Accuracy of Magnetically Controlled Capsule Endoscopy, Compared With Conventional Gastroscopy, in Detection of Gastric Diseases.

BACKGROUND & AIMS: Diseases of the stomach, including gastric cancer and peptic ulcer, are the most common digestive diseases. It is impossible to visualize the entire stomach with the passive capsule currently used in practice because of the large size of the gastric cavity. A magnetically controlled capsule endoscopy (MCE) system has been designed to explore the stomach. We performed a prospective study to compare the accuracy of detection of gastric focal lesions by MCE vs conventional gastroscopy (the standard method). METHODS: We performed a multicenter blinded study comparing MCE with conventional gastroscopy in 350 patients (mean age, 46.6 y), with upper abdominal complaints scheduled to undergo gastroscopy at a tertiary center in China from August 2014 through December 2014. All patients underwent MCE, followed by conventional gastroscopy 2 hours later, without sedation. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of detection of gastric focal lesions by MCE, using gastroscopy as the standard. RESULTS: MCE detected gastric focal lesions in the whole stomach with 90.4% sensitivity (95% confidence interval [CI], 84.7%-96.1%), 94.7% specificity (95% CI, 91.9%-97.5%), a positive predictive value of 87.9% (95% CI, 81.7%-94.0%), a negative predictive value of 95.9% (95% CI, 93.4%-98.4%), and 93.4% accuracy (95% CI, 90.83%-96.02%). MCE detected focal lesions in the upper stomach (cardia, fundus, and body) with 90.2% sensitivity (95% CI, 82.0%-98.4%) and 96.7% specificity (95% CI, 94.4%-98.9%). MCE detected focal lesions in the lower stomach (angulus, antrum, and pylorus) with 90.6% sensitivity (95% CI, 82.7%-98.4%) and 97.9% specificity (95% CI, 96.1%-99.7%). MCE detected 1 advanced gastric carcinoma, 2 malignant lymphomas, and 1 early stage gastric tumor. MCE did not miss any lesions of significance (including tumors or large ulcers). Among the 350 patients, 5 reported 9 adverse events (1.4%) and 335 preferred MCE over gastroscopy (95.7%). CONCLUSIONS: MCE detects focal lesions in the upper and lower stomach with comparable accuracy with conventional gastroscopy. MCE is preferred by almost all patients, compared with gastroscopy, and can be used to screen gastric diseases without sedation. Clinicaltrials.gov number: NCT02219529.

Esophageal variceal pressure influence on the effect of ligation.

AIM: To explore the effect of in vitro porcine esophageal variceal pressure on complete ligation degree for polycyclic ligators. METHODS: An in vitro model of experimental porcine venous vessels was used to test various venous pressures. Three treatment groups were designated according to the preset pressure range: P1 = 25-30 cmH2O; P2 = 35-40 cmH2O; P3 = 45-50 cmH2O. The effect of pressure on ligation was assessed and compared among the groups. RESULTS: Complete ligation was achieved at a rate of 56.25% (18/32) in group P1, 37.5% (12/32) in group P2, and 33.33% (11/33) in group P3 (χ (2) = 3.6126; P = 0.0573). CONCLUSION: Higher variceal pressures impair the ligation completion rate. Therefore, measuring variceal pressure may help predict the effect of endoscopic ligation and guide treatment choice.

Risk Factors Associated with Mortality and Increased Drug Costs in Nonvariceal Upper Gastrointestinal Bleeding.

