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Capsule Endoscopic Diagnosis of Extra-Intestinal Bleeding Samir K. Nath, Gottumukkala S. Raju Introduction & Aims: Unlike cable endoscopy, which requires sedation and distension of the lumen for visualization, CE provides imaging of the gut without disturbing its physiological state. It is unclear whether CE, designed primarily for small intestinal imaging, will be useful in the diagnosis of bleeding lesions in the stomach or colon that were not apparent to the cable endoscopy. We report the role of CE in 50 patients (pts) with obscure GI bleeding in the diagnosis of extraintestinal bleeding. Methods: CE reports & hospital charts of pts with obscure GI bleeding (2002-04) were reviewed to establish site of bleeding, etiology of bleeding, & CE indicators of bleeding & the outcome of these pts. Results: CE images of 50 pts (mean age: 67; range 39-90 years, M/F: 23/27) who underwent CE for diagnosis of obscure GI bleeding (overt n Z 20; occult with Hb ! 8 g/dl: n Z 3, Hb 8-11 g/dl: n Z 27) were reviewed. I. Bleeding Source was diagnosed in 15 of the 50 pts. In 4 pts the source of bleeding was present outside the small intestine: stomach (n Z 3) & colon (n Z 1). II. Etiology of Extra-intestinal Bleeding: a) Stomach: GAVE (n Z 1), Dielaufoy’s lesion (DL) (n Z 2) c) Colon: Cecal AVM (n Z 1). III. CE Findings Suspicious for Extra-intestinal Bleeding: Flecks of heme or blood clots in the stomach (nZ 2), fresh blood in the duodenum with normal stomach (n Z 1), blood in the cecum without any blood in the small intestine provided clues for extra-intestinal source of bleeding. IV. Specific Diagnosis: i. GAVE: At EGD, it was initially misdiagnosed as hemorrhagic gastritis. Capillary blanching & refilling along with active bleeding from the pylorus as the CE exited the stomach confirmed the diagnosis of GAVE. ii. Gastric DL: Of the two pts, in one CE identified the lesion. In the other, presence of old blood in the duodenum lead to suspicion of a gastric source of bleeding on repeat endoscopy actively bleeding DL was identified. iii. Cecal AVMs: Bleeding from the cecum was identified on a 3rd CE; cecal AVMs were identified at colonoscopy (narcotics were avoided for sedation) after injection of nalaxone. V. Outcome: Endoscopic therapy Abstracts

Purpose: Enteroclysis is considered the gold standard for evaluation of small bowel diseases. Small bowel series is preferred because of its simplicity and lack of patient (pt) discomfort. Recently, capsule endoscopy (CE) was shown to be superior to small bowel radiography for evaluation of small bowel diseases. (Gastroenterol 2002; 123; 999–1005) This study was undertaken to prospectively study the diagnostic yield of enteroclysis compared with CE in pts with obscure gastrointestinal bleeding.

Hemoclipping of a visible vessel feeding the bleeder in a thin walled duodenal diverticulum has been shown to prevent recurrence of bleeding (Gastrointest Endosc 2003;57:116–117). Submcuosal vessels not easily seen in other areas of the gastrointestinal tract can be easily identified on high frequency ultrasound probe sonography (HFUPS) and hemostatic therapy could be directed to the feeding vessel. We report a case to demonstrate the utility of HFUPS guided hemoclipping of a submucosal feeding vessel in the prevention of rebleeding from a colonic Dieulafoy's lesion.

