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Classification of Gastric Mucosal Patterns in the Uninvolved Gastric Antrum By Using Magnifying NBI, in Relation to H. Pylori Infection, Histological and Serological Severity of Chronic Gastritis
Abstracts
S1456 Classification of Gastric Mucosal Patterns in the Uninvolved Gastric Antrum By Using Magnifying NBI, in Relation to H. Pylori Infection, Histological and Serological Severity of Chronic Gastritis Masaaki Okubo, Tomomitsu Tahara, Tomoyuki Shibata, Masakatsu Nakamura, Daisuke Yoshioka, Naoko Maruyama, Toshiaki Kamano, Yoshio Kamiya, Hiroshi Fujita, Yoshihito Nakagawa, Mitsuo Nagasaka, Masami Iwata, Kazuya Takahama, Makoto Watanabe, Tomiyasu Arisawa, Ichiro Hirata Background/Aim: Magnifying NBI endoscope clearly visualizes superficial mucosal patterns and its capillary patterns. Recently, we have shown that gastric mucosal patterns using magnifying NBI in the gastric corpus well correlate with histological and serological severity of H. pylori induced chronic gastritis (Tahara T. Gastrointestinal Endoscopy, in press). Here, we investigated the mucosal patterns in the uninvolved gastric antrum using magnifying NBI endoscopy and its relation to H. pylori-induced gastritis. Materials/Method: 100 subjects including 13 gastric cancer (GC) patients were enrolled. Gastric mucosal patterns in the uninvolved gastric antrum were observed using magnifying NBI. We defined regular shaped villous or scale liked structures and coiled like vessels as the normal pattern, while having irregularities either in their structures or capillary patterns were defined as irregular patterns. According to the density of vessels, we divided the irregular patterns into two groups: irregular A (irregular pattern with regular or increased density of vessels), and irregular B (irregular pattern with decreased density of vessels) patterns. In addition, we also divided the irregular patterns into three groups according to the presence of light blue crest (LBC) or ridge/villous pattern: irregular, irregularþLBC and irregularþridge/villous patterns. Results: The sensitivity and specificity of irregular patterns for predicting H. pylori positive were 80.9%, and 84.4%. In the irregular patterns, presence of LBC or ridge/villous pattern were significantly associated with histological degree of atrophy (p!0.0001) and intestinal metaplasia (p!0.0001), low H. pylori titer (41.6 vs. 75.1, pZ0.04), low serum PGI (39.8 vs. 69.4, pZ0.004), PGII (16.0 vs. 21.7, pZ0.047), and PGI/II ratios (2.43 vs. 3.42, pZ0.04). In particular, PGI/II ratio was lowest in the irregularþ ridge/ villous pattern (1.63). The sensitivity and specificity of combination of both the irregularþLBC and irregularþridge/villous patterns for predicting intestinal metaplasia were 95.2%, 98.7%. Development of mucosal patterns from irregular to irregularþLBC, and irregularþridge/villous patterns was significantly associated with GC occurrence (10.6% vs. 29.4% vs. 75.0%, RZ0.39, pZ0.0008). Concerning the density of vessels in irregular patterns, histological degree of atrophy (pZ0.004) and intestinal metaplasia (pZ0.02) were significantly higher in irregular B than those of irregular A patterns. Conclusions: Gastric mucosal patterns in the uninvolved gastric antrum by using magnifying NBI well correlate with H. pylori infection, histological and serological severity of chronic gastritis.
