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A pilot study of push enteroscopy and colonoscopy in evaluation of obscure GI bleeding
AJG – September, Suppl., 2003
fashion. Histopathologic evaluation showed adenomatous tissue. The patient did well post-operatively. The duodenal adenoma-carcinoma sequence is well documented in patients with FAP.1 Endoscopic removal of duodenal polyps has previously, though rarely, been reported.2,3,4, This case represents the first reported case of endoscopic resection using a banding device in concert with snare polypectomy for removal of a large duodenal polyp. 897 A PILOT STUDY OF PUSH ENTEROSCOPY AND COLONOSCOPY IN EVALUATION OF OBSCURE GI BLEEDING Michael E. Jones, M.D., Nathan H. Massey, M.D., Nicholas J. Nickl, M.D.* University of Kentucky Medical Center, Lexington, KY. Purpose: Obscure gastrointestinal bleeding (OGIB), persistent or recurrent bleeding of unknown origin after negative EGD and colonoscopy, is a common problem. Push enteroscopy has been recommended as the initial step in this setting, but in up to 75% of examinations a source within EGD reach is found. Colonoscopy is an alternative initial step, but with lower reported yield. The purpose of this study is to identify the appropriate initial step (EGD, push enteroscopy, colonoscopy) by determining (1) the diagnostic yield of push enteroscopy, separately listing findings within, and distal to EGD reach (2) to determine the yield of colonoscopy and (3) to correlate the yield of these procedures with the training of the initial referring (GI trained vs. non- GI trained) endoscopists. Methods: Consecutive patients with OGIB referred to the University of Kentucky Medical Center were prospectively enrolled. Inclusion criteria: ⬎ 18 year-old with OGIB, negative EGD and colonoscopy within the last 12 months. Data collected included previous exam findings and prior endoscopist specialty. All underwent push enteroscopy separately listing lesions within reach of EGD, and colonoscopy. Endoscopic findings were reported as in the course of routine medical care. Results: Of the 11 patients enrolled, 1 patient withdrew (refused colon prep). 3/10 push enteroscopies identified lesions all within reach of EGD, and of those, 1 exam also found lesions distal to reach of EGD. Colonoscopy revealed causative lesions in 3/10 exams. In 4/10 subjects classified as negative, 2 had incidental lesions on colonoscopy. Of patients with lesions missed on prior EGD or colonoscopy 1/6 were referred by a gastroenterologist. Of lesions found within reach of EGD, the prior endoscopists were GI trained in 33% of cases and were non-GI in 67%. The prior endoscopists were non-GI trained in all cases of positive exams on repeat colonoscopy. Conclusions: This pilot study indicates that in patients referred for OGIB lesions are often missed on preceeding EGD or colonoscopy. The training and experience of the prior endoscopists may factor into this observation. These aspects should be taken into account when deciding among repeat EGD, push enteroscopy or colonoscopy as initial steps in evaluation of OGIB. Further studies are needed and should include evaluation of capsule endoscopy in this algorithm. 898 A PROSPECTIVE STUDY OF THE UTILITY OF ABDOMINAL X-RAY POST CAPSULE ENDOSCOPY (CE) FOR THE DIAGNOSIS OF NON-NATURAL EXCRETION (NNE) Virender K. Sharma, M.D., Mankanwal S. Sachdev, M.D., Jonathan A. Leighton, M.D., Russell I. Heigh, M.D., Janice A. Post, R.N., Paula J. Erickson, R.N., David E. Fleischer, M.D.* Mayo Clinic, Scottsdale, AZ. Purpose: NNE is a serious complication of CE that occurs in 1–2% of the patients undergoing CE. The utility of routine abdominal X-rays post CE for the diagnosis of CE is not established. The purpose of our study was to establish the utility of abdominal X-rays in the diagnosis of NNE in patients undergoing CE.
Abstracts
S299
Methods: All patients at our institution undergoing CE from December 2002 to May 2003 were scheduled to have abdominal X-rays on days 3, 7 and 14 post CE. If patient reported visualizing the passage of CE the subsequent abdominal X-ray was cancelled. Patients who had CE found on day 14 abdominal X-ray were diagnosed as having NNE. Data on capsule passage, abdominal X-ray results and outcome of NNE were collected prospectively. Results: One hundred and fifteen patients (46% men; mean age 65 years; range 20 – 88) underwent CE. Eighty six % CE were for obscure GI bleeding, 5% were for suspected Crohns disease and 9% for other indications. Thirty-four (29.6%) patients reported visualizing spontaneous passage of CE by day 3 and additional 2 by day 7. Of the 81 reporting non-passage by day 3, 66 (82%) underwent abdominal X-rays. Abdominal X-ray in 14/66 (21%), 3/12 (25%) and 2/3 (66%) patients showed retained capsule on day 3, 7 and 14, respectively. Two (1.7%) patients were diagnosed with NNE and underwent surgery. Histopathology revealed diaphragm disease of the small intestine as the cause of NNE. In both these patients colon was not visualized on CE. Conclusions: 1. NNE is a rare but serious complication of CE. 2. Most patients do not visualize capsule passage. 3. For patients who do not visualize capsule passage and in whom colon is not visualized during CE, abdominal X-ray on day 7 will help identify those at risk for NNE.
