Comparison of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy conducted by pediatric gastroenterologists.

Objectives: The effectiveness and safety of propofol-based sedation and midazolam sedation in pediatric bidirectional endoscopy were compared. Methods: We retrospectively analyzed the cases of pediatric patients (≤15 years old) who had undergone bidirectional endoscopy, esophagogastroduodenoscopy, and colonoscopy by pediatric gastroenterologists. Demographic data, indications, sedatives/dosages, clinical outcomes, endoscopic findings, adverse events, and total patient time requirements (total time in which patients stay in our hospital) were compared in the two sedation groups. Results: Ninety-one children (51 boys, 40 girls, mean age 13 years, range 9-15) treated at our hospital were enrolled. Propofol alone or in combination with midazolam and/or pentazocine was administered to 51 patients (propofol-based sedation group). Midazolam alone or in combination with pentazocine was administered to the other 40 patients (midazolam sedation group). In the propofol group, the following mean doses were used: propofol, 96 mg (range 40-145 mg); midazolam, 4.9 mg (range 3-5 mg); and pentazocine, 7.5 mg. In the midazolam group, the mean doses of midazolam and pentazocine were 6.2 mg (range 4-10 mg) and 15 mg, respectively. All procedures were successfully completed by pediatric gastroenterologists. The total procedure times and endoscopic findings were similar in the two groups, but the median patient time requirement in the propofol group was significantly shorter versus the midazolam group (7.3 h vs. 8.4 h, p < 0.001). No adverse events occurred in either group. Conclusions: Propofol-based sedation in pediatric bidirectional endoscopy was safely and effectively performed by pediatric gastroenterologists, and its patient time requirement was shorter than that for midazolam sedation.

Endoscopic assessment of minor papilla morphology: Predictors of successful cannulation and procedural pancreatitis risk in minor papilla endotherapy.

BACKGROUND: We evaluated for predictors of successful cannulation and post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis (PEP) in minor papilla endotherapy (MPE), emphasizing endoscopic minor papilla morphology. METHODS: We retrospectively analyzed 232 MPEs in 65 patients, assessing minor papilla morphology based on three features: bulge as "prominent" or "subtle," mucosal appearance as "papilla-like" resembling the main papilla or "SMT-like" akin to a gastrointestinal submucosal tumor, and orifice visibility as "clear" or "unclear." Cannulation success was evaluated in 65 enrolled patients, with PEP risk assessed in all 232 MPEs. RESULTS: Minor papilla morphology was categorized as prominent/subtle bulge in 42/23 patients, papilla-like/SMT-like mucosal appearance in 42/23, and clear/unclear orifice visibility in 24/41. Cannulation succeeded in 54/65 patients (83%). A papilla-like appearance and clear orifice visibility was significantly associated with cannulation success. PEP incidence was 5.2% and predominantly mild. A papilla-like appearance significantly decreased PEP incidence, while precutting technique and orifice dilation significantly increased PEP risk. CONCLUSION: Evaluating minor papilla morphology may help predict cannulation success and PEP risk in MPE. A papilla-like mucosal appearance prognosticates cannulation success and reduced PEP risk, with clear orifice visibility serving as a success predictor. These findings provide practical guidance for preprocedural planning by emphasizing the importance of minor papilla morphology evaluation.

Pharyngeal Residues Following Swallowing of Pureed Diets Thickened with a Gelling Agent or a Xanthan Gum-Based Thickener in Elderly Patients with Dysphagia.

The ideal texture of pureed diets to prevent aspiration pneumonia remains unclear. The aim of this study was to evaluate the effectiveness of a pureed diet with either a gelling agent or a xanthan gum-based thickener to prevent pharyngeal residues in patients with dysphagia. We retrospectively analyzed a randomized, crossover trial of pureed rice with either a gelling agent or a xanthan gum-based thickener in patients with dysphagia. The enrolled patients were classified into mild and moderate-to-severe dysphagia groups. The primary outcome measure was degree of need for cyclic ingestion using test jelly for pharyngeal residuals (cyclic ingestion score). The secondary outcome was the patient's sense of material remaining in the throat following swallowing. Sixty-two patients (58% men; mean age 83 ± 9 years) with dysphagia were included. They were classified into mild dysphagia (n = 26) and moderate-to-severe dysphagia (n = 36) groups. In the moderate-to-severe dysphagia group, pharyngeal residuals were significantly less likely with pureed diets using a gelling agent than with those using a xanthan gum-based thickener, with respective median cyclic ingestion scores (range) of 1 (0-4) vs. 2.5 (0-4) (p = 0.001). There was no significant difference in pharyngeal residuals between the pureed diets in the mild dysphagia group. The multivariate analysis identified gelling agent as an important factor significantly associated with less pharyngeal residual after swallowing of pureed diet in patients with moderate-to-severe dysphagia. Pureed diets thickened by a gelling agent decrease pharyngeal residues in patients with moderate-to-severe dysphagia and may reduce risk of aspiration pneumonia.

