Esophageal overtube facilitation of transesophageal echocardiography in patients with previously difficult esophageal intubation.

BACKGROUND: In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. OBJECTIVE: We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. METHODS: We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. CONCLUSIONS: Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with non-stricturing small bowel Crohn's disease.

OBJECTIVES: Capsule endoscopy (CE) allows for direct evaluation of the small bowel mucosa in patients with Crohn's disease (CD). A number of studies have revealed significantly improved yield for CE over other modalities for the diagnosis of CD, but as sample sizes have been small, the true degree of benefit is uncertain. Additionally, it is not clear whether patients with a suspected initial presentation of CD and those with suspected recurrent disease are equally likely to benefit from CE. The aim of this study was to evaluate the yield of CE compared with other modalities in symptomatic patients with suspected or established CD using meta-analysis. METHODS: We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with suspected or established CD. Data on yield among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE--yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. Subanalyses of patients with a suspected initial presentation of CD and those with suspected recurrent disease were also performed. RESULTS: Nine studies (n = 250) compared the yield of CE with small bowel barium radiography for the diagnosis of CD. The yield for CE versus barium radiography for all patients was 63% and 23%, respectively (IY = 40%, p < 0.001, 95% CI = 28-51%). Four trials compared the yield of CE to colonoscopy with ileoscopy (n = 114). The yield for CE versus ileoscopy for all patients was 61% and 46%, respectively (IY = 15%, p= 0.02, 95% CI = 2-27%). Three studies compared the yield of CE to computed tomography (CT) enterography/CT enteroclysis (n = 93). The yield for CE versus CT for all patients was 69% and 30%, respectively (IY = 38%, p= 0.001, 95% CI = 15-60%). Two trials compared CE to push enteroscopy (IY = 38%, p < 0.001, 95% CI = 26-50%) and one trial compared CE to small bowel magnetic resonance imaging (MRI) (IY = 22%, p= 0.16, 95% CI =-9% to 53%). Subanalysis of patients with a suspected initial presentation of CD showed no statistically significant difference between the yield of CE and barium radiography (p= 0.09), colonoscopy with ileoscopy (p= 0.48), CT enterography (p= 0.07), or push enteroscopy (p= 0.51). Subanalysis of patients with established CD with suspected small bowel recurrence revealed a statistically significant difference in yield in favor of CE compared with all other modalities (barium radiography (p < 0.001), colonoscopy with ileoscopy (p= 0.002), CT enterography (p < 0.001), and push enteroscopy (p < 0.001)). CONCLUSIONS: In study populations, CE is superior to all other modalities for diagnosing non-stricturing small bowel CD, with a number needed to test (NNT) of 3 to yield one additional diagnosis of CD over small bowel barium radiography and NNT = 7 over colonoscopy with ileoscopy. These results are due to a highly significant IY with CE over all other modalities in patients with established non-stricturing CD being evaluated for a small bowel recurrence. While there was no significant difference seen between CE and alternate modalities for diagnosing small bowel CD in patients with a suspected initial presentation of CD, the trend toward significance for a number of modalities suggests the possibility of a type II error. Larger studies are needed to better establish the role of CE for diagnosing small bowel CD in patients with a suspected initial presentation of CD.

Capsule endoscopy: a meta-analysis for use with obscure gastrointestinal bleeding and Crohn's disease.

In this study, CE was superior to push enteroscopy and small bowel radiography for diagnosing small bowel pathology in patients who had OGIB, and its yield may be comparable to intraoperative endoscopy. Incremental yield of CE over push enteroscopy and barium radiography is greater than 30% for clinically significant findings, primarily because visualization of additional vascular and inflammatory lesions is possible by CE.CE was also found to be superior to small bowel barium radiography, colonoscopy with ileoscopy, CT enterography, and push enteroscopy for diagnosing nonstricturing small bowel CD. These findings primarily result from a marked improvement in yield with the use of CE over all other methods in patients who had established CD and were evaluated for a small bowel recurrence. Because this analysis was designed to evaluate trials that examined the yield of various methods for the diagnosis of OGIB and CD, it is unknown whether these results will translate into improved patient outcomes with the use of CE versus alternate methods. Randomized controlled trials will be necessary to clarify this issue.

Colonic perforation after computed tomographic colonography in a patient with fibrostenosing Crohn's disease.

Computed tomographic colonography (CTC) offers great promise in the management of patients with disorders of the colon. Few complications have been reported with its use thus far. We describe herein a case of colonic perforation during CTC in a patient with active stenosing ileocolonic Crohn's disease. To our knowledge, this is the first reported case of CTC-related perforation in the setting of Crohn's disease, and the third reported perforation overall. Perforation likely occurred in this case due to barotrauma in the setting of colonic strictures and an inflamed, weakened colonic wall. Physician awareness of the increased risk of perforation with CTC in the setting of inflammatory and/or obstructive disease of the colon will allow for improved clinical decision-making in the care of these patients.

