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Magnifying Chromoendoscopy Using Acetic Acid for Diagnosis of the Depth of Submucosal Invasion in Colorectal Carcinoma
Abstracts
T1437 Magnifying Chromoendoscopy Using Acetic Acid for Diagnosis of the Depth of Submucosal Invasion in Colorectal Carcinoma Yutaka J. Kawamura, Kazutomo Togashi, Fumio Konishi
T1439 Inmunomodulation in Ulcerative Colitis. Second Line Therapy? ˜ez, E. Glasinovic, M. Gatica, Paula Vial, Eduardo Valdivieso, Patricio Iban Roque Saenz
Background and Aim: The depth of submucosal invasion in colorectal carcinoma is known to be associated with the risk of lymph node involvement. Therefore, endoscopic assessment of the depth of invasion is an important factor determining the appropriate treatment: endoscopic resection or surgical resection. Magnifying chromoendoscopy using indigo carmine (IC) or crystal violet (CV) dye has been reported to facilitate meticulous observation. Acetic acid (AA), an inexpensive and safe agent which removes mucous on a lesion and simultaneously enables enhancement of the fine structure of the pits could be an alternative to conventional dyes. The aim of this study was to compare the accuracy of IC- and AA-magnifying colonoscopy in terms of assessment of the depth of submucosal invasion. Patients and Methods: Fifty-nine colorectal polyps with diameter of 10 mm to 25 mm were prospectively studied. In IC-chromoendoscopy, 0.2% IC was sprayed to the polyps and in AA-chromoendoscopy, 0.5% AA was sprayed to the polyp and magnifying observation was done. The observed configuration of pits was classified by Kudo’s classification and categorized into two categories: deep (massive invasion of the submucosal layer) and shallow (intramucosal lesion or minimal invasion of the submucosal layer), according to the presence or absence of VN type pits, respectively. Histologically, if the depth of invasion was less than 1 mm, the lesion was defined as shallow, and if it was greater than or equal to 1 mm, the lesion was defined as deep. Results: Histologically, there were 20 cases with adenoma, 15 cases with intramucosal carcinoma, 8 cases with submucosal carcinoma with invasion of less than 1 mm, 8 cases with submucosal invasion greater than or equal to 1 mm, and 8 cases with proper muscle invasion. Sensitivity of conventional endoscopy, IC-, and AA- magnifying chromoendoscopy was 81.3%, 66.7% and 73.3%, respectively. Specificity was 88.4%, 95.0% and 94.4%, respectively. Positive predictive value (PPV) was 72.2%, 83.3%, and 84.6% and negative predictive value (NPV) was 92.6%, 88.4% and 89.5%, respectively. Conclusion: Clinical results of IC- and AA- chromoendoscopy were similar. Therefore, considereing the cost of the dye, AA is better agent for chromoendoscopy than IC. Sensitivity and NPV of conventional endoscopy was higher than that of chromoendoscopy. On the other hand, specificity and PPV of chromoendscopy was higher than that of conventional endoscopy. Endoscopist should be aware of these features and perform chromoendoscopy appropriately.
Introduction: Immnomodulation controls Iymphocyte dependent immune response. Azathyoprine (AZA/6-MP) has been considered, a second line therapy or as a complementary treatment to UC or Crohn Disease. Recent publications suggest a different therapeutic model, starting in IBD crisis with Steroids & AZA and progressive withdrawal of steroids. In our particular setting, due to socio economical handicap, (Aminosalicylates unavailable in such setting), we start from the onset of the crisis, treatment with Steroids & AZA and steroids progressive suspension as suggested. Aim: To evaluate clinical outcome and adverse effects in a cumulative case series of Ulcerative Colitis, treated with Steroids & AZA therapeutic combination. Method: First UC patients confirmed by endoscopy and histology, between 2003 and 2006 were recruited during a crisis episode. A conventional dosage of steroids plus Azathioprine (1, 5-2, 5 mg/kg/day) was used for all cases. No AZA antibodies were identified. The ‘‘Mayo score’’, was utilized at the beginning of the study and at steroidal withdrawal. Weekly clinical assessment and white cells count were performed until clinical response/remission and after the steroid withdrawal (every 3 months). Clinical response, clinical remission and endoscopical mucosal healing were assessed. A 50% Mayo Score reduction was considered a good responseResults: 20 Patients fulfilled the inclusion criteria, 13 women, average age of 34, 1 year old (16-60) Mayo score at the beginning was 7.61% (pancolitis), 16% (left colitis), and 22% (only rectal involvement). 27% of the patients had a severe crisis, 61% moderate and 11% mild. The averege AZA dosage used was 2 mg /kg/day (1, 5-2.7). Steroids were discontinued after 16 weeks (8-78 weeks). Only one patient kept steroid dependant. Final Mayo Score was 3 (4 points reduction) at 16 weeks. All patients achieved clinical response and remission. Only one case of leucopenia recovered after AZA dosage reduction. Conclusion: Our Data show an excellent clinical and endoscopical response with the Steroids & AZA model, for the treatment or initial Ulcerative Colitis Crisis. Only one case of hematological reversible, morbidity was present. It could be considered as a useful alternative but Randomized controlled trials or are required to prove this hypotheses.
