- Email: [email protected]
Sa1708 Endoscopic Resection Outcomes of Duodenal Brunner's Gland Adenoma
Abstracts
upper endoscopic procedures (OR 1.15, 95%CI 1.04 - 1.27), diabetes with end organ damage (OR 1.89, 95%CI 1.07 - 3.35), connective tissue disease (OR 2.09, 95%CI 1.1 - 4.0), Charlson comorbidity index (OR 1.11, 95%CI 1.02 - 1.20), and increasing transfusion requirements (3-9 units OR 1.72, 95%CI 1.13 - 2.63; ⱖ10 units OR 2.85, 95%CI 1.89 - 4.30) were significantly associated with positive findings on CE (all p ⬍ 0.027). Following multivariable analysis, only increasing transfusion requirements (3-9 units OR 1.63, 95%CI 1.04 - 2.56; ⱖ10 units OR 2.63, 95%CI 1.62 - 4.26) and connective tissue disease (OR 2.18, 95%CI 1.09 4.31) remained significant (all p ⬍ 0.033). Conclusions: While a number of trends were seen in the univariable analysis, only transfusion requirements and the presence of connective tissue disease were identified as significant factors associated with positive outcomes in the multivariable analysis. The low number of positive predictors limits our ability to utilize demographic and clinical factors as a tool to improve efficiency in selecting patients for CE.
Change to selective COX-2 inhibitor Reduced number of medications Continuation of the same medications Follow-up duration, months, mean ⴞ SD Rebleeding, number (%)
Total (nⴝ53)
Continuation of causative medications (nⴝ31)
Discontinuation of causative medications (nⴝ22)
4 (7.5)
0 (0.0)
4 (18.2)
4 (7.5)
4 (12.9)
0 (0.0)
27 (50.9)
27 (87.1)
0 (0.0)
24.5 ⫾ 12.7
26.7 ⫾ 11.5
21.5 ⫾ 14.0
0.142
11 (20.8)
2 (6.5)
9 (40.9)
0.002
p value
NSAID, non-steroidal anti-inflammatory drug; CE, capsule endoscopy.
Sa1706 Cessation of Potentially Causative Medications Decreases Rebleeding Rate in Patients of Obscure GI Bleeding Without Definite Lesions on Capsule Endoscopy Soung Min Jeon*, Bae Hwan Kim, Jeong Eun Shin, Hyun Deok Shin, Suk Bae Kim, Sung Hoon Moon, Hong-Ja Kim, Il Han Song Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea Background and Aims: In patients of obscure GI bleeding (OGIB) without definite findings on capsule endoscopy(CE), rebleeding is a difficult-to-predict problem and a treatment of choice to prevent their rebleeding is not clear. The aim of this study was to assess whether, in patients without diagnostic findings in CE, discontinuation of potentially causative medications decreased rebleeding rate, or not. Methods: This retrospective study involved a total of 53 patients who had undergone CE for OGIB, but discharged without subsequent therapeutic enteroscopy because of non-diagnostic findings of CE between January 2008 and February 2011 at Dankook University Hospital (DKUH). In 31 patients among them, potentially causative medications were discontinued. However, in 22 patients, the medications should be continuous due to the risk of cardiovascular attack or severe symptoms. The prevalence of recurrent bleeding was compared between two groups and risk factors of rebleeding were analyzed with a few variables including continuation of causative medications. Results: The basic characteristics including age, sex, initial symptoms of OGIB, initial level of hemoglobin, and findings of CE were not different significantly between two groups. However, patients (n⫽22) whose medications should be continuous had more underlying diseases and took more causative medications (mean number of underlying diseases, 1.9⫾0.8 vs 1.3⫾0.5, p⫽0.002; mean number of causative medications, 1.7⫾0.6 vs 1.1⫾0.3, p⬍0.001). During mean follow-up period of 24.5⫾12.7 months, rebleeding rates were 40.9% in cases whose medications could not be ceased and 6.5% in patients whose causative medications were discontinued, respectively (p⫽0.002). On multivariate analysis of risk factors for rebleeding after discharge in patients of OGIB without definite lesions on capsule endoscopy, continuation of medication was uniquely a significant risk factor (odds ratio, 8.987; 95% confidence interval, 1.035-78.072; p⫽0.047). Conclusions: In patients with non-diagnostic CE results, cessation of potentially causative medications is a treatment of choice in terms of prevention of recurrent bleeding of OGIB. If it is impossible to discontinue potentially causative medications due to risk of cardiovascular events and severe symptoms, further diagnosis and therapy such as enteroscopy as well as close observation should be considered for significantly higher rebleeding rate. Table. Potentially causative medications, findings of capsule endoscopy and rebleeding rates during follow-up period
