Flexible Spectral Imaging Color Enhancement and Probe-based Confocal Laser Endomicroscopy in Minimal Change Esophageal Reflux Disease / 대한소화기학회지

BACKGROUND/AIMS: Although flexible spectral imaging color enhancement (FICE) can facilitate the diagnosis of minimal change esophageal reflux disease (MERD), the complicated diagnostic criteria cause suboptimal inter-observer agreement. Confocal laser endomicroscopy (CLE) yields good diagnostic results but its inter-observer agreement has never been explored. This study compares the diagnostic value of magnifying FICE and probe-based CLE (pCLE) for MERD and evaluates the inter-observer agreement of both techniques. METHODS: Thirty-six patients with suspected MERD and 18 asymptomatic controls were recruited. Magnifying FICE was used for evaluation of distal esophagus. pCLE counted the number of intrapapillary capillary loops (IPCLs) using more than five IPCLs in 500×500 micron area as a criterion for MERD diagnosis. The validity scores and interobserever agreement of both FICE and pCLE were assessed. RESULTS: For FICE vs. pCLE, the accuracy was 79% vs. 87%, sensitivity 94% vs. 97%, specificity 50% vs. 66%, positive predictive value 79% vs. 85%, and negative predictive value 82% vs. 92%. Interobserver agreement of FICE was fair to substantial, whereas pCLE had substantial to almost perfect agreement. CONCLUSIONS: Both FICE and pCLE have good operating characteristics and can facilitate the MERD diagnosis. However, among different observers, pCLE is more consistent on MERD diagnosis.

Overwhelming strongyloidiasis

Background: Overwhelming strongyloidiasis defined by multi-organ dissemination causes severe morbidity and high mortality.Objective: To report a case of disseminated strongyloidiasis presenting with unusual gastrointestinal manifestations in an immunocompromised host.Methods: A Thai girl with myasthenia gravis treated by chronic administration of corticosteroids presented with disseminated strongyloidiasis. Pulmonary and gastrointestinal symptoms were the clinical manifestations of hyperinfection or disseminated strongyloidiasis.Results: Strongyloid larvae were found in her sputum, stool, and peritoneal fluid. They were present in all layers of the intestinal wall. She did not respond to oral antihelminthic drugs (albendazole). Subcutaneous ivermectin was administered. She succumbed to unresponsive cardiac arrest that was unresponsive to standard resuscitation protocols due to severe septicemia. Pulmonary and gastrointestinal symptoms were the clinical manifestations of hyperinfection or disseminated strongyloidiasis.Conclusion: Serial stool examination should be performed prior to the onset and during immunosuppressive treatment.

A case series of autoimmune pancreatitis: how can we avoid unnecessary surgery?

Background: Autoimmune pancreatitis (AIP) is a special form of chronic pancreatitis that can be treated with steroids. Jaundice is one of the main presentations of this condition which mimics pancreatico-biliary malignancy. Many physicians are not fully aware of this condition, and do not realize some typical features that can help the diagnosis before sending patients for unnecessary surgery. Objective: To report a case series of AIP in which surgery could have been avoided. Methods: We studied 4 autoimmune pancreatitis patients who presented either unexplained obstructive jaundice or pancreatic head mass. Results: Of the 4 patients, two underwent surgery and unfortunately one died post operatively. The other 2 patients were diagnosed using typical cholangiopancreatograms and surgery was avoidable. All 4 had elevated immunoglobulin isotype 4 (IgG4) level, and 3 had typical pancreatograms suggestive of autoimmune pancreatitis. Conclusion: Patients who present unexplained obstructive jaundice or pancreatic head mass should be subjected to helpful imaging studies and laboratory features on the possibility of autoimmune pancreatitis before sending them to surgery.