Capsule endoscopy or angiography in patients with acute overt obscure gastrointestinal bleeding: a prospective randomized study with long-term follow-up.

OBJECTIVES: Both capsule endoscopy (CE) and angiography have been recommended as first investigation for patients with acute overt obscure gastrointestinal bleeding (OGIB). However, no studies have directly compared the two modalities in patients with overt OGIB. We compared the diagnostic yield and long-term outcomes of patients with overt OGIB randomized to CE or angiogram. METHODS: Consecutive patients presented with acute melena or hematochezia, but nondiagnostic upper and lower endoscopy, were immediately randomized to receive small-bowel CE or angiography. All patients were monitored for rebleeding and anemia for up to 5 years. Primary end point was the diagnostic yield of the assigned investigation. Secondary end points included rebleeding, further transfusion, readmission for bleeding or anemia, and mortality. RESULTS: A total of 60 patients with overt OGIB were randomized. The mean follow-up was 48.5 months. The diagnostic yield of immediate CE was significantly higher than angiography (53.3% vs. 20.0%, P = 0.016). The cumulative risk of rebleeding in the angiography and CE group was 33.3% and 16.7%, respectively (P = 0.10, log-rank test). There was no significant difference in the long-term outcomes between the two groups including further transfusion, hospitalization for rebleeding, and mortality. CONCLUSIONS: In patients with overt OGIB, immediate CE has higher diagnostic yield and comparable long-term outcomes when compared with angiography.

Endoscopic submucosal dissection for colonic lesions: why and how should we do it?

Endoscopic submucosal dissection (ESD) is a safe and effective alternative to surgery for large non-polypoid colonic lesions and early colorectal carcinoma. In this article, we discuss the development, efficacy and safety of ESD. As the incidence of colorectal cancer is rapidly increasing in Asia, we advocate standardization of ESD program, including patient selection, hardware prerequisites, and training of operators.

Validation of Self-administrated Questionnaire for Psychiatric Disorders in Patients with Functional Dyspepsia.

INTRODUCTION: Psychiatric comorbidity is common in patients with functional dyspepsia (FD) but a good screening tool for psychiatric disorders in gastrointestinal clinical practice is lacking. AIMS: 1) Evaluate the performance and optimal cut-off of 12-item General Health Questionnaire (GHQ-12) as a screening tool for psychiatric disorders in FD patients; 2) Compare health-related quality of life (HRQoL) in FD patients with and without psychiatric comorbidities. METHODS: Consecutive patients fulfilling Rome III criteria for FD without medical co-morbidities and gastroesophageal reflux disease were recruited in a gastroenterology clinic. The followings were conducted at 4 weeks after index oesophagogastroduodenoscopy: self-administrated questionnaires on socio-demographics, dyspeptic symptom severity (4-point Likert scale), GHQ-12, and 36-item short-form health survey (SF-36). Psychiatric disorders were diagnosed with Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) by a trained psychiatrist, which served as reference standard. RESULTS: 55 patients underwent psychiatrist-conducted interview and questionnaire assessment. 27 (49.1%) had current psychiatric disorders as determined by SCID (anxiety disorders: 38.2%, depressive disorders: 16.4%). Receiver operating characteristic curve analysis of GHQ-12 revealed an area under curve of 0.825 (95%CI: 0.698-0.914). Cut-off of GHQ-12 at >/=3 gave a sensitivity of 63.0% (95%CI = 42.4-80.6%) and specificity of 92.9% (95%CI = 76.5%-98.9%). Subjects with co-existing psychiatric disorders scored significantly lower in multiple domains of SF-36 (mental component summary, general health, vitality and mental health). By multivariate linear regression analysis, current psychiatric morbidities (Beta = -0.396, p = 0.002) and family history of psychiatric illness (Beta = -0.299, p = 0.015) were independent risk factors for poorer mental component summary in SF-36, while dyspepsia severity was the only independent risk factor for poorer physical component summary (Beta = -0.332, p = 0.027). CONCLUSIONS: Concomitant psychiatric disorders adversely affect HRQoL in FD patients. The use of GHQ-12 as a reliable screening tool for psychiatric disorders allows early intervention and may improve clinical outcomes of these patients.

