Role of faecal calprotectin as a predictor of endoscopic activity in paediatric patients with ulcerative colitis

IntroductionColonoscopy is currently considered to be the gold standard for evaluation of colonic mucosa inflammation in patients with ulcerative colitis (UC), but the procedure is invasive and cannot be repeated frequently, especially in the paediatric population. The aim of this study was to assess the role of faecal calprotectin (FC) as a predictor of endoscopic disease activity in paediatric patients with UC in clinical remission.Material and methodsSingle-centre prospective study. Clinical remission was defined as Paediatric Ulcerative Colitis Activity Index <10. Endoscopic findings were assessed according to the Mayo Endoscopic Subscore (MES). MES ≤ 1 was defined as endoscopic remission. All participants provided fresh faecal samples for measurement of FC.ResultsA total of 34 visits of 24 children with UC were included in the study. There was a strong positive correlation between FC levels and endoscopic disease activity (n = 34, r = 0.83, p < 0.001). The median FC levels in the subgroup with endoscopic activity (MES 2–3) were significantly higher than the median FC levels in the subgroup without endoscopic activity (MES ≤ 1) (1000 μg/g, IQR 575–1800 μg/g vs. 100 μg/g, IQR 80–223 μg/g, p < 0.001). At a cut-off of 298.5 μg/g, FC had 92.3% sensitivity, 95.2% specificity and an AUROC 0.974 (SE 0.023, 95% CI 0.93–1, p < 0.001) to predict endoscopic activity.DiscussionFC is an accurate surrogate marker of endoscopic activity in children with clinically quiescent UC.     

A randomised study of hydro-jet vs. needle injection for lifting colorectal lesions prior to endoscopic resection

BackgroundSubmucosal lifting of lesions prior to endoscopic resection is crucial to reduce complications and improve the technical feasibility of the procedure.AimTo compare a self-assembled hydro-jet system vs. standard needle injection for tissue elevation prior to endoscopic resection of colorectal lesions.MethodsRandomised study performed at a single tertiary care institution. Consecutive patients with colonoscopic diagnosis of sessile polyps or non-polypoid lesions >5 mm or laterally spreading tumours. Outcome measures: successful elevation, time to proper elevation, completeness of excision, cautery damage, and general histological diagnostic quality (blinded pathologic assessment).Results79 patients were randomised to hydro-jet (40 patients, group A) and needle (39 patients, group B) elevation. Successful elevation was achieved in 97.5% and 94.8%, respectively. Time to proper elevation was 8 ± 5 s vs. 18 ± 3 s (p < 0.05). In group A, histology showed selective accumulation of fluid in the submucosa with intact collagen fibres. Damage to muscularis mucosa was never noted in the specimens of group A and in 7 cases of group B (p < 0.01). Artefacts from “cautery effect” were very limited. Radial margins of resection could be adequately evaluated in all cases and were negative.ConclusionsThe hydro-jet system is as effective and safe as standard needle injection for tissue elevation prior to endoscopic resection of colorectal lesions, but it is significantly faster.     

Oral ingestion versus endoscopic delivery of endoscopic capsule in patients with previous gastrointestinal surgery (ORENCES study): A Spanish multicentre observational study

BackgroundSmall Bowel Capsule Endoscopy is the first-choice technique for investigating the majority of small bowel diseases. Its most common complications are related to incomplete examinations and capsule retention. There is no consensus on how patients with previous gastrointestinal surgery should receive the capsule.ObjectiveThe primary endpoint was to compare the rate of complete small-bowel examinations (completion rate) between oral ingestion and endoscopic delivery of the capsule. The secondary endpoint was to compare diagnostic yield and adverse events in the two groups.MethodsA retrospective observational study was conducted in nine hospitals in Spain. Demographic data, previous surgery, indication for capsule endoscopy, intestinal transit time, diagnosis, completion rate (percentage of capsules reaching the caecum), diagnostic yield (percentage of results compatible with indication for the exam) and adverse events were collected.ResultsFrom January 2009 to May 2019 fifty-seven patients were included (39 male, mean age 66 ± 15 years). The most common indications for the exam were “overt” (50.9%) and “occult” (35.1%) small bowel bleeding. Previous Billroth II gastrectomy and Roux-en-Y gastric bypass were present in 52.6% and 17.5% of patients respectively. The capsule was swallowed in 34 patients and placed endoscopically in 23 patients. No significant differences were observed between the oral ingestion and endoscopic delivery groups in terms of completion rate (82.4% vs. 78.3%; p = 0.742), diagnostic yield (41.2% vs. 52.2%; p = 0.432) or small bowel transit time (301 vs. 377 min, p = 0.118). No capsule retention occurred. Only one severe adverse event (anastomotic perforation) was observed in the endoscopic delivery group.ConclusionsIn our case series, there were no significant differences between oral ingestion and endoscopic delivery in terms of completion rate, diagnostic yield or safety. Being less invasive, oral ingestion of the capsule should be the first-choice method in patients with previous gastrointestinal surgery.     

