Search

A relevant number of adenomas can be missed during colonoscopy.Assess the current status of colonoscopy procedures in Italian centers.A prospective observational study involving 17 hospitals (34 endoscopists) included consecutive patients undergoing standard colonoscopy. In the first phase, endoscopists performed consecutive colonoscopies. In the second phase, retraining via an online learning platform was planned, while in the third phase data were collected analogously to phase 1.A total of 3,504 patients were enrolled. Overall, a BBPS score ≥6 was obtained in 95.6% of cases (94.8% and 96.9% in the pre- and post-training phases, respectively). 88.4% of colonoscopies had a withdrawal time ≥6 min (88.2% and 88.7% in the pre- and post-training phases). Median adenoma detection rate (ADR) was 39.1%, with no significant differences between the pre- and post-training phases (40.1% vs 36.9%; P = 0.83). In total, 81% of endoscopists had a ADR performance above the 25% threshold.High colonoscopy quality standards are achieved by the Italian hospitals involved. Quality improvement initiatives and repeated module-based colonoscopy-training have been promoted in Italy during the last decade, which appear to have had a significant impact on quality colonoscopy metrics together with the activation of colorectal cancer screening programs.

The paper presents two cases of depressed skull fracture or “ping pong” fracture. This type of fracture is typical of neonatal age or toddlers, ages in which cranial bones are still malleable and not very resistant. Obstetrical causes are more frequent in neonates and traumatic causes in toddlers, abuse should be ruled out in older children. These two cases offer the opportunity to discuss about the possible complications of this type of fracture and about the diagnostic and therapeutic management.

The paper describes the case of a 13-year-old boy presenting with fever with chills, abdominal pain and diarrhoea. Further investigation showed an “enteric fever”. Finally, clinical onset, diagnosis and disease management are discussed.

Dehydration is a significant cause of morbidity and mortality in children worldwide. Infants and young children are vulnerable to dehydration, and clinical assessment plays a pivotal role in their care. In addition, laboratory investigations can, in some children, be helpful when assessing the severity of dehydration and for guiding rehydration treatment. In this interpretation, we review the current literature and provide an evidence-based approach to recognising and managing dehydration in children.

N/A

Mepolizumab, a monoclonal antibody blocking IL-5, is efficacious in the treatment of severe lung diseases sharing eosinophilic inflammation pattern. The paper describes two cases in which the drug was used with excellent results. The first involved a 14-year-old boy with obliterative bronchiolitis, the other an 11-year-old girl with non-atopic asthma. Both cases shared the eosinophilic phenotype of the disease, defined by an eosinophilic count in the peripheral blood equal to or greater than 2% (i.e. a baseline value of 150-200 cells/µl or 300 cells/µl during the previous year). Its use demonstrates clinical improvement in severe refractory asthma with eosinophilic phenotype and as off-label drug in obliterative bronchiolitis, leading to a decrease in the rate of exacerbations and enabling the reduction of corticosteroids as well as the resolution of structural anomalies, respectively.

Summary Introduction Bladder ultrasound is becoming pivotal in the management and treatment of lower urinary tract dysfunction. There is a paucity of data regarding intra-observer and interobserver reliability of bladder ultrasound, especially in children. A previous study assessed interobserver agreement for both the postvoid residual volume and measurement of the bladder dimensions in adults showing excellent agreement. Objective To examine the interobserver and intra-observer reliability of bladder wall thickness, bladder urinary and postvoid residual urinary volume using ultrasound evaluated by paediatricians having different training levels. Study design Four sonographers, 3 pediatric trainees and one experienced pediatric urologist measured the full bladder volume, the voiding residual volume, and the bladder wall thickness. Each sonographer made 3 measurements of each parameter. We assessed the interobserver and intra-observer variability by using intraclass correlations (ICCs). ICCs were calculated and tested with a significance level of 5%. The interrater ICC was calculated from the mean of the three measurements of each variable (full bladder volume, postvoid residual, bladder wall thickness). ICC ≥0.75 was considered excellent. Bland-Altman plots were also used to assess the interobserver agreement. Results Sixty children were recruited (7.3 ± 1.1 years). The interobserver ICCs for bladder volume and voiding residual volume were 0.91 (confidence interval 0.85–0.95) for both. The interobserver ICCs for the bladder wall thickness was satisfactory 0.43, with a minimum detectable difference of 2 mm. The observed values for intra-observer analysis showed an excellent (ICC ≥ 0.90) agreement between the three measurements performed by each one of the sonographers. Bland-Altman plots showed that the bias (mean difference) was −0.35 and the limits of agreement were −3.43 and 2.73 for the bladder wall thickness measurements (Figure). Discussion The interobserver reliability for both the postvoid residual volume and full bladder volume were excellent even in operators with different levels of training, pointing out the role of bladder ultrasound in the routine clinical practice. Weaker agreement was found for the bladder wall thickness measurement. The intra-observer agreement was excellent for all the measurements. Conclusion These results showed a good reliability of urinary bladder ultrasound in children aged 7.3 ± 1.1 years as far as bladder volume measurement is concerned. Given the variability of bladder wall thickness, a standardized methodology is desirable to increase its reliability.

