Endoscopy as a diagnostic and therapeutic alternative technique of taeniasis

Despite a low incidence in developed countries, gastrointestinal taeniasis should be suspected in patients with abdominal pain, diarrhea, anemia, and/or malabsorption of unknown origin, even more so if they come from endemic regions or areas with poor hygienic and alimentary habits. Diagnosis is traditionally reached by identifying the parasite in stools, but more recently both serological and immunological approaches are also available. Based on a patient diagnosed by gastroscopy, a literature review was undertaken of patients diagnosed by endoscopy. We discuss endoscopy as diagnostic modality, and the effectiveness and safety that endoscopic treatment may provide in view of the potential risk for neurocysticercosis.

Endoluminal calprotectin measurement in assessment of pouchitis and a new index of disease activity: a pilot study

Pouchitis is the most common complication following proctocolectomy with ileal pouch-anal anastomosis for ulcerative colitis (UC). To provide a standardized definition of pouchitis clinical, endoscopic and histological markers were grouped and weighted in the pouch disease activity index (PDAI). However, the delay in the assessment of the final score due to the time requested for histological analysis remains the main obstacle to the index implementation in clinical practice so that the use of modified-PDAI (mPDAI) with exclusion of histologic subscore has been proposed. We tested the ability of calprotectin measurement in the pouch endoluminal content to mimic the histologic score as defined in the PDAI, the index that we adopted as gold standard for pouchitis diagnosis. Calprotectin was measured by ELISA in the pouch endoluminal content collected during endoscopy in 40 consecutive patients with J-pouch. In each patient PDAI and mPDAI were calculated and 15% of patients were erroneously classified by mPDAI. ROC analysis of calprotectin values vs. acute histological subscore ≥ 3 identified different calprotectin cut-off values with corresponding sensitivity and specificity allowing the definition and scoring of different range of calprotectin subscores. We incorporated the calprotectin score in the mPDAI obtaining a new score that shows the same specificity as PDAI for diagnosis of pouchitis and higher sensitivity when compared with mPDAI. The use of the proposed new score, once validated in a larger series of patients, might be useful in the early management of patients with symptoms of pouchitis.

Endoscopic sleeve gastroplasty (the Apollo method): a new approach to obesity management

Background: Many obese patients cannot lose weight or reject conventional obesity management. Endoscopic sleeve gastroplasty (the Apollo method) is a pioneering coadjuvant, interventionist technique for the integral management of obesity. Objectives: The goals of this study were to report safety and efficacy results obtained at 6 months in patients undergoing endoscopic sleeve gastroplasty. Material and methods: A prospective study was performed in 55 patients (13 males, 42 females) who were subjected to the Apollo technique; mean age was 43.5 years (range 25-60) and mean BMI was 37.7 kg/m² (range 30-48). All received multidisciplinary follow-up for weight loss. Weight changes and presence of complications were assessed. Through the endoscope a triangular pattern suture is performed consisting of approximately 3-6 transmural (mucosa to serosa) stitches, using a cinch device to bring them nearer and form a plication. Results: A total of 6-8 plications are used to provide a tubular or sleeve-shaped restriction to the gastric cavity. No major complications developed and patients were discharged at 24 hours following the procedure. Endoscopic and radiographic follow-up at 6 months post-procedure showed a well preserved tubular form to the stomach. After 6 months patients had lost 18.9 kg and 55.3% of excess weight. Conclusions: Endoscopic sleeve gastroplasty, together with dietary and psycho-behavioral changes, is a safe, effective technique in the coadjuvant management of obese patients.

Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study

Background: There are limited data concerning endoscopist-directed endoscopic retrograde cholangiopancreatography deep sedation. The aim of this study was to establish the safety and risk factors for difficult sedation in daily practice. Patients and methods: Hospital-based, frequency matched case-control study. All patients were identified from a database of 1,008 patients between 2014 and 2015. The cases were those with difficult sedations. This concept was defined based on the combination of the receipt of high-doses of midazolam or propofol, poor tolerance, use of reversal agents or sedation-related adverse events. The presence of different factors was evaluated to determine whether they predicted difficult sedation. Results: One-hundred and eighty-nine patients (63 cases, 126 controls) were included. Cases were classified in terms of high-dose requirements (n = 35, 55.56%), sedation-related adverse events (n = 14, 22.22%), the use of reversal agents (n = 13, 20.63%) and agitation/discomfort (n = 8, 12.7%). Concerning adverse events, the total rate was 1.39%, including clinically relevant hypoxemia (n = 11), severe hypotension (n = 2) and paradoxical reactions to midazolam (n = 1). The rate of hypoxemia was higher in patients under propofol combined with midazolam than in patients with propofol alone (2.56% vs. 0.8%, p < 0.001). Alcohol consumption (OR: 2.674 [CI 95%: 1.098-6.515], p = 0.030), opioid consumption (OR: 2.713 [CI 95%: 1.096-6.716], p = 0.031) and the consumption of other psychoactive drugs (OR: 2.015 [CI 95%: 1.017-3.991], p = 0.045) were confirmed to be independent risk factors for difficult sedation. Conclusions: Endoscopist-directed deep sedation during endoscopic retrograde cholangiopancreatography is safe. The presence of certain factors should be assessed before the procedure to identify patients who are high-risk for difficult sedation.

Primary squamous cell carcinoma of the stomach presenting as a huge retroperitoneal tumor: a case report

A man complained of upper abdominal pain and early satiety for one month. An upper gastrointestinal endoscopy showed nothing special. A CT scan of the abdomen was performed, which demonstrated a huge heterogeneous retroperitoneal mass close to the dorsal wall of the stomach and surrounding the abdominal aortic and celiac trunk. The resected specimen suggested that an irregular tumor invaded the dorsal wall of the stomach. Postoperative histological examination confirmed that it was a gastric squamous cell carcinoma.

Therapeutic failure with thalidomide in patients with recurrent intestinal bleeding due to angiodysplasias

Angiodysplasias are one of the reasons of gastrointestinal bleeding, whose origin is usually due to vascular malformations. There are different types of therapies for angiodysplasia such as endoscopic, angiographic and pharmacological techniques. Among the last ones, there is little variety of effective drugs to treat the disease. We describe the therapeutic failure with thalidomide in a male with recurrent gastrointestinal bleeding due to angiodysplasias. A thorough diagnostic work-up, including gastroscopy, enteroscopy, angiography and capsule endoscopy were performed. Despite treatment with high-dose somatostatin analogues and oral iron, the patient continued bleeding. The patient was administered then thalidomide for three months with no clinical response. Thalidomide had to be withdrawn owing to adverse effects.

Atypical diagnosis by endoscopic capsule: Whipple's disease

Whipple's disease is a chronic systemic infection produced by the actinomycete Tropheryma whipplei. Endoscopic tests are key in the diagnosis as they allow biopsy and histopathological examination for definitive diagnosis of this entity. We present a case of Whipple's disease where capsule endoscopy, uncommon for the diagnosis of this condition, was essential for it and its performance before and after antibiotic treatment allows to describe the macroscopic evolution of the findings in the small bowel. This case illustrates the usefulness of capsule endoscopy to allow complete examination of the small bowel disease in which up to 30% of patients may present with normal endoscopy.

Flexible endoscopic treatment of Zenker's diverticulum: thirteen years' experience in Spain

Introduction: Flexible endoscopic treatment is one of the alternative approaches for the management of Zenker's diverticum. The present paper shows our short-term and long-term results with flexible endoscopic cricopharyngeal myotomy/septotomy. Patients and methods: A retrospective analysis of our experience in patients with Zenker's diverticulum treated using a flexible endoscope, assisted by a flexible diverticuloscope, between 2002 and 2015. Myotomy/septotomy was performed with a needle-knife papillotome under deep sedation or general anesthesia. Results: Among the 64 patients treated, two died within 10 days of surgery from causes not directly related to the procedure, and one presented with pharyngo-esophageal perforation, which recovered with conservative management at 47 days after admission. Four additional patients were lost to short-term follow-up. Among the 57 remaining patients, 52 had complete relief of dysphagia after 6 weeks. Eleven of these had recurrent symptoms on the mid and the long term. Eight were retreated with the same flexible endoscopic technique, one with a hybrid endoscopic approach, one with classical open surgery and one refused retreatment. After a mean follow-up of 2 years and a half, 33 of 37 patients reported absent or minimal dysphagia, controllable with punctual dietary restrictions. Conclusions: Flexible endoscopic treatment for Zenker's diverticulum is effective and safe. It represents an option on an equal footing to rigid endoscopy and classical open surgery and may also be used when the latter two are technically impracticable or contraindicated.

