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Risk Assessment of Patients with Non-Variceal Upper Gastrointestinal Bleeding Using the Rockall Score
Abstracts
M1333 Endoscopic Resection of Elevated Lesions in the Small Bowel by Using Double-Balloon Endoscopy Yoshikazu Hayashi, Hironori Yamamoto, Hiroto Kita, Hiroyuki Sato, Keijiro Sunada, Michiko Iwamoto, Hironari Ajibe, Hisashi Hachimori, Toru Takamatsu, Katsunori Ito, Satoshi Shinozaki, Tomohiko Miyata, Tomonori Yano, Akiko Kuno, Kenichi Ido, Kentaro Sugano Background: Double-balloon endoscopy (DBE) enables endoscopic scrutiny of the entire small bowel with intervention capabilities; targeted biopsy as well as endoscopic treatments including electrocoagulation, clip placement, balloon dilatation, and polypectomy are possible. The aim of this study was to clinically evaluate the patients in whom small bowel elevated lesions were endoscopically resected with DBE. Methods: We have analyzed 5 consecutive patients with elevated lesions in the small bowel that were endoscopically resected with DBE among 201 patients that have undergone DBE between September 2000 and November 2004 at Jichi medical school hospital in Japan. Results: Case 1: 69-year-old man with a history of Roux-en-Y gastrojejunostomy. There was an elevated lesion in the cecum of the afferent loop found by DBE during the examination of persistent diarrhea and eosinophilia. Endoscopic mucosal resection (EMR) was completed and pathological diagnosis of the resected specimen was well-differentiated adenocarcinoma. Case 2: 58-year-old woman with overt gastrointestinal bleeding. Hemorrhagic small bowel polyp was identified by capsule endoscopy. The polyp was also found in the upper ileum by DBE and resected endoscopically. Case 3: 83-year-old woman with elevated lesion in the terminal ileum incidentally found by colonoscopy. The lesion was endoscopically resected with DBE. Case 4: 40-year-old man with Peutz-Jeghers syndrome. He had a history of partial enterectomy for bowel obstruction induced by a small-intestinal polyp. DBE found multiple small–intestinal polyps, 6-30 mm in diameter, and polypectomy was carried out. Case 5: 16-year-old man with a history of total colectomy for multiple colon polyps and partial enterectomy for multiple smallintestinal polyps. DBE found more than fifty polyps in the small intestine and eighteen polyps of them in total were endoscopically resected using DBE. No significant complications encountered in these 5 cases except for minor bleeding after the polypectomy in case 2. Conclusions: Small bowel elevated lesions were resected by EMR or polypectomy using DBE without considerable complicaitons. Polyps in the small bowel are best removed endoscopically using DBE.
M1334 Double Balloon Enteroscopy: The Dutch One Year Experience Indications, Yield, and Complications in a Series of 125 Cases Dimitri G. Heine, Muhammed Hadithi, Marcel J. Groenen, Ernst J. Kuipers, Maarten A. Jacobs, Chris Mulder Background: With the advent of the double balloon endoscopy method (DBE, Fujinon Japan) enabling true full length enteroscopy for the first time, a major shortcoming of conventional methods has been surpassed. With this new technique 125 patients were investigated in the first year after introduction in the Netherlands in September 2003. The results of this series with regard to indications, diagnostic yield, therapeutic interventions and safety are presented. Methods: Double balloon enteroscopy was performed in 125 patients. The main indication was unidentified GI blood loss (80/125 Z 64%), followed by refractory celiac disease (17/125 Z 13,6%), suspected Crohn’s disease (9/125 Z 7,2%), hereditary tumours (8/125 Z 6,4%), others (8/125 Z 6,4%), and protein losing enteropathy (3/125 Z 2,4%). Midazolam was used for sedation; average dose 12,5 mg. Insertion length was measured. Treatment of angiodysplasias was performed upon antegrade encounter. In a small series an inquiry into per- and post -procedure comfort was performed. All patients were monitored for complications. An interobserver blinded conventional enteroclysis was performed before DBE in 55% of patients Results: 122 patients were approached orally, 3 via the colon, 11 from both sides. Average insertion length was 280 cm. The average procedure duration was 82 min (range 55 to 190), mainly as a result of intentionally restricted procedure duration. An explanation for GI blood loss was found in (56/80 Z 70%) mostly angiodysplasias of which almost 100% were removed without further blood loss after 2,2 consecutive DBE C APC sessions. Surprisingly also 6 malignant neoplasias (4 lymphoma’s/2 melanoma’s) were found in the GI blood loss group. In the refractory celiacs (4/17 Z 23,5%) EATLs were diagnosed. Crohn’s disease was diagnosed in (2/9 Z 22,2%). Protein losing enteropathy revealed a lymphoma in one and lymphangiectasia in another case. Patient tolerability was excellent and was judged ‘‘comparable to unsedated gastroscopy’’ on inquiry. Two complications occurred: one case of intra-abdominal abscesses after combined endoscopic – surgical treatment for Peutz Jeghers obstruction, one case of mild pancreatitis probably because of balloon inflation at the ampulla of Vater. Conclusion: Double balloon enteroscopy is a safe endoscopic technique with a high diagnostic yield in selected patients and excellent patient tolerability. In the group with GI blood loss a surprising number of malignant neoplasias are found.