S1458 Prediction of the Need for Endoscopic Hemostasis in Upper Gastrointestinal Hemorrhage (UGIH): A Risk Score Derivation and Validation Study Sandy H. Pang, Kelvin K. Tsoi, Jessica Ching, James Y. Lau, Francis K.L. Chan, Joseph J. Sung Background and Aims: Esophagogastroduodenoscopy (EGD) is the first line therapy in the investigation of and treatment for UGIH. The ability to predict the need for therapeutic endoscopy (TE) may streamline hospital resource utilization, save costs and select low risk patients for outpatient management. There is little data and no risk scores available to date to predict this outcome. This study aims to derive and validate a risk score for predicting the need for TE in non-cirrhotic patients with UGIH. Methods: We prospectively collected clinical and laboratory variables on 1013 noncirrhotic patients, who presented with hematemesis, melena, coffee ground vomiting or hematochezia between January 2006 and March 2007. Univariate analyses were performed on the variables and a risk score was derived using logistic regression. This risk score was then prospectively validated in a separate cohort of non-cirrhotic patients with UGIH. We compared the accuracy of this score with the Blatchford score in the validation cohort using receiver operating characteristic (ROC) curves. Results Of the 1013 patients, 252 (24.9%) required TE for haemostasis according to international consensus guidelines, of which 81% were for peptic ulcers. The presence of shock (SBP!100 mmHg), tachycardia (HRO100 bpm), low hemoglobin (!8 g/dL) and high urea were independently associated with the need for TE (all p!0.001). Hematemesis was a stronger predictor for TE when compared to melaena. The use of H2-receptor blockers and proton pump inhibitors was protective against this need (pZ0.02). Age, co-morbidities and the use of non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin played no role. The area under a ROC curve for the new risk score in the validation cohort of 337 non-cirrhotic patients was 0.71 (95% CI 0.660.77). A threshold of 3 or above predicted the need for TE with 100% sensitivity and 17% specificity, and identified 12.5% of patients as low risk. The area under a ROC curve for the Blatchford score applied to the same cohort was 0.66 (95% CI 0.60-0.73); this identified 2.7% of patients as low risk. There was a significant difference between the 2 areas (pZ0.04). Conclusion Hemodynamics, urea and hemoglobin continue to be important predictors of the need for TE; acid suppressive agents play a protective role. Age, co-morbidities and the use of NSAIDs and aspirin do not appear to influence this risk. Risk scores predicting the need for TE perform better at identifying low risk patients. Compared to the Blatchford score, our new risk score identifies more low risk patients who may be suitable for outpatient management.
S1459 Bacteremia and Endotoxemia After Endoscopic Submucosal Dissection for Gastric Neoplasia Masayuki Kato, Mitsuru Kaise, Toru Obata, Jin Yonezawa, Toyoizumi Hirobumi, Noboru Yoshimura, Yukinaga Yoshida, Hiroshi Horiuchi, Muneo Kawamura, Hisao Tajiri
S1457 Does Helicobacter Pylori Influence the Disease-Free Periods of Patients Receiving Endoscopic Submucosal Dissection (ESD) for Early Gastric Cancer? Joo Young Cho, Youn Sun Park, Won Young Cho, Taehee Lee, Hyun Gun Kim, Wan Jung Kim, Jin-Oh Kim, Joon Seong Lee, So Young Jin, Seok R. Choi Background/Aims: H.pylori is one of risk factor for gastric cancer. The aim of this study is to evaluate any long-term clinical differences in patients receiving ESD for EGC with appearance of H.pylori. Retrospective study. Methods/Patients: From Oct 2003 to Mar 2008, 385 patients with 414 lesions were investigated. Including criteria were as follows; 1) follow up period was at least 6months, 2) Patients with positive H.pylori did not have eradication therapy. Recurrence rate, incidence of synchronous or metachronous gastric epithelial neoplasia were evaluated. Results: Male was 288 (71,9%), female was 108 (28.1%). Mean age was 62 (range 33-86). 167 cases (40.3%) had H.pylori positive. Mean size of lesion was 44.3 mm (range 14110 mm), en-bloc resection rates 87.9%, complete resection rates 77.1%, respectively. differentiated cell type was 97.2%, undifferentiated type was 12.8%. There were no clinical significance of age, gender and pathology according to existence of H.pylori. Mean follow up periods was 2.5 year (range 0.6-5.2) of H.pylori negative group and 2 year (0.5-5.2) of positive group. During this periods, there are no clinical significance in recurrence, synchronous or metachronous lesion and incidence of gastric epithelial neoplasia. (pZ0.166). 3-year disease-free periods also had no clinical significance between two groups (pZ0.843). Conclusions: Eradication of H.pylori does not influence 3-year disease-free periods of patients with EGC received ESD.
