignant diseases of the esophagus. Recent technological advances in endoscopic imaging and tissue analysis obtained from the esophagus have been useful to better understand and manage highly relevant diseases such as gastroesophageal reflux disease, eosinophilic esophagitis and esophageal cancer. Using endoscopy to elucidate esophageal disorders in children has been another field of intensive and challenging research. This editorial highlights the latest advances in the endoscopic management of esophageal diseases, and focuses on Barrett’s esophagus, esophageal cancer, eosinophilic esophagitis, as well as esophageal disorders in the pediatric population.     

Magnifying endoscopy in upper gastrointestinal tract]

For the diagnosis of upper gastrointestinal (GI) lesions, magnification method is usually used in conjunction with chromoscopy, enabling the endoscopist to view subtle mucosal patterns in exquisite detail. Recently published datas have shown that magnifying endoscopy might be a valuable adjunct for the diagnosis, detection, and characterization of inflammatory and neoplastic lesions of the upper GI tract. It is also proven to be an useful surveillance protocol in identifying dysplastic epithelium or early cancer within a segment of Barrett's esophagus. Possible indications for magnifying endoscopy in upper GI tract include screening and surveillance of Barrett's esophagus, defining the extent of esophageal and gastric adenocarcinoma, detecting synchronous/metachronous gastric and esophageal cancers, diagnosing Helicobacter pylori infection, and recognizing minimal mucosal changes in gastroesophageal reflux disease. By grading the quality of evidence for the currently published trials, it is clear that the majority are case series, case reports, and/or observational studies without randomization, control, or blinding. Moreover, other evidence-based criteria such as independent, blind comparisons of magnifying endoscopy with a standard method which evaluates this technology in an appropriate spectrum of patients to whom the test may be applicable, and standardizing methodology would be crucial before magnifying endoscopy becomes a standard procedure in clinical practice. In the future, a uniform classification system for staining and magnifying patterns should be devised and observer agreement should be tested. Futher studies then could be performed based upon consistent, validated, and standardized terminologies and criteria.     

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.     

Endoscopic treatment of a Zenker''s diverticulum using argon plasma coagulation in a patient with massive cachexia and esophageal obstruction: a case report and review of literature

A case report is presented of an 86-year-old man in a very poor general condition with a 10-year history of a Zenker's diverticulum as a cause of a complete obstruction of the esophagus with subsequent aphagia and massive cachexia. Because of high surgical risk and contraindications to general anesthesia, an approach with the flexible endoscope to perform cricopharyngeal myotomy was undertaken. Several attempts with the flexible endoscope by experienced investigators had been performed until the esophageal inlet was intubated and argon plasma coagulation could be applied in several sessions to divide the tissue bridge between the esophagus and the Zenker diverticulum to successfully restore the pharyngoesophageal passage.     

Plastic tube-assisted gastroscopic removal of embedded esophageal metal stents: A case report

A patient with stent embedding after placement of an esophageal stent for an esophagobronchial fistula was treated with an ST-E plastic tube inserted into the esophagus to the upper end of the stent using gastroscopy.The gastroscope was guided into the esophagus through the ST-E tube,and an alligator forceps was inserted into the esophagus through the ST-E tube alongside the gastroscope.Under gastroscopy,the stent wire was grasped with the forceps and pulled into the ST-E tube.When resistance was met during withdrawal,the gastroscope was guided further to the esophageal section where the stent was embedded.Biopsy forceps were guided through a biopsy hole in the gastroscope to the embedded stent to remove silicone membranes and connection threads linking the Z-shaped wire mesh.While the lower section of the Z-shaped stent was fixed by the biopsy forceps,the alligator forceps were used to pull the upper section of the metal wire until the Z-shaped metal loops elongated.The wire mesh of the stent was then removed in stages through the ST-E tube.Care was taken to avoid bleeding and perforation.Under the assistance of an ST-E plastic tube,an embedded esophageal metal stent was successfully removed with no bleeding or perforation.The patient experienced an uneventful recovery after surgery.Plastic tube-assisted gastroscopic removal of embedded metal stents can be minimally invasive,safe,and effective.     

Radiographic techniques and efficacy in evaluating esophageal dysphagia

The radiographic examination of the esophagus to determine structural and/or functional causes of dysphagia is best performed with multiple techniques. These include full-column studies to produce distended films with or without the use of a solid bolus, mucosal relief films to identify mucosal defects such as esophagitis or the presence of varices, double-contrast films, and motion recording (fluoroscopy). The efficacy of each technique depends on the quality of the study and the specific disorder to be detected. Esophageal lesions producing dysphagia are classified into extrinsic structural lesions, intrinsic structural lesions, and esophageal motility disorders. Radiographic studies are the preferred screening techniques for patients with dysphagia. Although not as sensitive for the evaluation of mucosal lesions, radiographic studies are superior to endoscopy for the detection of abnormal motility, esophageal rings, and strictures.     

Combined antegrade and retrograde dilation: a new endoscopic technique in the management of complex esophageal obstruction

BACKGROUND: Esophageal strictures that cause complete obstruction are often difficult to dilate with standard bougienage techniques. METHODS: A new technique was developed and applied, combined antegrade and retrograde dilation, for dilatation of complex esophageal strictures. The stomach is accessed and an endoscope (9.8 mm diameter) is directed under fluoroscopy in a retrograde fashion into the distal esophagus. A guidewire with a hydrophilic coating is advanced through the stricture and then pulled through the mouth with a simultaneously placed proximal endoscope. The guidewire is then used as a guide for antegrade esophageal dilatation. RESULTS: Ten patients with complex esophageal strictures (with and without fistulas) were treated with this technique. Three required a second combined antegrade and retrograde dilation procedure. All strictures were dilated and no perforations occurred. CONCLUSIONS: Combined antegrade and retrograde dilation is a safe and effective technique for dilation of complex obstructing esophageal lesions.