Potentially causativ medications, number of cases*(%) Low-dose aspirin NSAID Wafarin Clopidogrel Cilostazole Others(herbal medications, etc.) Findings of CE Negative** Suspicious*** Adjustment of medications, number (%) Discontinuation of all medications
Total (nⴝ53)
Continuation of causative medications (nⴝ31)
Discontinuation of causative medications (nⴝ22)
33 (62.3) 17 (32.1) 4 (7.5) 12 (22.6) 4 (7.5) 2 (3.8)
17 (54.8) 12 (38.7) 0 (0.0) 2 (6.5) 1 (3.2) 2 (6.5)
16 (72.7) 5 (22.7) 4 (18.2) 10 (45.5) 3 (13.6) 0 (0.0)
22 (41.5) 31 (58.5)
15 (48.4) 16 (51.6)
7 (31.8) 15 (68.2)
p value
0.186 0.219 0.014 0.001 0.157 0.225 0.228
⬍0.001 18 (34.0)
0 (0.0)
18 (81.8)
*Number of cases can be counted several times in a patient using multiple drugs. **Negative result denotes normal small-bowel mucosa on CE. ***Suspicious findings include suspicious mucosal changes, such as small isolated vascular ectasia, red spots, and single small erosion, but without definite relationship with bleeding.
Sa1707 Cyp2c9*3 Genetic Polymorphism and the Clinicopathologic Characteristics of Small-Intestinal Injury Caused by Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)/Low-Dose Aspirin (LDA) Makoto Ishihara*1, Naoki Ohmiya1, Kei Ohara1, Koji Yamada1, Asuka Nagura1, Ryoji Miyahara2, Osamu Watanabe1, Takafumi Ando1, Eizaburo Ohno2, Hiroki Kawashima1, Akihiro Itoh1, Yoshiki Hirooka2, Hidemi Goto1,2 1 Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Endoscopy, Nagoya University Hospital, Nagoya, Japan Background/Aims: Since the advent of videocapsule endoscopy and doubleballoon endoscopy (DBE), NSAIDs/LDA-induced small-intestinal injuries have been frequently observed. As both drugs are being prescribed increasingly due to longevity, precise diagnosis at enteroscopy is necessary because these injuries can cause overt bleeding, anemia, and small bowel obstruction. In this study, we determine the clinicopathologic characteristics of NSAIDs/LDA-induced smallintestinal injuries in our hospital, and further determined the genetic effect of CYP2C9*3 on the development and the severity of these injuries. Methods: A total of 109 NSAIDs/LDA users (LDA 48, NSAIDs 48, and both 13; 67.6 ⫾ 10.8 years of age, 59 men and 50 women) who underwent DBE at our hospital between June 2003 and September 2011 were enrolled. CYP2C9*3 genetic polymorphism was analyzed by using TaqManPCR assay. Results: The indications for DBE were obscure gastrointestinal bleeding (n⫽92), small bowel obstruction (n⫽10), and the others (n⫽7). Small-intestinal lesions were observed at DBE in 78 patients, 40 of which had ulcerative lesions, 21 of which had vascular disease, and 17 of which had neoplastic lesions. Of 40 ulcerative lesions, 30 (LDA 5, NSAIDs 16, and both 9) were diagnosed as NSAIDs/LDA injuries. Loxoprofen caused injuries less than diclofenac and meloxicam. Of 30 patients with NSAIDs/ LDA injuries, 8 had diaphragm-like strictures, in whom endoscopic balloon dilation was performed at DBE (n⫽7) or at laparotomy (n⫽1). As 5 of these 8 cases had taken meloxicam, meloxicam was significantly associated with diaphragm-like strictures. Histologic diagnosis such as apoptotic body by using biopsy specimens at DBE was positive in 3 of 21 patients (14%). There were no significant association of CYP2C9*3 genetic polymorphism with overall NSAIDsinduced small-intestinal injuries, but CYP2C9*3 carrier was significantly associated with NSAIDs-induced diaphragm-like strictures, when compared with 856 controls without obscure gastrointestinal bleeding (adjusted OR 8.2; 95% CI, 1.5-43.4). Conclusions: DBE was useful for diagnosis and treatment of NSAIDs/ LDA-induced small-intestinal injuries. This study provides evidence supporting the association of CYP2C9*3 genetic polymorphism and meloxicam with NSAIDsinduced diaphragm-like strictures.