A meta-analysis of the yield of capsule endoscopy compared to other diagnostic modalities in patients with obscure gastrointestinal bleeding.

OBJECTIVES: Due to its superior ability to examine the entire small bowel mucosa, capsule endoscopy (CE) has broadened the diagnostic evaluation of patients with obscure gastrointestinal bleeding (OGIB). Published studies have revealed a numerically superior performance of CE in determining a source of OGIB compared with other modalities, but due to small sample sizes, the overall magnitude of benefit is unknown. Additionally, the types of lesions more likely to be found by CE versus alternate modalities are also unknown. The aim of this study was to evaluate the yield of small bowel findings with CE in patients with OGIB compared to other modalities using meta-analysis. METHODS: We performed a recursive literature search of prospective studies comparing the yield of CE to other modalities in patients with OGIB. Data on yield and types of lesions identified among various modalities were extracted, pooled, and analyzed. Incremental yield (IY) (yield of CE-yield of comparative modality) and 95% confidence intervals (95% CI) of CE over comparative modalities were calculated. RESULTS: A total of 14 studies (n = 396) compared the yield of CE with push enteroscopy for OGIB. The yield for CE and push enteroscopy was 63% and 28%, respectively (IY = 35%, p < 0.00001, 95% CI = 26-43%) and for clinically significant findings (n = 376) was 56% and 26%, respectively (IY = 30%, p < 0.00001, 95% CI = 21-38%). Three studies (n = 88) compared the yield of CE to small bowel barium radiography. The yield for CE and small bowel barium radiography for any finding was 67% and 8%, respectively (IY = 59%, p < 0.00001, 95% CI = 48-70%) and for clinically significant findings was 42% and 6%, respectively (IY = 36%, p < 0.00001, 95% CI = 25-48%). Number needed to test (NNT) to yield one additional clinically significant finding with CE over either modality was 3 (95% CI = 2-4). One study each compared the yield of significant findings on CE to intraoperative enteroscopy (n = 42, IY = 0%, p= 1.0, 95% CI =-16% to 16%), computed tomography enteroclysis (n = 8, IY = 38%, p= 0.08, 95% CI =-4% to 79%), mesenteric angiogram (n = 17, IY =-6%, p= 0.73, 95% CI =-39% to 28%), and small bowel magnetic resonance imaging (n = 14, IY = 36%, p= 0.007, 95% CI = 10-62%). Ten of the 14 trials comparing CE with push enteroscopy classified the types of lesions found on examination. CE had a 36% yield for vascular lesions versus 20% for push enteroscopy, with an IY of 16% (p < 0.00001, 95% CI = 9-23%). Inflammatory lesions were also found more often in CE (11%) than in push enteroscopy (2%), with an IY of 9% (p= 0.0001, 95% CI = 5-13%). There was no significant difference in the yield of tumors or "other" findings between CE and push enteroscopy. CONCLUSIONS: CE is superior to push enteroscopy and small bowel barium radiography for diagnosing clinically significant small bowel pathology in patients with OGIB. In study populations, the IY of CE over push enteroscopy and small bowel barium radiography for clinically significant findings is >or=30% with an NNT of 3, primarily due to visualization of additional vascular and inflammatory lesions by CE.

Development of macro-aspartate aminotransferase in a patient undergoing specific allergen injection immunotherapy.

Macro-aspartate aminotransferase (macro-AST), a complex between normal AST and an immunoglobulin, is recognized as a cause of isolated elevation of AST. Though its pathogenesis is unknown, previous reports have been suggestive of an autoimmune process. We describe a case of macro-AST formation in a patient with previously normal liver enzymes in whom an isolated AST elevation was discovered after initiation of specific allergen injection immunotherapy (SIT) for allergic rhinitis. We propose that SIT in this otherwise healthy patient led to the formation of macro-AST as a consequence of antibody cross-reaction (molecular mimicry). Awareness of this possible mechanism of macroenzyme development may be helpful to physicians evaluating patients with isolated elevations in AST.

Prognostic factors in acute pancreatitis.

The assessment of the severity of acute pancreatitis (AP) is a critical early step in its management, as severity of AP predicts prognosis. A range of options are available for assessment of severity in AP, including clinical evaluation, standardized prognostic criteria, computed tomography (CT), and biochemical markers. Clinical assessment has limited accuracy for predicting severity early in the course of AP. Therefore, additional assessment using biochemical and radiologic criteria in combination with standardized criteria is appropriate to determine severity and prognosis in AP; a strategy emphasizing daily assessment of severity should be used. The APACHE II is the scoring system of choice for evaluating severity in AP, although it remains an imperfect tool. Computed tomographic grading of AP and the development of the CT severity index allow for heightened accuracy in the prediction of severity. C-Reactive protein is the standard for serum marker assessment of severity and prognosis in AP; other markers, including interleukin-6, polymorphonuclear elastase, and trypsinogen activation peptide, hold promise. The focus of this review is to examine the role of diagnostic tests in evaluating severity and predicting prognosis among patients with AP and to provide a diagnostic algorithm for initial management.