The purpose of this study is to evaluate an endoscopic trimodal imaging (ETMI) system (high resolution, autofluorescence, and NBI) in the detection and differentiation of colorectal adenomas.A prospective randomised trial of tandem colonoscopies was carried out using the Olympus XCF-FH260AZI system. Each colonic segment was examined twice for lesions, once with HRE and once with AFI, in random order per patient. All detected lesions were assessed with NBI for pit pattern and with AFI for colour. All lesions were removed and sent for histology. Any lesion identified on the second examination was considered as missed by the first examination. Outcome measures are adenoma miss rates of AFI and HRE, and diagnostic accuracy of NBI and AFI for differentiating neoplastic from non-neoplastic lesions.Ninety-four patients underwent colonoscopy with ETMI (47 in each group). Among 47 patients examined with AFI first, 31 adenomas in 15 patients were detected initially [detection rate 0.66 (0.52-0.75)]. Subsequent HRE inspection identified six additional adenomas. Among 47 patients examined with HRE first, 29 adenomas in 14 patients were detected initially [detection rate 0.62 (0.53-0.79)]. Successive AFI yielded seven additional adenomas. Adenoma miss rates of AFI and HRE were 14% and 16.2%, respectively (p = 0.29). Accuracy of AFI alone for differentiation was lower than NBI (63% vs. 80%, p 0.001). Combined use of AFI and NBI achieved improved accuracy for differentiation (84%), showing a trend for superiority compared with NBI alone (p = 0.064).AFI did not significantly reduce the adenoma miss rate compared with HRE. AFI alone had a disappointing accuracy for adenoma differentiation, which could be improved by combination of AFI and NBI.

The aim of this study is to assess the capability of endocytoscopy (ECS) in differentiating neoplastic from nonneoplastic lesions in the colorectum and to validate an ECS classification.Patients with colorectal polypoid and nonpolypoid lesionsor =10 mm were prospectively included. ECS classification subgrouped nonneoplastic (EC 0) and neoplastic (EC 1-3) lesions. Lesions were observed at super-magnified view (450x) before endoscopic resection. Blinded pathological assessment was obtained.Fifty-two lesions were examined in 49 patients (17 polypoid and 35 nonpolypoid). Final pathological diagnosis was normal mucosa or hyperplastic polyp in ten cases, low-grade adenoma in 29, high-grade adenoma in 11, and submucosal invasive cancer in two cases. Positive predictive values of each EC group were 100%, 93.1%, 90.1%, and 100%, respectively. ECS diagnosis correlated completely with pathology in the differentiation between neoplastic and nonneoplastic lesions.ECS enabled observation of colorectal lesion at a subcellular level in vivo. The classification of ECS images had a good correlation with the final pathological diagnosis. ECS was useful to differentiate between neoplastic and nonneoplastic lesions.

Background Endoscopic resection of colorectal nonpolypoid lesions requires adequate submucosal lifting of the lesion. Objective To evaluate a self-assembled hydro-jet system for tissue elevation to improve endoscopic resection of colorectal nonpolypoid lesions. Design Prospective study. Setting Single-center teaching hospital. Main Outcome Measurements Efficacy and safety of the hydro-jet system and rate of complete resection. Results The system was clinically applied in 31 patients to remove a total of 34 lesions throughout the colon. An adequate submucosal fluid cushion was achieved in all but 1 case without any lifting-associated complications. Complete endoscopic resection was possible in all 33 lifted lesions by using a snare. The size of the resected lesions ranged from 7 to 60 mm. Major intraprocedure bleeding occurred in only 1 case. No perforation or late bleeding was recorded. Histological examination showed a selective accumulation of fluid in the submucosa with edema and dissociation of submucosal structures, with no damage to the muscularis mucosa and very limited "burn effect" hampering assessment of radial margins. Limitations Lack of controls. Conclusions This inexpensive system allows safe and rapid submucosal lifting of colorectal nonpolypoid lesions to assist endoscopic resection.

