A case of collagenous colitis associated with novel oral anticoagulants use.

An 84-year-old man was referred to our hospital because of watery diarrhea. Due to cerebral infarction, he had started treatment with a novel oral anticoagulants (NOAC) 1 month prior to admission. The patient underwent blood tests, enhanced computed tomography, and colonoscopy, which indicated infectious or medicinal colitis. The diarrhea persisted and he developed hypokalemia, so a second colonoscopy was performed, which showed edematous mucosa. Colonic mucosal biopsies showed a thick collagen band in the subepithelial region, and collagenous colitis was diagnosed. The watery diarrhea subsequently resolved 1 week after changing the NOAC to warfarin. Reports on collagenous colitis caused by NOAC are very rare, and we consider this case valuable.

Effectiveness of polaprezinc for low-dose aspirin-induced small-bowel mucosal injuries as evaluated by capsule endoscopy: a pilot randomized controlled study.

BACKGROUND: Treatment of low-dose aspirin (LDA)-induced small-bowel injury has not been established. Polaprezinc, a chelate of zinc and L-carnosine, may be efficacious for such injury. We conducted a pilot randomized controlled study to investigate whether polaprezinc is effective against LDA-induced small-bowel injuries. METHODS: Consecutive patients under long-term (>3 months) LDA treatment and who agreed to participate in our study underwent initial capsule endoscopy (CE). Patients with LDA-induced small-bowel injury apparent upon initial CE (n = 20) were randomized into a polaprezinc (150 mg/day for 4 weeks) group and a control (no polaprezinc treatment) group. All underwent follow-up CE after 4 weeks. Changes in the number and characteristics of small-bowel mucosal injuries were compared within and between the two groups. RESULTS: The median number of reddened lesions and erosions/ulcers upon follow-up CE in the polaprezinc group significantly decreased (P < 0.05). However, there was no significant difference in the median number of reddened lesions and erosions/ulcers upon follow-up CE in the control group. CONCLUSIONS: Co-administration of polaprezinc may be effective against small-bowel mucosal injury associated with long-term LDA therapy.

Diagnostic yield of capsule endoscopy vs. double-balloon endoscopy for patients who have undergone total enteroscopy with obscure gastrointestinal bleeding.

BACKGROUND/AIMS: The usefulness of capsule endoscopy (CE) and of double-balloon endoscopy (DBE) for detection of small-bowel lesions is widely accepted. We compared CE- and DBE-based detection of small-bowel lesions in patients with obscure gastrointestinal bleeding (OGIB) who underwent total enteroscopy by both CE and DBE. METHODOLOGY: One hundred eighteen consecutive patients (70 men, 48 women; mean age 62.9±18.4 years) with OGIB underwent both CE and DBE. CE was performed and DBE was then performed within 1 week by both retrograde and antegrade approaches. Differences in detection rates were analyzed. RESULTS: Overall, small-bowel lesions were detected by CE in 53 patients (44.9%) and by DBE in 63 patients (53.4%) (p=0.01); agreement between CE and DBE findings was good (kappa statistic=0.76). Total enteroscopy was achieved by both modalities in 54 patients; CE detected small-bowel lesions in 25 of these patients (46.3%), and DBE detected lesions in 28 of these patients (51.9%) (p=0.25); agreement between CE and DBE findings was very good (kappa statistic=0.88). CONCLUSIONS: Our data support preferential use of noninvasive CE for patients with OGIB and subsequent DBE examination in most cases.

Outcome of patients who have undergone total enteroscopy for obscure gastrointestinal bleeding.