Serum Leucine-Rich α2 Glycoprotein Could Be a Useful Biomarker to Differentiate Patients with Normal Colonic Mucosa from Those with Inflammatory Bowel Disease or Other Forms of Colitis.

(1) Background: Serum leucine-rich α2 glycoprotein (LRG) has been reported as a useful biomarker for monitoring disease activity in patients with inflammatory bowel disease (IBD). We investigated whether serum LRG can differentiate patients with normal colonic mucosa from those with IBD or other forms of colitis. (2) Methods: Patients with diarrhea, abdominal pain, or bloody stools were consecutively enrolled at their initial visit to our hospital. Serum LRG and C-reactive protein were measured, and a colonoscopy and histology were performed. (3) Results: We enrolled 317 patients (181 men, 136 women; median age: 51 years). Based on the endoscopic and histological criteria, 260 patients were diagnosed with ulcerative colitis (n = 134), Crohn's disease (n = 10), infectious colitis (n = 43), diverticular colitis (n = 17), or nonspecific colitis (n = 56). The remaining 57 patients were diagnosed with normal colonic mucosa including histology. The latter group's median LRG value (9.5 µg/mL, range: 5.8-13.5) was significantly lower than that of the other 260 patients (13.6 µg/mL, range: 6.8-62.7, p < 0.0001). The optimal LRG cut-off value of <10.4 µg/mL was derived from the receiver operating characteristic (ROC) curve, showing a 91% sensitivity and 77% specificity for identifying patients with normal colonic mucosa. (4) Conclusions: serum LRG values < 10.4 µg/mL could be a useful biomarker for predicting patients with normal colonic mucosa.

Predictive Insights Into Exocrine Pancreatic Insufficiency in Chronic Pancreatitis and Autoimmune Pancreatitis: A Decision Tree Approach.

OBJECTIVE: Exocrine pancreatic insufficiency (EPI) is a common manifestation of chronic pancreatitis (CP) and autoimmune pancreatitis (AIP). This study aimed to estimate the presence of EPI in patients with CP or AIP using alternative clinical markers. MATERIALS AND METHODS: A machine learning analysis employing a decision tree model was conducted on a retrospective training cohort comprising 57 patients with CP or AIP to identify EPI, defined as fecal elastase-1 levels less than 200 µg/g. The outcomes were then confirmed in a validation cohort of 26 patients. RESULTS: Thirty-nine patients (68%) exhibited EPI in the training cohort. The decision tree algorithm revealed body mass index (≤21.378 kg/m 2 ) and total protein level (≤7.15 g/dL) as key variables for identifying EPI. The algorithm's performance was assessed using 5-fold cross-validation, yielding area under the receiver operating characteristic curve values of 0.890, 0.875, 0.750, 0.625, and 0.771, respectively. The results from the validation cohort closely replicated those in the training cohort. CONCLUSIONS: Decision tree analysis revealed that EPI in patients with CP or AIP can be identified based on body mass index and total protein. These findings may help guide the implementation of appropriate treatments for EPI.

A 2-week intensive gastrointestinal endoscopy training program for pediatricians.

BACKGROUND: In Japan there are limited opportunities for pediatricians to learn gastrointestinal (GI) endoscopy. This study investigated whether a short-term intensive training for 2 weeks in an adult GI setting enabled pediatricians to acquire basic technical competence for pediatric GI endoscopic procedures. METHODS: This was a retrospective case series of pediatricians who underwent 2 weeks of intensive endoscopy training at an adult endoscopy unit in a community hospital. The numbers of esophagogastroduodenoscopy (EGD) and ileocolonoscopy procedures each pediatrician performed were evaluated. All enrolled pediatricians were asked to answer questionnaires regarding the 2 week intensive GI endoscopy training program. RESULTS: There were 17 enrolled pediatricians, of whom 13 were men; average age 32 years (range 27-54). The median (range) numbers of EGDs and ileocolonoscopies performed by each pediatrician during the 2-week training period were 102 (66-144) and 14 (1-48), respectively. Fifteen out of 17 pediatricians experienced more than 100 GI endoscopies during the 2 weeks. All pediatricians performed biopsies as part of some EGD procedures. All 17 pediatricians found this program satisfactory. All pediatricians became cable of performing pediatric EGD (i.e., for children ≤15 years) after this training program. Sixteen pediatricians have continued to perform pediatric GI endoscopy since this training program. CONCLUSIONS: A short-term intensive training program for 2 weeks in an adult GI setting enabled pediatricians to acquire basic technical competence for pediatric endoscopic procedures.