Background : Bleeding gastric varices (BGV) is a challenging condition whose management remains controversial and often empirical. Methods : Over the past 6 months, emergency ligation of BGV was performed in seven cirrhotic patients (five men, two women; age range 47 to 70 years) using a detachable snare. Child's grade was B in two and C in five patients. Two patients had a concurrent hepatocellular carcinoma. Three patients had been previously treated with either balloon tamponade or injection sclerotherapy for bleeding esophageal varices. Results : Hemostasis was achieved in all patients. Morbidity consisted of fever in one case. Six snares passed spontaneously, one was removed from the stomach on follow-up examination. Post-ligation ulcers were detected in all patients after treatment (mean diameter 7.4 ± 2.1 mm) with no stigmata of recurrent hemorrhage. No early rebleeding was observed during hospital stay. On a mean follow-up of 3.8 months (range 2 to 6 months), no digestive hemorrhage was recorded. Ligated gastric varices were significantly reduced in size in four patients. Conclusions : Emergency ligation with detachable snare is feasible and may be an alternative life-saving method of endoscopic hemostasis in BGV.

Background Not all exposed vessels carry the same risk of recurrent bleeding, and sometimes endoscopic therapy may not be warranted in the setting of profound acid inhibition therapy. Objective To investigate the role of magnification endoscopy (ME) in improving the characterization of exposed vessels in ulcer hemorrhage. Design Prospective study. Setting Single-center teaching hospital. Main Outcome Measurements Diagnostic accuracy and safety of ME in patients with bleeding peptic ulcers. Results A total of 43 patients were studied. Exposed vessels were initially categorized as high risk (protuberant, translucent, or pale) in 25 and low risk (nonprotruding through the ulcer floor, pigmented, or dark red) in 18 cases. ME was subsequently performed, and the operator was asked to reclassify the vessel into 1 of these 2 categories. A magnified view provided a clear image of the vessel and allowed visualization of the artery, the site of rupture, and the presence of a clot plugging the hole. In 6 cases previously categorized as low risk, ME clearly showed the 2 ends of the vessel, the longitudinal tear in the vessel wall, and a protuberant aspect that was not seen with standard view. The lesion was then reclassified as high risk (diagnostic gain 33%). The mean procedure time for ME inspection was 7 ± 4 minutes. No complications occurred. Limitations Absence of controls. Conclusions In patients with peptic ulcer bleeding and exposed vessels, ME allows clear visualization of the vessel wall and provides detailed clues to further characterize the lesion.

Background and study aim A catheter-type endocytoscope has recently been developed that is able to provide in vivo cellular images of gastrointestinal mucosa. Aberrant crypt foci (ACF) represent the earliest precursor of colorectal cancer featuring the dysplasia-carcinoma sequence. The aim of the current study was to assess the potential of the endocytoscopy system (ECS) in the "in vivo" detection of dysplasia in colorectal ACF. Patients and methods Consecutive patients with colorectal ACF were studied with endocytoscopy. Blinded endoscopic and histological assessments were obtained. Lesions were excised en bloc for histology. Results A total of 48 colorectal lesions were examined in 41 patients. The mean duration of the ECS procedure was 44 +/- 12 minutes (range 31 - 62 minutes). The quality of ECS images was rated as good in 39/48, medium in six, and poor in three (6.2 %). It was possible to observe lesions at the cellular level and evaluate both cellular and structural atypia in vivo. In normal mucosa, crypts had preserved individuality and round-shaped contours. Nuclei were located at the basal third of the crypt in a single line, and the lumen was circular. In dysplastic ACF, crypt contours were polygonal, cell nuclei were elongated with pseudostratification toward the luminal half of the crypt and irregularly arranged, and the lumen was linear. In all, 23 endocytoscopic images were labeled as dysplastic and 25 as nondysplastic. Histology confirmed low-grade dysplasia in 21/23 cases (91.4 % sensitivity). Absence of dysplasia was confirmed in the remaining 25 cases (100 % specificity). Interobserver agreement between trained endoscopist and pathologist was good (wK 0.68; 95 % CI 0.59 - 0.78). Conclusions Endocytoscopy provides real-time histological images in vivo, with clear visualization of cellular details and features of dysplasia in colorectal ACF.

Gastric outlet obstruction secondary to the impaction of large biliary stones into the duodenum (Bouveret's syndrome) is a well-known complication of biliary lithiasis, most often requiring surgical intervention. We report a case of successful endoscopic removal of a large stone impacted in the duodenal bulb by means of mechanical lithotripsy.

