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Push enteroscopy in celiac disease: Endoscopic and histological findings
*4350 GASTRIC CANCER SCREENING IN ASYM:PTOMATIC JAPANESE AMERICANS USING SERUM P E P S I N O G E N LEVELS AND ENDOSCOPY Hubert Nietsch, Univ of Washington, Seattle, WA; Tsukasa Namekata, Pacific Rim Disease Prevention Ctr, Seattle, WA; Cyrus E. Rubin, Univ of Washington, Seattle, WA; Kazuraasa Miki, Toho Univ, Tokyo Japan; Michael B. Kimmey, Univ of Washington, Seattle, WA Screening for gastric cancer is commonly performed in Japan and some other countries with a high prevalence of gastric cancer but has not been accepted in low prevalence countries such as the United States. Nevertheless, some ethnic populations in the U.S. such as most Asian Americans are at increased risk for developing gastric cancer. OBJECTIVE: The pepsinogen method which has been used in Japan for gastric cancer screening was applied to a cohort of Japanese Americans to determine the yield and feasibility of screening for gastric cancer in the United States. METHODS: Sera from 776 asymptomatic Seattle residents of Japanese descent were serologically screened for H. pylori (immunosorbent assay) and for pepsinogen I (PG I) and pepsinogen II (PG II) by radioimmunoassay. 69 out of 103 subjects with PG I levels < 70 ;ag/l and PGI/II ratios < 3.0 consented to upper endoscopy to screen for gastric neoplasia. There were 44 men and 25 women with a mean age of 65 (range 31 - 81). Nine representative gastric mucosal biopsies were obtained to map the extent and location of intestinal metaplasia (IM). RESULTS: Adenomas were detected in two subjects (2.9%) with IM and were removed endoscopically. No cancers were found. 42 (61%) individuals had abnormal findings on endoscopy including nodularity (n=21), pallor (n=9), diffuse erythema (n=9) and antral erosions (n=3). Intestinal metaplasia (IM) was confirmed on biopsy in 57 subjects (83%), with the greatest yield found on biopsies taken from the angularis and the antrum. Abnormal endoscopic appearance did not accurately predict the presence of IM on histopathology with a sensitivity, specificity and PPV of only 61.4%, 41.7% and 83.3% respectively. CONCLUSIONS: Screening U.S. populations with an increased risk of gastric cancer using serum pepsinogens to select candidates for endoscopy is feasible and detected gastric neoplasia in 2.9% in this cohort, comparable to findings in Japan using this screening method. Serum pepsinogen testing also detects individuals with intestinal metaplasia who may be candidates for gastric cancer surveillance. Endoscopic mucosal appearance is a poor predictor of gastric intestinal metaplasia. "4351 WHAT TYPE OF ERYTHEMAS R E F L E C T H E L I C O B A C T E R PYLORI INFECTION? Yoshihisa Urita, Kazuo Hike, Naotaka Torii, Yoshinobu Kikuchi, Eiko Kanda, Masahiko Sasajima, Motonobu 0zaki, Kazumasa Miki, First Dept of Internal Medicine, Toho Univ, Tokyo Japan Background: Although endoscopic findings, including antral nodularity and large gastric folds, have been suggested to be a sign of Helicobaeter pylori IH.pylori) infection, it is uncertain what type of erythemas are produced by H.pylori-infected chronic gastritis. We therefore identified the type of erythema associated with H.pylori-infected gastritis. Patients and Methods: A total of 590 consecutive patients (mean age 58.7(19-85), M/F= 185/405 ) attending our hospital for diagnostic upper gastrointestinal endoscopy were recruited in this study. We assessed endoscopically the type of erythema, including spotty erythema, haemorrhagic erosion, reddish streaks , and raised erosion, because it was difficult to adequately diagnose and find endoscopic features such as edema, nodularity, granularity, friability, surface texture, and color of mucosa. H.pylori infection was established by a positive endoscopic 13C-urea breath test (e-UBT). Results: Of the 402 H.pylori-positive subjects, spotty erythemas in the corpus were found in 177 ~44.0%), haemorrhagic erosions in 26 (6.5%), reddish streaks in the antrum in 21 (5.2%) and in the corpus in 10 (2.5%), and raised erosions in the antrum in 58 (14.4%) and in the corpus in 4 (1.0%). For spotty erythema in the upper body, sensitivity was 44.0%, specificity was 92.6%, positive predictive value was 92.7%, and negative predictive value was 43.6% for H.pylori infection. Seventy-two (86.7%) of 83 patients with antral reddish streaks and 65 (52.8%) of 123 with antral raised erosions were decided as H.pylori-negative by e-UBT. The odds ratios for reddish streaks, raised erosion, and haemorrhagic erosion were under 1.0. Conclusions: Spotty erythema in the corpus was considered to be one of endoscopic findings which reflect H.pylori infection. In contrast, it was suggested that antral reddish streaks and raised erosions indicated the absence of H.pylori. *4352 PUSH ENTEROSCOPY IN CELIAC DISEASE: ENDOSCOPIC AND I~HSTOLOGICAL FINDINGS Matthew Priest, John F. Mackenzie, John Morris, Glasgow Royal Infirmary, Glasgow United Kingdom Background Endoscopic small bowel biopsy is the investigation of choice in celiac disease (CD) and the endoscopic appearances of this condition are well documented. We report a retrospective review of mueosal appearances