T1438 Does Narrow Band Imaging (NBI) Colonoscopy Increase the Detection Rate of Colon Polyps? - A Pilot Feasibility Study Amit Rastogi, Ajay Bansal, Sachin B. Wani, Peggy Callahan, Prashant K. Pandya, Sharad Mathur, Prateek Sharma Background: Although standard white light colonoscopy is the preferred method for the detection and removal of colon polyps, multiple studies have shown that it can miss not only polyps but also cancer. Depending on the polyp size, polyp miss rates of 5-20% have been reported in tandem colonoscopy studies. Several new techniques have been utilized to decrease the polyp miss rate with variable results. NBI is a novel technique that allows detailed visualization of the colonic mucosa and thus has the potential to increase the detection rate of colon polyps. Aim: To test the feasibility of NBI colonoscopy for the detection of colon polyps missed by standard colonoscopy. Methods: Patients referred for screening colonoscopy were enrolled in this study and underwent standard colonic preparation with polyethylene glycol. A high resolution colonoscope with the capability of NBI was utilized for all procedures (180 series, Olympus). In all patients, initially the endoscope (standard white light) was advanced to the cecum; during withdrawal the cecum and ascending colon were visualized with standard white light and all polyps were recorded, photographed and then removed. Thereafter, the endoscope was again advanced to the cecum, the cecum and ascending colon were inspected during withdrawal with NBI. Additional polyps seen in these areas with NBI were recorded, photographed and removed. The remainder of the colon was examined sequentially in a similar fashion, initially with standard white light followed by NBI (15 to 20 cm increments). Results: A total of 40 patients referred for screening colonoscopy were prospectively enrolled; all males, majority Caucasians (80%) with a mean age of 62 years (range 40-83). Standard colonoscopy detected 72 polyps in all patients (average 1.8/patient). With NBI, an additional 51 polyps were detected, mean size 4.4 mm (range: 2-20). Of these, 43 polyps were %5 mm, 5 were 6-9 mm and 3 were R10 mm. The polyp distribution was: cecum 4, ascending colon 15, transverse colon 3, descending colon and sigmoid 18, rectum 11. 29 of these polyps were tubular adenomas and 22 were hyperplastic. Overall, NBI detected 41% additional polyps missed by standard colonoscopy. Conclusions: This pilot feasibility study demonstrates that NBI colonoscopy can detect up to 40% polyps missed by standard colonoscopy. This is much higher compared to 5-20% additional polyps detected by tandem standard colonoscopies as reported previously. NBI thus has the potential to significantly improve colonoscopy screening practices but large-scale, randomized cross over trials comparing NBI to standard colonoscopy need to be performed.
www.giejournal.org
T1440 Ischemic Colitis: Clinical and Endoscopic Findings Paula B. Poletti, Ying S. Tung, Thiago F. Secchi, Artur A. Parada Aims: The aim of this study was determine the prevalence, age distribution, the pattern of disease involvement in the colon and clinical findings of the ischemic colitis. Material and Method: A total of 2228 colonoscopies(videooscope Pentax and Fujinon) were performed from july 2001 to june 2004 at the endoscopic unit of the hospital 9 de Julho/ sa˜o Paulo/ brazil. we diagnosed 69 (3,09%) cases of ischemic colitis with histological confirmation. We reviewed the clinicals and endoscopics reports retrospectively. Results: Over a total of 2228 patients, we diagnosed 69 (3,09%) cases of ischemic colitis. The age ranged from 32 to 88 years, with a higher prevalence at the 8 decade with 29 cases (42%). Females had a higher prevalence (56,6%). In the evalution of the location of the disease, we observed 41 (59,45) cases in sigmoid colon, 19 (27,5%) in descending colon and 18 (26%) in the rectum. The most common presenting symtoms were hematochezia in 35 (56,6%), abodominal pain in 23 (33,3%) and diarrhea in 19 (27,5%). The endoscopic findings were: edema with erosions in 33 (47,8%), edema with erosions and ulcers in 16 (23,2%), hyperemics areas in 6 (8,7%) and swollen mucosa in 6 (8,7%). Conclusion: The ischemic colitis is not an uncommon injury and must be considered in the differential diagnosis in eldery patients with colitis. The disease presents a wide range of clinical and endoscopic findings.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB259
T1437 Magnifying Chromoendoscopy Using Acetic Acid for Diagnosis of the Depth of Submucosal Invasion in Colorectal Carcinoma Yutaka J. Kawamura, Kazutomo Togashi, Fumio Konishi
T1439 Inmunomodulation in Ulcerative Colitis. Second Line Therapy? ˜ez, E. Glasinovic, M. Gatica, Paula Vial, Eduardo Valdivieso, Patricio Iban Roque Saenz