Nonsteroid anti-inflammatory drug-induced gastroduodenal injury.

PURPOSE OF REVIEW: This article reviews selected publications related to nonsteroid anti-inflammatory drug (NSAID)-induced gastroduodenal toxicity in recent years. RECENT FINDINGS: This article provides a comprehensive review of the latest evidence on the epidemiology of NSAID-induced gastroduodenal injury, recommendations on optimal gastroprotective regimens among patients in need of NSAID, risk stratification approach by considering gastrointestinal and cardiovascular risks, and negative interaction between proton pump inhibitors (PPIs) and clopidogrel. SUMMARY: Current evidence indicates that a PPI and a cyclooxygenase (COX)-2-selective NSAID provides the best gastric protection. In light of potential cardiovascular hazard of NSAIDs, physicians should select an NSAID according to individual patients' cardiovascular risk (i.e., naproxen vs. a nonnaproxen NSAID). The choice of gastroprotective therapy depends on the number and nature of gastrointestinal risk factors. PPI co-therapy is recommended in patients with high gastrointestinal risk on aspirin. Whether there is any clinically important interaction between PPIs and clopidogrel remains uncertain.

Repeat-screening colonoscopy 5 years after normal baseline-screening colonoscopy in average-risk Chinese: a prospective study.

OBJECTIVES: Although colonoscopy is considered the most accurate screening tool for colorectal neoplasm, the optimal interval of repeating a screening colonoscopy, particularly in average-risk subjects after a negative colonoscopy, is poorly defined. We determine the 5-year risk of advanced neoplasia on rescreening colonoscopy in a cohort of average-risk Chinese subjects. METHODS: We invited a cohort of asymptomatic average-risk Chinese subjects (aged 55-75 years) who were recruited in our previous screening colonoscopy studies to undergo a repeat colonoscopy at the end of 5 years. The rates of advanced colorectal neoplasia at the end of 5 years in these subjects were determined according to their baseline colonoscopy findings. RESULTS: A total of 511 of the 620 eligible subjects underwent repeat-screening colonoscopy at the end of 5 years. Among them, 401 subjects had no baseline neoplasia (370 with no baseline polyps and 31 with hyperplastic polyps). In subjects with no baseline polyp, 24.6% were found to have at least one adenoma and 1.4% had advanced neoplasia on rescreening. The number needed to rescreen for one advanced neoplasia in subjects with no baseline polyp was 74 (95% confidence interval (CI), 32-168). The prevalence of advanced neoplasia at 5 years in subjects with baseline-advanced neoplasia was 20.7% (relative risk 19.6; 95% CI, 5.2-74.1; vs. subjects with no baseline polyp). The presence of baseline-advanced neoplasia (odds ratio (OR) 13.1; 95% CI, 4.1-41.7) and age in years (OR 1.11; 95% CI, 1.01-1.22) are two independent factors for development of advanced neoplasia at 5 years. CONCLUSIONS: The risk of advanced neoplasia is sufficiently low 5 years after a normal screening colonoscopy in Chinese subjects.

Changes in Crohn's disease phenotype over time in the Chinese population: validation of the Montreal classification system.

BACKGROUND: Phenotypic evolution of Crohn's disease occurs in whites but has never been described in other populations. The Montreal classification may describe phenotypes more precisely. The aim of this study was to validate the Montreal classification through a longitudinal sensitivity analysis in detecting phenotypic variation compared to the Vienna classification. METHODS: This was a retrospective longitudinal study of consecutive Chinese Crohn's disease patients. All cases were classified by the Montreal classification and the Vienna classification for behavior and location. The evolution of these characteristics and the need for surgery were evaluated. RESULTS: A total of 109 patients were recruited (median follow-up: 4 years, range: 6 months-18 years). Crohn's disease behavior changed 3 years after diagnosis (P = 0.025), with an increase in stricturing and penetrating phenotypes, as determined by the Montreal classification, but was only detected by the Vienna classification after 5 years (P = 0.015). Disease location remained stable on follow-up in both classifications. Thirty-four patients (31%) underwent major surgery during the follow-up period with the stricturing [P = 0.002; hazard ratio (HR): 3.3; 95% CI: 1.5-7.0] and penetrating (P = 0.03; HR: 5.8; 95% CI: 1.2-28.2) phenotypes according to the Montreal classification associated with the need for major surgery. In contrast, colonic disease was protective against a major operation (P = 0.02; HR: 0.3; 95% CI: 0.08-0.8). CONCLUSIONS: This is the first study demonstrating phenotypic evolution of Crohn's disease in a nonwhite population. The Montreal classification is more sensitive to behavior phenotypic changes than is the Vienna classification after excluding perianal disease from the penetrating disease category and was useful in predicting course and the need for surgery.

