The diagnostic accuracy of esophageal capsule endoscopy in patients with gastroesophageal reflux disease and Barrett's esophagus: a blinded, prospective study

BACKGROUND: Esophageal capsule endoscopy (ECE) is a novel technique that offers noninvasive evaluation of esophageal pathology in gastroesophageal reflux disease (GERD) patients. OBJECTIVE: To assess the diagnostic accuracy of ECE for Barrett's esophagus (BE), erosive esophagitis, and hiatal hernia and to assess the safety profile of ECE. METHODS: Patients with GERD symptoms and those undergoing BE surveillance were prospectively enrolled. All patients underwent ECE followed by standard upper endoscopy. ECE findings were interpreted by examiners blinded to endoscopy results. The gold standard was the findings at endoscopy and ECE results were compared with those at endoscopy. RESULTS: One hundred patients were enrolled of which 94 completed the study. At upper endoscopy, BE was suspected in 53 (mean length 3.1 cm) and confirmed in 45 patients. Erosive esophagitis and hiatal hernia were identified in 18 and 70 patients, respectively. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of ECE for BE in GERD patients were 67%, 87%, 60%, and 90%, respectively. The sensitivity, specificity, PPV, and NPV of ECE for BE patients undergoing surveillance were 79%, 78%, 94%, and 44%, respectively. The sensitivity, specificity, PPV, and NPV for erosive esophagitis were 50%, 90%, 56%, and 88% and for hiatal hernia were 54%, 67%, 83%, and 33%, respectively. CONCLUSIONS: Current diagnostic rates of ECE for BE are not yet accurate enough for application in clinical practice. An improvement in technology and learning curve assessments are required, until then standard upper endoscopy remains the gold standard.     

Incidence of esophageal adenocarcinoma in patients with Barrett's esophagus and high-grade dysplasia: a meta-analysis

BACKGROUND: Patients with Barrett's esophagus (BE) and high-grade dysplasia (HGD) are at a high risk for developing esophageal adenocarcinoma. However, the reported rate of cancer development in patients with HGD who were undergoing surveillance has varied among published studies. OBJECTIVE: To determine an overall precise estimate of cancer incidence in patients with HGD who were undergoing surveillance endoscopy. DESIGN: Systematic review and meta-analysis. METHODS: We conducted a systematic search of the published literature and selected original articles that examined patients with histologically proven BE and HGD, patients who had not undergone endoscopic ablation or surgical therapy, patients with 6 months' follow-up, no esophageal cancer at the time of enrollment or within 6 months, and studies in which follow-up was reported in person-time. Two investigators independently conducted the search and abstraction. MAIN OUTCOME MEASUREMENT: The weighted mean event rate was calculated and expressed as the weighted incidence rate, and its CIs were calculated. RESULTS: The search yielded 4 articles that met the inclusion criteria, and these were analyzed. A total of 236 patients with HGD were followed for 1241 patient-years, and esophageal adenocarcinoma was reported in 69 patients, providing a crude incidence rate of 5.57 per 100 patient-years. The weighted incidence rate was 6.58 per 100 patient-years (95% CI, 4.97-8.19). LIMITATIONS: A small number of studies that met inclusion criteria. CONCLUSIONS: In patients with BE and with HGD who were undergoing surveillance, esophageal adenocarcinoma develops in approximately 6 per 100 patient-years during the first few years of follow-up. These data may better inform physicians and patients in management decisions.     

Adrenal insufficiency due to primary bilateral adrenal non-Hodgkin's lymphoma.

A case of primary adrenal insufficiency, secondary to primary bilateral adrenal lymphoma is reported. A 50-year-old woman presented with features of primary adrenal insufficiency (darkening of skin, asthenia, anorexia, constipation) for at least 8 months. Clinical examination was unremarkable except for low body mass index and generalized skin and buccal mucosal pigmentation. Routine investigations including complete hemogram, serum chemistry, urine analysis, chest radiograph and electrocardiogram were normal; serum lactate dehydrogenase was moderately elevated. Primary adrenal insufficiency was confirmed on cortisol dynamics (very low basal and peak cortisol) after insulin-induced hypoglycemia. Routinely detected adrenal masses on ultrasonography were confirmed by contrast enhanced CT abdomen. A diagnosis of primary adrenal non- Hodgkin's lymphoma (B-cell) was made after exploratory laprotomy and further staging. The patient was put on combination chemotherapy (CHOP) protocol, but was lost to follow-up after receiving two cycles of treatment. Primary adrenal lymphoma, although a rare entity, needs to be suspected in patients with features of primary adrenal insufficiency who have evidence of bilateral adrenal masses on imaging.     

Effect of Proton Pump Inhibitor Therapy on Inflammatory Changes in the Gastric Cardia (Carditis)

The etiology of inflammation of the gastric cardia (carditis) is controversial, and gastroesophageal reflux disease (GERD) and H. pylori infection have been proposed as etiological factors. This study aimed to investigate the effect of acid suppression on histological changes in the gastric cardia. Gastric cardia biopsies of reflux patients were evaluated at baseline and after proton pump inhibitor (PPI) therapy. The updated Sydney classification was used to score the biopsies, and carditis scores (pre- and post-PPI therapy) were compared. A total of 31 patients were included, of which 5 patients were excluded, as cardiac mucosa was not documented in either pre- or post-PPI biopsies. The mean duration of PPI therapy was 30 months (SE, 3.04 months). There was no significant change in carditis scores post-PPI therapy. The mean mononuclear and neutrophil scores were 1.23 and 0.35 pre-PPI therapy and 1.73 and 0.62 post-PPI therapy, respectively. No change in mean intestinal metaplasia and atrophy scores was identified. In conclusion, acid suppressive therapy with PPI did not lead to a significant reduction in carditis scores. These results suggest that GERD probably does not play a major role in the pathogenesis of inflammation in the gastric cardia.     