899 PNEUMOBILIA FUGAX Fadi Braiteh, M.D., Mehrnaz Hojjati, M.D., William Ramsey, M.D., FACG* Saint Raphael Hospital, NewHaven, CT. Purpose: A 74 year-old man presented for evaluation of a non-complicated asymptomatic inguinal hernia prior to surgery. A routine chest film revealed a left mediastinal mass. The patient is known to be a heavy smoker (60 pack years) with occasional alcohol consumption. His medications included atenolol, amoxicillin, aspirin and vitamins. Past medical history is consistent with bilateral hip replacement, benign palpitations and lower GI bleed with negative colonoscopy three years earlier. The patient denied having chills, fever, jaundice, dark urine, light stool or passing any stones per rectum. Physical examination was negative. The rectal exam showed dark brown feces, guaic-positive. Upper endoscopy demonstrated diffuse erosions in the duodenal bulb and sweep that were superficial, without active bleeding. Later that day, a chest CT scan-guided nodule biopsy was performed. Incidentally noted on the lung windows, at the level of the liver sections, were multiple air bubbles within the intrahepatic and the extrahepatic bile ducts. A repeated abdominal CT scan three days later showed disappearance of this pneumobilia and old calcified granulomatous lesions in the liver spleen and pancreas. It did not reveal bowel obstruction, congenital anomalies, gallstones or other biliary abnormality. The patient remained asymptomatic and stable. The pathology showed small cell carcinoma of the lung, which was treated with chemotherapy and irradiation. Pneumobilia almost always results from some type of communication between the bile duct and the intestine. The most common cause is surgical creation of a biliary-enteric fistula. In most of the cases surgical intervention will be required to correct the underlying pathological condition. Review of the radiologic and gastrorenterologic literature includes many pathological causes for pneumobilia, all requiring urgent medical attention. The only non-surgical etiology, and the most benign, is post endotrachealintubation pneumobilia. In regards to our case, we would like the internist to be familiar with this entity, which was not described previously in the medical literature: Transient pneumobilia following upper gastrointestinalendoscopy, occurs due to temporary incompetence of the Sphincter of Oddi. This radiological finding should not interfere with medical decisionmaking unless more serious data would suggest so, e.g. persistent pneumobilia, pneumobilia with right upper quadrant pain or cholangitis. It was recognized that a prior endoscopy as a cause of transient benign pneumobilia.
fashion. Histopathologic evaluation showed adenomatous tissue. The patient did well post-operatively. The duodenal adenoma-carcinoma sequence is well documented in patients with FAP.1 Endoscopic removal of duodenal polyps has previously, though rarely, been reported.2,3,4, This case represents the first reported case of endoscopic resection using a banding device in concert with snare polypectomy for removal of a large duodenal polyp. 897 A PILOT STUDY OF PUSH ENTEROSCOPY AND COLONOSCOPY IN EVALUATION OF OBSCURE GI BLEEDING Michael E. Jones, M.D., Nathan H. Massey, M.D., Nicholas J. Nickl, M.D.* University of Kentucky Medical Center, Lexington, KY. Purpose: Obscure gastrointestinal bleeding (OGIB), persistent or recurrent bleeding of unknown origin after negative EGD and colonoscopy, is a common problem. Push enteroscopy has been recommended as the initial step in this setting, but in up to 75% of examinations a source within EGD reach is found. Colonoscopy is an alternative initial step, but with lower reported yield. The purpose of this study is to identify the appropriate initial step (EGD, push enteroscopy, colonoscopy) by determining (1) the diagnostic yield of push enteroscopy, separately listing findings within, and distal to EGD reach (2) to determine the yield of colonoscopy and (3) to correlate the yield of these procedures with the training of the initial referring (GI trained vs. non- GI trained) endoscopists. Methods: Consecutive patients with OGIB referred to the University of Kentucky Medical Center were prospectively enrolled. Inclusion criteria: ⬎ 18 year-old with OGIB, negative EGD and colonoscopy within the last 12 months. Data collected included previous exam findings and prior endoscopist specialty. All underwent push enteroscopy separately listing lesions within reach of EGD, and colonoscopy. Endoscopic findings were reported as in the course of routine medical care. Results: Of the 11 patients enrolled, 1 patient withdrew (refused colon prep). 3/10 push enteroscopies identified lesions all within reach of EGD, and of those, 1 exam also found lesions distal to reach of EGD. Colonoscopy revealed causative lesions in 3/10 exams. In 4/10 subjects classified as negative, 2 had incidental lesions on colonoscopy. Of patients with lesions missed on prior EGD or colonoscopy 1/6 were referred by a gastroenterologist. Of lesions found within reach of EGD, the prior endoscopists were GI trained in 33% of cases and were non-GI in 67%. The prior endoscopists were non-GI trained in all cases of positive exams on repeat colonoscopy. Conclusions: This pilot study indicates that in patients referred for OGIB lesions are often missed on preceeding EGD or colonoscopy. The training and experience of the prior endoscopists may factor into this observation. These aspects should be taken into account when deciding among repeat EGD, push enteroscopy or colonoscopy as initial steps in evaluation of OGIB. Further studies are needed and should include evaluation of capsule endoscopy in this algorithm. 898 A PROSPECTIVE STUDY OF THE UTILITY OF ABDOMINAL X-RAY POST CAPSULE ENDOSCOPY (CE) FOR THE DIAGNOSIS OF NON-NATURAL EXCRETION (NNE) Virender K. Sharma, M.D., Mankanwal S. Sachdev, M.D., Jonathan A. Leighton, M.D., Russell I. Heigh, M.D., Janice A. Post, R.N., Paula J. Erickson, R.N., David E. Fleischer, M.D.* Mayo Clinic, Scottsdale, AZ. Purpose: NNE is a serious complication of CE that occurs in 1–2% of the patients undergoing CE. The utility of routine abdominal X-rays post CE for the diagnosis of CE is not established. The purpose of our study was to establish the utility of abdominal X-rays in the diagnosis of NNE in patients undergoing CE.
