- Email: [email protected]
The Role of CT Angiography Before Endoscopy in Acute Nonvariceal Large Gastrointestinal Bleeding
AGA Abstracts
shows that prucalopride accelerates gastric emptying. The purpose of this study was to test whether prucalopride is able to speed up the transit time of VCE through the proximal section of the gut. Patients and Methods: Fifty-four patients underwent small-bowel VCE for several indications. None of the patients studied had an apparent motility disorder or undergone to abdominal surgery in their clinical history. All the patients had a standard bowel preparation (SBP) the day before examination with 4 liters of PEG solution. Moreover, 30 mg of NaP followed by 1 liter of tap water when the VCE reached the duodenum ware administered and a second boost of 25 mg of NaP plus 1 liter of tap water were administered 180 min later. Twenty of these patients were treated in addition with 2 mg of prucalopride for five days before the examination (SBP+PRU). The following parameters for each procedure were evaluated: gastric transit time (GTT), small bowel transit time (SBTT), gastric plus small bowel transit time (G+SBTT) and diagnostic yield (DY). Results: All capsules of both groups reached the caecum. GTT was faster in the SBP+PRU group (p=0.017) and to a lower extent also SBTT was faster in this group without however a significant difference. Finally G+SBTT was significantly reduced in SBP+PRU group (p=0.023) (table 1). No significant difference was found in the DY between the two groups: SBP 27/34 (79.4%; 95%CI 65.8-93.0) vs SBP+PRU 16/20 (80.0%; 95%CI 62.5-97.5) (RR 1.01; 95%CI 0.761.33; p=0.96). Conclusions: Prucalopride accelerates the transit of VCE through the proximal gastrointestinal segments and in particular GTT is markedly reduced. The DY however does not seem to change. Procalupride could be usefully used in different situations in which an acceleration through the proximal gut is needed. Table 1. Transit times of the different gastrointestinal segments in the two groups of patients
Tu2008 ENDOSCOPIC PREDICTION MODEL FOR DEPTH OF INVASION IN SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA JoohWan Bae Endoscopic prediction model for depth of invasion in superficial esophageal squamous cell carcinoma Joo Hwan Bae, In Seub Shin, Hyuk Lee, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim, Yang Won Min Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Corresponding author: Yang Won Min, M.D., Ph.D. Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Korea Phone: +82-2-3410-3409; Fax: +82-2-3410-6983; E-mail: [email protected] Background/Aims: Accurate staging of esophageal cancer is crucial to establishing appropriate treatment strategies especially in superficial esophageal squamous cell carcinoma (SESCC). We aimed to investigate the diagnostic accuracy of white light endoscopy (WLE) to discriminate the depth of invasion in SESCC and to establish predictive model for depth of invasion in SESCC. Methods: Between April 2007 and August 2016, 187 patients who underwent esophageal endoscopic submucosal dissection (ESD) for SESCC were included in this study. We measured the dominant shape of tumor, surface erosion, surface nodularity, surface granularity, surface unevenness, multiplicity of elevated foci, maximal tumor gross size with resected specimen, calculated 2 dimensional size with measured perpendicular size. We defined surface nodularity, granularity and unevenness as gross protuberance size over 5mm, between 2 - 5mm and less than 2mm respectively. Multiplicity of elevated foci was defined as more than 3 foci of surface nodularity or granularity. We reviewed pathological depth of invasion of SESCC with ESD specimen Results: Among the subjects (185 patients), 144 patients was belong to mucosal SESCC group (depth of invasion ≤ M3) and 41 patients was belong to submucosal SESCC group (depth of invasion ≥ SM1). Between two groups, endoscopic factors associated with submucosal invasion were tumor maximal size, 2 dimensional size, surface nodularity, surface granularity, multiplicity of elevated foci in univariate analysis (p <0.001, 0.026, <0.001, 0.009 and 0.001 respectively). In multiple logistic regression with stepwise selection, surface erosion, surface nodularity, multiplicity of elevated foci was selected for establishment of predictive model (OR 2.436, 5.137 and 3.082 respectively). After 10-fold cross validation, AUROC of validated prediction model was 0.684 Conclusions: Endoscopic findings of SESCC including surface erosion, surface nodularity, and multifocal elevated foci were associated with submucosal invasion. With these findings, a good prediction model for submucosal invasion was established.