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Background: Prophylactic administration of antibiotics is currently recommended for certain high-risk endoscopic procedures with a high incidence of bacteremia, such as an esophageal variceal sclerotherapy or stricture dilation. Although endoscopic submucosal dissection (ESD) achieves a much higher rate of radical en bloc resection, even for large neoplasias, ESD-induced ulcers are usually left as opened without endoscopic closure, and extensive submucosal exposure to indigenous bacterial florae in the gastrointestinal tracts may cause bacteremia and/ or endotoxemia. Aim: To elucidate whether post-ESD bacteremia and/or endotoxemia occur in gastric neoplasia patients. Patients and Method: Between January and October 2008, 49 patients referred for gastric ESD were eligible for this study. Exclusion criteria were recent antibiotics intake and systemic infectious disorders. Gastric ESD were performed using the hook knife and 0.5% hyaluronate injection without prophylactic administration of antibiotics. The skin site for blood sampling was initially cleaned with 70% isopropyl alcohol, followed by 10% povidone-iodine sterilization. Sets of blood cultures and plasma were obtained at three time periods; before ESD, immediately after ESD, and in the next morning. Plasma endotoxin levels were evaluated by a newly developed Limulus amebocyte lysate (LAL) test, which can measure low levels under 1 pg/ml. CRP and WBC were examined for correlation to endotoxin levels. Result: 1) Fortynine patients (men/ women Z 41/8, mean SD age; 68 8 y) were enrolled. Sizes of total sample removal were 38 18 (mean SD, mm), and ESD operating time was 64 53 (mean SD, min). 2) Although blood cultures showed positive results in 3, 1 and 1 of 49 patients at these three periods, these isolated microorganisms were regarded as contaminants. 3) Endotoxin levels were evaluated in 25 of 49 enrolled patients. Clinical levels of endotoxemia (O 5 pg/ml) were observed in 24% immediately after ESD, and in 24% in the next morning. Endotoxin levels immediately after ESD were significantly (pZ0.04) correlated to CRP levels in the next morning. Conclusion: In spite of massive submucosal exposure, gastric ESD do not cause bacteremia and prophylactic administration of antibiotics may not be required. However, gastric ESD induce endotoxemia, which increase inflammatory response after ESD.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB177
S1456 Classification of Gastric Mucosal Patterns in the Uninvolved Gastric Antrum By Using Magnifying NBI, in Relation to H. Pylori Infection, Histological and Serological Severity of Chronic Gastritis Masaaki Okubo, Tomomitsu Tahara, Tomoyuki Shibata, Masakatsu Nakamura, Daisuke Yoshioka, Naoko Maruyama, Toshiaki Kamano, Yoshio Kamiya, Hiroshi Fujita, Yoshihito Nakagawa, Mitsuo Nagasaka, Masami Iwata, Kazuya Takahama, Makoto Watanabe, Tomiyasu Arisawa, Ichiro Hirata Background/Aim: Magnifying NBI endoscope clearly visualizes superficial mucosal patterns and its capillary patterns. Recently, we have shown that gastric mucosal patterns using magnifying NBI in the gastric corpus well correlate with histological and serological severity of H. pylori induced chronic gastritis (Tahara T. Gastrointestinal Endoscopy, in press). Here, we investigated the mucosal patterns in the uninvolved gastric antrum using magnifying NBI endoscopy and its relation to H. pylori-induced gastritis. Materials/Method: 100 subjects including 13 gastric cancer (GC) patients were enrolled. Gastric mucosal patterns in the uninvolved gastric antrum were observed using magnifying NBI. We defined regular shaped villous or scale liked structures and coiled like vessels as the normal pattern, while having irregularities either in their structures or capillary patterns were defined as irregular patterns. According to the density of vessels, we divided the irregular patterns into two groups: irregular A (irregular pattern with regular or increased density of vessels), and irregular B (irregular pattern with decreased density of vessels) patterns. In addition, we also divided the irregular patterns into three groups according to the presence of light blue crest (LBC) or ridge/villous pattern: irregular, irregularþLBC and irregularþridge/villous patterns. Results: The sensitivity and specificity of irregular patterns for predicting H. pylori positive were 80.9%, and 84.4%. In the irregular patterns, presence of LBC or ridge/villous pattern were significantly associated with histological degree of atrophy (p!0.0001) and intestinal metaplasia (p!0.0001), low H. pylori titer (41.6 vs. 75.1, pZ0.04), low serum PGI (39.8 vs. 69.4, pZ0.004), PGII (16.0 vs. 21.7, pZ0.047), and PGI/II ratios (2.43 vs. 3.42, pZ0.04). In particular, PGI/II ratio was lowest in the irregularþ ridge/ villous pattern (1.63). The sensitivity and specificity of combination of both the irregularþLBC and irregularþridge/villous patterns for predicting intestinal metaplasia were 95.2%, 98.7%. Development of mucosal patterns from irregular to irregularþLBC, and irregularþridge/villous patterns was significantly associated with GC occurrence (10.6% vs. 29.4% vs. 75.0%, RZ0.39, pZ0.0008). Concerning the density of vessels in irregular patterns, histological degree of atrophy (pZ0.004) and intestinal metaplasia (pZ0.02) were significantly higher in irregular B than those of irregular A patterns. Conclusions: Gastric mucosal patterns in the uninvolved gastric antrum by using magnifying NBI well correlate with H. pylori infection, histological and serological severity of chronic gastritis.
S1458 Prediction of the Need for Endoscopic Hemostasis in Upper Gastrointestinal Hemorrhage (UGIH): A Risk Score Derivation and Validation Study Sandy H. Pang, Kelvin K. Tsoi, Jessica Ching, James Y. Lau, Francis K.L. Chan, Joseph J. Sung Background and Aims: Esophagogastroduodenoscopy (EGD) is the first line therapy in the investigation of and treatment for UGIH. The ability to predict the need for therapeutic endoscopy (TE) may streamline hospital resource utilization, save costs and select low risk patients for outpatient management. There is little data and no risk scores available to date to predict this outcome. This study aims to derive and validate a risk score for predicting the need for TE in non-cirrhotic patients with UGIH. Methods: We prospectively collected clinical and laboratory variables on 1013 noncirrhotic patients, who presented with hematemesis, melena, coffee ground vomiting or hematochezia between January 2006 and March 2007. Univariate analyses were performed on the variables and a risk score was derived using logistic regression. This risk score was then prospectively validated in a separate cohort of non-cirrhotic patients with UGIH. We compared the accuracy of this score with the Blatchford score in the validation cohort using receiver operating characteristic (ROC) curves. Results Of the 1013 patients, 252 (24.9%) required TE for haemostasis according to international consensus guidelines, of which 81% were for peptic ulcers. The presence of shock (SBP!100 mmHg), tachycardia (HRO100 bpm), low hemoglobin (!8 g/dL) and high urea were independently associated with the need for TE (all p!0.001). Hematemesis was a stronger predictor for TE when compared to melaena. The use of H2-receptor blockers and proton pump inhibitors was protective against this need (pZ0.02). Age, co-morbidities and the use of non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin played no role. The area under a ROC curve for the new risk score in the validation cohort of 337 non-cirrhotic patients was 0.71 (95% CI 0.660.77). A threshold of 3 or above predicted the need for TE with 100% sensitivity and 17% specificity, and identified 12.5% of patients as low risk. The area under a ROC curve for the Blatchford score applied to the same cohort was 0.66 (95% CI 0.60-0.73); this identified 2.7% of patients as low risk. There was a significant difference between the 2 areas (pZ0.04). Conclusion Hemodynamics, urea and hemoglobin continue to be important predictors of the need for TE; acid suppressive agents play a protective role. Age, co-morbidities and the use of NSAIDs and aspirin do not appear to influence this risk. Risk scores predicting the need for TE perform better at identifying low risk patients. Compared to the Blatchford score, our new risk score identifies more low risk patients who may be suitable for outpatient management.
