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Pancreatogastric fistulas associated with chronic pancreatitis: a case report and review of the literature
Brief Reports
REFERENCES 1. Patel NM. Chronic gastric volvulus. Report of a case and review of literature. Am J Gastroenterol 1985;80:170-3. 2. Bhasin DK, Nagi B, Kochhar R, et al. Endoscopic management of chronic organoaxial volvulus of the stomach. Am J Gastroenterol 1990;85:1486-8. 3. Creedon PJ, Burman JF. Volvulus of the stomach. Report of a case with complications. Am J Surg 1965;110:964-6. 4. Haddad JK, Doherty C, Clark RE. Acute gastric volvulus: endoscopic derotation. West J Med 1977;127:341-6. 5. Tod R, Danon G, Thierree RA. The gastric volvulus and absence of liver left lobe syndrome. J Radiol Electrol Med Nucl 1971;52:106-8. 6. Iliesco G, Neagu N, Splouchal J. Stomach volvulus due to liver anomalies. Bull Soc Int Chir 1968;27:557-62. 7. Sookpotarom P, Vejchapipat P, Chongsrisawat V, et al. Gastric volvulus caused by percutaneous endoscopic gastrostomy: a case report. J Pediatr Surg 2005;40:e21-3. 8. Akamatsu T, Nakamura N, Kiyosawa K, et al. Gastric volvulus in living, related liver transplantation donors and usefulness of endoscopic correction. Gastrointest Endosc 2002;55:55-7.
9. Varma JS, Wyatt JP, MacIntyre IM. Gastric volvulus caused by giant ovarian cyst. J R Coll Surg Edinb 1992;37:194. 10. Sultan J, Vassallo PP, Davis P, et al. Intermittent gastric volvulus secondary to gall bladder adhesions: a rare cause of gastric outlet obstruction. Hosp Med 2005;66:245. 11. Baty V, Rocca P, Fontaumard E. Acute gastric volvulus related to adhesions after laparoscopic fundoplication. Surg Endosc 2002;16:538.
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research Chandigarh, India. Reprint requests: Deepak Kumar Bhasin, MD, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, 1041, Sector 24-B, Chandigarh – 160 023, India. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.09.015
Pancreatogastric fistulas associated with chronic pancreatitis: a case report and review of the literature Hamed A. Shabaneh Al-Tamimi, MD, Joseph Hancock, MD, Carlos Palacio, MD, Xin Yao, MD Lubbock, Texas, USA
The medical literature describes many cases of pancreatogastric fistulas arising in the setting of intraductal papillary mucinous neoplasms.1-3 Surgical specimens have identified tumor invasion, as well as an inflammatory reaction induced by the tumor, without invasion, as a cause. Chronic pancreatitis is associated with many complications. The literature describes the development of internal fistulous tracts between the pancreas and the colon4,5; the small intestine, the pleura, and the mediastinum6; and with the skin (external fistulas).7 We report a rare case of chronic relapsing pancreatitis complicated by a pancreatogastric fistula identified on ERCP.
A 55-year-old white man presented with a medical history significant for chronic alcoholic pancreatitis. The pa-
tient was transferred with a 3-day history of dull, constant, left upper-quadrant abdominal pain, which radiated to the epigastrium and the right upper-quadrant associated with nausea, constipation, anorexia, subjective fever and chills, with shortness of breath. A physical examination on admission showed a temperature of 36.7 C (98 F), the heart rate was 98 beats/min, blood pressure was 153/91 mm Hg, and the respiratory rate was 22 breaths/min. His oxygen saturation was 97% on room air. His head and neck examination was unremarkable. His chest examination showed diminished air entry at both lung bases, mainly on the right base. His cardiovascular examination showed regular S1 and S2 heart sounds, with no murmurs or gallop. The abdominal examination showed severe tenderness and rebound tenderness in the right upper quadrant, with hypoactive bowel sounds. The lower-limb examination showed no clubbing, cyanosis, or edema. The patient’s laboratory data results were a white blood cell count of 22
942 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 6 : 2007
www.giejournal.org
CASE REPORT
Brief Reports
Figure 1. CT scan of the abdomen. Notice bilateral pleural effusion, mainly on the right side.