Port-a-Cath perforation of the right atrium closed with an amplatzer ASD occluder.

Right atrial perforation can lead to tamponade and death. Closure devices are used for sealing of shunts in the heart. We describe an indwelling catheter that caused perforation of the right atrium and was treated with a percutaneous closure device.     

Copper, zinc and magnesium levels in fibrocalculous pancreatic diabetes.

Alterations in trace elements and mineral homeostasis have been documented both in insulin-dependent diabetes mellitus and non-insulin dependent diabetes mellitus. No data are available about trace elements in fibrocalculous pancreatic diabetes, a unique form of secondary diabetes mellitus. This study evaluated the plasma concentrations of copper, zinc and magnesium in this form of diabetes. Twenty-five patients (9 men and 16 women) with fibrocalculous pancreatic diabetes and 25 healthy non-diabetic subjects (16 men and 9 women) were studied. Patients with overt nephropathy were excluded. Plasma copper, zinc, and magnesium levels were analyzed using a GBC 902 double beam absorption spectrophotometer. The effect of glycemic control, microalbuminuria, sex and modality of treatment received on the plasma levels of copper, zinc and magnesium was assessed. Results of the study revealed that plasma copper, zinc, and magnesium levels were comparable between patients with fibrocalculous pancreatic diabetes and control subjects. Plasma copper levels were significantly higher in patients with controlled diabetes (16.15 +/- 0.67 micromol L(-1)) as compared to those with uncontrolled diabetes (13.75 +/- 0.61 micromol L(-1)) and healthy controls (13.91 +/- 0.55 micromol L(-1)). This merits further investigation. Microalbuminuria, modality of treatment received and sex did not influence the levels of these elements in fibrocalculous pancreatic diabetes.     

Is intra-operative cholangiography necessary during laparoscopic cholecystectomy？ A multicentre rural experience from a developing world country

AIM: To evaluate the feasibility and safety of performing laparoscopic cholecystectomy (LC) in nonteaching rural hospitals of a developing country without intra-operative cholangiography (IOC). To evaluate the possibility of reduction of costs and hospital stay for patients undergoing LC.METHODS: A prospective analysis of patients with symptomatic benign diseases of gall bladder undergoing LC in three non-teaching rural hospitals of Kashmir Valley from Jan 2001 to Jan 2007. The cohort represented a sample of patients requiring LC, aged 13 to 78 (mean 47.2) years. Main outcome parameters included mortality, complications, re-operation, conversion to open procedure without resorting to IOC, reduction in costs borne by the hospital, and the duration of hospital stay.RESULTS: Twelve hundred and sixty-seven patients (976 females/291 males) underwent laparoscopic cholecystectomy. Twenty-three cases were converted to open procedures; 12 patients developed port site infection, nobody died because of the procedure. One patient had common bile duct (CBD) injury, 4 patients had biliary leak, and 4 patients had subcutaneous emphysema. One cholecystohepatic duct was detected and managed intraoperatively, 1 patient had retained CBD stones, while 1 patient had retained cystic duct stones. Incidental gallbladder malignancy was detected in 2 cases. No long-term complications were detected up to now.CONCLUSION: LC can be performed safely even in non-teaching rural hospitals of a developing country provided proper equipment is available and the surgeons and other team members are well trained in the procedure. It is stressed that IOC is not essential to prevent biliary tract injuries and missed CBD stones. The costs to the patient and the hospital can be minimized by using reusable instruments, intracorporeal sutures, and condoms instead of titanium clips and endobags.     

Gastrointestinal amyloidosis: A focused review

Amyloidosis, a heterogenous group of disorders, is characterized by the extracellular deposition of autologous, insoluble, fibrillar misfolded proteins. These extracellular proteins deposit in tissues aggregated in ß-pleated sheets arranged in an antiparallel fashion and cause distortion to the tissue architecture and function. In the current literature, about 60 heterogeneous amyloidogenic proteins have been identified, out of which 27 have been associated with human disease. Classified as a rare disease, amyloidosis is known to have a wide range of possible etiologies and clinical manifestations. The exact incidence and prevalence of the disease is currently unknown. In both systemic and localized amyloidosis, there is infiltration of the abnormal proteins in the layers of the gastrointestinal (GI) tract or the liver parenchyma. The gold standard test for establishing a diagnosis is tissue biopsy followed by Congo Red staining and apple-green birefringence of the Congo Red-stained deposits under polarized light. However, not all patients may have a positive tissue confirmation of the disease. In these cases additional workup and referral to a gastroenterologist may be warranted. Along with symptomatic management, the treatment for GI amyloidosis consists of observation or localized surgical excision in patients with localized disease, and treatment of the underlying pathology in cases of systemic amyloidosis. In this review of the literature, we describe the subtypes of amyloidosis, with a primary focus on the epidemiology, pathogenesis, clinical features, diagnosis and treatment strategies available for GI amyloidosis.     

Meckel's Diverticulum��Revisited

Meckel''s diverticulum is a true intestinal diverticulum that results from the failure of the vitelline duct to obliterate during the fifth week of fetal development. In about 50% cases, it contains ectopic or heterotopic tissue which can be the cause of complications. A systematic review of literature was undertaken to study the history, incidence, embryoanatomy, clinical presentation, complication and management of Meckel''s diverticulum. Although Meckel''s diverticulum is the most common congenital abnormality of the gastrointestinal tract, it is often difficult to diagnose. It may remain asymptomatic or it may mimic disorders such as Crohn''s disease, appendicitis and peptic ulcer disease.