Background and Aim: The depth of submucosal invasion in colorectal carcinoma is known to be associated with the risk of lymph node involvement. Therefore, endoscopic assessment of the depth of invasion is an important factor determining the appropriate treatment: endoscopic resection or surgical resection. Magnifying chromoendoscopy using indigo carmine (IC) or crystal violet (CV) dye has been reported to facilitate meticulous observation. Acetic acid (AA), an inexpensive and safe agent which removes mucous on a lesion and simultaneously enables enhancement of the fine structure of the pits could be an alternative to conventional dyes. The aim of this study was to compare the accuracy of IC- and AA-magnifying colonoscopy in terms of assessment of the depth of submucosal invasion. Patients and Methods: Fifty-nine colorectal polyps with diameter of 10 mm to 25 mm were prospectively studied. In IC-chromoendoscopy, 0.2% IC was sprayed to the polyps and in AA-chromoendoscopy, 0.5% AA was sprayed to the polyp and magnifying observation was done. The observed configuration of pits was classified by Kudo’s classification and categorized into two categories: deep (massive invasion of the submucosal layer) and shallow (intramucosal lesion or minimal invasion of the submucosal layer), according to the presence or absence of VN type pits, respectively. Histologically, if the depth of invasion was less than 1 mm, the lesion was defined as shallow, and if it was greater than or equal to 1 mm, the lesion was defined as deep. Results: Histologically, there were 20 cases with adenoma, 15 cases with intramucosal carcinoma, 8 cases with submucosal carcinoma with invasion of less than 1 mm, 8 cases with submucosal invasion greater than or equal to 1 mm, and 8 cases with proper muscle invasion. Sensitivity of conventional endoscopy, IC-, and AA- magnifying chromoendoscopy was 81.3%, 66.7% and 73.3%, respectively. Specificity was 88.4%, 95.0% and 94.4%, respectively. Positive predictive value (PPV) was 72.2%, 83.3%, and 84.6% and negative predictive value (NPV) was 92.6%, 88.4% and 89.5%, respectively. Conclusion: Clinical results of IC- and AA- chromoendoscopy were similar. Therefore, considereing the cost of the dye, AA is better agent for chromoendoscopy than IC. Sensitivity and NPV of conventional endoscopy was higher than that of chromoendoscopy. On the other hand, specificity and PPV of chromoendscopy was higher than that of conventional endoscopy. Endoscopist should be aware of these features and perform chromoendoscopy appropriately.
Introduction: Immnomodulation controls Iymphocyte dependent immune response. Azathyoprine (AZA/6-MP) has been considered, a second line therapy or as a complementary treatment to UC or Crohn Disease. Recent publications suggest a different therapeutic model, starting in IBD crisis with Steroids & AZA and progressive withdrawal of steroids. In our particular setting, due to socio economical handicap, (Aminosalicylates unavailable in such setting), we start from the onset of the crisis, treatment with Steroids & AZA and steroids progressive suspension as suggested. Aim: To evaluate clinical outcome and adverse effects in a cumulative case series of Ulcerative Colitis, treated with Steroids & AZA therapeutic combination. Method: First UC patients confirmed by endoscopy and histology, between 2003 and 2006 were recruited during a crisis episode. A conventional dosage of steroids plus Azathioprine (1, 5-2, 5 mg/kg/day) was used for all cases. No AZA antibodies were identified. The ‘‘Mayo score’’, was utilized at the beginning of the study and at steroidal withdrawal. Weekly clinical assessment and white cells count were performed until clinical response/remission and after the steroid withdrawal (every 3 months). Clinical response, clinical remission and endoscopical mucosal healing were assessed. A 50% Mayo Score reduction was considered a good responseResults: 20 Patients fulfilled the inclusion criteria, 13 women, average age of 34, 1 year old (16-60) Mayo score at the beginning was 7.61% (pancolitis), 16% (left colitis), and 22% (only rectal involvement). 27% of the patients had a severe crisis, 61% moderate and 11% mild. The averege AZA dosage used was 2 mg /kg/day (1, 5-2.7). Steroids were discontinued after 16 weeks (8-78 weeks). Only one patient kept steroid dependant. Final Mayo Score was 3 (4 points reduction) at 16 weeks. All patients achieved clinical response and remission. Only one case of leucopenia recovered after AZA dosage reduction. Conclusion: Our Data show an excellent clinical and endoscopical response with the Steroids & AZA model, for the treatment or initial Ulcerative Colitis Crisis. Only one case of hematological reversible, morbidity was present. It could be considered as a useful alternative but Randomized controlled trials or are required to prove this hypotheses.