Figure 2. CT scan of the abdomen. Notice pancreatic atrophy, calcification, and dilated pancreatic duct.
109/L (reference range, 4-10 109/L); Hb, 13.5 g/L (120160 g/L); a platelet count, 389 109/L (150-450 109/L); glucose, 5.7 mmol/L (4.4-6.4 mmol/L); serum urea nitrogen, 2.1 mmol/L (2.1-7.1 mmol/L); and creatinine, 53 mmol/L (44.2-106 mmol/L). Total protein, 55 g/L (60-80 g/L); albumin, 20 g/L (3.5-5 g/L); calcium, 2.05 mmol/L (2.1-2.6 mmol/L); total bilirubin, 16.6 mmol/L (0-17.1 mmol/L); aspartate aminotransferase, 103 U/L (0-45 U/L); alanine aminotransferase, 98 U/L (0-37 U/L); amylase, 666 U/L (25-125 U/L); and lipase, 2976 U/L (10-140 U/L). A right-sided pleural fluid thoracentesis was done and showed a pancreatic pleural effusion. The abdominal CT showed a large rightsided pleural effusion and consolidation; fluid collection around the right lateral liver margin; an enlarged pancreatic head, with calcification suggestive of chronic pancreatitis with pseudocyst; and dilated pancreatic duct and common bile duct (Fig. 2). An ERCP was done (Fig. 3). The cannulation of the pancreatic duct was only possible through the minor papilla and showed a dilated and tortuous pancreatic duct in the body and the tail, and major tortuosity in the head region, where there appeared to be a stricture and ductal deformity. Extravasation of contrast into the stomach lumen suggestive of a pancreatogastric fistula was seen. A pancreatic pseudocyst was also seen, which drained well into the pancreatic duct. Pancreatic ductal stent placement failed. The bile duct had a distal stricture, which was successfully stented by using a 7F, 9-cm biliary stent. The patient was thus managed conservatively with intravenous (IV) fluids, analgesia, IV antibiotics, and subcutaneous
Sandostatin injection (Novartis Pharmaceuticals, East Hanover, NJ), and remained stable all during his hospitalization.
www.giejournal.org
Volume 65, No. 6 : 2007 GASTROINTESTINAL ENDOSCOPY 943
DISCUSSION The occurrence of pancreatogastric fistulas has been well described in the setting of intraductal papillary mucinous neoplasm of the pancreas.1-3,8 In 1989, Hansen et al4 describe a case of chronic relapsing pancreatitis complicated by pancreatogastric and pancreatocolonic fistulas successfully treated with excision of the fistula and closure of the gastric and colonic wall. In our patient, the occurrence of the pancreatogastric fistula was merely related to the chronic relapsing pancreatitis in the absence of ulcer disease or malignancy. The mechanism behind fistula formation in the absence of cancer invasion could be either mechanical (increased main pancreatic diameter and disruption of the wall in the absence of inflammation) or secondary to acute inflammation or pseudocyst formation, with penetration or rupture into the stomach. The treatment of pancreatogastric fistulas should be individualized according to the medical status of the patient. General measures include nothing by mouth, nasogastric suction, total parenteral nutrition and Sandostatin injections. In the literature, most cases required surgery, and the general measures were used as a bridge to surgery for about 2 to 3 weeks before definitive plan for surgery was made.6
Brief Reports
Figure 3. ERCP showing dilated CBD, PD, pseudocyst, and pancreatogastric fistula.
The present case highlights that a pancreatogastric fistula can develop in the setting of chronic relapsing pancreatitis in the absence of malignancy or pancreatic pseudocyst rupture into adjacent organs and can be considered, therefore, among the rare cases described in the literature.