Data presented as minutes (mean ± SEM)
Tu2007 THE ROLE OF CT ANGIOGRAPHY BEFORE ENDOSCOPY IN ACUTE NONVARICEAL LARGE GASTROINTESTINAL BLEEDING Jooyoung Lee, Jaeyoung Chun, Jihye Kim, Kyoung Sup Hong, Jong Pil Im, Sang Gyun Kim, Joo Sung Kim
Tu2009 Background/Aims: The clinical significance of CT angiography (CTA) for acute nonvariceal large gastrointestinal (GI) bleeding still remains unclear. The aim of this study was to evaluate the clinical role of CTA in patients who presented with symptoms suggesting suspected acute nonvariceal large GI bleeding. Methods: Between June 2014 and December 2015, the medical records of all patients who visited the emergency department with the symptoms of hematochezia at Seoul National University Hospital were retrospectively reviewed. The subjects with underlying liver cirrhosis were excluded. All patients underwent colonoscopy for diagnosis and treatment of the suspected large GI bleeding. Upper GI bleeding was excluded from the diagnosis after performing esophagogastroduodenoscopy. All subjects were divided into two groups: patients who underwent CTA before endoscopy (CTA group) versus who did not CTA before endoscopy (No CTA group). Primary endpoints were total procedure time and detection rate for the bleeding foci. Secondary endpoints were clinical outcomes including success rate of endoscopic hemostasis, need for second look endoscopy, and 30-day rebleeding rate. Results: A total of 94 patients were enrolled in this study. Among them, 53 patients(56.4%) performed CTA before endoscopic hemostasis. Initial blood urea nitrogen (BUN) and creatinine level was significantly lower in CTA group compared to No CTA group. (20.1±11.1mg/dL vs 26.9±16.5mg/dL p=0.020, 1.2±1.3mg/ dL vs 2.1±2.3mg/dL p=0.016) Total procedure time was significantly shorter in CTA group than No CTA group. (12.2±9.7min vs 17.4±10.3min p=0.015) Detection rate for the bleeding focus tended to higher in CTA groups than No CTA group, but there was no significant statistical difference. (93.9% vs 90.6%, p=0.676). Success rate of hemostasis was higher in CTA group than No CTA group. (100% vs 90.0%, p=0.013). There was no significant difference in other clinical outcomes including need for second look endoscopy, and 30day rebleeding rate between two groups. Conclusions: CTA before the large GI endoscopic evaluation could provide additional support to endoscopists performing endoscopic hemostasis in patients who presented with symptoms suggesting suspected acute nonvariceal large GI bleeding. Comparison of endpoints in patients with nonvariceal lower GI bleeding
ULTRASOUNDX: ADVANCED INTERACTIVE GRAPHICAL USER INTERFACE FOR THE CALCULATION OF CROSS-SECTIONAL AREA AND THICKNESS FROM ULTRASOUND VIDEO SEQUENCES OF THE ESOPHAGUS Ali Zifan, Ravinder K. Mittal Background: Ultrasound imaging is an important diagnostic method both in upper GI-tract and the pelvic floor (e.g., fecal incontinence). However the presence of speckle noise and the lack of resolution compared to other modalities (e.g., computed tomography or magnetic resonance imaging), making it near impossible to build automatic segmentation methods to segment out cavities, different types of tissues organs from the US images. The speckled noise becomes more pronounced, when dealing with dynamic high frequency ultrasound images, when one seeks to calculate temporal shape changes of the organ across multiple time frames. Aim: in light of the aforementioned points, the goal was to build a state of the art, interactive software (UltrasoundX) under Matlab (MathWorks Ltd) to alleviate the stated problems. Method: In brief, the program consists of converting an US B-mode image sequence into 16 M-mode images in planes 22.5° apart, over time. In each M-mode image, the radial distance between the center of the image (US catheter location) and the inner luminal edge and outer esophageal wall is determined. Total area is the sum of each individual triangular region encompassed by two adjacent radial lines ( area = 0.5 * R1* R2* sin α where R1 and R2 are two adjacent radius and α = 22.5° (angle between the two radial lines). One of the highly interesting features of the interface, is the ability to visualize the corresponding B-mode image of an M-mode time point by hovering the mouse no a particular M-mode, which allows better delineation of the boundaries by the user. Result: A screenshot of the program and a sample result is shown in Figure 1B. The program also allows the superposition of the calculated CSA of the esophageal lumen and wall thickness superimposed on the High-resolution manometry data. The user is also able to export pertinent data statistics outside the program for further processing. Conclusion: We introduce a highly user friendly program that allows researchers calculate cross-sectional area and wall thickness information form UltrasoundX video sequences of the esophagus.