T1438 Does Narrow Band Imaging (NBI) Colonoscopy Increase the Detection Rate of Colon Polyps? - A Pilot Feasibility Study Amit Rastogi, Ajay Bansal, Sachin B. Wani, Peggy Callahan, Prashant K. Pandya, Sharad Mathur, Prateek Sharma Background: Although standard white light colonoscopy is the preferred method for the detection and removal of colon polyps, multiple studies have shown that it can miss not only polyps but also cancer. Depending on the polyp size, polyp miss rates of 5-20% have been reported in tandem colonoscopy studies. Several new techniques have been utilized to decrease the polyp miss rate with variable results. NBI is a novel technique that allows detailed visualization of the colonic mucosa and thus has the potential to increase the detection rate of colon polyps. Aim: To test the feasibility of NBI colonoscopy for the detection of colon polyps missed by standard colonoscopy. Methods: Patients referred for screening colonoscopy were enrolled in this study and underwent standard colonic preparation with polyethylene glycol. A high resolution colonoscope with the capability of NBI was utilized for all procedures (180 series, Olympus). In all patients, initially the endoscope (standard white light) was advanced to the cecum; during withdrawal the cecum and ascending colon were visualized with standard white light and all polyps were recorded, photographed and then removed. Thereafter, the endoscope was again advanced to the cecum, the cecum and ascending colon were inspected during withdrawal with NBI. Additional polyps seen in these areas with NBI were recorded, photographed and removed. The remainder of the colon was examined sequentially in a similar fashion, initially with standard white light followed by NBI (15 to 20 cm increments). Results: A total of 40 patients referred for screening colonoscopy were prospectively enrolled; all males, majority Caucasians (80%) with a mean age of 62 years (range 40-83). Standard colonoscopy detected 72 polyps in all patients (average 1.8/patient). With NBI, an additional 51 polyps were detected, mean size 4.4 mm (range: 2-20). Of these, 43 polyps were %5 mm, 5 were 6-9 mm and 3 were R10 mm. The polyp distribution was: cecum 4, ascending colon 15, transverse colon 3, descending colon and sigmoid 18, rectum 11. 29 of these polyps were tubular adenomas and 22 were hyperplastic. Overall, NBI detected 41% additional polyps missed by standard colonoscopy. Conclusions: This pilot feasibility study demonstrates that NBI colonoscopy can detect up to 40% polyps missed by standard colonoscopy. This is much higher compared to 5-20% additional polyps detected by tandem standard colonoscopies as reported previously. NBI thus has the potential to significantly improve colonoscopy screening practices but large-scale, randomized cross over trials comparing NBI to standard colonoscopy need to be performed.
www.giejournal.org
T1440 Ischemic Colitis: Clinical and Endoscopic Findings Paula B. Poletti, Ying S. Tung, Thiago F. Secchi, Artur A. Parada Aims: The aim of this study was determine the prevalence, age distribution, the pattern of disease involvement in the colon and clinical findings of the ischemic colitis. Material and Method: A total of 2228 colonoscopies(videooscope Pentax and Fujinon) were performed from july 2001 to june 2004 at the endoscopic unit of the hospital 9 de Julho/ sa˜o Paulo/ brazil. we diagnosed 69 (3,09%) cases of ischemic colitis with histological confirmation. We reviewed the clinicals and endoscopics reports retrospectively. Results: Over a total of 2228 patients, we diagnosed 69 (3,09%) cases of ischemic colitis. The age ranged from 32 to 88 years, with a higher prevalence at the 8 decade with 29 cases (42%). Females had a higher prevalence (56,6%). In the evalution of the location of the disease, we observed 41 (59,45) cases in sigmoid colon, 19 (27,5%) in descending colon and 18 (26%) in the rectum. The most common presenting symtoms were hematochezia in 35 (56,6%), abodominal pain in 23 (33,3%) and diarrhea in 19 (27,5%). The endoscopic findings were: edema with erosions in 33 (47,8%), edema with erosions and ulcers in 16 (23,2%), hyperemics areas in 6 (8,7%) and swollen mucosa in 6 (8,7%). Conclusion: The ischemic colitis is not an uncommon injury and must be considered in the differential diagnosis in eldery patients with colitis. The disease presents a wide range of clinical and endoscopic findings.
Volume 65, No. 5 : 2007 GASTROINTESTINAL ENDOSCOPY AB259