DISCLOSURE None of the authors have anything to disclose. 944 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 6 : 2007
REFERENCES 1. Le Corguille M, Levy P, Ponsot P, et al. Intraductal papillary mucinous tumor with pancreatobiliary and pancreatodigestive fistulae: a case report [in French with English abstract]. Gastroenterol Clin Biol 2002;26: 1172-4. 2. Koizumi M, Sata N, Yoshizawa K, et al. Post-ERCP pancreatogastric fistula associated with an intraductal papillary mucinous neoplasm of the pancreas: a case report and literature review. World J Surg Oncol 2005;3:70. 3. Fteriche FS, Chebbi F, Bedioui H, et al. Intraductal papillary mucinous tumor of the pancreas degenerated and fistulated in the stomach, the duodenum and colon. Ann Chir 2006;131:118-20.
www.giejournal.org
Brief Reports 4. Hansen CP, Christensen A, Thagaard CS, et al. Gastrocolic fistula resulting from chronic pancreatitis. South Med J 1989;82:1309-10. 5. Abeygunasekera S, Freiman J, Engelman J, et al. Gastropancreaticocolic fistula: complication of a benign ulcer. Gastrointest Endosc 2004;59: 450-2. 6. Kaman L, Behera A, Singh R, et al. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. ANZ J Surg 2001;71:221-5. 7. Ihse I, Larsson J, Lindstrom E. Surgical management of pure pancreatic fistulas. Hepatogastroenterology 1994;41:271-5. 8. Yago A, Fujita N, Noda Y, et al. A case of non-invasive intraductal papillary adenocarcinoma of the pancreas showing penetration of the stomach. Fukubu Gazo Shindan 1995;15:496-500.
Division of Gastroenterology, Department of Internal Medicine Texas Tech University Health Sciences Center (H.A.S.A-T., C.P., X.Y.), Southplains Gastroenterology Group (J.H.), Lubbock, Texas, USA. Reprint requests: Hamed A. Shabaneh Al-Tamimi, MD, Internal Medicine, Gastroenterology, Texas Tech University, HSC, 3601 4th Street, Lubbock, TX 79430. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.10.011
Metastatic signet-ring carcinoma of the colon diagnosed by EUS-guided FNA in a patient with Crohn’s disease Brad E. Maltz, MD, David A. Schwartz, MD Nashville, Tennessee, USA
Patients with ulcerative colitis (UC) and Crohn’s colitis are at increased risk of developing colorectal carcinoma.1 Histologically, this is usually an adenocarcinoma. Herein, we present a case of a patient with a 7-year history of Crohn’s disease (CD) who presented with widely metastatic signet-ring carcinoma of the colon diagnosed by EUSguided FNA.
CASE REPORT A 35-year-old man presented with the chief complaint of anorexia, early satiety, and weight loss. He was diagnosed with CD 7 years earlier. A routine colonoscopy several months before presentation showed moderately active colitis. Biopsies were not performed. An abdominal radiograph revealed a dilated stomach. A CT of the abdomen demonstrated ascites and bulky retroperitoneal, mesenteric, and aortocaval lymphadenopathy (Fig. 1). An EGD was performed to rule out a gastric outlet obstruction. The EGD revealed diffusely thickened gastric mucosa and a polypoid mass in the body of the stomach (Fig. 2). No obstruction was appreciated. Biopsy specimens of the mass were consistent with chronic inflammation without dysplasia. EUS was then performed to assess the gastric wall and to evaluate the adenopathy seen on CT. EUS demonstrated ascites and bulky celiac adenopathy, but the gastric wall did not have changes suggestive of a gastric malignancy (ie, there was a normal wall-layering pattern on EUS) (Fig. 3). EUS-guided FNA of the celiac nodes and ascitic fluid was performed. Both specimens revealed signet-ring–type adenocarcinoma (Figs. 4A and B). www.giejournal.org
Figure 1. CT, showing bulky intra-abdominal adenopathy and ascites.
A colonoscopy was performed later to identify the primary lesion, and a stricture was identified at 60 cm (Fig. 5); a biopsy confirmed signet-ring-cell carcinoma of the colon. The patient died 8 weeks later, secondary to complications of his metastatic disease.