BACKGROUND/AIMS: To determine risk factors associated with mortality and increased drug costs in patients with nonvariceal upper gastrointestinal bleeding. METHODOLOGY: We retrospectively analyzed data from patients hospitalized with nonvariceal upper gastrointestinal bleeding between January 2001-December 2011. Demographic and clinical characteristics and drug costs were documented. Univariate analysis determined possible risk factors for mortality. Statistically significant variables were analyzed using a logistic regression model. Multiple linear regression analyzed factors influencing drug costs. p < 0.05 was considered statistically significant. RESULTS: The study included data from 627 patients. Risk factors associated with increased mortality were age > 60, systolic blood pressure<100 mmHg, lack of endoscopic examination, comorbidities, blood transfusion, and rebleeding. Drug costs were higher in patients with rebleeding, blood transfusion, and prolonged hospital stay. CONCLUSION: In this patient cohort, re-bleeding rate is 11.20% and mortality is 5.74%. The mortality risk in patients with comorbidities was higher than in patients without comorbidities, and was higher in patients requiring blood transfusion than in patients not requiring transfusion. Rebleeding was associ-ated with mortality. Rebleeding, blood transfusion, and prolonged hospital stay were associated with increased drug costs, whereas bleeding from lesions in the esophagus and duodenum was associated with lower drug costs.

[The difference in diagnosis rate of different diagnostic criteria of autoimmune pancreatitis and its major influential factors].

OBJECTIVE: To discuss the difference in diagnostic criteria of autoimmune pancreatitis(AIP) and its major influential factors, so as to provide guidance for AIP diagnosis and treatment. METHODS: The clinical data of 561 cases of chronic pancreatitis admitted to PLA General Hospital from June, 2008 to January, 2013 were retrospectively reviewed and analyzed. Data were extracted and analyzed to summarize the reasons of the differences in AIP diagnosis rate diagnosed by different diagnostic criteria. RESULTS: A total of 34 cases were eligible for the 2006 American HISORt criteria of AIP of whom, 5, 10 and 26 met the criteria of histology, pancreatic imaging findings and increasing serum IgG4 levels, and response to steroids and increasing serum IgG4 levels, respectively. Seven AIP patients met the latter two criteria. Fifteen patients were eligible for the 2008 Asian diagnostic criteria for AIP, of which, 10 met the two necessary imaging findings and 5 met the criteria of pathology of lymphoplasmacytic sclerosing pancreatitis (LPSP) after surgical resection. CONCLUSIONS: AIP is characterized by autoimmune inflammatory process, and is easy to be misdiagnosed as pancreatic cancer or cholangiocarcinoma etc. As a few sets of criteria issued from different countries, the 2008 Asian diagnostic criterion is more suitable with Chinese population. We should pay full attention to the importance of imaging examination of the diagnosis of AIP on the base of the detection of immune parameters, pathological examination and response to steroids.

Verification of the Tokyo guidelines for acute cholangitis secondary to benign and malignant biliary obstruction: experience from a Chinese tertiary hospital.

BACKGROUND: The lack of widely-accepted guidelines for acute cholangitis largely lags behind the progress in medical and surgical technology and science for the management of acute cholangitis. This study aimed to verify the Tokyo guidelines for the management of acute cholangitis and cholecystitis of 2007 edition (TG07) in patients with obstructive cholangitis due to benign and malignant diseases. METHODS: The patients were retrieved from our existing ERCP database. Final diagnosis of acute cholangitis was made by detecting purulent bile during biliary drainage. We examined and compared the guidelines concerning benign and malignant obstruction. RESULTS: In 120 patients in our study, 82 and 38 had benign and malignant biliary obstruction, respectively. Guidelines based diagnosis was made in 68 (82.9%), 36 (94.7%), and 104 (86.7%) patients with benign, malignant, and overall biliary obstruction, respectively, which were significantly higher than 44 (53.7%), 17 (44.7%), and 61 (50.8%) diagnosed by Charcot's triad (P<0.001). Treatment consistent with the guidelines was offered to 58 (70.7%) patients with benign obstruction and 15 (39.5%) patients with malignant obstruction (P=0.001). No significant association was observed between clinical compliance, guidelines-based severity grades and clinical outcomes. In the multivariate model, intrahepatic obstruction (OR=11.2, 95% CI: 1.55-226.9) and hypoalbuminemia (≤25.0 g/L; OR=17.3, 95% CI: 3.5-313.6) were independent risk factors for a 30-day mortality. CONCLUSIONS: The TG07 are more reliable than Charcot's triad for the diagnosis of acute cholangitis albeit with limited prognostic values. Intrahepatic obstruction and hypoalbuminemia are new predictors of poor prognosis and need further assessment.

