Efficacy and safety of capsule endoscopy in octogenarian patients: a retrospective study.

BACKGROUND: Life expectancy and the number of ultra-octogenarians increased significantly, thus making crucial the appropriateness of several endoscopic procedures in elderly patients. The aim of our study was to provide a retrospective analysis of the efficacy and safety of capsule endoscopy (CE) in patients aged over 80 years. METHODS: In this single-centre study, 900 patients underwent capsule endoscopy between 2002 and 2015 for different indications; of these 106 patients aged ≥80 years (group A) and 99 patients aged 40-60 years (control group B) were retrospectively selected. RESULTS: Occult gastrointestinal bleeding accounted for 62.1% of all indications for capsule endoscopy in group B, compared to 95.2% in group A (P<0.001). Although not statistically significant, the diagnostic yield was higher in group A (71%) vs. group B (62%). The percentages of reaching the cecum and the median gastric transit time were uniform within the two groups. In contrast, small bowel transit time was longer in group A vs. B. Small bowel preparation was similar in the two groups. The exam was generally well tolerated in both groups, with capsule aspiration being one of the main adverse events, which occurred in two elderly patients. CONCLUSIONS: Our data expand previous findings confirming that capsule endoscopy can be performed safely even in very old patients and show that the diagnostic yield is similar to that of younger patients.

Combined Endoscopic Stent-In-Stent Placement by Lumen-Apposing Metal Stents Through Self-Expanding Metal Stents for Simultaneous Malignant Biliary and Duodenal Obstruction.

The palliation of simultaneous biliary and duodenal obstruction in patients with advanced pancreatic cancer is a clinically and technically challenging scenario. Endoscopic procedures are a valid alternative to surgical or percutaneous transhepatic biliary drainage. The availability of self-expanding metal stents (SEMSs) and lumen-apposing metal stents (LAMS) have expanded therapeutic options. We describe a case in which biliary and duodenal obstructions were treated successfully with the combined use of SEMS and LAMS devices. Endoscopic ultrasound-guided biliary drainage with the use of new LAMS and a duodenal SEMS can be a valid option in expert hands as a palliative and minimally invasive treatment for gastric outlet and biliary obstruction.

Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy.

AIM: To investigate whether discharge scoring criteria are as safe as clinical criteria for discharge decision and allow for earlier discharge. METHODS: About 220 consecutive outpatients undergoing colonoscopy under sedation with Meperidine plus Midazolam were enrolled and assigned to 2 groups: in Control-group (110 subjects) discharge decision was based on the clinical assessment; in PADSS-group (110 subjects) discharge decision was based on the modified Post-Anaesthetic Discharge Scoring System (PADSS). Measurements of the PADDS score were taken every 20 min after colonoscopy, and patients were discharged after two consecutive PADSS scores ≥ 9. The investigator called each patient 24-48 h after discharge to administer a standardized questionnaire, to detect any delayed complications. Patients in which cecal intubation was not performed and those who were not found at follow-up phone call were excluded from the study. RESULTS: Thirteen patients (7 in Control-group and 6 in PADSS-group) were excluded from the study. Recovery from sedation was faster in PADSS-group than in Control-group (58.75 ± 18.67 min vs 95.14 ± 10.85 min, respectively; P < 0.001). Recovery time resulted shorter than 60 min in 39 patients of PADSS-group (37.5%), and in no patient of Control-group (P < 0.001). At follow-up phone call, no patient declared any hospital re-admission because of problems related to colonoscopy and/or sedation. Mild delayed post-discharge symptoms occurred in 57 patients in Control-group (55.3%) and in 32 in PADSS-group (30.7%). The most common symptoms were drowsiness, weakness, abdominal distension, and headache. Only 3 subjects needed to take some drugs because of post-discharge symptoms. CONCLUSION: The Post-Anaesthetic Discharge Scoring System is as safe as the clinical assessment and allows for an earlier patient discharge after colonoscopy performed under sedation.

Portal hypertensive enteropathy diagnosed by capsule endoscopy and demonstration of the ileal changes after transjugular intrahepatic portosystemic shunt placement: a case report.

INTRODUCTION: Recent data suggest that mucosal abnormalities can occur even in the duodenum, jejunum, and distal ileum of cirrhosis patients. We present a case of portal hypertensive enteropathy in a cirrhosis patient shown by capsule endoscopy and the effect of transjugular intrahepatic portosystemic shunt on the ileal pictures. CASE PRESENTATION: An 83-year-old Caucasian woman was admitted to our hospital for anemia and a positive fecal occult blood test. An upper gastrointestinal endoscopy revealed small varices without bleeding signs and hypertensive gastropathy. Colonoscopy was negative. To rule out any other cause of bleeding, capsule endoscopy was performed; capsule endoscopy revealed severe hyperemia of the jejunum-ileal mucosa with active bleeding. Because of the persistence of anemia and the frequent blood transfusions, not responding to ß-blocker drugs or octreotide infusion, a transjugular intrahepatic portosystemic shunt was performed. Anemia improved quickly after the transjugular intrahepatic portosystemic shunt, and no further blood transfusion was necessary in the follow-up. The patient developed portal encephalopathy two months later and was readmitted to our department. We repeated the capsule endoscopy that showed a significant improvement of the gastric and ileal mucosa without any signs of bleeding. CONCLUSION: Hypertensive enteropathy is a rare condition, but it seems more common with the introduction of capsule endoscopy in clinical practice. This case shows that the jejunum can be a source of bleeding in cirrhosis patients, and this is the first demonstration of its resolution after transjugular intrahepatic portosystemic shunt placement.