DISCUSSION Overview of colorectal cancer in inflammatory bowel disease This case demonstrates the increased risk of colon cancer associated with both UC and CD.1 The cumulative risk Volume 65, No. 6 : 2007 GASTROINTESTINAL ENDOSCOPY 945
REFERENCES 1. Patel NM. Chronic gastric volvulus. Report of a case and review of literature. Am J Gastroenterol 1985;80:170-3. 2. Bhasin DK, Nagi B, Kochhar R, et al. Endoscopic management of chronic organoaxial volvulus of the stomach. Am J Gastroenterol 1990;85:1486-8. 3. Creedon PJ, Burman JF. Volvulus of the stomach. Report of a case with complications. Am J Surg 1965;110:964-6. 4. Haddad JK, Doherty C, Clark RE. Acute gastric volvulus: endoscopic derotation. West J Med 1977;127:341-6. 5. Tod R, Danon G, Thierree RA. The gastric volvulus and absence of liver left lobe syndrome. J Radiol Electrol Med Nucl 1971;52:106-8. 6. Iliesco G, Neagu N, Splouchal J. Stomach volvulus due to liver anomalies. Bull Soc Int Chir 1968;27:557-62. 7. Sookpotarom P, Vejchapipat P, Chongsrisawat V, et al. Gastric volvulus caused by percutaneous endoscopic gastrostomy: a case report. J Pediatr Surg 2005;40:e21-3. 8. Akamatsu T, Nakamura N, Kiyosawa K, et al. Gastric volvulus in living, related liver transplantation donors and usefulness of endoscopic correction. Gastrointest Endosc 2002;55:55-7.
9. Varma JS, Wyatt JP, MacIntyre IM. Gastric volvulus caused by giant ovarian cyst. J R Coll Surg Edinb 1992;37:194. 10. Sultan J, Vassallo PP, Davis P, et al. Intermittent gastric volvulus secondary to gall bladder adhesions: a rare cause of gastric outlet obstruction. Hosp Med 2005;66:245. 11. Baty V, Rocca P, Fontaumard E. Acute gastric volvulus related to adhesions after laparoscopic fundoplication. Surg Endosc 2002;16:538.
Department of Gastroenterology, Post Graduate Institute of Medical Education and Research Chandigarh, India. Reprint requests: Deepak Kumar Bhasin, MD, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, 1041, Sector 24-B, Chandigarh – 160 023, India. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.09.015
Pancreatogastric fistulas associated with chronic pancreatitis: a case report and review of the literature Hamed A. Shabaneh Al-Tamimi, MD, Joseph Hancock, MD, Carlos Palacio, MD, Xin Yao, MD Lubbock, Texas, USA
The medical literature describes many cases of pancreatogastric fistulas arising in the setting of intraductal papillary mucinous neoplasms.1-3 Surgical specimens have identified tumor invasion, as well as an inflammatory reaction induced by the tumor, without invasion, as a cause. Chronic pancreatitis is associated with many complications. The literature describes the development of internal fistulous tracts between the pancreas and the colon4,5; the small intestine, the pleura, and the mediastinum6; and with the skin (external fistulas).7 We report a rare case of chronic relapsing pancreatitis complicated by a pancreatogastric fistula identified on ERCP.
A 55-year-old white man presented with a medical history significant for chronic alcoholic pancreatitis. The pa-
tient was transferred with a 3-day history of dull, constant, left upper-quadrant abdominal pain, which radiated to the epigastrium and the right upper-quadrant associated with nausea, constipation, anorexia, subjective fever and chills, with shortness of breath. A physical examination on admission showed a temperature of 36.7 C (98 F), the heart rate was 98 beats/min, blood pressure was 153/91 mm Hg, and the respiratory rate was 22 breaths/min. His oxygen saturation was 97% on room air. His head and neck examination was unremarkable. His chest examination showed diminished air entry at both lung bases, mainly on the right base. His cardiovascular examination showed regular S1 and S2 heart sounds, with no murmurs or gallop. The abdominal examination showed severe tenderness and rebound tenderness in the right upper quadrant, with hypoactive bowel sounds. The lower-limb examination showed no clubbing, cyanosis, or edema. The patient’s laboratory data results were a white blood cell count of 22
942 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 6 : 2007
www.giejournal.org
CASE REPORT
Brief Reports
Figure 1. CT scan of the abdomen. Notice bilateral pleural effusion, mainly on the right side.
Figure 2. CT scan of the abdomen. Notice pancreatic atrophy, calcification, and dilated pancreatic duct.
109/L (reference range, 4-10 109/L); Hb, 13.5 g/L (120160 g/L); a platelet count, 389 109/L (150-450 109/L); glucose, 5.7 mmol/L (4.4-6.4 mmol/L); serum urea nitrogen, 2.1 mmol/L (2.1-7.1 mmol/L); and creatinine, 53 mmol/L (44.2-106 mmol/L). Total protein, 55 g/L (60-80 g/L); albumin, 20 g/L (3.5-5 g/L); calcium, 2.05 mmol/L (2.1-2.6 mmol/L); total bilirubin, 16.6 mmol/L (0-17.1 mmol/L); aspartate aminotransferase, 103 U/L (0-45 U/L); alanine aminotransferase, 98 U/L (0-37 U/L); amylase, 666 U/L (25-125 U/L); and lipase, 2976 U/L (10-140 U/L). A right-sided pleural fluid thoracentesis was done and showed a pancreatic pleural effusion. The abdominal CT showed a large rightsided pleural effusion and consolidation; fluid collection around the right lateral liver margin; an enlarged pancreatic head, with calcification suggestive of chronic pancreatitis with pseudocyst; and dilated pancreatic duct and common bile duct (Fig. 2). An ERCP was done (Fig. 3). The cannulation of the pancreatic duct was only possible through the minor papilla and showed a dilated and tortuous pancreatic duct in the body and the tail, and major tortuosity in the head region, where there appeared to be a stricture and ductal deformity. Extravasation of contrast into the stomach lumen suggestive of a pancreatogastric fistula was seen. A pancreatic pseudocyst was also seen, which drained well into the pancreatic duct. Pancreatic ductal stent placement failed. The bile duct had a distal stricture, which was successfully stented by using a 7F, 9-cm biliary stent. The patient was thus managed conservatively with intravenous (IV) fluids, analgesia, IV antibiotics, and subcutaneous
Sandostatin injection (Novartis Pharmaceuticals, East Hanover, NJ), and remained stable all during his hospitalization.
www.giejournal.org
Volume 65, No. 6 : 2007 GASTROINTESTINAL ENDOSCOPY 943
DISCUSSION The occurrence of pancreatogastric fistulas has been well described in the setting of intraductal papillary mucinous neoplasm of the pancreas.1-3,8 In 1989, Hansen et al4 describe a case of chronic relapsing pancreatitis complicated by pancreatogastric and pancreatocolonic fistulas successfully treated with excision of the fistula and closure of the gastric and colonic wall. In our patient, the occurrence of the pancreatogastric fistula was merely related to the chronic relapsing pancreatitis in the absence of ulcer disease or malignancy. The mechanism behind fistula formation in the absence of cancer invasion could be either mechanical (increased main pancreatic diameter and disruption of the wall in the absence of inflammation) or secondary to acute inflammation or pseudocyst formation, with penetration or rupture into the stomach. The treatment of pancreatogastric fistulas should be individualized according to the medical status of the patient. General measures include nothing by mouth, nasogastric suction, total parenteral nutrition and Sandostatin injections. In the literature, most cases required surgery, and the general measures were used as a bridge to surgery for about 2 to 3 weeks before definitive plan for surgery was made.6
Brief Reports
Figure 3. ERCP showing dilated CBD, PD, pseudocyst, and pancreatogastric fistula.
The present case highlights that a pancreatogastric fistula can develop in the setting of chronic relapsing pancreatitis in the absence of malignancy or pancreatic pseudocyst rupture into adjacent organs and can be considered, therefore, among the rare cases described in the literature.