Choledocholithiasis with a dilated CBD masquerading as a cystic pancreatic mass: importance of real-time eus imaging in the evaluation of pancreatico-biliary lesions

Implementation of colorectal cancer screening guidelines by residents in training is poor-need for an educational intervention

Stridor—a complication of PEG placement in the postoperative (& post-radiation) period of patients with head and neck cancer

“Water filled view of balloon dilation”—a new technique, to enhance the visualization of esophageal stricture dilation

“Endoscopic balloon extraction of PEG”—a new technique for endoscopic retrieval of retained internal PEG bumper

Introduction/Aim: Management options for PCES following HN 2M & 3F) underwent endoscopic dilation of PCES following H&N cancer treatment. The following protocol to access PCES for endoscopic dilation was used in a stepwise approach (Step 1,2,3). Endoscopic dilation techniques: 1) Antegrade dilation-Conventional technique: In 3 patients, wire guided endoscopic dilation with Savary dilators was performed under conscious sedation. Dilation to 15 mm was achieved in 4 wks. 2) Antegrade dilation- Laryngeal Jack assisted technique: In a 57 yr. female, the stricture opening could not be identified at endoscopy. A novel approach, the Laryngeal Jack technique (elevation of the larynx from the posterior pharyngeal wall and maintaining the position with a Dedo laryngoscope suspended in a stabilizer) was used to identify the opening of the PCES under general anesthesia with the assisance of ENT team.Wire guided endoscopic dilation of the PCES was done to 12 mm. In 2 mo, the stricture was dilated to 16 mm. 3) Combined approach- Laryngeal Jack technique and Retrograde Esophageal Membranotomy: In a 41 yr. female with complete dysphagia (even to saliva), PCES opening could not be identified despite the Laryngeal Jack technique under general anesthesia. After the removal of PEG tube(24 Fr), a 6-mm endoscope(EG1840, Pentax)was passed into the stomach and up into the esophagus. A complete esophageal membranous obstruction was noted. After transillumination from above through the laryngoscope, the thinnest portion of the membrane was punctured with a 5-4-3 catheter, followed by wire guided balloon dilation to 8 mm. In 3 mo, the stricture was dilated to 12-mm. Outcome: All patients gained weight & their PEG tubes were removed. Complications:nil. Conclusions: PCES can be successfully managed by endoscopic dilation without significant morbidity or mortality. Special techniques like the Laryngeal Jack assistance or the combined approach can be useful in difficult cases. Reconstructive surgery can be avoided.

Introduction: There is little data on the time spent by the patient for endoscopy. Information on the time spent for various components may help identify areas for future improvement to contain the cost of endoscopy. Aim: To prospectively study the time spent by the patient in the endoscopy unit (before, during, and after the procedure) for conscious sedation endoscopy in an academic center. Methods & Results: Data was collected on a proforma prospectively by the endoscopy unit nurses on all the pts undergoing GI endoscopy for four weeks in August & September 1999. 165 endoscopies were done on 160 pts. Data collection was complete (100%) in 121 (73%) procedures and data of this 121 pts forms the basis for this report. Demography of the endoscopy unit: a) Endoscopy Unit: Procedure rooms for endocopy: 2 (3rd room for bronchoscopy, liver biopsy, paracentesis, and bone biopsy); Preparation & recovery beds for all the procedures: 5; b) Staff: One endoscopist supervised 2 fellows in training for the day; a nurse & a technician assisted the procedure in each room; 2 nurses staffed the preparation & recovery area; 2 secretaries ran the endoscopy office. c) Endoscopy equipment: EGD: 5 (3 adult, 1 Pediatric, 1 Therapeutic); colonoscopes: 4; ERCP scopes: 2; scope cleaning units: 2. Time study: See table Conclusions: Our findings suggest that efforts should be directed towards reducing preparation & recovery time & waiting prior to the procedure. Alternatives include unsedated endoscopy & reversal of sedation.