S1459 Bacteremia and Endotoxemia After Endoscopic Submucosal Dissection for Gastric Neoplasia Masayuki Kato, Mitsuru Kaise, Toru Obata, Jin Yonezawa, Toyoizumi Hirobumi, Noboru Yoshimura, Yukinaga Yoshida, Hiroshi Horiuchi, Muneo Kawamura, Hisao Tajiri
S1457 Does Helicobacter Pylori Influence the Disease-Free Periods of Patients Receiving Endoscopic Submucosal Dissection (ESD) for Early Gastric Cancer? Joo Young Cho, Youn Sun Park, Won Young Cho, Taehee Lee, Hyun Gun Kim, Wan Jung Kim, Jin-Oh Kim, Joon Seong Lee, So Young Jin, Seok R. Choi Background/Aims: H.pylori is one of risk factor for gastric cancer. The aim of this study is to evaluate any long-term clinical differences in patients receiving ESD for EGC with appearance of H.pylori. Retrospective study. Methods/Patients: From Oct 2003 to Mar 2008, 385 patients with 414 lesions were investigated. Including criteria were as follows; 1) follow up period was at least 6months, 2) Patients with positive H.pylori did not have eradication therapy. Recurrence rate, incidence of synchronous or metachronous gastric epithelial neoplasia were evaluated. Results: Male was 288 (71,9%), female was 108 (28.1%). Mean age was 62 (range 33-86). 167 cases (40.3%) had H.pylori positive. Mean size of lesion was 44.3 mm (range 14110 mm), en-bloc resection rates 87.9%, complete resection rates 77.1%, respectively. differentiated cell type was 97.2%, undifferentiated type was 12.8%. There were no clinical significance of age, gender and pathology according to existence of H.pylori. Mean follow up periods was 2.5 year (range 0.6-5.2) of H.pylori negative group and 2 year (0.5-5.2) of positive group. During this periods, there are no clinical significance in recurrence, synchronous or metachronous lesion and incidence of gastric epithelial neoplasia. (pZ0.166). 3-year disease-free periods also had no clinical significance between two groups (pZ0.843). Conclusions: Eradication of H.pylori does not influence 3-year disease-free periods of patients with EGC received ESD.
www.giejournal.org
Background: Prophylactic administration of antibiotics is currently recommended for certain high-risk endoscopic procedures with a high incidence of bacteremia, such as an esophageal variceal sclerotherapy or stricture dilation. Although endoscopic submucosal dissection (ESD) achieves a much higher rate of radical en bloc resection, even for large neoplasias, ESD-induced ulcers are usually left as opened without endoscopic closure, and extensive submucosal exposure to indigenous bacterial florae in the gastrointestinal tracts may cause bacteremia and/ or endotoxemia. Aim: To elucidate whether post-ESD bacteremia and/or endotoxemia occur in gastric neoplasia patients. Patients and Method: Between January and October 2008, 49 patients referred for gastric ESD were eligible for this study. Exclusion criteria were recent antibiotics intake and systemic infectious disorders. Gastric ESD were performed using the hook knife and 0.5% hyaluronate injection without prophylactic administration of antibiotics. The skin site for blood sampling was initially cleaned with 70% isopropyl alcohol, followed by 10% povidone-iodine sterilization. Sets of blood cultures and plasma were obtained at three time periods; before ESD, immediately after ESD, and in the next morning. Plasma endotoxin levels were evaluated by a newly developed Limulus amebocyte lysate (LAL) test, which can measure low levels under 1 pg/ml. CRP and WBC were examined for correlation to endotoxin levels. Result: 1) Fortynine patients (men/ women Z 41/8, mean SD age; 68 8 y) were enrolled. Sizes of total sample removal were 38 18 (mean SD, mm), and ESD operating time was 64 53 (mean SD, min). 2) Although blood cultures showed positive results in 3, 1 and 1 of 49 patients at these three periods, these isolated microorganisms were regarded as contaminants. 3) Endotoxin levels were evaluated in 25 of 49 enrolled patients. Clinical levels of endotoxemia (O 5 pg/ml) were observed in 24% immediately after ESD, and in 24% in the next morning. Endotoxin levels immediately after ESD were significantly (pZ0.04) correlated to CRP levels in the next morning. Conclusion: In spite of massive submucosal exposure, gastric ESD do not cause bacteremia and prophylactic administration of antibiotics may not be required. However, gastric ESD induce endotoxemia, which increase inflammatory response after ESD.
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB177