The perfect biliary plastic stent: the search goes on.

The introduction of biliary plastic stents has been a landmark achievement in the field of endoscopic retrograde cholangiopancreatography, ensuring minimally invasive and highly effective relief of the obstructed biliary system. Attempts to improve the patency and avoid complications after biliary plastic stenting have led to several innovations, but complications due to stent occlusion are still frequent. Because these complications are clinically relevant, and may guide stent choice and patient management, efforts have been made to elucidate the causes of and ways to prevent occlusion of indwelling stents. In this narrative review we focus on biliary plastic stents and discuss the mechanisms of stent occlusion, existing evidence on salient outcomes, as well as options to overcome existing limitations and prolong plastic stent patency.

Is the use of AGILE patency capsule prior to videocapsule endoscopy useful in all patients with spondyloarthritis?

BACKGROUND AND AIMS: As already known, spondyloarthritis patients present a striking resemblance in intestinal inflammation with early Crohn's disease. Moreover, the frequent use of nonsteroidal anti-inflammatory drugs is an important part of their treatment. Both conditions could lead to intestinal stenoses. Therefore we proposed to investigate the usefulness of the patency capsule test in patients with spondyloarthritis. MATERIAL AND METHODS: 64 consecutive patients (33 males; mean age 38 ± 11 years) that fulfilled the AMOR criteria for seronegative spondyloarthropathy (59.4% ankylosing spondylitis) lacking symptoms or signs of intestinal stenosis were enrolled and submitted to an AGILE™ capsule patency test followed by a video capsule endoscopy (PillCam SB2™), as part of a protocol investigating the presence of intestinal inflammatory lesions. After reviewing the VCE recordings, the Lewis score (of small bowel inflammatory involvement) was computed. RESULTS: In only 5 patients (7.8%) of the study group, the luminal patency test was negative. However, there was no retention of the videocapsule in any of the patients. From the 59 patients with a positive patency test, 3 patients presented single small bowel stenoses (two with ulcerated overlying inflamed mucosa, one cicatricial), all being traversed by the videocapsule along the length of the recording. None of the patients with a negative test had bowel stenoses. There was no correlation between the patency test and the Lewis score, the C reactive protein value, diagnosis of inflammatory bowel disease, or the family history of spondyloarthritis, psoriasis or inflammatory bowel disease. CONCLUSION: The AGILE patency capsule does not seem to be a useful tool for all patients with spondyloarthritis prior to small bowel videocapsule endoscopy (ClinicalTrial.gov ID NCT 00768950).

Significant Delay Posed by the Ileocecal Valve in Videocapsule Endoscopy Small Bowel Transit Time.

Because the ileocecal valve could theoretically influence the progression of the videocapsule, we aimed to characterize its posed delay in videocapsule passage to the cecum. A retrospective study was conducted of all procedures in which patients experienced in the same day colonoscopy with ileal biopsy and videocapsule endoscopy. In all 11 patients who satisfied the criteria, at least one biopsy-induced ileal mucosal defect could be identified. There was a mean delay in the passage of the videocapsule through the ileocecal valve of more than 43 minutes (range: 9 seconds to 143 minutes). This article draws attention to the physiologic sphincter role of the ileocecal valve, which could significantly delay the progression of the endoscopic videocapsule to the cecum. The fact that the small bowel videocapsules may get hung up at the ileocecal valve for a while (and sometimes for a considerable amount of time) we find interesting, and essentially confirms intuition. This could be important in some circumstances, such as choosing the route for deep enteroscopy or calculation of the Lewis score.

The Impact of Hypoxaemia on the Outcome in Liver Cirrhosis.