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at push enteroscopy (PE) compared with the histology obtained during these procedures. Methods 127 procedures were performed on 102 patients (38 male, 64 female, mean age 51.1 years) with endoscopic or histological features of CD. The indications for enteroscopy were as follows: investigation of malabsorption n=34, disease follow up n=65, refractory sprue n=28. Results A comparison between enteroscopic and histological appearances is shown in Table 1. T h e endoscopic assessment was accurate in only 78.7% of procedures. In 14 procedures (11%) endoscopic features suggestive of CD were reported but histology was normal, and in 13 procedures (10.2%) enteroscopy appeared normal but histology showed villous atrophy. Ulceration was correctly identified in 11 patients (10.8% of the total population) of which 6 (54.5%} had suspected refractory sprue, 3 (27.3%) were having routine follow up and in 2 (18.2%) cases ulceration was present at diagnosis. The histological diagnosis in these patients was: enteropathy associated T cell lymphoma (EATL) n=6, B cell lymphoma n=l, adenocarcinoma n=l, ulcerative jejunitis (UJ) n=3. In only 1 case (9.1%} was ulceration identified within reach of the standard gastroscope. Conclusions Small bowel biopsy remains essential for diagnosis and disease follow up in celiac disease. Push enteroscopy is useful in the investigation of patients with suspected complication of CD. The classical endoscopic features of CD are recognised throughout the proximal jejunum, however milder changes in villous architecture are more difficult to detect endoscopically. Table 1 Comparisonof endoscopicand histologicalappearances
Enteroscopic appearances . Normal (n=23) Mild features of CD (n=24) Classical features of CD (n=80)
Normal (n=24)
Histology Minor villous blunting (n=36)
10 (43,5%) 10 (41.7%) 4
11 (47.8%) 11 (45.8%) 14
(5%)
(17.5%)
Subtotal villous atrophy {n=66) 2 (8.7%) 3 (12.5%)
62 (77.5%)
*4353 PLACEMENT OF D I R E C T PERCUTANEOUS E N D O S C O P I C JEJUNOSTOMY TUBE IN PATIENTS WITH COMPLICATIONS FOLLOWING ESOPHAGEAL RESECTION Jack Thomas S. Bueno, Rafael Barrera, Hans Gerdes, Moshe Shike, Memorial Sloan-Kettering Cancer Ctr, New York, NY Background: Esophagectomy performed for cancer and Barrett's esophagus with high-grade dysplasia remains a major operation with a significant mortality and morbidity rate. Development of anastomotic leaks, fistulas, sepsis, respiratory insufficiency and aspiration post-operatively often preclude oral intake and lead to dependence on total parenteral nutrition (TPN) for support. Placement of a direct percutaneous endoscopic jejunostomy tube (PEJ) allows enteral feeding even in the presence of post-operative complications, thus eliminating the need for TPN. Methods: A prospective TPN database was used to identify all patients who had undergone esophagectomy and required TPN support. Records of all consecutive patients from this database who underwent PEJ placement during the immediate post-operative period from February 1996 to July 2000 were reviewed. Factors that were analyzed include age, indication for PEJ placement, number of days post-surgery PEJ placement was performed, procedural complications, number of days needed to discontinue TPN, mean number of calories received, and patients' outcome. Results: There were 19 patients referred for PEJ placement during the study period. The mean age was 68 yo (range 45-82 yo). Indications for the procedure were anastomotic leak (15), recurrent aspiration (3l, and tracheo-esophageal fistula (1). Twenty attempts at PEJ placement were made at a mean of 32 days (range 13-53 days) post-esophagectomy. This was successful in 16 patients (80%). All patients were dependent on TPN prior to PEJ placement. In all cases, enteral feeding was started on the day of tube placement. Patients were weaned offTPN support at a mean of 2.5 days (range 1-6 days) after PEJ placement. The mean caloric intake through the PEJ was 2076 kcal/day (range 1526-3180 kcal/day). There were no major complications. Six patients (31%) had minor complications (abdominal pain, erythema, diarrhea, and dislodgement). Eight of the ten patients discharged from the hospital were able to resume po intake with eventual removal of the PEJ at a mean of 91 days (range 20-300 days) after tube placement. Six patients expired for reasons unrelated to the PEJ placement at a mean of 20 days (range 5-40 days) after the procedure. Conclusion: Direct PEJ placement is a safe and effective method of providing long-term complete enteral nutrition in patients with complications following esophagectomy.