The first 2 years of colorectal cancer screening in Ferrara, Italy.

We report on the first screening round in the District of Ferrara, a region of Emilia-Romagna, carried out between March 2005 and March 2007 to illustrate the effort of colorectal cancer (CRC) screening from administration and information to therapy and follow-up. After invitation of 38 344 persons aged 50-69 years (28.5%), 19 480 (50.8%) accepted the immunological faecal occult blood test, with 1 149 (6%) resulting positive. One thousand and one individuals (88.2%) who tested positive for immunological faecal occult blood test accepted examination by either colonoscopy (99.5%) or barium enema (0.5%). Out of 996 screenees having a colonoscopy, 231 had low-risk adenomas (23.2%) and 239 had high-risk adenomas (24%), and were treated endoscopically (96%) or surgically (4%). Ninety-one cancers were diagnosed in 9.1% of colonoscopies (Dukes stadia: A, 58.2%; B, 19.8%; C, 18.7%; D, 3.3%). Fourteen cancers (all in polyps) were treated endoscopically, and the remaining 77 were treated by surgery. One Dukes B patient and 13 of 17 Dukes C patients received adjuvant chemotherapy. Three Dukes D patients had chemotherapy only. During the 2-year study period, 87 screenees had a follow-up colonoscopy: no neoplasia was found in 35 patients initially diagnosed with cancer; low-risk adenomas were found in 31 of 52 patients with initial high-risk adenomas. In conclusion, the first CRC screening round in Ferrara was easy to organize, had a high acceptance, and detected 91 cancers (78% of which were in Dukes stages A and B, compared with only 40% in sporadic CRC in the same background population). Chemotherapy was necessary in 17 cases. This report may motivate other health authorities to initiate CRC screening campaigns.

[Intestinal intussusception in adult. Abdominal ultrasound is useful as diagnostic method, if correctly assessed]. / Invaginazione intestinale nell'adulto. Ruolo dell'ecografia addominale.

We report a case of adult intestinal intussusception. The patient had complained of intermittent nonspecific abdominal pain and nausea for two weeks, when acute abdomen appeared and required a segmental small bowell resection. During hospitalization in our Department three abdominal ultrasound examinations were performed, but only one of which was useful in making the diagnosis. We stress the role of ultrasound imaging in the diagnosis of intussusception in adults.

[Screening for colorectal cancer in high-risk and intermediate-risk subject: what's the best tool?]. / Screeening per la prevenzione del cancro del colon nei soggetti ad alto rischio ed in quelli a rischio intermedio. Qual e la migliore opzione?

Although several screening tests are now available, at present none of them has been proven the best one. Colonoscopy is usually used in high-risk subjects (family history of either colorectal cancer [CRC] or adenomas). In intermediate-risk subjects, fecal occult blood test (FOBT) is preferred, and colonoscopy is performed only when FOBT results positive. The aim of this study is to better define the role of colonoscopy in a screening program. Three groups of subjects were retrospectively reviewed. RSP (Regional Screening Program), FDR (First Degree Relatives), and Control-groups included 362, 581, and 300 subjects, respectively. Adenoma or carcinoma were more frequent in RSP-group than in FDR- and Control-group (53%, 23.7%, and 20%, respectively; p < 0.001). CRC rate was 11.6% in RSP-group, 2.2% in FDR-group (p < 0.001), 6% in Control-group (p < 0.05). Adenoma rate was 41.4% in RSP-group, 21.5% in FDR-group (p < 0.05), 14% in Control-group (p < 0.01). Our results showed that colonoscopy probably can not be regarded as a first-line tool for the screening of CRC in FDR of patients with CRC or adenoma. Some stratification or scoring system for the risk of CRC should be adopted. As an alternative, FOBT could be used also in these subjects.

[Physicians working in internal medicine's ward: a survey on their role in the management of the gastrointestinal endoscopy services in Emilia Romagna]. / L'Internista nei Servizi di Endoscopia Digestiva: indagine sugli Ospedali pubblici dell'Emilia Romagna.

We carried out a survey on the role played by the Wards of Internal Medicine in the management of the Gastrointestinal Endoscopy (G.E.) Services operating in Emilia Romagna. 45 G.E. Services were censored, for a total of 225 endoscopists: 105 out of them (46.7%) were gastroenterologists and 84 (37.3%) were surgeons, whereas just 35 (15.6%) were working in Internal Medicine's Ward and 1 (0.4%) was working in a Division of Geriatrics. A significant difference was observed analyzing the composition of the G.E. staffs on the basis of the size and activity of G.E. Services (p < 0.001). Physicians working in Wards of Internal Medicine represented 9.2% and 24.5% of the endoscopists in the hospitals with or without a Gastroenterology Unit, respectively (p = 0.003). Based on these results, the physicians working in Internal Medicine's Ward seem to play a secondary role in G.E. Services. Their role is greater in small hospitals, but they are often compelled to operate under suboptimal circumstances.