Submucosal tunnelling endoscopic resection for the treatment of esophageal submucosal tumours originating from the muscularis propria layer: An analysis of 15 cases

Background and aimsThe aim of this prospective study was to evaluate the feasibility of submucosal tunnelling endoscopic resection of esophageal tumours originating from the muscularis propria layer.MethodsFifteen patients with esophageal submucosal tumours originating from the muscularis propria layer underwent submucosal tunnelling endoscopic resection between August 2011 and February 2012. The key steps were: (1) creating a submucosal tunnel from 5 cm above the tumour between the submucosal and muscular layers with a hook knife or hybrid knife; (2) dissecting the tumour by the technique of endoscopic submucosal dissection; (3) closing the mucosal incision site with clips after the tumour was removed.ResultsSubmucosal tunnelling endoscopic resection was successfully performed in all cases. The en bloc resection rate was 100%. The average tumour diameter was 1.8 cm (range 1.0–3.0 cm). During the procedure, perforation occurred in 3 patients, who recovered after conservative treatment. No residual tumour or tumour recurrence was detected during the follow-up period (mean: 3.5 months, range: 1–9 months). Pathological diagnoses of these tumours were leiomyomas (12/15) and gastrointestinal stromal tumours (3/15).ConclusionsSubmucosal tunnelling endoscopic resection is a feasible method for the treatment of small esophageal submucosal tumours originating from the muscularis propria layer.     

Endoscopic resection for superficial colorectal neoplasia in Italy: A prospective multicentre study

BackgroundSince there are few prospective studies on colorectal endoscopic resection to date, we aimed to prospectively assess safety and efficacy of endoscopic resection in a cohort of Italian patients.MethodsProspective multicentre assessment of resection of sessile polyps or non-polypoid lesions ≥ 10 mm in size or smaller (if depressed). Outcome measures included complete excision, morbidity, mortality, and residual/recurrence at 12 months.ResultsOverall, 1012 resections in 928 patients were analysed (62.4% sessile polyps, 28.8% laterally spreading tumours, 8.7% depressed non-polypoid lesions). Lesions were prevalent in the proximal colon. Enbloc resection was possible in 715/1012 cases (70.7%), whereas piecemeal resection was required in 297 (29.3%). Endoscopically complete excision was achieved in 866 cases (85.6%). Adverse events occurred in 83 (8.2%), and no deaths occurred. Independent predictors of 12-month residual/recurrence were the location of the lesion in the proximal colon (OR 2.22 [95% CI 1.16–4.26]; p = 0.015) and piecemeal endoscopic resection (OR 2.76 [95% CI 1.56–4.87]; p = 0.0005). Limitations of the study were: potential expertise bias, no data on eligible and potentially resectable excluded lesions, high percentage of lesions < 20 mm, follow-up limited to 1 year.ConclusionIn this registry study the endoscopic resection of colorectal lesions was safe and achieved high rates of long-term endoscopic clearance.     

