Changing perspectives in the training of endoscopic ultrasonography in Asia.

Training of endoscopic ultrasound (EUS) in Asia faces challenges of the ever-increasing demand for skills to handle a growing range of both diagnostic and interventional EUS procedures, and a continual shortage of EUS training programs. To keep up with the pace of development in EUS, more short-term EUS programs have been conducted across Asia in recent years. In this aspect, the Asian EUS Group (AEG) has taken the lead to fast-track the dissemination of EUS knowledge and skills across Asia through its multinational network of training centers. AEG's programs are brought to wherever there is demand. Its versatile modular structure allows the program to be easily customized and scaled up or down to align to local needs, making it highly adaptable to the changing and varying needs in different countries. Even with the current pandemic situation, it has been able to continue its training efforts through the use of technology, including webinars, and live case demonstration.

Endoscopic treatment modalities and outcomes in nonvariceal upper gastrointestinal bleeding.

BACKGROUND: In nonvariceal upper gastrointestinal bleeding (NVUGIB), the optimal volume of adrenaline, the optimal number of hemoclips, and the application of thermal coagulation in determining patient outcomes have not been well studied. AIM: To demonstrate a dose-response relationship between the commonly used endoscopic modalities for the treatment of non-variceal upper gastrointestinal bleeding and various clinical outcomes. METHODS: Patients presenting with NVUGIB were retrospectively identified and analyzed. These patients were stratified as follows: (1) > 10 mL of adrenaline injected vs ≤ 10 mL; (2) > 1 hemoclip placed vs ≤ 1 hemoclip; (3) Heater probe used or not; and (4) > 2 treatment modalities used vs ≤ 2. The primary outcomes were rebleeding and the need for repeat endoscopy. The secondary outcomes were the need for surgery, required transfusions, length of hospital stay, death during the same admission period and 30 d mortality. Patients with NVUGIB who required endoscopic therapy were included. Those who did not require endoscopic therapy or were initially treated with surgery or embolization were excluded. RESULTS: In all, 501 patients with NVUGIB were treated. One hundred sixty-one (32.1%) patients needed endoscopic therapy. The injection of < 10 mL of adrenaline was associated with less rebleeding (P < 0.0001), the need for repeat endoscopy (P = 0.001) and a decreased length of hospital stay (P = 0.026). The use of > 2 treatment modalities were associated with increased rebleeding (P = 0.009) and the need for repeat endoscopy (P = 0.048). The placement of > 1 hemoclip was associated with a decreased length of hospital stay (P = 0.044). The rates of surgery and death were low, and there were no other significant differences between the patient groups. CONCLUSION: The more restrictive use of adrenaline and number of endoscopic modalities to treat NVUGIB with the more liberal use of hemoclips was associated with better patient outcomes.

Predictors of suboptimal bowel preparation in asymptomatic patients undergoing average-risk screening colonoscopy.

AIM: To identify risk factors for a suboptimal preparation among a population undergoing screening or surveillance colonoscopy. METHODS: Retrospective review of the University of Michigan and Veteran's Administration (VA) Hospital records from 2009 to identify patients age 50 and older who underwent screening or surveillance procedure and had resection of polyps less than 1 cm in size and no more than 2 polyps. Patients with inflammatory bowel disease or a family history of colorectal cancer were excluded. Suboptimal procedures were defined as procedure preparations categorized as fair, poor or inadequate by the endoscopist. Multivariable logistic regression was used to identify predictors of suboptimal preparation. RESULTS: Of 4427 colonoscopies reviewed, 2401 met our inclusion criteria and were analyzed. Of our population, 16% had a suboptimal preparation. African Americans were 70% more likely to have a suboptimal preparation (95%CI: 1.2-2.4). Univariable analysis revealed that narcotic and tricyclic antidepressants (TCA) use, diabetes, prep type, site (VA vs non-VA), and presence of a gastroenterology (GI) fellow were associated with suboptimal prep quality. In a multivariable model controlling for gender, age, ethnicity, procedure site and presence of a GI fellow, diabetes [odds ratio (OR) = 2.3; 95%CI: 1.6-3.2], TCA use (OR = 2.5; 95%CI: 1.3-4.9), narcotic use (OR = 1.7; 95%CI: 1.2-2.5) and Miralax-Gatorade prep vs 4L polyethylene glycol 3350 (OR = 0.6; 95%CI: 0.4-0.9) were associated with a suboptimal prep quality. CONCLUSION: Diabetes, narcotics use and TCA use were identified as predictors of poor preparation in screening colonoscopies while Miralax-Gatorade preps were associated with better bowel preparation.

Cap-assisted ERCP with a forward-viewing gastroscope as a rescue endoscopic intervention in patients with Billroth II anatomy.

BACKGROUND: ERCP, especially therapeutic, is difficult in patients with Billroth II surgical reconstruction and is associated with a higher rate of complications. This has led to controversy on the choice between a forward-viewing and side-viewing endoscope for performing the procedure. A previous case series from Asia reported a high rate of success with a cap-fitted ERCP technique. To our knowledge, the utility of cap-assisted ERCP with a forward-viewing gastroscope when other techniques fail has not been reported. We describe and demonstrate a novel rescue approach using a cap-fitted, forward-viewing gastroscope in patients with Billroth II anatomy, when attempts with duodenoscopes, pediatric colonoscopes, and gastroscopes previously failed. METHODS: Retrospective case series. Inclusion criteria were: (a) documented Billroth II anatomy; and (b) use of cap-assisted ERCP as a rescue intervention on the first endoscopic encounter after failed attempts to perform ERCP with a duodenoscope. Patients were excluded if they successfully underwent ERCP with a duodenoscope. One advanced endoscopist and one advanced endoscopy fellow performed all but one of the procedures. RESULTS: Five cap-assisted ERCP procedures were performed in three patients with Billroth II anatomy. A wide variety of diagnostic and therapeutic endoscopic maneuvers were technically feasible and successful, including the endoscopic treatment of an afferent limb perforation caused by a duodenoscope. CONCLUSIONS: Cap-assisted ERCP is a novel and underutilized technique that adds to the armamentarium of experienced therapeutic endoscopists. This approach may help ensure a successful endoscopic outcome and spare patients with Billroth II anatomy a percutaneous or surgical approach when ERCP with a duodenoscope, pediatric colonoscope or non-cap-fitted gastroscope fails.