BACKGROUND AND AIMS: Prognostic factors for poor evolution are critical in the setting of limited access to liver transplantation for patients with cirrhosis. We aimed to investigate the impact of hypoxaemia on the outcome in cirrhosis and the evolution of arterial oxygen tension during long-term follow-up in these patients. METHODS: Consecutive cirrhotic patients were prospectively enroled and followed-up in our tertiary referral center. Clinical features, biological tests, arterial blood gases, NT-proBNP levels, pulse oximetry measurements, 12-lead ECG, and transthoracic contrast echocardiography were documented on enrolment. The main outcomes were death and decompensation due to liver disease. RESULTS: 87 cirrhotic patients were included in the analysis and followed-up for a mean of 16 months. At enrolment, 27 (31%) patients were hypoxaemic, 19 had hepatopulmonary syndrome (HPS), but only 6 of those who were sampled at follow-up had persistent hypoxaemia. During the study period, 22 patients died of liver-related complications. Nine of them (41%) were hypoxaemic on enrolment but none had severe hypoxaemia. Hypoxaemia present at enrollment was not a risk factor for death (p=0.29) or decompensation of liver disease (p=0.7). A higher MELD score at baseline or increase during follow-up was a risk factor for death (p=0.02) and correlated with the presence of hypoxaemia. Normalization of the arterial oxygen levels was accompanied by a significant decrease in NT-proBNP (83 pg/ml vs 0 pg/mL, p=0.023). CONCLUSION: Mild and moderate hypoxaemia was frequent in our patients but was not associated with adverse outcome in cirrhosis. Repeated arterial blood gas sampling is advisable, especially in patients diagnosed with hepatopulmonary syndrome.

Functional dyspepsia today.

Functional dyspepsia (FD) is a disorder presenting with symptoms such as postprandial fullness, early satiety or epigastric pain. Although there is a 10 to 30% reported prevalence worldwide, there is currently no clear explanation of the pathophysiology behind this condition. Motility disorders, visceral hypersensitivity, acid disorders, Helicobacter pylori infection or psychosocial factors have all been reported to play a part in the pathophysiology of FD. The diagnosis of FD is one of exclusion, based on the Rome III criteria. The main therapeutic modalities include lifestyle changes, eradicating Helicobacter pylori infection and treatment with either proton pump inhibitors, prokinetics or antidepressants.

Computed virtual chromoendoscopy - enhanced videocapsule endoscopy is of potential benefit in gastric antral vascular ectasia syndrome refractory to endoscopic treatment.

Gastric antral vascular ectasia (GAVE) syndrome represents a rare cause of gastrointestinal bleeding. More extensive small-bowel involvement must be excluded in those patients with GAVE syndrome in whom aggressive endoscopic treatment of antral lesions results in lack of control of digestive bleeding, and for this subset of patients videocapsule endoscopy examination should be considered. However, since the dim angioectatic lesions, even if located in the gastric antrum, might be difficult to accurately outline with standard endoscopy, virtual chromoendoscopy techniques have been employed to aid in their detection, and the presented case illustrates how Fujinon intelligent color-enhancement (FICE) technology implemented in videocapsule endoscopy clearly emphasizes the vascular morphology and delineation of antral angioectasias, allowing better targeted endoscopic treatment and improving patient outcome.

NSAID-induced deleterious effects on the proximal and mid small bowel in seronegative spondyloarthropathy patients.

AIM: To investigate the small bowel of seronegative spondyloarthropathy (SpA) patients in order to ascertain the presence of mucosal lesions. METHODS: Between January 2008 and June 2010, 54 consecutive patients were enrolled and submitted to a video capsule endoscopy (VCE) examination. History and demographic data were taken, as well as the history of non-steroidal anti-inflammatory drug (NSAID) consumption. After reading each VCE recording, a capsule endoscopy scoring index for small bowel mucosal inflammatory change (Lewis score) was calculated. Statistical analysis of the data was performed. RESULTS: The Lewis score for the whole cohort was 397.73. It was higher in the NSAID consumption subgroup (P = 0.036). The difference in Lewis score between NSAID users and non-users was reproduced for the first and second proximal tertiles of the small bowel, but not for its distal third (P values of 0.036, 0.001 and 0.18, respectively). There was no statistical significant difference between the groups with regard to age or sex of the patients. CONCLUSION: The intestinal inflammatory involvement of SpA patients is more prominent in NSAID users for the proximal/mid small bowel, but not for its distal part.