Clinical utility of the SMSA grading tool for the management of colonic neoplastic lesions

BackgroundWhilst polyp size has been traditionally used as a predictor of the complexity of endoscopic resection, the influence of other factors is increasingly recognised. The SMSA grading system takes into account polyp Site, Morphology, Size and Access, with higher scores correlating with increased technical difficulty.AimsTo evaluate whether the SMSA grading tool correlates with endoscopic and clinical outcomes.MethodsThis retrospective study was conducted at two high volume centres in the United Kingdom and Italy. All polyps identified at colonoscopy were included in this study and classified as per the SMSA grading system.ResultsA total of 1668 lesions were resected in 1016 patients. There was a positive correlation between increasing SMSA level and the inability to resect lesions “en bloc” (p < 0.001). Histologically complete clearance was higher in the lower SMSA groups (p < 0.0001). Additional endoscopic therapies, were more commonly required with the higher SMSA groups to achieve histological clearance (p < 0.0001). Moreover, advanced histology in resection specimens and procedural complications were significantly less common in SMSA level 1 lesions compared to level 3 or 4 lesions (p < 0.0001).ConclusionsThe SMSA grading tool is a useful predictor of outcome following the resection of colonic neoplastic lesions.     

Clinical outcomes of endoscopic submucosal dissection (ESD) for treating early gastric cancer: Comparison with endoscopic mucosal resection after circumferential precutting (EMR-P)

BackgroundTo achieve en bloc resection for large lesions, endoscopic mucosal resection after circumferential precutting and endoscopic submucosal dissection techniques have been developed.AimTo compare endoscopic submucosal dissection with endoscopic mucosal resection after circumferential precutting in terms of the clinical efficacy and safety.Patients and methods346 consecutive patients underwent their first endoscopic mucosal resection after circumferential precutting (103 patients) or endoscopic submucosal dissection (243 patients) for early gastric cancer and their clinical outcomes were compared.ResultsFor early gastric cancer ≥20 mm endoscopic submucosal dissection group demonstrated significantly higher en bloc resection and en bloc plus R0 resection rate compared with endoscopic mucosal resection after circumferential precutting group. For early gastric cancer with size of 10–19 mm, endoscopic submucosal dissection group also showed significantly higher en bloc resection rate. For early gastric cancer <20 mm, however, en bloc plus R0 resection rate for endoscopic mucosal resection after circumferential precutting group was comparable to that for endoscopic submucosal dissection group. In case of R0 resection of intramucosal differentiated cancer, neither group showed local recurrence during the median 29 and 17 months of follow-up. Two groups did not show significant difference in the bleeding or perforation rates.ConclusionFor early gastric cancer <20 mm endoscopic mucosal resection after circumferential precutting may be considered as an alternative choice to endoscopic submucosal dissection. However, for early gastric cancer ≥20 mm endoscopic submucosal dissection should be considered as the first choice for treating early gastric cancer.     

Measures of trainee performance in advanced endoscopy: A systematic review

IntroductionThe diversity, technical skills required, and risk inherent to advanced endoscopy techniques all contribute to complex training curricula and steep learning curves. Since trainees develop endoscopy skills at different rates, there has been a shift towards competency-based training and certification. Validated endoscopy performance measures for trainees are, therefore, necessary. The aim of this systematic review was to describe and critically assess the existing evidence regarding measures of performance for trainees in advanced endoscopy.MethodsA systematic review of the literature from January 1980 to January 2016 was carried out using the MEDLINE, EMBASE, CENTRAL, and ISI Web of knowledge databases. MeSH terms related to 'advanced endoscopy' and 'performance' were applied to a highly sensitive search strategy. The main outcomes were face, content, and construct validity, as well as reliability.ResultsThe literature search yielded 1,662 studies and 77 met the inclusion criteria after abstract and full-text review (endoscopic retrograde cholangiopancreatography (ERCP) = 23, endoscopic ultrasound (EUS) = 30, colonoscopic polypectomy (CP) = 11, balloon-assisted enteroscopy (BAE) = 7, luminal stenting = 3, radiofrequency ablation (RFA) = 2, and endoscopic muscosal resection (EMR) = 1). Good validity and reliability were found for measurement tools of overall performance in ERCP, EUS and CP, with applications for both patient-based and simulator training models. A number of specific technical skills were also shown to be valid measures of performance. These include: selective biliary cannulation, sphincterotomy, biliary stent placement, stone extraction and procedure time for ERCP; pancreatic solid mass T-staging, EUS-guided fine needle aspiration (EUS-FNA) procedure time, number of EUS-FNA passes and puncture precision for EUS; procedure time and en bloc resection rate for CP; retrograde fluoroscopy time for BAE; and mean number of endoscopy sessions required to achieve complete eradication of intestinal metaplasia (CIEM) for RFA. The evidence for EMR and luminal stenting is of insufficient quality to make recommendations.ConclusionsWe have identified multiple valid and readily available performance measures for advanced endoscopy trainees for ERCP, EUS, CP, BAE and RFA procedures. These tools should be considered in advanced endoscopy training programs wishing to move away from apprenticeship-based training and towards competency-based learning with the help of patient-based and simulator tools.     