Initial experience of real-time capsule endoscopy in monitoring progress of the videocapsule through the upper GI tract.

BACKGROUND: Wireless capsule endoscopy (WCE) is one of the most important investigations for small bowel examination. Although newer-generation WCE is equipped with a real-time viewer, the role of this advancement in daily practice remains unknown. OBJECTIVE: Our purpose was to determine the role of the real-time viewer for monitoring of the videoendoscope passage through the upper GI tract. DESIGN: Case-control comparison. SETTING: Single tertiary referral center. PATIENTS: Forty-five consecutive patients who underwent capsule endoscopy in a 12-month period were studied. Twenty-seven patients received conventional WCE, whereas 18 patients were examined by real-time WCE. Passage into the small bowel was monitored with the real-time viewer in the second group of patients. Gastric transit time and the rate of complete small bowel examination were compared. INTERVENTIONS: On-demand polyethylene glycol and erythromycin were prescribed according to the progress as viewed by the real-time monitor. MAIN OUTCOME MEASUREMENTS: Small bowel examination completion rate and gastric transit time. RESULTS: Small bowel examination was completed in 19 (70.4%) and 17 (94.4%) patients undergoing conventional and real-time WCE, respectively (P = .048). With the real-time monitoring and on-demand preparations, gastric passage time was significantly reduced (100 vs 59 minutes, P = .02). LIMITATIONS: Nonrandomized study. CONCLUSIONS: The use of the real-time viewer may help to secure the passage of the capsule endoscope into the small bowel and hence result in a higher rate of complete small bowel examination.

Endoscopic clipping versus injection and thermo-coagulation in the treatment of non-variceal upper gastrointestinal bleeding: a meta-analysis.

BACKGROUND: Hemoclips, injection therapy and thermocoagulation (heater probe or electrocoagulation) are the most commonly used types of endoscopic hemostasis for the control of non-variceal gastrointestinal bleeding. AIM: To compare the efficacy of hemoclips versus injection or thermocoagulation in endoscopic hemostasis by pooling data from the literature. METHOD: Publications in the English literature (MEDLINE, EMBASE and Cochrane Library) as well as abstracts in major international conferences were searched using the keywords "hemoclips" and "bleeding", and 15 trials fulfilling the search criteria were found. Outcome measures included: initial hemostasis (after endoscopic intervention); recurrent bleeding; definitive hemostasis (no recurrent bleeding until the end of follow-up); the requirement for surgical intervention; and all-cause mortality. The heterogeneity of trials was examined and the effects were pooled by meta-analysis. RESULTS: Of 1156 patients recruited in the 15 studies, 390 were randomly assigned to receive clips alone, 242 received clips combined with injection, 359 received injection alone, and 165 received thermocoagulation with or without injection. Definitive hemostasis was higher with hemoclips (86.5%) than injection (75.4%; RR 1.14, 95% CI 1.00-1.30), or endoscopic clips with injection (88.5%) compared with injections alone (78.1%; RR 1.13, 95% CI 1.03-1.23), leading to a reduced requirement for surgery but no difference in mortality. Compared with thermocoagulation, there was no improvement in definitive hemostasis with clips (81.5% versus 81.2%; RR 1.00, 95% CI 0.77-1.31). These estimates were robust in sensitivity analyses. There was also no difference between clips and thermocoagulation in rebleeding, the need for surgery and mortality. The reported locations of failed hemoclip applications included posterior wall of duodenal bulb, posterior wall of gastric body and lesser curve of the stomach. CONCLUSION: Successful application of hemoclips is superior to injection alone but comparable to thermocoagulation in producing definitive hemostasis. There was no difference in all-cause mortality irrespective of the modalities of endoscopic treatment.