Diagnostic accuracy of a rapid fecal test to confirm H pylori eradication after therapy: prospective comparison with a laboratory stool test.

AIM: To investigate the clinical performances of rapid stool test (ImmunoCard STAT HpSA, Meridian Diagnostic Inc.) in the evaluation of eradication therapy of H pylori and to compare it with a well-known and validated laboratory stool test (Amplified IDEA Hp StAR, Dako). METHODS: Stool samples of 122 patients were evaluated after eradication therapy of H pylori. H pylori status was assessed by 13C-urea breath test (UBT). Stool specimens were tested using either the rapid immunoassay kit or the laboratory immunoassay kit. RESULTS: Forty-three patients were infected and 79 non-infected. Sensitivity and specificity of ImmunoCard STAT and Hp StAR were 58.14% and 76.4%, and 97.47% and 98.73%, respectively (P > 0.05). Overall agreement between the two tests was 92.6% (113 of 122 cases). CONCLUSION: ImmunoCard STAT seems to have rather low performances, and it cannot be regarded as a reliable tool in the post-treatment setting. Also Hp StAR cannot be recommended to confirm H pylori eradication after treatment.

Unsedated ultrathin upper endoscopy is better than conventional endoscopy in routine outpatient gastroenterology practice: a randomized trial.

AIM: to compare the feasibility and patients' tolerance of esophagogastroduodenoscopy (EGD) using a thin endoscope with those of conventional oral EGD and to determine the optimal route of introduction of small-caliber endoscopes. METHODS: One hundred and sixty outpatients referred for diagnostic EGD were randomly allocated to 3 groups: conventional (C)-EGD (9.8 mm in diameter), transnasal (TN)-EGD and transoral (TO)-EGD (5.9 mm in diameter). Pre-EGD anxiety was measured using a 100-mm visual analogue scale (VAS). After EGD, patients and endoscopists completed a questionnaire on the pain, nausea, choking, overall discomfort, and quality of the examination either using VAS or answering some questions. The duration of EGD was timed. Blood oxygen saturation (SaO2) and heart rate (HR) were monitored during EGD. RESULTS: Twenty-one patients refused to participate in the study. The 3 groups were well-matched for age, gender, experience with EGD, and anxiety. EGD was completed in 91.1% (41/45), 97.5% (40/41), and 96.2% (51/53) of cases in TN-EGD, TO-EGD, and C-EGD groups, respectively. TN-EGD lasted longer (3.11 +/- 1.60 min) than TO-EGD (2.25 +/- 1.45 min) and C-EGD (2.49 +/- 1.64 min) (P<0.05). The overall tolerance was higher (P<0.05) and the overall discomfort was lower (P<0.05) in TN-EGD group than in C-EGD group. EGD was tolerated "better than expected" in 73.2% of patients in TN-EGD group and 55% and 39.2% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). Endoscopy was tolerated "worst than expected" in 4.9% of patients in TN-EGD group and 17.5% and 23.5% of patients in TO-EGD and C-EGD groups, respectively (P<0.05). TN-EGD caused mild epistaxis in one case. The ability to insufflate air, wash the lens, and suction of the thin endoscope were lower than those of conventional instrument (P<0.001). All biopsies performed were adequate for histological assessment. CONCLUSION: Diagnostic TN-EGD is better tolerated than C-EGD. Narrow-diameter endoscope has a level of diagnostic accuracy comparable to that of conventional gastroscope, even though some technical characteristics of these instruments should be improved. Transnasal EGD with narrow-diameter endoscope should be proposed to all patients undergoing diagnostic EGD.

[Stool antigen test for diagnosis of Helicobacter pylori infection. Merely a research opportunity, or an effective diagnostic tool?]. / Test fecale per la diagnosi di infezione da Helicobacter pylori: argomento di ricerca o realtà?

Since Helicobacter pylori (H. pylori) infection was recognized as a major cause of peptic ulcer disease and an important risk factor for gastric malignancy, several strategies have been used to diagnose it. These methods are split up along two lines: 1) direct detection of the bacteria, and 2) detection of antigen-antibody assay against H. pylori, or anyhow detection of H. pylori by indirect methods. In this review of literature about the methods to diagnose H. pylori infection, we focused in particular on the non-invasive tests based on H. pylori antigens detection in faeces. Some meta-analyses showed that immunoenzymatic stool tests can be considered reliable in untreated patients, whereas further confirmations are needed before extending their use also in anti-H. pylori treated patients. As it concerns cost-analysis, immunoenzymatic stool test is the most cost-effective among the tests today available. Finally, a newly developed office-based stool test has been evaluated. It does not require laboratory assay, and the results are available within 10 minutes. Preliminary data about its clinical usefulness are promising, but further and wider confirmations are needed, as it has been put on the market quite recently.