Portal hypertensive colopathy and haematochezia in cirrhotic patients: An endoscopic study

Background and study aimsIn patients with liver cirrhosis, portal hypertensive colopathy (PHC) and anorectal varices (ARVs) are thought to cause lower gastrointestinal (GI) bleeding. In the present work, we studied the diagnostic yield of colonoscopy in cirrhotic patients and haematochezia.Patients and methodsThe current study was conducted on 77 consecutive cirrhotic patients who underwent colonoscopy at Mansoura Emergency Hospital, Egypt, between May 2007 and May 2011. Following rapid evaluation and adequate resuscitation, a thorough history was obtained with complete physical examination including digital rectal examination and routine laboratory investigations. Colonoscopic evaluation was performed for the included patients by recording endoscopic abnormalities and obtaining biopsies from lesions.ResultsThere was no significant difference between the PHC-positive group when compared with the PHC-negative group regarding patients’ age, sex, severity of haematochezia, positive family history and the history of intake of non-steroidal anti-inflammatory drugs (NSAIDs). Significant difference was noted regarding the Child–Pugh class (p < 0.05), history of splenectomy (p < 0.05), prior history of endoscopic sclerotherapy (EST) or endoscopic variceal ligation (EVL) (p < 0.05), prior history of upper gut bleeding (p < 0.05), the presence of gastric varices (GVs) (p < 0.05), presence of portal hypertensive gastropathy (PHG) (p < 0.05), presence of haemorrhoids (p < 0.05) and rectal varices (<0.05) and therapy with β-blockers (p < 0.05). Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p < 0.05). All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.Regarding the laboratory parameters, the platelet count only was markedly reduced in the PHC-positive group (p < 0.05).All the PHC-related sources of bleeding (7/32 cases (21.87%)) were successfully managed with argon plasma coagulation.ConclusionOur data revealed that it is not only PHC which is involved in haematochezia in cirrhotic patients despite the significant association. Instead, a high prevalence of inflammatory lesions came on the top of the list. Complete colonoscopy is highly advocated to detect probable proximal neoplastic lesions.     

Diagnosis of submucosal tumor of the upper GI tract by endoscopic resection.

BACKGROUND: Submucosal tumors are frequent findings during endoscopy, although definitive diagnosis based on histologic confirmation presents some difficulties. The aim of this study was to evaluate the efficacy and safety of endoscopic resection based on endoscopic ultrasonography (EUS) findings to reach a definitive diagnosis of submucosal tumor. METHODS: Fifty-four submucosal tumors of the upper gastrointestinal (GI) tract were included in this study. EUS was performed to determine the layer of origin and location of the lesion and to rule out malignancy. En bloc resection was attempted for lesions originating in the muscularis mucosa or submucosa. For tumors originating in the muscularis propria, we performed partial resection limited to the covering mucosa to expose the lesion and obtained a sample with standard biopsy forceps. RESULTS: Sufficient samples were obtained in all 54 cases. There was no perforation. Bleeding occurred in only 5 cases (9%) and was easily managed with endoscopic hemostatic methods. EUS and pathologic findings coincided in 74.1% of cases (40 of 54). Benign lesions (leiomyoma, aberrant pancreas, and others) were predominant (52 of 54), although 2 small lesions were confirmed at pathologic study to be malignant (leiomyosarcoma and leiomyoblastoma). CONCLUSIONS: Endoscopic resection based on EUS findings proved to be an effective and safe method to confirm the histologic diagnosis of submucosal tumor of the upper GI tract. Endoscopic resection should be considered a valuable choice for definitive management of benign submucosal tumors originating in the superficial layers.     