AB166 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
M1335 A Prospective Comparison of Capsule Endoscopy, Enteroclysis and Enteroscopy in Peutz-Jeghers Syndrome David G. Hewett, Jillian M. O’Neil, John C. Gibbons, Paul Tesar, Mark N. Appleyard Background: Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps throughout the gastrointestinal tract, most frequently in the small intestine. Management centres on the prevention of gastrointestinal complications arising from small bowel polyposis. Small bowel radiography is recommended to reduce the risk of complications. Capsule endoscopy is a promising technique for endoscopic surveillance of small bowel polyposis. Aims: To compare polyp detection rates in patients with known PJS, using capsule endoscopy (CE), small bowel enteroclysis (SBE) and push enteroscopy (PE). Methods: 14 patients with established PJS were enrolled prospectively and 11 (4M7F) have completed evaluation (mean age/range M27.2/17-39, F30.6/17-57). After initial clinical evaluation to confirm the diagnosis, patients were evaluated by blinded investigators. All patients underwent SBE and CE before proceeding to PE when possible. SBE was performed by an expert gastrointestinal radiologist, using naso-jejunal intubation and double contrast technique (barium, methylcellulose and water). PE was performed by an experienced endoscopist using an Olympus SIF140 250 cm enteroscope. Polyps were deemed to be clinically significant when R1 cm (as measured at fluoroscopy, or at PE using an open biopsy forcep technique, or when occupying the majority of the lumen on CE). Patients were referred for surgery where clinically appropriate. Results: 3 patients (27%) did not tolerate nasojejunal intubation for SBE, and the procedure was performed as a barium meal with follow through. The difference between the mean number of polyps detected by SBE (0.54, range 0-1) and CE (2.63, range 0-10) approached statistical significance (p Z 0.06). PE was undertaken in 8 patients (4M4F) and the mean number of polyps found was 2.42. Conclusions: These data suggest that capsule endoscopy should be the first-line investigation of the small bowel in PJS, rather than small bowel enteroclysis. In comparison with CE, SBE appears to have poor sensitivity in detecting clinically significant small bowel polyps. PE confirmed the presence of proximal polyps found on CE. CE may have underestimated the number of large polyps clustered in the proximal small bowel (as is common in PJS). CE did detect a number of distal polyps not identified on PE. Capsule endoscopy findings can be used to direct subsequent management (surgery or PE) depending on the location of the polyps.
M1336 Risk Assessment of Patients with Non-Variceal Upper Gastrointestinal Bleeding Using the Rockall Score Martin Hunstiger, Werner Schmidbaur, Juergen Barnert, Thomas Eberl, Reinhard Fleischmann, Reinhard Scheubel, Max Bittinger, Gertrud Jechart, Andreas Probst, Helmut Messmann The Rockall score is one of the best known scoring system which was developed to predict recurrent hemorrhage and mortality in patients with acute upper gastrointestinal bleeding. However, until now scoring systems are not widely accepted in daily clinical use. Aim: Of the study was a retrospective evaluation of the Rockall score to analyse its use in the prediction of rebleeding and mortality in patients presenting with signs of upper gastrointestinal hemorrhage (e.g. hematemesis) in our emergency unit. Methods: 237 patients (95 female/142 male; 22-95 years, median age 72 years) with a history or clinical signs of an upper gastrointestinal bleeding were registered in our emergency unit in a 12-month period (from 6/03 to 6/04). All patients were examined by oesophagogastroduodenoscopy within 12 hours after admission. The Rockall score includes 3 nonendoscopic (age, shock, and comorbidity) and 2 endoscopic variables (endoscopic diagnosis and presence or absence of endoscopic stigmata of recent hemorrhage), which were analysed for each patient retrospectively. Results:
Conclusion: We find a very good reliability of the Rockall score in identifying patients with a low risk for complications of upper gastrointestinal bleeding such as rebleeding or death. The Rockall score is a useful parameter to manage patients with non-variceal upper gastrointestinal bleeding as in– or outpatients.