AIM: To assess the diagnostic success and outcome among patients with obscure gastrointestinal bleeding who underwent total enteroscopy with double-balloon endoscopy. METHODS: Total enteroscopy was attempted in 156 patients between August 2003 and June 2008 at Hiroshima University Hospital and achieved in 75 (48.1%). It is assessed whether sources of bleeding were identified, treatment methods, complications, and 1-year outcomes (including re-bleeding) after treatment, and we compared re-bleeding rates among patients. RESULTS: The source of small bowel bleeding was identified in 36 (48.0%) of the 75 total enteroscopy patients; the source was outside the small bowel in 11 patients (14.7%) and not identified in 28 patients (37.3%). Sixty-one of the 75 patients were followed up for more than 1 year (27.2 ± 13.3 mo). Four (6.6%) of these patients showed signs of re-bleeding during the first year, but bleeding did not recur after treatment. Although statistical significance was not reached, a marked difference was found in the re-bleeding rate between patients in whom total enteroscopy findings were positive (8.6%, 3/35) and negative (3.8%, 1/26) (3/35 vs 1/26, P = 0.63). CONCLUSION: A good outcome can be expected for patients who undergo total enteroscopy and receive proper treatment for the source of bleeding in the small bowel.

Clinical validity of endoscopic submucosal dissection for submucosal invasive gastric cancer: a single-center study.

BACKGROUND: The 2010 Japanese Gastric Cancer Association guidelines for the treatment of submucosal invasive gastric cancer (SM-GC) specify size 30 mm or less, differentiated-dominant histology, lack of vessel involvement, and submucosal invasion of less than 500 µm (SM1) as expanded criteria for curative endoscopic resection. Our purpose in this study was to confirm the validity of the expanded indications for curative endoscopic submucosal dissection (ESD) of SM-GC. METHODS: The study subjects were 173 patients with SM-GC resected by ESD at Hiroshima University Hospital between April 2002 and September 2010, including 99 patients for whom 3-plus years' follow-up information was available. Post-ESD outcomes were compared between cases of SM1-GC that met the expanded ESD criteria, those that did not, and SM2-GC cases. RESULTS: Complete resection was achieved for 93.2% of the SM1-GCs that met the expanded criteria. There was neither metastasis to lymph nodes or other organs nor local recurrence among the SM1-GCs. Disease-specific survival did not differ significantly between patients that were simply followed up after ESD and those that were treated by additional surgical resection. CONCLUSIONS: Our outcome data support the clinical validity of ESD without additional surgical resection for SM1-GCs that meet the expanded criteria.

Removal of a sewing needle penetrating the wall of the third portion of the duodenum by double-balloon endoscopy.

We describe successful removal a sewing needle penetrating the wall of the third portion of the duodenum by means of double-balloon endoscopy (DBE). The patient was a 47-year-old woman who accidentally swallowed a sewing needle and was admitted to our hospital. Abdominal radiography and abdominal computed tomography revealed a metallic object in the third portion of the duodenum. DBE performed by the antegrade approach, revealed that the sewing needle had penetrated the duodenal wall. The sewing needle was retrieved with biopsy forceps and pulled out together with the endoscope through the flexible overtube that remained positioned in the duodenum. There was no injury to the patient's esophagus or gastrointestinal wall. Our experience in this case suggests that sharp foreign bodies in the gastrointestinal tract can be safely removed by means of DBE.

Risk factors for bleeding after endoscopic submucosal dissection of gastric epithelial neoplasm.

BACKGROUND: Although endoscopic submucosal dissection (ESD) is standard therapy in Japan for gastric epithelial neoplasm, the complication rate is unsatisfactory, with postoperative bleeding as the major complication. The aim of the present study was to determine risk factors for post-ESD bleeding in patients with gastric epithelial neoplasm. PATIENTS AND METHODS: The study included 764 patients in whom 924 gastric epithelial neoplasms were resected endoscopically between June 2005 and December 2009: the period during which preventative coagulation for all exposed vessels on the artificial ulcer with hemostatic forceps upon completion of ESD was performed routinely. We analyzed the risk factors for bleeding after ESD in relation to the various clinical factors. RESULTS: The post-ESD bleeding rate was 3.0%. Dialysis (vs no dialysis, P = 0.034), operation time ≥75 min (vs <75 min, P = 0.012) and poor control of bleeding during ESD (vs good control, P = 0.014) were significantly related to post-ESD bleeding. Poor control of bleeding during ESD (vs good control; P = 0.04) and operation time ≥75 min (vs <75 min; P = 0.012) were significantly related to bleeding after second-look endoscopy. CONCLUSIONS: Patients at high risk for post-ESD bleeding in gastric epithelial neoplasm were those undergoing dialysis, those in whom operation time was ≥75 min, and those in whom bleeding during ESD was poorly controlled. The latter two are risk factors for bleeding even after second-look endoscopy.