Cap-assisted colonoscopy can increase the rate of sessile serrated lesion detection at the left lateral decubitus position: A retrospective case-control study.

We investigated the effectiveness of cap-assisted colonoscopy conducted with the patient in the left lateral decubitus position at both the colonoscope's insertion and withdrawal timepoints compared to the effectiveness of colonoscopy without a cap conducted in the supine position at withdrawal. This was a case-control study, based on historical comparisons of patients over 2 time periods. The first group of patients underwent colonoscopies with a transparent cap and the patient was in the left lateral decubitus position at both the insertion and withdrawal timepoints from April to June 2019. The subsequent group underwent colonoscopies without a cap and with the patient in the supine position at withdrawal from July to September 2019. The rates of successful intubation, cecal intubation time, and number, size, shape, and location of the detected adenomas and sessile serrated lesions were compared between the 2 groups. Data from 644 colonoscopies (cap-assisted colonoscopy + left lateral decubitus position, n=320; other colonoscopies, n=324) were analyzed. The demographic characteristics and technical performances were similar. The SSL detection rate was significantly higher with cap-assisted colonoscopy and the left lateral decubitus position than with other colonoscopies (3.4% vs 0.93%, P=.029). The adenoma detection rates in the 2 groups were similar (31% and 28%, respectively, P=.43).Cap-assisted colonoscopy in the left lateral decubitus position may increase the detection rate of sessile serrated lesions compared to colonoscopy without a cap and supine position at withdrawal.

Rising Trends of Endoscopic Barrett's Esophagus and Gastric Fundic Gland Polyps in Young Japanese Adults.

BACKGROUND/AIMS: This study examined changes in the esophageal-gastric junction and gastric mucosa in young Japanese adults undergoing endoscopy in the last 15 years. MATERIALS AND METHODS: This was a retrospective study of young Japanese adults (aged 19-30 years) who underwent esophagogastrod uodenoscopy between 2006 and 2020. The indications were upper gastrointestinal symptoms and anemia. Changes in the appearance of the esophago-gastric junction (i.e., the Z line and distal esophagitis) and gastric mucosa were examined. Endoscopic Barrett's esophagus was defined using the Japanese criteria. RESULTS: One thousand eight hundred forty-five patients were examined: 848 from 2006 to 2012 [400 males, mean age 26.5 years (range 19-30)] and 997 from 2013 to 2020 [433 males, mean age 26.2 years (range 19-30)]. The proportion showing endoscopic Barrett's esophagus and gastric fundic gland polyps increased significantly between the 2 periods (12.5% vs. 22.4%, P < .001; 3.4% vs. 7.2%, P < .001) with a significant correlation between the prevalence trends for endoscopic Barrett's esophagus and gastric fundic gland polyps (r = 0.789, P = .0008). Pathological examination showed that the prevalence of traditional fundic gland polyps unrelated to the use of proton pump inhibitors significantly increased from 40% (4/10) to 81% (25/31) between the 2 periods (P = .04). CONCLUSION: The prevalence of both endoscopic Barrett's esophagus and gastric fundic gland polyps among young Japanese adults significantly increased in the last 15 years. The trend in endoscopic Barrett's esophagus was significantly correlated with that of nonproton pump inhibitor-related gastric fundic gland polyps.

Serum Leucine-Rich α2 Glycoprotein: A Biomarker for Predicting the Presence of Ulcerative Colitis but Not Ulcerative Proctitis.

The serum level of leucine-rich α2 glycoprotein (LRG) is a biomarker for active ulcerative colitis (UC). We examined the serum level of LRG as a biomarker for predicting the presence of UC. Patients with persistent diarrhea and/or bloody stool with no history of UC were consecutively enrolled at their initial visit. Serum LRG measurement and colonoscopy with histology were performed on the same day. We enrolled 103 patients (69 men; median age, 45 years) with suspected UC; 66 patients were diagnosed with active UC (proctitis, n = 10; left-sided colitis, n = 26; and pancolitis, n = 30) based on endoscopic and histological criteria. Although the median LRG value in patients with proctitis was similar to that of patients with normal colonoscopic findings (8.5 vs. 8.6 mg/mL, p = 0.24), the median LRG values were significantly elevated in patients with left-sided colitis and pancolitis compared with those of patients with normal colonoscopy (13.6 or 18.0 vs. 8.6 mg/mL, p < 0.0001). The LRG cut-off value of 10.8 µg/mL was derived from the ROC curve, showing 96% sensitivity and 97% specificity for active UC but not active proctitis. Using a cut-off value of 10.8 mg/mL serum, LRG could be a novel biomarker for predicting patients with active UC except for proctitis.