Helicobacter pylori and benign upper digestive disease.

Acute infection with Helicobacter pylori causes hypochlorhydria and gastrointestinal upset. As the infection persists, patients develop chronic antral-predominant or pangastritis. Gastric and duodenal ulcers arise from chronic mucosal inflammation and disordered acid secretion in the stomach. With successful eradication of H. pylori, non-NSAID-related gastric and duodenal ulcers heal even without long-term acid suppression. More importantly, peptic ulcers and their complications rarely recur. Clearing H. pylori infection also reduces the risk of mucosal injury in NSAID and aspirin users; the protective effects are more pronounced in NSAID-naïve and aspirin users. H. pylori is unlikely to be the cause of gastro-oesophageal reflux disease. However, a patient's reflux symptoms may be more difficult to control after clearing the infection. Although there is little evidence to support a causal relationship between H. pylori and non-ulcer dyspepsia, treatment of the infection gives a modest improvement of symptoms.

Long-term follow-up of patients with obscure gastrointestinal bleeding after negative capsule endoscopy.

BACKGROUND AND AIMS: Capsule endoscopy (CE) is one of the widely accepted investigations for obscure gastrointestinal bleeding (OGIB), but little is known about the impact of CE on the long-term outcome of patients with OGIB. We studied the long-term outcome of patients with OGIB after CE examination. PATIENTS AND METHODS: Forty-nine consecutive patients (45% men, mean age 58.3 yr) who underwent CE for OGIB were studied. The most clinically relevant finding that was related to bleeding was identified by CE. All patients were followed up for at least 12 months for clinical overt and occult bleeding. RESULTS: The median follow-up was 19 months (range 12 to 31). Possible bleeding lesions were detected by CE in 31 (63.3%) patients, and 15 (30.6%) patients, underwent further interventions including laparotomy and push enteroscopy. The overall long-term rebleeding rate in this cohort was 32.7%. The cumulative rebleeding rate was significantly lower in patients with a negative CE (5.6%) than in patients with a positive CE (48.4%, p=0.03 log-rank test). The sensitivity and negative predictive value of CE in predicting rebleeding were 93.8% and 94.4%, respectively. CONCLUSIONS: Patients with OGIB and negative CE had a very low rebleeding rate, and further invasive investigations can be deferred.

Inter-observer variations on interpretation of capsule endoscopies.

OBJECTIVE: Capsule endoscopy is a novel investigation for diagnosing small bowel diseases. However, its interpretation is highly subjective and the potential variability may compromise its accuracy and reliability. Here we studied the potential inter-observer variations on the interpretation of capsule endoscopy. METHOD: Two residents and one specialist in gastroenterology independently reviewed 58 capsule endoscopy studies in the same sequential order. The gastric transit time, small bowel transit time, and the most significant small bowel lesion were independently recorded. The consensus transit time was determined by the joint review of the three gastroenterologists. The 'gold standard' for small bowel diagnoses was based on final surgical, endoscopic findings or consensus diagnosis. RESULTS: Clinically significant and relevant small bowel lesions were found in 32 (55%) cases by consensus review. The overall mean accuracy in determining gastric emptying time, small bowel transit time and small bowel lesion was 89%, 76% and 80%, respectively. There was a significant difference in the accuracy between the residents and specialist on small bowel transit time (P<0.05) and small bowel diagnosis (P<0.05). The mean kappa values on small bowel diagnosis among the three viewers was 0.56 (range, 0.52-0.59). Among various small bowel diagnoses, small bowel bleeding was more accurately identified than other pathology. CONCLUSIONS: Our results show that there is moderate degree of inter-observer discrepancies on the interpretation of capsule endoscopy. A second reading by an experienced viewer might improve the diagnostic accuracy of this investigation.