Treatment of gastric varices by endoscopic sclerotherapy using butyl cyanoacrylate: 10 years' experience of 635 cases.

BACKGROUND: Gastric varices (GV) are life-threatening for patients with portal hypertension. Endoscopic injection with butyl cyanoacrylate (BC), the mainstay of the therapy for GV, has been reported to be effective for hemostasis of bleeding varices, but its efficacy in the obliteration of GV and impact on the survival of patients still needs clarification. Here we summarized our experience of 10 years' practice to evaluate the efficacy and safety of endoscopic therapy using BC for GV patients. METHODS: From January 1997 to April 2006, GV cases treated with endoscopic injection using BC were collected. The "sandwich method" and the "modified sandwich method" were used to inject BC intravascularly. Retrograde analysis was made on the data of treatment and follow-up. RESULTS: A total of 635 GV cases treated with endoscopic injection using BC were collected, most of them (90.2%) suffered from post-hepatitis cirrhosis. Emergency hemostasis was achieved in 139 out of 146 sessions (95.2%). Complications occurred in 32 cases (5.2%), including hemorrhage due to early expulsion of tissue glue (3.1%), septicemia (1%) and ectopic thrombosis (0.5%), such as spleen infarction. Endoscopic follow-up in 503 patients showed complete disappearance (76.9%), collapse (17.3%) or remnants (5.8%) of gastric varices. A total of 550 patients were followed up clinically for 3 to 115 months. Of these patients, 44 had recurrent bleeding (8.0%) and 44 died from hepatic failure, recurrent bleeding, hepatic carcinoma or other causes. The longest survival was 115 months, with a median survival of 25 months. Survival rates at 1, 2, 3, 4 and 5 year were 95%, 92%, 90%, 83% and 81%, respectively. CONCLUSIONS: Endoscopic sclerotherapy with BC is effective for the hemostasis of bleeding GV, as well as obliteration of GV which contributes to less rebleeding and better survival. The modified sandwich method may be useful to minimize ectopic embolism, which we speculated to result from excess iodized oil.

Primary jejunoileal neoplasmas: a review of 60 cases.

AIM: Primary neoplasmas of the jejunum and ileum are infrequent and lack specific manifestations and inaccessibility of conventional endoscopy, so the diagnosis of these tumors are usually delayed. So far the data of primary jejunoileal neoplasmas is still scarce, especially in Chinese medical literature in English. There may be some differences among the Chinese and the westerners in jejunoileal neoplasmas. METHODS: A retrospective analysis was made on clinical findings and pathological types. RESULTS: Of the 60 patients with jejunal or ileal neoplasmas, the most frequent symptom was abdominal pain (57 %), followed by tarry stool (43 %) and hematochezia (10 %). Abdominal mass (40 %) was the most common finding on physical examination, followed by anemia and weight loss (35 %). 67 % of the jejunoileal neoplasms were located in the jejunum. Among the malignant neoplasmas (68 %), malignant stroma (47 %) was most common, while the benign stromoma (20 %) was the most common benign neoplasmas. Preoperatively, 40 patients (67 %) were diagnosed as small bowel neoplasmas, of which 34 were found by enteroclysis. Abdominal mass was shown by CT in 18 cases and by ultrasonography in 13. The mean duration of symptoms before diagnosis was 7 months. In 41 patients with malignant tumors, the duration of symptoms before diagnosis exceeded 12 months in 21 cases, lymphatic or distant metastases were found in 26 (63 %)cases during operation. An emergency laparotomy was performed in 4 patients (7 %) owing to intestinal obstruction or perforation. CONCLUSION: Primary jejunoileal neoplasmas in Chinese present some difference from Westerners on clinical features and histopathologic types. Enteroclysis remains the major relevant diagnostic procedure in this study, the misdiagnotic rate is high preoperatively due to failure of detection by conventional imaging procedures such as CT and inaccessibility of routine endoscopy. For the suspected patients, combined application of aforementioned procedures may facilitate early diagnosis. The wireless capsule endoscopy may improve the diagnostic rate of jejunoileal neoplasmas in the future.