*Student t-test Fisher's exact probability test § Chi-square test
Figure 1: Screenshots from UltrasoundX in a normal subject with swallow of a 10cc 0.5N saline volume from initial M-mode generation in (A) to the final superposition on the HRM
AGA Abstracts
S-1034
shows that prucalopride accelerates gastric emptying. The purpose of this study was to test whether prucalopride is able to speed up the transit time of VCE through the proximal section of the gut. Patients and Methods: Fifty-four patients underwent small-bowel VCE for several indications. None of the patients studied had an apparent motility disorder or undergone to abdominal surgery in their clinical history. All the patients had a standard bowel preparation (SBP) the day before examination with 4 liters of PEG solution. Moreover, 30 mg of NaP followed by 1 liter of tap water when the VCE reached the duodenum ware administered and a second boost of 25 mg of NaP plus 1 liter of tap water were administered 180 min later. Twenty of these patients were treated in addition with 2 mg of prucalopride for five days before the examination (SBP+PRU). The following parameters for each procedure were evaluated: gastric transit time (GTT), small bowel transit time (SBTT), gastric plus small bowel transit time (G+SBTT) and diagnostic yield (DY). Results: All capsules of both groups reached the caecum. GTT was faster in the SBP+PRU group (p=0.017) and to a lower extent also SBTT was faster in this group without however a significant difference. Finally G+SBTT was significantly reduced in SBP+PRU group (p=0.023) (table 1). No significant difference was found in the DY between the two groups: SBP 27/34 (79.4%; 95%CI 65.8-93.0) vs SBP+PRU 16/20 (80.0%; 95%CI 62.5-97.5) (RR 1.01; 95%CI 0.761.33; p=0.96). Conclusions: Prucalopride accelerates the transit of VCE through the proximal gastrointestinal segments and in particular GTT is markedly reduced. The DY however does not seem to change. Procalupride could be usefully used in different situations in which an acceleration through the proximal gut is needed. Table 1. Transit times of the different gastrointestinal segments in the two groups of patients
Tu2008 ENDOSCOPIC PREDICTION MODEL FOR DEPTH OF INVASION IN SUPERFICIAL ESOPHAGEAL SQUAMOUS CELL CARCINOMA JoohWan Bae Endoscopic prediction model for depth of invasion in superficial esophageal squamous cell carcinoma Joo Hwan Bae, In Seub Shin, Hyuk Lee, Byung-Hoon Min, Jun Haeng Lee, Poong-Lyul Rhee, Jae J. Kim, Yang Won Min Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea Corresponding author: Yang Won Min, M.D., Ph.D. Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 135-710, Korea Phone: +82-2-3410-3409; Fax: +82-2-3410-6983; E-mail: [email protected] Background/Aims: Accurate staging of esophageal cancer is crucial to establishing appropriate treatment strategies especially in superficial esophageal squamous cell carcinoma (SESCC). We aimed to investigate the diagnostic accuracy of white light endoscopy (WLE) to discriminate the depth of invasion in SESCC and to establish predictive model for depth of invasion in SESCC. Methods: Between April 2007 and August 2016, 187 patients who underwent esophageal endoscopic submucosal dissection (ESD) for SESCC were included in this study. We measured the dominant shape of tumor, surface erosion, surface nodularity, surface granularity, surface unevenness, multiplicity of elevated foci, maximal tumor gross size with resected specimen, calculated 2 dimensional size with measured perpendicular size. We defined surface nodularity, granularity and unevenness as gross protuberance size over 5mm, between 2 - 5mm and less than 2mm respectively. Multiplicity of elevated foci was defined as more than 3 foci of surface nodularity or granularity. We reviewed pathological depth of invasion of SESCC with ESD specimen Results: Among the subjects (185 patients), 144 patients was belong to mucosal SESCC group (depth of invasion ≤ M3) and 41 patients was belong to submucosal SESCC group (depth of invasion ≥ SM1). Between two groups, endoscopic factors associated with submucosal invasion were tumor maximal size, 2 dimensional size, surface nodularity, surface granularity, multiplicity of elevated foci in univariate analysis (p <0.001, 0.026, <0.001, 0.009 and 0.001 respectively). In multiple logistic regression with stepwise selection, surface erosion, surface nodularity, multiplicity of elevated foci was selected for establishment of predictive model (OR 2.436, 5.137 and 3.082 respectively). After 10-fold cross validation, AUROC of validated prediction model was 0.684 Conclusions: Endoscopic findings of SESCC including surface erosion, surface nodularity, and multifocal elevated foci were associated with submucosal invasion. With these findings, a good prediction model for submucosal invasion was established.