Detection of carbapenemase-producing Pseudomonas aeruginosa: Evaluation of the carbapenem inactivation method (CIM)

IntroductionThe carbapenem inactivation method (CIM) is a cost-effective assay for detecting carbapenemases. However, its interpretation is unclear for Pseudomonas spp. We evaluate its accuracy when meropenem is changed to imipenem.MethodsWe analyzed 266 P. aeruginosa isolates. The CIM method consists of: resuspend bacterial colonies (a full 10 μL loop) in 400 μL water, in which a 10 μg disk of meropenem/imipenem is immersed. After 2 h of incubation (35 °C), remove the disk, place it onto a Mueller-Hinton agar plate previously inoculated with Escherichia coli (ATCC 25922), and incubate at 35 ̊C between 18-24 h. Interpretation criteria (mm of inhibition zone): ≤19 mm, positive; ≥25 mm negative; 20–24 mm, undetermined.ResultsImipenem improves the sensitivity and specificity of CIM when compared to meropenem (99.4% and 98.9%, vs. 91.9% and 94.7%, respectively).ConclusionsThe accuracy of CIM for carbapenemase detection in P. aeruginosa is increased with the use of imipenem.     

Colonic endoscopic mucosal resection of large polyps: Is it safe in the very elderly?

BackgroundOutcomes on colon endoscopic mucosal resection in the very elderly patient population are unknown.AimsAims of this study were to evaluate the outcomes and safety of colon endoscopic mucosal resection in this target population.MethodsObservational, retrospective study of patients ≥80 years of age that underwent colon endoscopic mucosal resection ≥2 cm. Demographics, American Society of Anesthesiologists classification, procedural data, and surgical treatment data were collected.ResultsOne-hundred-and-thirty-one colon endoscopic mucosal resections were performed on 99 patients ≥80 years of age with a mean age of 84. The majority of American Society of Anesthesiologists class was II. Mean lesion size was 3.3 cm (range, 2–12.5 cm), more procedures were performed in the right colon and adenoma/tubulovillous adenoma was the most common pathology. En bloc resection was performed on 26.7% of polyps (N = 35). Eight procedure-related adverse events (8/131, 6.1%) occurred. No anaesthesia related adverse events or deaths occurred. Six patients required a colonic operation, and overall, 94% of the patient cohort evaded a colon operation.ConclusionsColon endoscopic mucosal resection in very elderly patients can be performed at experienced endoscopy centres with a low rate of complications and offers these patients a non-surgical option of management of colorectal lesions.     

Long-term outcome of early gastric cancer after endoscopic submucosal dissection: Expanded indication is comparable to absolute indication

BackgroundEndoscopic submucosal dissection has become widely used for early gastric cancer with an expanded indication, although there is no strong consensus. We aimed to compare the clinical and long-term oncological outcome after endoscopic submucosal dissection according to indication.MethodsRetrospective review of 1152 patients with 1175 lesions who had undergone endoscopic submucosal dissection for early gastric cancer at tertiary educational hospital in Korea, between March 2005 and November 2011. Of these, 366 and 565 lesions were included in the absolute and expanded indication groups, respectively.ResultsEn bloc resection rates were not significantly different between the absolute and expanded indication groups. The complete resection rate was higher in the absolute indication group versus the expanded indication group (94.8% vs. 89.9%, respectively; P = 0.008). In the expanded indication group, complete resection rate was higher in the differentiated versus undifferentiated tumour subgroups (92.9% vs. 78.4%, respectively; P < 0.001). Recurrence rates were 7.7% in the absolute indication group vs. 9.3% in the expanded indication group (P = 0.524). Disease-free survival was not significantly different between the two indication groups (P = 0.634).ConclusionsEndoscopic submucosal dissection for early gastric cancer with expanded indication is a feasible approach to disease management. Periodic endoscopic follow-up is necessary to detect cancer recurrence.     