Improved detectability of small-bowel lesions via capsule endoscopy with computed virtual chromoendoscopy: a pilot study.

OBJECTIVE: Real-time video capsule endoscopy (CE) with flexible spectral imaging color enhancement (FICE) improves visibility of small-bowel lesions. This article aims to clarify whether CE-FICE also improves detectability of small-bowel lesions. PATIENTS AND METHODS: A total of 55 patients who underwent CE at Hiroshima University Hospital during the period November 2009 through March 2010 were enrolled in the study. Five patients were excluded from the study because residues and transit delays prevented sufficient evaluation. Thus, 50 patients participated. Two experienced endoscopists (each having interpreted more than 50 capsule videos) analyzed the images. One interpreted conventional capsule videos; the other, blinded to interpretation of the conventional images, interpreted CE-FICE images obtained at settings 1-3 (setting 1: red 595 nm, green 540 nm, blue 535 nm; setting 2: red 420 nm, green 520 nm, blue 530 nm; setting 3: red 595 nm, green 570 nm, blue 415 nm). Lesions were classified as angioectasia, erosion, ulceration, or tumor. Detectability was compared between the two modalities. Time taken to interpret the capsule videos was also determined. RESULTS: Seventeen angioectasias were identified by conventional CE; 48 were detected by CE-FICE at setting 1, 45 at setting 2, and 24 at setting 3, with significant differences at settings 1 and 2 (p = 0.0003, p < 0.0001, respectively). Detection of erosion, ulceration, and tumor did not differ statistically between conventional CE and CE-FICE, nor did interpretation time (conventional CE 36 ± 6.9 min; CE-FICE setting 1, 36 ± 6.4 min; setting 2, 38 ± 5.8 min; setting 3, 35 ± 6.7 min). CONCLUSIONS: CE-FICE is superior in the lesion detection in comparison with conventional CE and improves detection of angioectasia.

Improved visibility of lesions of the small intestine via capsule endoscopy with computed virtual chromoendoscopy.

BACKGROUND: We can now enhance video capsule endoscopy (CE) images in real time by means of a flexible spectral imaging color enhancement (FICE) digital processing system. Reports on the clinical usefulness of this system are few. OBJECTIVE: To clarify whether visualization of lesions of the small intestine is improved by FICE image analysis. DESIGN: A retrospective study. SETTING: Academic medical center. METHODS: Five physicians compared FICE images with corresponding conventional images of 145 lesions obtained from 122 patients who underwent video CE at our hospital. The lesions were classified as angioectasia (n=23), erosion/ulceration (n=45), or tumor (n=75), and 3 different sets of FICE images were viewed (ie, at 3 different wavelength settings). Physicians rated the visibility of the lesions on FICE images as follows: +2 (improved visibility), +1 (somewhat improved visibility), 0 (visibility equivalent to that of conventional video CE visibility), -1 (somewhat decreased visibility), and -2 (decreased visibility). Scores for each lesion were totaled (per FICE setting) and evaluated. Intraobserver agreement was also examined. RESULTS: With FICE setting 1 (red 595 nm, green 540 nm, blue 535 nm), improvement was achieved for 87% (20/23) of angioectasia images, 53.3% (26/47) of erosion/ulceration images, and 25.3% (19/75) of tumor images. With setting 2 (red 420 nm, green, 520 nm, blue 530 nm), improvement was achieved for 87% (20/23), 25.5% (12/47), and 20.0% (15/75), respectively. With setting 3, only equivalence was achieved. Intraobserver agreement was good to satisfactory at 5.4 or higher. LIMITATIONS: Single-center study. CONCLUSIONS: CE-FICE improves visibility of small-bowel angioectasia, erosion/ulceration, and tumor.