We report an unusual case of primary amyloidosis of the stomach in a patient complaining of dyspeptic symptoms. The diagnosis was confirmed histologically and other gastrointestinal site or systemic involvement was ruled out. Uncharacteristic dyspeptic symptoms may hide this rare metabolic disease.

Endoscopic therapy for GI bleeding is highly effective. Nevertheless, bleeding recurs in 10% to 25% of cases, irrespective of the method of treatment used. Whether a second-look endoscopy with retreatment after initial hemostasis is of clinical value is controversial. A meta-analysis was performed to assess whether systematic second-look endoscopy with retreatment reduces the risks of recurrent bleeding, salvage surgery, and death in patients with peptic ulcer bleeding.A systematic review was performed of randomized controlled studies of the value of second-look endoscopy in patients with peptic ulcer bleeding published between 1990 and 2000. Four studies were selected according to predefined criteria. Two investigators extracted the data independently. Pooled risk estimates and number need to treat were calculated for each procedure. Heterogeneity of effects was tested.The absolute risk reduction in clinical recurrent bleeding was 6.2% (p0.01). Absolute risk reduction for surgery and mortality were, respectively, 1.7% and 1.0% (not significant). The second look with retreatment significantly reduced the risk of recurrent bleeding compared with control patients (OR 0.64; 95% CI [0.44, 0.95]; p0.01), with a number needed to treat of 16. There was no heterogeneity among studies. The risk of surgery as well as the risk of death were not significantly influenced by the second-look endoscopy with retreatment (number needed to treat, respectively, 58 and 97).Systematic second-look endoscopy with retreatment significantly reduces the risk of recurrent bleeding in patients with peptic ulcer bleeding compared with control patients, but it does not substantially reduce the risk of salvage surgery or mortality.

Background: Large pedunculated colorectal polyps are often difficult to remove endoscopically. Methods: Four patients with giant pedunculated polyps (>3 cm) underwent an endoscopic procedure in which the polyp stalk was ligated with multiple clips and resected with a needle-knife papillotome. Results: No complications occurred either during or immediately after the procedure. Mean size of the resected polyps was 4.8 ± 1.2 cm (range 3 to 6 cm). Mean time for the entire procedure was 31 ± 5 minutes (range 25 to 45). No bleeding was found after a mean follow-up period of 4.3 ± 1.1 months (range 3 to 6 months). Conclusions: Although technical refinements are necessary to make the procedure easier and faster, this approach might represent the only option for selected patients who would otherwise need surgical resection of large pedunculated colonic polyps.

Background: Argon plasma coagulator was prospectively compared with heater probe in patients with bleeding peptic ulcers. Methods: Forty-one patients with major stigmata of ulcer hemorrhage were randomly assigned to receive either heater probe (n = 20) or argon plasm coagulation (n = 21) treatment; 40% had active bleeding and 60% had a nonbleeding visible vessel in the ulcer crater. The two groups were similar with respect to all background variables. Episodes of recurrent bleeding were retreated with the same modality as used previously. Patients in whom treatment or retreatment failed underwent emergency surgery. Results: Initial hemostasis (95% vs. 95.2%), recurrent bleeding (21% vs. 15%), 30-day mortality (5% vs. 4.7%), and emergency surgery (15% vs. 9.5%) were comparable in the heater probe and argon plasma coagulation groups, respectively. Argon plasma coagulation provided faster hemostasis (mean 60 ± 19 vs. 115 ± 28 seconds, p Conclusions: Argon plasma coagulation is safe and effective. Larger studies in patients with bleeding peptic ulcers are needed to confirm these promising results. Endoscopic hemostasis has been a major advancement in the management of bleeding peptic ulcers. The most commonly used methods are injection therapy and contact thermal coagulation with multipolar and heater probes (HP) that allow heat and pressure to be applied simultaneously. These methods have been shown to be clinically useful, 1-4 whereas noncontact laser coagulation has never gained widespread popularity, mainly because of its high cost and risk for serious complications. The argon plasma coagulator (APC) is a new device that offers controlled noncontact electrocoagulation by means of high-frequency energy delivered to tissue through an ionized gas (argon plasma). APC has proved to be safe and effective for coagulation of tissue surfaces to achieve hemostasis and for debulking of tumors. 5-7 The present study compares the effectiveness of APC with that of a well-established contact procedure of endoscopic hemostasis (i.e., HP) in patients with bleeding peptic ulcers.