DISCLOSURE None of the authors have anything to disclose. 944 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 6 : 2007
REFERENCES 1. Le Corguille M, Levy P, Ponsot P, et al. Intraductal papillary mucinous tumor with pancreatobiliary and pancreatodigestive fistulae: a case report [in French with English abstract]. Gastroenterol Clin Biol 2002;26: 1172-4. 2. Koizumi M, Sata N, Yoshizawa K, et al. Post-ERCP pancreatogastric fistula associated with an intraductal papillary mucinous neoplasm of the pancreas: a case report and literature review. World J Surg Oncol 2005;3:70. 3. Fteriche FS, Chebbi F, Bedioui H, et al. Intraductal papillary mucinous tumor of the pancreas degenerated and fistulated in the stomach, the duodenum and colon. Ann Chir 2006;131:118-20.
www.giejournal.org
Brief Reports 4. Hansen CP, Christensen A, Thagaard CS, et al. Gastrocolic fistula resulting from chronic pancreatitis. South Med J 1989;82:1309-10. 5. Abeygunasekera S, Freiman J, Engelman J, et al. Gastropancreaticocolic fistula: complication of a benign ulcer. Gastrointest Endosc 2004;59: 450-2. 6. Kaman L, Behera A, Singh R, et al. Internal pancreatic fistulas with pancreatic ascites and pancreatic pleural effusions: recognition and management. ANZ J Surg 2001;71:221-5. 7. Ihse I, Larsson J, Lindstrom E. Surgical management of pure pancreatic fistulas. Hepatogastroenterology 1994;41:271-5. 8. Yago A, Fujita N, Noda Y, et al. A case of non-invasive intraductal papillary adenocarcinoma of the pancreas showing penetration of the stomach. Fukubu Gazo Shindan 1995;15:496-500.
Division of Gastroenterology, Department of Internal Medicine Texas Tech University Health Sciences Center (H.A.S.A-T., C.P., X.Y.), Southplains Gastroenterology Group (J.H.), Lubbock, Texas, USA. Reprint requests: Hamed A. Shabaneh Al-Tamimi, MD, Internal Medicine, Gastroenterology, Texas Tech University, HSC, 3601 4th Street, Lubbock, TX 79430. Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.10.011
Metastatic signet-ring carcinoma of the colon diagnosed by EUS-guided FNA in a patient with Crohn’s disease Brad E. Maltz, MD, David A. Schwartz, MD Nashville, Tennessee, USA
Patients with ulcerative colitis (UC) and Crohn’s colitis are at increased risk of developing colorectal carcinoma.1 Histologically, this is usually an adenocarcinoma. Herein, we present a case of a patient with a 7-year history of Crohn’s disease (CD) who presented with widely metastatic signet-ring carcinoma of the colon diagnosed by EUSguided FNA.
CASE REPORT A 35-year-old man presented with the chief complaint of anorexia, early satiety, and weight loss. He was diagnosed with CD 7 years earlier. A routine colonoscopy several months before presentation showed moderately active colitis. Biopsies were not performed. An abdominal radiograph revealed a dilated stomach. A CT of the abdomen demonstrated ascites and bulky retroperitoneal, mesenteric, and aortocaval lymphadenopathy (Fig. 1). An EGD was performed to rule out a gastric outlet obstruction. The EGD revealed diffusely thickened gastric mucosa and a polypoid mass in the body of the stomach (Fig. 2). No obstruction was appreciated. Biopsy specimens of the mass were consistent with chronic inflammation without dysplasia. EUS was then performed to assess the gastric wall and to evaluate the adenopathy seen on CT. EUS demonstrated ascites and bulky celiac adenopathy, but the gastric wall did not have changes suggestive of a gastric malignancy (ie, there was a normal wall-layering pattern on EUS) (Fig. 3). EUS-guided FNA of the celiac nodes and ascitic fluid was performed. Both specimens revealed signet-ring–type adenocarcinoma (Figs. 4A and B). www.giejournal.org
Figure 1. CT, showing bulky intra-abdominal adenopathy and ascites.
A colonoscopy was performed later to identify the primary lesion, and a stricture was identified at 60 cm (Fig. 5); a biopsy confirmed signet-ring-cell carcinoma of the colon. The patient died 8 weeks later, secondary to complications of his metastatic disease.
DISCUSSION Overview of colorectal cancer in inflammatory bowel disease This case demonstrates the increased risk of colon cancer associated with both UC and CD.1 The cumulative risk Volume 65, No. 6 : 2007 GASTROINTESTINAL ENDOSCOPY 945