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at push enteroscopy (PE) compared with the histology obtained during these procedures. Methods 127 procedures were performed on 102 patients (38 male, 64 female, mean age 51.1 years) with endoscopic or histological features of CD. The indications for enteroscopy were as follows: investigation of malabsorption n=34, disease follow up n=65, refractory sprue n=28. Results A comparison between enteroscopic and histological appearances is shown in Table 1. T h e endoscopic assessment was accurate in only 78.7% of procedures. In 14 procedures (11%) endoscopic features suggestive of CD were reported but histology was normal, and in 13 procedures (10.2%) enteroscopy appeared normal but histology showed villous atrophy. Ulceration was correctly identified in 11 patients (10.8% of the total population) of which 6 (54.5%} had suspected refractory sprue, 3 (27.3%) were having routine follow up and in 2 (18.2%) cases ulceration was present at diagnosis. The histological diagnosis in these patients was: enteropathy associated T cell lymphoma (EATL) n=6, B cell lymphoma n=l, adenocarcinoma n=l, ulcerative jejunitis (UJ) n=3. In only 1 case (9.1%} was ulceration identified within reach of the standard gastroscope. Conclusions Small bowel biopsy remains essential for diagnosis and disease follow up in celiac disease. Push enteroscopy is useful in the investigation of patients with suspected complication of CD. The classical endoscopic features of CD are recognised throughout the proximal jejunum, however milder changes in villous architecture are more difficult to detect endoscopically. Table 1 Comparisonof endoscopicand histologicalappearances
Enteroscopic appearances . Normal (n=23) Mild features of CD (n=24) Classical features of CD (n=80)
Normal (n=24)
Histology Minor villous blunting (n=36)
10 (43,5%) 10 (41.7%) 4
11 (47.8%) 11 (45.8%) 14
(5%)
(17.5%)
Subtotal villous atrophy {n=66) 2 (8.7%) 3 (12.5%)
62 (77.5%)
*4353 PLACEMENT OF D I R E C T PERCUTANEOUS E N D O S C O P I C JEJUNOSTOMY TUBE IN PATIENTS WITH COMPLICATIONS FOLLOWING ESOPHAGEAL RESECTION Jack Thomas S. Bueno, Rafael Barrera, Hans Gerdes, Moshe Shike, Memorial Sloan-Kettering Cancer Ctr, New York, NY Background: Esophagectomy performed for cancer and Barrett's esophagus with high-grade dysplasia remains a major operation with a significant mortality and morbidity rate. Development of anastomotic leaks, fistulas, sepsis, respiratory insufficiency and aspiration post-operatively often preclude oral intake and lead to dependence on total parenteral nutrition (TPN) for support. Placement of a direct percutaneous endoscopic jejunostomy tube (PEJ) allows enteral feeding even in the presence of post-operative complications, thus eliminating the need for TPN. Methods: A prospective TPN database was used to identify all patients who had undergone esophagectomy and required TPN support. Records of all consecutive patients from this database who underwent PEJ placement during the immediate post-operative period from February 1996 to July 2000 were reviewed. Factors that were analyzed include age, indication for PEJ placement, number of days post-surgery PEJ placement was performed, procedural complications, number of days needed to discontinue TPN, mean number of calories received, and patients' outcome. Results: There were 19 patients referred for PEJ placement during the study period. The mean age was 68 yo (range 45-82 yo). Indications for the procedure were anastomotic leak (15), recurrent aspiration (3l, and tracheo-esophageal fistula (1). Twenty attempts at PEJ placement were made at a mean of 32 days (range 13-53 days) post-esophagectomy. This was successful in 16 patients (80%). All patients were dependent on TPN prior to PEJ placement. In all cases, enteral feeding was started on the day of tube placement. Patients were weaned offTPN support at a mean of 2.5 days (range 1-6 days) after PEJ placement. The mean caloric intake through the PEJ was 2076 kcal/day (range 1526-3180 kcal/day). There were no major complications. Six patients (31%) had minor complications (abdominal pain, erythema, diarrhea, and dislodgement). Eight of the ten patients discharged from the hospital were able to resume po intake with eventual removal of the PEJ at a mean of 91 days (range 20-300 days) after tube placement. Six patients expired for reasons unrelated to the PEJ placement at a mean of 20 days (range 5-40 days) after the procedure. Conclusion: Direct PEJ placement is a safe and effective method of providing long-term complete enteral nutrition in patients with complications following esophagectomy.
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AB209