Managing bleeding risk after cold snare polypectomy in patients receiving direct-acting oral anticoagulants.

BACKGROUND AND AIMS: The best strategy to manage direct-acting oral anticoagulants (DOACs) for patients undergoing cold snare polypectomy remains unclear. This study compared the effect of continuing versus stopping DOACs only on the day of the procedure on bleeding after cold snare polypectomy. METHODS: This prospective, observational, single-center cohort study enrolled consecutive patients receiving antithrombotic agents and undergoing cold snare polypectomy of colorectal polyps ≤10 mm in diameter. During period 1 (2017 and 2018) antithrombotic agents including DOACs were not discontinued (DOAC continued group). In period 2 (2019 and 2020) DOACs were withheld only on the day of the procedure (DOAC withheld group) and restarted the next day after the procedure. The primary outcome was delayed bleeding requiring endoscopic treatment occurring within 2 weeks after cold snare polypectomy. Secondary outcomes were immediate bleeding and the number of hemostatic clips used. RESULTS: For the 2 groups, 204 (DOAC continued group; 34% women; mean age, 75 years) and 264 (DOAC withheld group; 36% women; mean age, 74 years) patients were enrolled. Clinical features were similar between the 2 groups. Delayed bleeding after cold snare polypectomy occurred in 4 of 47 patients (8.5%) in the DOAC continued group versus 0 of 66 (0%) in the DOAC withheld group (P < .001). Immediate postpolypectomy bleeding occurred in 12 of 47 patients (25.5%) in the DOAC continued group versus 4 of 66 (6.1%) in the DOAC withheld group (P < .008). CONCLUSIONS: Cold snare polypectomy may be safely preformed if DOACs are withheld only on the day of the procedure. (Clinical trial registration number: NCT02594813.).

Effectiveness of Water Jelly Ingestion for Both Rehabilitation and Prevention of Aspiration Pneumonia in Elderly Patients With Moderate to Severe Dysphagia.

BACKGROUND AND AIMS: We evaluated the effectiveness of water jelly ingestion for both rehabilitation and the prevention of aspiration pneumonia in a retrospective analysis of elderly patients with moderate to severe dysphagia. PATIENTS AND METHODS: Study 1: consecutive patients with borderline ingestion in an endoscopic swallowing evaluation were enrolled (n=36, 18 men and 18 women: mean age 82±9 y) and categorized into a group with water jelly (50 to 100 mL) ingestion training 3×/day or an untrained control group. Their food intake levels were then compared using a Food Intake Level Scale. Study 2: consecutive patients who were hospitalized because of aspiration pneumonia were enrolled (n=64, 35 men and 29 women: mean age 81±9 y) and categorized into a group with cyclic ingestion of water jelly immediately after each meal or a control group. The incidence of aspiration pneumonia that was newly developed during hospitalization was compared between the groups. RESULTS: In study 1, 36 patients with a Hyodo-Komagane score of 8 were enrolled. Three of the 12 (25%) patients who underwent water jelly ingestion training were able to eat a pureed diet (level 5, 2 patients; level 6, 1 patient) while none of the 24 patients (0%) who did not undergo this training were able to eat any form of diet (levels 5 and 6, no patients) (P=0.011). In study 2, 64 patients were enrolled. No newly developed aspiration pneumonia was observed in the 34 patients (0%) who received cyclic water jelly ingestion, whereas 17% (5/30) of patients not receiving water jelly after meals newly developed aspiration pneumonia during hospitalization (P=0.031). CONCLUSIONS: Water jelly ingestion was effective for both rehabilitation and the prevention of aspiration pneumonia in elderly patients with moderate to severe dysphagia.

Mucosal defect size predicts the adequacy of resection of ≤10 mm nonpedunculated colorectal polyps using a new cold snare polypectomy technique.