Comparison of detectability of small-bowel lesions between capsule endoscopy and double-balloon endoscopy for patients with suspected small-bowel disease.

BACKGROUND: There are many reports of the usefulness of capsule endoscopy (CE) or double-balloon endoscopy (DBE) for the detection of small-bowel disease. However, there are few reports that compared CE and DBE. OBJECTIVE: To determine whether CE or DBE better detects small-bowel lesions in patients with suspected small-bowel disease. DESIGN: A prospective single-center study. SETTING: Department of Endoscopy, Hiroshima University Hospital. MAIN OUTCOME MEASUREMENTS: Rates of CE and DBE detection of small-bowel lesions. PATIENTS: Seventy-six consecutive patients (47 men, 29 women; mean age 56.0 years) who underwent both CE and DBE. METHODS: CE was performed before DBE. DBEs were performed within 1 week, by both retrograde and antegrade approaches so that the entire small bowel could be examined, if possible. RESULTS: Small-bowel lesions were detected by CE in 42 patients (55.3%) and by DBE in 46 patients (60.5%). The difference was not significant (P = .45). Total enteroscopy was achieved by both examinations in 35 patients, and small-bowel lesions were detected by both examinations in 21 of the 35 patients (60.0%). Agreement between results of the 2 examinations was good (kappa = 0.76). LIMITATION: The main indication for examinations was not the same. CONCLUSIONS: CE and DBE are nearly equal in their ability to detect small-bowel lesions if the entire small bowel is examined.

Usefulness and limitations of transabdominal ultrasonography for detecting small-bowel tumors.

OBJECTIVE: New methods of examining the small bowel, e.g. capsule endoscopy (CE) and double-balloon endoscopy (DBE), have recently been developed. Transabdominal ultrasonography (TUS) is a conventional, non-invasive, and less-expensive modality. The aim of this study was to evaluate the usefulness and limitations of TUS for the detection of small-bowel tumors. MATERIAL AND METHODS: A total of 371 patients who underwent CE and/or DBE were enrolled in the study. All patients underwent TUS prior to CE and DBE. We evaluated the sensitivity and specificity of TUS in detecting small-bowel tumors, diagnosis and size of tumors, overall detection rate of tumors by TUS, detection rate according to tumor size and shape, and the ultrasonographic features of the tumors. RESULTS: The sensitivity and specificity rates of TUS were 26.4% and 98.6%, respectively. A total of 92 tumors detected by CE and/or DBE were analyzed. Mean size of small-bowel tumors was 20.0 mm. The detection rate of TUS was 25.0%; the detection rate for tumors smaller than 20 mm was only 1.8%, while that for tumors of 20 mm or larger was 59.5%. Despite the tumor size being 20 mm or larger, none of the granular lateral spreading lesions were detected by TUS, but all of the circumferential ulcerative lesions could be detected using this procedure. CONCLUSIONS: TUS is considered to be a useful modality for detecting small-bowel lesions of large volume. We consider that TUS is the first choice modality for examining small-bowel lesions because it is a non-invasive and non-expensive procedure that can detect large lesions.

[Diagnosis and treatment for benign small bowel tumor].

Even if small bowel tumors are benign, they need to be treated when they cause symptoms, such as gastrointestinal bleeding or enteric intussusception. It became possible to perform endoscopic treatment for small bowel lesions using DBE. Therefore for preventing surgical operation, it became important to detect small bowel tumors while endoscopic treatment is possible. CE has potential to survey small bowel tumors, especially in patients with polyposis.