Data presented as minutes (mean ± SEM)
Tu2007 THE ROLE OF CT ANGIOGRAPHY BEFORE ENDOSCOPY IN ACUTE NONVARICEAL LARGE GASTROINTESTINAL BLEEDING Jooyoung Lee, Jaeyoung Chun, Jihye Kim, Kyoung Sup Hong, Jong Pil Im, Sang Gyun Kim, Joo Sung Kim
Tu2009 Background/Aims: The clinical significance of CT angiography (CTA) for acute nonvariceal large gastrointestinal (GI) bleeding still remains unclear. The aim of this study was to evaluate the clinical role of CTA in patients who presented with symptoms suggesting suspected acute nonvariceal large GI bleeding. Methods: Between June 2014 and December 2015, the medical records of all patients who visited the emergency department with the symptoms of hematochezia at Seoul National University Hospital were retrospectively reviewed. The subjects with underlying liver cirrhosis were excluded. All patients underwent colonoscopy for diagnosis and treatment of the suspected large GI bleeding. Upper GI bleeding was excluded from the diagnosis after performing esophagogastroduodenoscopy. All subjects were divided into two groups: patients who underwent CTA before endoscopy (CTA group) versus who did not CTA before endoscopy (No CTA group). Primary endpoints were total procedure time and detection rate for the bleeding foci. Secondary endpoints were clinical outcomes including success rate of endoscopic hemostasis, need for second look endoscopy, and 30-day rebleeding rate. Results: A total of 94 patients were enrolled in this study. Among them, 53 patients(56.4%) performed CTA before endoscopic hemostasis. Initial blood urea nitrogen (BUN) and creatinine level was significantly lower in CTA group compared to No CTA group. (20.1±11.1mg/dL vs 26.9±16.5mg/dL p=0.020, 1.2±1.3mg/ dL vs 2.1±2.3mg/dL p=0.016) Total procedure time was significantly shorter in CTA group than No CTA group. (12.2±9.7min vs 17.4±10.3min p=0.015) Detection rate for the bleeding focus tended to higher in CTA groups than No CTA group, but there was no significant statistical difference. (93.9% vs 90.6%, p=0.676). Success rate of hemostasis was higher in CTA group than No CTA group. (100% vs 90.0%, p=0.013). There was no significant difference in other clinical outcomes including need for second look endoscopy, and 30day rebleeding rate between two groups. Conclusions: CTA before the large GI endoscopic evaluation could provide additional support to endoscopists performing endoscopic hemostasis in patients who presented with symptoms suggesting suspected acute nonvariceal large GI bleeding. Comparison of endpoints in patients with nonvariceal lower GI bleeding
ULTRASOUNDX: ADVANCED INTERACTIVE GRAPHICAL USER INTERFACE FOR THE CALCULATION OF CROSS-SECTIONAL AREA AND THICKNESS FROM ULTRASOUND VIDEO SEQUENCES OF THE ESOPHAGUS Ali Zifan, Ravinder K. Mittal Background: Ultrasound imaging is an important diagnostic method both in upper GI-tract and the pelvic floor (e.g., fecal incontinence). However the presence of speckle noise and the lack of resolution compared to other modalities (e.g., computed tomography or magnetic resonance imaging), making it near impossible to build automatic segmentation methods to segment out cavities, different types of tissues organs from the US images. The speckled noise becomes more pronounced, when dealing with dynamic high frequency ultrasound images, when one seeks to calculate temporal shape changes of the organ across multiple time frames. Aim: in light of the aforementioned points, the goal was to build a state of the art, interactive software (UltrasoundX) under Matlab (MathWorks Ltd) to alleviate the stated problems. Method: In brief, the program consists of converting an US B-mode image sequence into 16 M-mode images in planes 22.5° apart, over time. In each M-mode image, the radial distance between the center of the image (US catheter location) and the inner luminal edge and outer esophageal wall is determined. Total area is the sum of each individual triangular region encompassed by two adjacent radial lines ( area = 0.5 * R1* R2* sin α where R1 and R2 are two adjacent radius and α = 22.5° (angle between the two radial lines). One of the highly interesting features of the interface, is the ability to visualize the corresponding B-mode image of an M-mode time point by hovering the mouse no a particular M-mode, which allows better delineation of the boundaries by the user. Result: A screenshot of the program and a sample result is shown in Figure 1B. The program also allows the superposition of the calculated CSA of the esophageal lumen and wall thickness superimposed on the High-resolution manometry data. The user is also able to export pertinent data statistics outside the program for further processing. Conclusion: We introduce a highly user friendly program that allows researchers calculate cross-sectional area and wall thickness information form UltrasoundX video sequences of the esophagus.
*Student t-test Fisher's exact probability test § Chi-square test
Figure 1: Screenshots from UltrasoundX in a normal subject with swallow of a 10cc 0.5N saline volume from initial M-mode generation in (A) to the final superposition on the HRM
AGA Abstracts
S-1034