Pilot Trial of Extended Hypothermic Lung Preservation to Analyze Ischemia-reperfusion Injury in Pigs

BackgroundIn lung transplantation (LT), the length of ischemia time is controversial as it was arbitrarily stablished. We ought to explore the impact of extended cold-ischemia time (CIT) on ischemia-reperfusion injury in an experimental model.MethodsExperimental, randomized pilot trial of parallel groups and final blind analysis using a swine model of LT. Donor animals (n = 8) were submitted to organ procurement. Lungs were subjected to 6 h (n = 4) or 12 h (n = 4) aerobic hypothermic preservation. The left lung was transplanted and re-perfused for 4 h. Lung biopsies were obtained at (i) the beginning of CIT, (ii) the end of CIT, (iii) 30 min after reperfusion, and (iv) 4 h after reperfusion. Lung-grafts were histologically assessed by microscopic lung injury score and wet-to-dry ratio. Inflammatory response was measured by determination of inflammatory cytokines. Caspase-3 activity was determined as apoptosis marker.ResultsWe observed no differences on lung injury score or wet-to-dry ratio any given time between lungs subjected to 6 h-CIT or 12h-CIT. IL-1β and IL6 showed an upward trend during reperfusion in both groups. TNF-α was peaked within 30 min of reperfusion. IFN-γ was hardly detected. Caspase-3 immunoexpression was graded semiquantitatively by the percentage of stained cells. Twenty percent of apoptotic cells were observed 30 min after reperfusion.ConclusionsWe observed that 6 and 12 h of CIT were equivalent in terms of microscopic lung injury, inflammatory profile and apoptosis in a LT swine model. The extent of lung injury measured by microscopic lung injury score, proinflammatory cytokines and caspase-3 determination was mild.     

Development of knowledge-based clinical decision support system for patients included in colorectal screening program

Background & aimsColorectal (CRC) screening programs represent a large volume of procedures that need a follow-up endoscopy. A knowledge-based clinical decision support system (K-CDSS) is a technology which contains clinical rules and associations of compiled data that assist with clinical decision-making tasks. We develop a K-CDSS for management of patients included in CRC screening and surveillance of colorectal polyps.MethodsWe collected information on 48 variables from hospital colonoscopy records. Using DILEMMA Solutions Platform © (https://www.dilemasolution.com) we designed a prototype K-CDSS (PoliCare CDSS), to provide tailored recommendations by combining patients data and current guidelines recommendations. The accuracy of rules was verified using four scenarios (normal colonoscopy, lesions different than polyps, non-advanced adenomas and advanced adenomas). We studied the degree of agreement between the clinical assessments made by expert doctors and nurses equipped with PoliCare CDSS. Two experts confirmed a correlation between guidelines and PoliCare recommendations.Results56 consecutive endoscopy cases from colorectal screening program were included (62.8 years; range 53-71). Colonoscopy results were: absence of colon lesions (n = 7, 12.5%), lesions in the colon that are not polyps (n = 3, 5.4%) and resected colonic polyps (n = 46, 82.1%; 100% R0 resection). Patients with resected polyps presented non-advanced adenoma (n = 21, 45.6%) or advanced lesions (n = 25, 54.4%). There were no differences in erroneous orders with PoliCare CDSS (Kappa value 1.0).ConclusionsPoliCare CDSS can easily be integrated into the workflow for improving the overall efficiency and better adherence to evidence-based guidelines.     

Fecal calprotectin one year after ileocaecal resection for Crohn's disease — A comparison with findings at ileocolonoscopy

Background and AimsIleocaecal resection for Crohn's disease is commonly performed. The severity of endoscopic lesions in the anastomotic area one year postoperatively is considered to reflect the subsequent clinical course.Fecal calprotectin (FC) has been shown to correlate with the findings at ileocolonoscopy in Crohn's disease. The objectives of this study were to assess whether the concentration of FC reflects the endoscopic findings one year after ileocaecal resection and to evaluate the variation of FC in individual patients during 6 months prior to the ileocolonoscopy.MethodsThirty patients with Crohn's disease and ileocaecal resection performed within one year were included. Stool samples were delivered monthly until an ileocolonoscopy was performed one year postoperatively.ResultsOne year after surgery the median values of FC were not significantly different between the patients in endoscopic remission (n = 17) and the patients with an endoscopic recurrence (189 (75–364) vs 227 (120–1066)μg/g; p = 0.25). However, most patients with low values were in remission and all patients with high (> 600 μg/g) calprotectin values had recurrent disease. The variability of the FC concentration was most pronounced in patients with diarrhea.ConclusionsWe found no statistical difference in the concentrations of calprotectin between patients in endoscopic remission and patients with a recurrent disease one year after ileocaecal resection for Crohn's disease. However, among the minority of patients with low or high values, FC indicated remission and recurrence, respectively. There was significant variation of the fecal calprotectin concentrations over time, which affects the utility of calprotectin in clinical practice.     

Comparative performance of FAS equation and Asian modified CKD-EPI in the determination of GFR in Chinese patients with CKD with the 99mTc-DTPA plasma clearance as the reference method

BackgroundGlomerular filtration rate (GFR) is a useful index in many clinical conditions. However, very few studies have assessed the performance of full age spectrum (FAS) equation and the Asian modified Chronic Kidney Disease-Epidemiology Collaboration (CKD-EPI) equation in the approximation of GFR in Chinese patients with chronic kidney disease.ObjectiveThis study aimed to compare the diagnostic performance of the above two creatinine-based equations.MethodsA well designed single-center cross-sectional study was performed and the GFR was determined by 3 methods separately in the same day: technetium-99m-diethylene triamine pentaacetic acid (^99mTc-DTPA) dual plasma sample clearance method (mGFR); FAS equation method; Asian modified CKD-EPI equation method. The gold standard method was the mGFR. Equations performance criteria considered correlation coefficient, bias, precision, accuracy and the ability to detect the mGFR less than 60 ml/min/1.73 m².ResultsA total of 160 patients were enrolled. The diagnostic performance of FAS showed no significant difference in the correlation coefficient (0.89 vs 0.89), precision (15.9 vs 16.1 ml/min/1.73 m²), accuracy (75.0% vs 76.3%) and the ability to detect the mGFR less than 60 ml/min/1.73 m² (0.94 vs 0.94) compared with the Asian modified CKD-EPI equation in all participants. The FAS showed a negative bias, while the new CKD-EPI equation showed a positive bias (?1.20 vs 1.30 ml/min/1.73 m², P < 0.001). However, they were all near to zero. In the mGFR < 60 ml/min/1.73 m² subgroup and mGFR > 60 ml/min/1.73 m² subgroup were consistent with that in the whole cohort. The precision and accuracy decreased when GFR > 60 ml/min/1.73 m² in both equations.ConclusionsThe FAS equation and the Asian modified CKD-EPI equation had similar performance in determining the glomerular filtration rate in the Chinese patients with chronic kidney disease. Both the FAS equation and Asian modified CKD-EPI can be a satisfactory method and may be the most suitable creatinine-based equation.     

Obstructing giant post-inflammatory polyposis in ulcerative colitis: Case report and review of the literature

BackgroundPost-inflammatory polyps > 15 mm in diameter or length are termed “giant”. This benign and rare sequel of ulcerative colitis or colonic Crohn's disease can mimic colorectal carcinoma.ObjectiveTo illustrate this rare complication of inflammatory bowel disease and outline the characteristic radiological, endoscopic and histopathological features, by reviewing all previously published cases of giant post-inflammatory polyps in the English literature.ResultsReports of 81 giant post-inflammatory polyps in 78 patients were identified by systematic review of the literature. The incidence of giant post-inflammatory polyps is related to the extent of ulcerative colitis (incidence: 0%, 30%, and 70%, in proctitis, left-sided, and extensive disease, respectively). These lesions are typically located in the transverse or descending colon. Giant post-inflammatory polyps are as common in Crohn's disease (n = 36) as in ulcerative colitis (n = 42, 54%). Clinical presentations varies, including pain (n = 29), rectal bleeding (n = 20), diarrhoea (n = 19), luminal obstruction (n = 15), or a palpable mass (n = 11). Symptomatic presentation results in surgical resection. Clinical details and outcomes are comprehensively tabulated.ConclusionRecognition of this rare entity will prevent unnecessary radical surgical resection for presumed carcinoma. It highlights the need for clinical, radiological, endoscopic and histopathological correlation.