OBJECTIVES: There is still room for improvement in the methods used to achieve complete polyp resection. The aim of this study was to develop a cold snare polypectomy technique that will reliably result in resections containing the muscularis mucosae and the lateral polyp margins. MATERIALS AND METHODS: Nonpedunculated polyps ≤10 mm were resected using a dedicated cold snare with the goal of creating a mucosal defect approximately 1 cm in dia. The completeness of resection of the lateral and vertical polyp margins was examined histologically. RESULTS: The cases of 201 patients (mean age 67 ± 13 years; 115 men) with 500 eligible polyps were enrolled. The mean polyp size was 6.1 ± 1.8 mm (range 1-10 mm). The mean mucosal defect size immediately after resection was 7.7 ± 2.5 mm (range 3-15 mm). Overall, the complete resection rate in which the lateral and vertical margins were free from the neoplasia tissue was 92% (417/454, 95% CI, 89-94); in the remaining 8% of cases, the vertical margins showed complete resection but the lateral margins could not be evaluated due to the fragmentation of resected polyps. A mucosal defect ≥7 mm predicted complete resection of the mucosal layer containing the muscularis mucosae. CONCLUSION: Complete mucosal layer resection of nonpedunculated colorectal polyps ≤10 mm was reliably achieved using a cold snare technique that produced a mucosal defect ≥7 mm in dia.

Linked colour imaging versus white-light colonoscopy for the detection of flat colorectal lesions: A randomized controlled trial.

AIM: Linked colour imaging is an image-enhanced endoscopy system that emphasizes the red portion of the mucosa's colour. Our aim was to compare the effectiveness of linked colour imaging with white-light colonoscopy for the detection of flat-type colorectal polyps. METHOD: This was a single-centre, randomized controlled trial. Enrolled patients were those aged ≥50 years undergoing cap-assisted colonoscopy for colorectal cancer screening. They were randomized in a 1:1 ratio for observation using linked colour imaging or white-light colonoscopy. All colorectal polyps detected were removed or biopsied. The primary outcome was the number of flat-type polyps per patient in patients in whom flat polyps were detected. Secondary outcomes included adenoma and polyp detection rates. RESULTS: There were 302 subjects randomized: 152 to linked colour imaging and 150 to white-light colonoscopy. There were no differences in the clinical features between the two arms. The number of flat polyps detected per patient using linked colour imaging was approximately twice that with white light (2.9 ± 3.0 vs 1.2 ± 1.6, p = 0.045). Linked colour imaging also proved superior to white-light colonoscopy in terms of adenoma and polyp detection rates [adenomas 66% (101/152) vs 49% (73/150), p = 0.0024; polyps 69% (105/152) vs 55% (82/150), p = 0.013]. The ratio of polyps detected in the right colon compared with those detected in the left colon was significantly greater using linked colour than white-light imaging (168/64 vs 93/84; p < 0.001). CONCLUSION: Compared with white-light colonoscopy, linked colour imaging improved adenoma and polyp detection rates, including detection of flat-type colorectal polyps.

Risk of Gastrointestinal Endoscopic Procedure-Related Bleeding in Patients With or Without Continued Antithrombotic Therapy.

BACKGROUND: Prospective studies on bleeding risk during/after gastrointestinal endoscopic procedures are rare. AIM: We investigated the risk of endoscopic procedure-related bleeding in patients with biopsy and/or cold snare polypectomy (CSP) in relation to antithrombotic therapy. METHODS: This prospective, observational single-center cohort study (NCT02594813) enrolled consecutive patients who underwent diagnostic esophagogastroduodenoscopy (EGD) or colonoscopy. The primary outcome measure was delayed bleeding in patients with biopsy and/or CSP who required endoscopic treatment within 2 weeks post-procedure. The secondary outcomes were immediate bleeding and the number of hemostatic clips used during the procedure. RESULTS: From November 2015 to October 2018 at our institution, 3069 (mean age, 66 years) and 37,887 (57 years) patients underwent EGD with and without antithrombotic therapy, respectively. In addition, 1116 (72 years) and 11,901 (65 years) patients had colonoscopy with and without antithrombotic therapy, respectively. In the 3069 EGD patients receiving antithrombotic therapy, no delayed bleeding occurred, whereas immediate bleeding occurred in 9 of 141 patients (6.4%) with biopsy. Of the 1116 colonoscopy patients receiving antithrombotic therapy, delayed bleeding occurred in three of 228 (1.3%) following CSP. Immediate bleeding occurred in nine of 225 (4%) following biopsy and in 32 of 228 (14%) following CSP. Multivariate analysis following univariate analysis identified chronic kidney disease and CSP as factors significantly associated with procedure-related bleeding in patients taking antithrombotic agents. CONCLUSION: The risk of delayed bleeding in diagnostic EGD with biopsy or in colonoscopy with biopsy and/or CSP was low despite continuation of antithrombotic therapy.