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M1333 Endoscopic Resection of Elevated Lesions in the Small Bowel by Using Double-Balloon Endoscopy Yoshikazu Hayashi, Hironori Yamamoto, Hiroto Kita, Hiroyuki Sato, Keijiro Sunada, Michiko Iwamoto, Hironari Ajibe, Hisashi Hachimori, Toru Takamatsu, Katsunori Ito, Satoshi Shinozaki, Tomohiko Miyata, Tomonori Yano, Akiko Kuno, Kenichi Ido, Kentaro Sugano Background: Double-balloon endoscopy (DBE) enables endoscopic scrutiny of the entire small bowel with intervention capabilities; targeted biopsy as well as endoscopic treatments including electrocoagulation, clip placement, balloon dilatation, and polypectomy are possible. The aim of this study was to clinically evaluate the patients in whom small bowel elevated lesions were endoscopically resected with DBE. Methods: We have analyzed 5 consecutive patients with elevated lesions in the small bowel that were endoscopically resected with DBE among 201 patients that have undergone DBE between September 2000 and November 2004 at Jichi medical school hospital in Japan. Results: Case 1: 69-year-old man with a history of Roux-en-Y gastrojejunostomy. There was an elevated lesion in the cecum of the afferent loop found by DBE during the examination of persistent diarrhea and eosinophilia. Endoscopic mucosal resection (EMR) was completed and pathological diagnosis of the resected specimen was well-differentiated adenocarcinoma. Case 2: 58-year-old woman with overt gastrointestinal bleeding. Hemorrhagic small bowel polyp was identified by capsule endoscopy. The polyp was also found in the upper ileum by DBE and resected endoscopically. Case 3: 83-year-old woman with elevated lesion in the terminal ileum incidentally found by colonoscopy. The lesion was endoscopically resected with DBE. Case 4: 40-year-old man with Peutz-Jeghers syndrome. He had a history of partial enterectomy for bowel obstruction induced by a small-intestinal polyp. DBE found multiple small–intestinal polyps, 6-30 mm in diameter, and polypectomy was carried out. Case 5: 16-year-old man with a history of total colectomy for multiple colon polyps and partial enterectomy for multiple smallintestinal polyps. DBE found more than fifty polyps in the small intestine and eighteen polyps of them in total were endoscopically resected using DBE. No significant complications encountered in these 5 cases except for minor bleeding after the polypectomy in case 2. Conclusions: Small bowel elevated lesions were resected by EMR or polypectomy using DBE without considerable complicaitons. Polyps in the small bowel are best removed endoscopically using DBE.
M1334 Double Balloon Enteroscopy: The Dutch One Year Experience Indications, Yield, and Complications in a Series of 125 Cases Dimitri G. Heine, Muhammed Hadithi, Marcel J. Groenen, Ernst J. Kuipers, Maarten A. Jacobs, Chris Mulder Background: With the advent of the double balloon endoscopy method (DBE, Fujinon Japan) enabling true full length enteroscopy for the first time, a major shortcoming of conventional methods has been surpassed. With this new technique 125 patients were investigated in the first year after introduction in the Netherlands in September 2003. The results of this series with regard to indications, diagnostic yield, therapeutic interventions and safety are presented. Methods: Double balloon enteroscopy was performed in 125 patients. The main indication was unidentified GI blood loss (80/125 Z 64%), followed by refractory celiac disease (17/125 Z 13,6%), suspected Crohn’s disease (9/125 Z 7,2%), hereditary tumours (8/125 Z 6,4%), others (8/125 Z 6,4%), and protein losing enteropathy (3/125 Z 2,4%). Midazolam was used for sedation; average dose 12,5 mg. Insertion length was measured. Treatment of angiodysplasias was performed upon antegrade encounter. In a small series an inquiry into per- and post -procedure comfort was performed. All patients were monitored for complications. An interobserver blinded conventional enteroclysis was performed before DBE in 55% of patients Results: 122 patients were approached orally, 3 via the colon, 11 from both sides. Average insertion length was 280 cm. The average procedure duration was 82 min (range 55 to 190), mainly as a result of intentionally restricted procedure duration. An explanation for GI blood loss was found in (56/80 Z 70%) mostly angiodysplasias of which almost 100% were removed without further blood loss after 2,2 consecutive DBE C APC sessions. Surprisingly also 6 malignant neoplasias (4 lymphoma’s/2 melanoma’s) were found in the GI blood loss group. In the refractory celiacs (4/17 Z 23,5%) EATLs were diagnosed. Crohn’s disease was diagnosed in (2/9 Z 22,2%). Protein losing enteropathy revealed a lymphoma in one and lymphangiectasia in another case. Patient tolerability was excellent and was judged ‘‘comparable to unsedated gastroscopy’’ on inquiry. Two complications occurred: one case of intra-abdominal abscesses after combined endoscopic – surgical treatment for Peutz Jeghers obstruction, one case of mild pancreatitis probably because of balloon inflation at the ampulla of Vater. Conclusion: Double balloon enteroscopy is a safe endoscopic technique with a high diagnostic yield in selected patients and excellent patient tolerability. In the group with GI blood loss a surprising number of malignant neoplasias are found.