Affinity peptide for targeted detection of dysplasia in Barrett's esophagus.

BACKGROUND & AIMS: Dysplasia is a premalignant condition in Barrett's esophagus that is difficult to detect on endoscopy because of its flat architecture and patchy distribution. Peptides are promising for use as novel molecular probes that identify cell surface targets unique to disease and can be fluorescence-labeled for detection. We aim to select and validate an affinity peptide that binds to esophageal dysplasia for future clinical studies. METHODS: Peptide selection was performed using phage display by removing nonspecific binders using Q-hTERT (intestinal metaplasia) cells and achieving specific binding against OE33 (esophageal adenocarcinoma) cells. Selective binding was confirmed on bound phage counts, enzyme-linked immunosorbent assay (ELISA), flow cytometry, competitive inhibition, and fluorescence microscopy. On stereomicroscopy, specific peptide binding to dysplasia on endoscopically resected specimens was assessed by rigorous registration of fluorescence intensity to histology in 1-mm intervals. RESULTS: The peptide sequence SNFYMPL was selected and showed preferential binding to target cells. Reduced binding was observed on competition with unlabeled peptide in a dose-dependent manner, an affinity of K(d) = 164 nmol/L was measured, and peptide binding to the surface of OE33 cells was validated on fluorescence microscopy. On esophageal specimens (n = 12), the fluorescence intensity (mean ± SEM) in 1-mm intervals classified histologically as squamous (n = 145), intestinal metaplasia (n = 83), dysplasia (n = 61), and gastric mucosa (n = 69) was 46.5 ± 1.6, 62.3 ± 5.8, 100.0 ± 9.0, and 42.4 ± 3.0 arb units, respectively. CONCLUSIONS: The peptide sequence SNFYMPL binds specifically to dysplasia in Barrett's esophagus and can be fluorescence labeled to target premalignant mucosa on imaging.

Fluorescence and Raman spectroscopy.

Reflectance spectroscopy is an emerging technology which provides rapid and safe evaluation of tissue for dysplasia and ischemia. The probe-based devices can be passed through most endoscopes. Current applications include detection of dysplasia in Barrett's esophagus, colitis, and colon polyps.

Endoscopic clipping for the management of gastrointestinal bleeding.

Endoscopic clipping is a safe and effective technique for the treatment of various bleeding gastrointestinal lesions. Randomized controlled trials and a meta-analysis have shown comparable efficacy between clipping and conventional contact thermal therapy for definitive hemostasis of nonvariceal upper gastrointestinal hemorrhage. Clipping also seems to be efficacious for selected lower gastrointestinal bleeding lesions, such as diverticular bleeding and postpolypectomy bleeding. Proficiency in clip application and endoscopic identification of lesions that are amenable to clipping are key determinants of a successful outcome.

Virchow's node, jaundice, and weight loss--lymphoma mimicking gastrointestinal malignancy.

BACKGROUND: A 46-year-old white male with a history of well-controlled paranoid schizophrenia presented with painless jaundice, progressive anorexia, weight loss, and dyspnea of 3 months' duration. His only medication at presentation was the antipsychotic olanzapine, taken orally. INVESTIGATIONS: Physical examination and laboratory tests, including a complete blood cell count, electrolyte, lactate dehydrogenase and haptoglobin levels, liver function tests, and a Coombs' test; CT scan of the chest and abdomen; invasive investigations, including thoracentesis and pleural fluid analysis, bone-marrow biopsy, and left supraclavicular lymph-node biopsy. DIAGNOSIS: Diffuse large B-cell lymphoma. MANAGEMENT: Large-volume thoracentesis. Rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone chemotherapy followed by dexamethasone, cytarabine, and cisplatin chemotherapy, and autologous stem-cell transplantation.

From scleredema to AL amyloidosis: disease progression or coincidence? Review of the literature.

Scleredema (also called scleredema of Buschke) is a fibromucinous connective tissue disorder of unknown cause that belongs to a group of scleroderma-like disorders. We report the case of a 64-year-old lady with long-standing scleredema, associated with a paraprotein, and progressing to multiple myeloma and AL amyloidosis. The relationship of scleredema with paraprotein and multiple myeloma is well established, but only two cases of scleredema associated with amyloidosis have been reported to date. We suggest that amyloidosis may be underdiagnosed in patients with scleredema and paraproteinaemia. Features attributed to extracutaneous manifestations of scleredema could represent systemic amyloidosis. We review published reports of scleredema associated with paraprotein and discuss the difficulties in the differential diagnosis of scleroderma-like disorders. We discuss the diagnosis of plasma cell dyscrasias and amyloidosis and their relevance in rheumatology practice.

Infundibular ventricular septal defect, aneurysm of the sinus of Valsalva, and bicuspid aortic valve in a caucasian male.

We report the case of a Caucasian man with the unusual combination of an infundibular ventricular septal defect (VSD), an aneurysm of the sinus of Valsalva communicating with the right ventricle, and a bicuspid aortic valve. When aortic valve regurgitation associated with mild right aortic cusp prolapse appeared during follow-up examination, the patient, although totally asymptomatic, underwent surgical repair of the aortic sinus and closure of the VSD.