EUS-guided tissue samples for the diagnosis of patients with a thickened gastric wall and prior negative endoscopic biopsies.

AIM: Evaluate the diagnostic yield of biopsies obtained by EUS guidance in patients with gastric wall thickening and prior negative endoscopic biopsies. MATERIAL AND METHODS: Data collected from October 2008 to January 2016 were analyzed in a retrospective manner. All included patients had undergone at least one endoscopy with a negative biopsy and showed evidence of gastric wall thickening by tomography, confirmed by endoscopy. All patients gave their written informed consent before the procedure. Demographics and baseline characteristics, including age, sex, number of previous endoscopies, and histopathological diagnosis were recorded. Follow-up data were obtained from a review of the electronic medical records. RESULT: In total, 22 patients with previous negative endoscopic biopsies and gastric wall thickening were included. Using EUSFNA/FNB, the diagnosis was made in the first procedure in 19/22 (86.30%) cases, while in 1/22 (4.5%) patients the diagnosis was made in the second EUS-FNA. A total of 18 (81.82%) patients with EUS-FNA were assessed using a standard Echo-tip, while the remaining four (18.18%) patients underwent EUS-FNB and using a ProCore needle. All patients with a final diagnosis of malignancy had a thickened gastric wall with impaired gastric distension and a loss of wall structure determined by EUS. Of patients with a benign final diagnosis, all (n=8) showed a thickened gastric wall by EUS but with preservation of the deep layers. CONCLUSION: EUS-FNA/FNB is necessary in patients with a thickened gastric wall and prior negative biopsy on endoscopy. The procedure is safe and has a good diagnostic.

Barrett's esophagus: Ten years of experience at a tertiary care hospital center in Mexico. / Esófago de Barrett: experiencia de 10 años en un centro de tercer nivel en México.

INTRODUCTION: The prevalence of Barrett's esophagus has been calculated at between 1.3 and 1.6%. There is little information with respect to this in Mexico. AIM: To determine the frequency and characteristics of Barrett's esophagus in patients that underwent endoscopy at a national referral center, within a 10-year time frame. MATERIAL AND METHODS: The databases of the pathology and gastrointestinal endoscopy departments of the Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán" were analyzed, covering the period of January 2002 to December 2012. Patients with a histologic diagnosis of Barrett's esophagus were included. The variables of age, sex, the presence of dysplasia/esophageal adenocarcinoma, Barrett's esophagus length, and follow-up were analyzed. RESULTS: Of 43,639 upper gastrointestinal endoscopies performed, 420 revealed Barrett's esophagus, corresponding to a frequency of 9.6 patients for every 1,000 endoscopies. Of those patients, 66.9% (n=281) were men, mean patient age±SD was 57.2±15.3 years, 223 patients (53%) presented with long-segment Barrett's esophagus, and 197 (47%) with short-segment Barrett's esophagus. Dysplasia was not present in 339 patients (80.7%). Eighty-one (19.3%) patients had some grade of dysplasia or cancer: 48/420 (11.42%) presented with low-grade dysplasia, 20/420 (4.76%) with high-grade dysplasia, and 13/420 (3.1%) were diagnosed with esophageal cancer arising from Barrett's esophagus. Mean follow-up time was 5.6 years. CONCLUSIONS: The frequency of Barrett's esophagus was 9.6 cases for every 1,000 upper gastrointestinal endoscopies performed. Dysplasia was not documented in the majority of the patients with Barrett's esophagus and they had no histopathologic changes during follow-up. A total of 19.3% of the patients presented with dysplasia or cancer.

[Mexican consensus on portal hypertension]. / Consenso Mexicano de Hipertensión Portal.

The aim of the Mexican Consensus on Portal Hypertension was to develop documented guidelines to facilitate clinical practice when dealing with key events of the patient presenting with portal hypertension and variceal bleeding. The panel of experts was made up of Mexican gastroenterologists, hepatologists, and endoscopists, all distinguished professionals. The document analyzes themes of interest in the following modules: preprimary and primary prophylaxis, acute variceal hemorrhage, and secondary prophylaxis. The management of variceal bleeding has improved considerably in recent years. Current information indicates that the general management of the cirrhotic patient presenting with variceal bleeding should be carried out by a multidisciplinary team, with such an approach playing a major role in the final outcome. The combination of drug and endoscopic therapies is recommended for initial management; vasoactive drugs should be started as soon as variceal bleeding is suspected and maintained for 5 days. After the patient is stabilized, urgent diagnostic endoscopy should be carried out by a qualified endoscopist, who then performs the corresponding endoscopic variceal treatment. Antibiotic prophylaxis should be regarded as an integral part of treatment, started upon hospital admittance and continued for 5 days. If there is treatment failure, rescue therapies should be carried out immediately, taking into account that interventional radiology therapies are very effective in controlling refractory variceal bleeding. These guidelines have been developed for the purpose of achieving greater clinical efficacy and are based on the best evidence of portal hypertension that is presently available.