Introduction: ASGE recommends one year of intensive therapeutic ERCP training for receiving previleges in an academic center. Aims: To examine the outcome of one year of advanced ERCP training on the technical success & complication rate of therapeutic ERCP by one endoscopist during the first year after graduation from advanced endoscopy fellowship training program. Methods & Results: ERCP Training: During 7/98-6/99, the trainee (GSR) participated in 697 ERCPs & shared the ERCP caseload with 4 GI fellows at the BIDMC. The trainee did 50% of the ERCP cases and also assisted in the training of the 3rd year GI fellows. The trainee was encouraged to do multiple stages of each procedure. If cannulation was unsuccessful, the mentor cannulated & gave the endoscope back to the trainee to complete the remaining procedure. Endoscopic sphincterotomy was taught early on & during the latter half of training, the trainee learned precut techniques. During the last quarter, the trainee completed 19 of 21 consecutive therapeutic ERCP cases successfully, without assistance from the mentor. First year after ERCP training: After joining KUMC as a therapeutic endoscopist(GSR) in 7/98, the outcome of consecutive ERCP cases done in first year by GSR was analyzed (n= 100). Classification of the ERCP cases according to the difficulty of the ERCP procedures ( Gastrointest endosc 1999;49:AB148 ): Group 1-Simple diagnostic ERCP: 22/24 (92%); Group 2-Simple therapeutic ERCP: 15/16 (94%) (biliary sphincterotomy, cbd stone ( 3) / large (>1cm) CBD stone removal, CBD stricture dilation, CBD stenting); Group 5-Ultracomplex therapeutic ERCP:13/17 (76%)(needle knife sphincteotomy, CBD stone lithotripsy+ stone removal, intrahepatic stone removal or stricture dilation, & all pancreatic therapy). Complications: pancreatitis: 8; bleeding: 0; perforation: 0; neck infection: 1; cardiac arrest: 1 (revived). Mortality: one patient died 48 hours after the procedure due to a CVA & aspiration. Conclusions: Dedicated therapeutic ERCP training for one year provides the necessary endoscopic skills to perform ERCP successfully with low complication rate. The outcome is comparable to the results published in the literature (Gastrointest endosc 1999;49:AB148). The ASGE guidelines on therapeutic ERCP training appear to be appropriate.

BackgroundThe aim of this study was to determine whether enteral self-expanding metal stent (SEMS) placement or gastrojejunostomy (GJY) for palliation of malignant gastric outlet obstruction (GOO) symptoms results in better survival and quality-of-life outcomes.MethodsThis retrospective cohort study included 334 patients who underwent enteral SEMS (n = 241; 56.8% men) or GJY (n = 93; 61.3% men) for palliation of GOO due to unresectable cancer at our tertiary cancer center between 2001 and 2011. Patient demographic and post-procedure outcome data were collected.ResultsThe mean times to tolerate a liquid diet and a soft diet were significantly shorter in the SEMS group (2.2 ± 3.9 days and 4.8 ± 6.2 days, respectively) than in the GJY group (8.9 ± 5.6 days and 13.6 ± 20.3 days, respectively; P = 0.0001). The mean duration of hospital stay was significantly longer for patients who underwent GJY (17.5 ± 9.5 days) than for patients who underwent SEMS placement (12.3 ± 7.9 days; P

Endoscopic sclerotherapy is now a well-established form of treatment for bleeding esophageal varices. However, it is not known what effect obliteration of varices has on the development of natural portosystemic shunts. We have studied 15 patients bleeding from esophageal varices due to extrahepatic portal venous obstruction with splenoportovenography, before and after endoscopic obliteration of varices. A splenorenal (natural) shunt was defined when the contrast, injected into the spleen, immediately revealed the inferior vena cava. Such shunts were seen in 6 (40%) of 15 patients after the obliteration of esophageal varices and with a mean interval between the two sessions of splenoportovenography of 23.5 mo. In contrast, none of the 13 patients with bleeding due to extrahepatic portal venous obstruction developed splenorenal shunts (p less than 0.05) in the absence of treatment over a mean period of 40.8 mo. After obliteration, reappearance of esophageal varices requiring sclerotherapy was observed only in patients who did not develop shunts (p less than 0.05). In conclusion, natural splenorenal shunts were seen frequently in a group of patients with extrahepatic portal venous obstruction observed for 23.5 mo who also underwent sclerotherapy. It appears that splenorenal shunts result from sclerotherapy, and protect patients from rebleeding and recurrence of varices.