AB166 GASTROINTESTINAL ENDOSCOPY Volume 61, No. 5 : 2005
M1335 A Prospective Comparison of Capsule Endoscopy, Enteroclysis and Enteroscopy in Peutz-Jeghers Syndrome David G. Hewett, Jillian M. O’Neil, John C. Gibbons, Paul Tesar, Mark N. Appleyard Background: Peutz-Jeghers syndrome (PJS) is characterized by the presence of hamartomatous polyps throughout the gastrointestinal tract, most frequently in the small intestine. Management centres on the prevention of gastrointestinal complications arising from small bowel polyposis. Small bowel radiography is recommended to reduce the risk of complications. Capsule endoscopy is a promising technique for endoscopic surveillance of small bowel polyposis. Aims: To compare polyp detection rates in patients with known PJS, using capsule endoscopy (CE), small bowel enteroclysis (SBE) and push enteroscopy (PE). Methods: 14 patients with established PJS were enrolled prospectively and 11 (4M7F) have completed evaluation (mean age/range M27.2/17-39, F30.6/17-57). After initial clinical evaluation to confirm the diagnosis, patients were evaluated by blinded investigators. All patients underwent SBE and CE before proceeding to PE when possible. SBE was performed by an expert gastrointestinal radiologist, using naso-jejunal intubation and double contrast technique (barium, methylcellulose and water). PE was performed by an experienced endoscopist using an Olympus SIF140 250 cm enteroscope. Polyps were deemed to be clinically significant when R1 cm (as measured at fluoroscopy, or at PE using an open biopsy forcep technique, or when occupying the majority of the lumen on CE). Patients were referred for surgery where clinically appropriate. Results: 3 patients (27%) did not tolerate nasojejunal intubation for SBE, and the procedure was performed as a barium meal with follow through. The difference between the mean number of polyps detected by SBE (0.54, range 0-1) and CE (2.63, range 0-10) approached statistical significance (p Z 0.06). PE was undertaken in 8 patients (4M4F) and the mean number of polyps found was 2.42. Conclusions: These data suggest that capsule endoscopy should be the first-line investigation of the small bowel in PJS, rather than small bowel enteroclysis. In comparison with CE, SBE appears to have poor sensitivity in detecting clinically significant small bowel polyps. PE confirmed the presence of proximal polyps found on CE. CE may have underestimated the number of large polyps clustered in the proximal small bowel (as is common in PJS). CE did detect a number of distal polyps not identified on PE. Capsule endoscopy findings can be used to direct subsequent management (surgery or PE) depending on the location of the polyps.
M1336 Risk Assessment of Patients with Non-Variceal Upper Gastrointestinal Bleeding Using the Rockall Score Martin Hunstiger, Werner Schmidbaur, Juergen Barnert, Thomas Eberl, Reinhard Fleischmann, Reinhard Scheubel, Max Bittinger, Gertrud Jechart, Andreas Probst, Helmut Messmann The Rockall score is one of the best known scoring system which was developed to predict recurrent hemorrhage and mortality in patients with acute upper gastrointestinal bleeding. However, until now scoring systems are not widely accepted in daily clinical use. Aim: Of the study was a retrospective evaluation of the Rockall score to analyse its use in the prediction of rebleeding and mortality in patients presenting with signs of upper gastrointestinal hemorrhage (e.g. hematemesis) in our emergency unit. Methods: 237 patients (95 female/142 male; 22-95 years, median age 72 years) with a history or clinical signs of an upper gastrointestinal bleeding were registered in our emergency unit in a 12-month period (from 6/03 to 6/04). All patients were examined by oesophagogastroduodenoscopy within 12 hours after admission. The Rockall score includes 3 nonendoscopic (age, shock, and comorbidity) and 2 endoscopic variables (endoscopic diagnosis and presence or absence of endoscopic stigmata of recent hemorrhage), which were analysed for each patient retrospectively. Results:
Conclusion: We find a very good reliability of the Rockall score in identifying patients with a low risk for complications of upper gastrointestinal bleeding such as rebleeding or death. The Rockall score is a useful parameter to manage patients with non-variceal upper gastrointestinal bleeding as in– or outpatients.
www.mosby.com/gie