Endoscopic ultrasound-guided biliodigestive drainage is a good alternative in patients with unresectable cancer.

A total of 11 prospective cases of endoscopic ultrasound (EUS)-guided cholangio-drainage (EUCD) in patients with end-stage biliopancreatic cancer and biliary tract obstruction are reported. Other available drainage methods (endoscopic retrograde cholangiopancreatography and/or percutaneous transhepatic biliary drainage) of the biliary tract were attempted without success prior to EUS. Technical and clinical success was achieved in 10/11 patients (91%) and in 9/10 patients (90%), respectively. Bilirubin decreased by more than 50% in 7/11 patients (64%). One patient had a complication that required re-intervention and another patient developed biloma. No mortality directly related to the procedure was documented. In conclusion, EUCD is a good alternative for patients with malignant obstruction of the biliary tract in whom other drainage methods have failed.

Risk of hyperamylasemia and acute pancreatitis after double-balloon enteroscopy: a prospective study.

BACKGROUND AND STUDY AIMS: There have been reports, mainly retrospective, of pancreatitis and hyperamylasemia after anterograde double-balloon enteroscopy (DBE). Our aim was to report the incidence of pancreatitis and hyperamylasemia after DBE and investigate possible risk factors associated with its occurrence. PATIENTS AND METHODS: In this single-center prospective cohort study, serum samples were taken for amylase and lipase before and 3 hours after anterograde DBE in consecutive patients. Multiple variables were recorded, including total procedure time, insertion depth, and number of passes. Patients were evaluated to 24 hours later for signs of pancreatitis. The main outcome measures were the occurrence of hyperamylasemia and pancreatitis. RESULTS: 92 patients were included in the analysis (58 women, 34 men; mean age 54 years, range 18-89). The mean total procedure time was 62 minutes (range 30-120). The mean post-procedure amylase and lipase levels were significantly higher in comparison with the baseline levels (165 U/L vs. 69 U/L and 144 U/L vs. 28 U/L respectively, P<.05); 36 patients (39%) showed hyperamylasemia after the procedure and three patients developed acute mild pancreatitis. Hyperamylasemia was associated more frequently with procedure duration greater than 60 minutes ( P<.001) and insertion depth greater than 25 cm ( P<.013). CONCLUSIONS: The incidence of hyperamylasemia after anterograde DBE is common and particularly associated with longer procedure time and insertion depth. The cumulative incidence of pancreatitis was 3%. We recommend the avoidance of both unnecessarily lengthy procedures and deep insertion distances in patients who undergo anterograde DBE.

Diagnostic yield, therapeutic impact, and complications of double-balloon enteroscopy in patients with small-bowel pathology.

BACKGROUND AND AIMS: Until recently the study of small bowel was limited to the radiographic approach. This paper describes experience with the first 86 procedures evaluated and treated with the new technique of double-balloon enteroscopy (DBE). PATIENTS AND METHODS: Between August 2005 and September 2006, DBE was conducted in consecutive patients. The characteristics of the patients, indications for the procedures, procedural parameters, and diagnostic yield are described here. All conventional treatment options were available. All the patients had previously undergone esophagogastroduodenoscopy and colonoscopy. RESULTS: Eighty-six procedures in sixty-eight patients were carried out (41 women, 27 men; mean age 48.5 years, range 20-82). The most common indications were gastrointestinal bleeding (n = 40) and iron deficiency anemia (n = 7). The mean duration of the procedure was 63 (range 20-194) mins and 80 (range 20-150) minutes for the oral and anal routes, respectively. The mean depth of small-bowel insertion was 250 and 200 cm for the oral and anal routes, respectively. Impact in diagnosis and/or treatment was obtained in 50 patients (73.5%). The commonest findings in the 68 patients were angiodysplasia (n = 11), polyps (n = 8), nodular lymphoid hyperplasia (n = 5) and normal (n = 20). No major complications were observed. CONCLUSION: DBE is a useful tool for the diagnosis and treatment of patients with small-bowel pathology in whom traditional methods have not been effective. In almost two-thirds of patients DBE was clinically useful for diagnosis and treatment. The complication rate with the procedure was very low.