Accuracy of ASGE criteria for the prediction of choledocholithiasis

Background/aims: Few studies have validated the performance of guidelines for the prediction of choledocholithiasis (CL). Our objective was to prospectively assess the accuracy of the American Society for Gastrointestinal Endoscopy (ASGE) guidelines for the identification of CL. Methods: A two-year prospective evaluation of patients with suspected CL was performed. We evaluated the ASGE guidelines and its component variables in predicting CL. Results: A total of 256 patients with suspected CL were analyzed. Of the 208 patients with high-probability criteria for CL, 124 (59.6%) were found to have a stone/sludge at endoscopic retrograde cholangiopancreatography (ERCP). Among 48 patients with intermediate-probability criteria, 21 (43.8%) had a stone/sludge. The performance of ASGE high- and intermediate-probability criteria in our population had an accuracy of 59.0% (85.5% sensitivity, 24.3% specificity) and 41.0% (14.4% sensitivity, 75.6% specificity), respectively. The mean ERCP delay time was 6.1 days in the CL group and 6.4 days in the group without CL, p = 0.638. The presence of a common bile duct (CBD) > 6 mm (OR 2.21; 95% CI, 1.20-4.10), ascending cholangitis (OR 2.37; 95% CI, 1.01-5.55) and a CBD stone visualized on transabdominal US (OR 3.33; 95% CI, 1.48-7.52) were stronger predictors of CL. The occurrence of biliary pancreatitis was a strong protective factor for the presence of a retained CBD stone (OR 0.30; 95% CI, 0.17-0.55). Conclusions: Irrespective of a patient's ASGE probability for CL, the application of current guidelines in our population led to unnecessary performance of ERCPs in nearly half of cases.

Nutritional status in children with esophageal stenosis and dysphagia associated with caustic ingestion

Introduction: Caustic ingestion (CI) in children and adolescents may lead to esophageal burns, esophageal stenosis and secondary dysphagia. These complications may limit the normal feeding process leading to malnutrition and growth impairment. Aims: Our aim was to evaluate the nutritional status and its association with dysphagia and esophageal stenosis in children with CI. Methods: Sixty-two patients with caustic ingestion treated at a pediatric referral hospital were included in this cross-sectional study. Independent variables were dysphagia/normal swallowing and esophageal stenosis/normal barium-swallow. The dependent variables were growth and nutritional status evaluated by anthropometry. Analysis: χ² test, OR, 95% CI, kappa test and Student's t-test. Results: The average age at the time of CI was 39.7 months; 38.7% of the patients were girls. Endoscopy performed upon admission revealed erosive esophagitis (II-b, III-a, and III-b) in 46 (77.8%) of the patients, dysphagia in twenty-four (38.7%) and esophageal stenosis in forty (64.5%). Both complications occurred simultaneously in 20 children (32.3%, kappa = 0.3, p = 0.014). The z-score of height-for-age was below -2 SD in five children (8.1%). The z score of body mass index (BMI) was < -2 SD in three children (4.8%) and it was above +1 SD in 24.2%. The z-score means of the arm anthropometric indicators of fat stores and muscle mass in both the dysphagia and esophageal stenosis groups were located in the negative area of the z-score curve and their values differed significantly from the z-scores of the non-dysphagia and non-stenosis groups. Conclusions: The proportion of erosive esophagitis, esophageal stenosis and dysphagia was high. Children with dysphagia and/or esophageal stenosis associated with CI had lower fat stores and muscle mass than the cases without esophageal complications.