Abstracts
S299
Methods: All patients at our institution undergoing CE from December 2002 to May 2003 were scheduled to have abdominal X-rays on days 3, 7 and 14 post CE. If patient reported visualizing the passage of CE the subsequent abdominal X-ray was cancelled. Patients who had CE found on day 14 abdominal X-ray were diagnosed as having NNE. Data on capsule passage, abdominal X-ray results and outcome of NNE were collected prospectively. Results: One hundred and fifteen patients (46% men; mean age 65 years; range 20 – 88) underwent CE. Eighty six % CE were for obscure GI bleeding, 5% were for suspected Crohns disease and 9% for other indications. Thirty-four (29.6%) patients reported visualizing spontaneous passage of CE by day 3 and additional 2 by day 7. Of the 81 reporting non-passage by day 3, 66 (82%) underwent abdominal X-rays. Abdominal X-ray in 14/66 (21%), 3/12 (25%) and 2/3 (66%) patients showed retained capsule on day 3, 7 and 14, respectively. Two (1.7%) patients were diagnosed with NNE and underwent surgery. Histopathology revealed diaphragm disease of the small intestine as the cause of NNE. In both these patients colon was not visualized on CE. Conclusions: 1. NNE is a rare but serious complication of CE. 2. Most patients do not visualize capsule passage. 3. For patients who do not visualize capsule passage and in whom colon is not visualized during CE, abdominal X-ray on day 7 will help identify those at risk for NNE.
899 PNEUMOBILIA FUGAX Fadi Braiteh, M.D., Mehrnaz Hojjati, M.D., William Ramsey, M.D., FACG* Saint Raphael Hospital, NewHaven, CT. Purpose: A 74 year-old man presented for evaluation of a non-complicated asymptomatic inguinal hernia prior to surgery. A routine chest film revealed a left mediastinal mass. The patient is known to be a heavy smoker (60 pack years) with occasional alcohol consumption. His medications included atenolol, amoxicillin, aspirin and vitamins. Past medical history is consistent with bilateral hip replacement, benign palpitations and lower GI bleed with negative colonoscopy three years earlier. The patient denied having chills, fever, jaundice, dark urine, light stool or passing any stones per rectum. Physical examination was negative. The rectal exam showed dark brown feces, guaic-positive. Upper endoscopy demonstrated diffuse erosions in the duodenal bulb and sweep that were superficial, without active bleeding. Later that day, a chest CT scan-guided nodule biopsy was performed. Incidentally noted on the lung windows, at the level of the liver sections, were multiple air bubbles within the intrahepatic and the extrahepatic bile ducts. A repeated abdominal CT scan three days later showed disappearance of this pneumobilia and old calcified granulomatous lesions in the liver spleen and pancreas. It did not reveal bowel obstruction, congenital anomalies, gallstones or other biliary abnormality. The patient remained asymptomatic and stable. The pathology showed small cell carcinoma of the lung, which was treated with chemotherapy and irradiation. Pneumobilia almost always results from some type of communication between the bile duct and the intestine. The most common cause is surgical creation of a biliary-enteric fistula. In most of the cases surgical intervention will be required to correct the underlying pathological condition. Review of the radiologic and gastrorenterologic literature includes many pathological causes for pneumobilia, all requiring urgent medical attention. The only non-surgical etiology, and the most benign, is post endotrachealintubation pneumobilia. In regards to our case, we would like the internist to be familiar with this entity, which was not described previously in the medical literature: Transient pneumobilia following upper gastrointestinalendoscopy, occurs due to temporary incompetence of the Sphincter of Oddi. This radiological finding should not interfere with medical decisionmaking unless more serious data would suggest so, e.g. persistent pneumobilia, pneumobilia with right upper quadrant pain or cholangitis. It was recognized that a prior endoscopy as a cause of transient benign pneumobilia.