Sa1708 Endoscopic Resection Outcomes of Duodenal Brunner’s Gland Adenoma Mingyan Cai*, Ping-Hong Zhou, Liqing Yao Endoscopic Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China Objectives: Duodenal Brunner’s gland adenoma is a rare duodenal neoplasm. Because it usually locates in the mucosal and submucosal layer, it is thought can be treated with endoscopic surgery with good outcomes. We describe the outcomes of those tumors with endoscopic resection, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Methods:
AB250 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
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Abstracts
We retrospectively review the database for patients who underwent endoscopic resection of duodenal Brunner’s gland adenoma between 2006 and March 2011. Clinical and pathological features and long-term outcomes are described. Results: All the 25 duodenal duodenal Brunner’s gland adenomas underwent endoscopic resection successfully. 22 tumors were located in the duodenal bulb and 3 in the descending part of duodenum. 19 lesions were sessile and 6 pedunculated. There were 10 male patients and 15 females. The average age was 53 years (range, 35 - 69 years). The average tumor size was 1.6cm (range, 0.5 - 7.0cm). 13 lesions were treated by EMR, 10 by ESD and 2 by piecemeal EMR (EPMR). All margins were tumor free. No perforation occurred. One patient with a large size tumor (7cm) who received EPMR had a volume of 200ml blood loss during procedure. The bleeding was successfully managed by closing the wound with clips and a nylon loop after tumor removal. One patient underwent EPMR had delayed bleeding on postoperative day 2. The bleeding was controlled by endoscopic haemostasis. There was no difference between groups in age (p⫽0.08) and tumor size (p⫽0.178). However, the mean operation time of EMR group was significantly shorter than that of ESD group [(8.0⫾5.4 min for EMR), (21.7⫾17.1 min for ESD), p⫽0.002]. No recurrence or metastasis was found during follow-up time (mean, 18 months; range; 7-38 months). There was no difference in the mean follow-up time [17.9⫾10.3 months for EMR; 20.0⫾7.4 months for ESD; p⫽0.60] between groups of EMR and ESD. Conclusion: Both EMR and ESD are efficacious endoscopic methods for the removal of duodenal Brunner’s gland adenoma. However, the use of EPMR for treating larger lesions should be carried out with caution because of the possibility of operative bleeding or delayed bleeding. The operation time of EMR group was significantly shorter than ESD group. No difference of recurrence or metastasis was found between groups. The outcome of endoscopic methods for treating duodenal Brunner’s gland adenoma is satisfactory.
Sa1709 Usefulness of Endoscopic Diagnosis of Postoperative SmallBowel Lesions and Balloon Dilation for Strictures in Patients With Crohn’s Disease at Double-Balloon Enteroscopy Koji Yamada*1, Naoki Ohmiya1, Asuka Nagura1, Makoto Ishihara1, Kei Ohara1, Eizaburo Ohno2, Hiroki Kawashima1, Ryoji Miyahara2, Akihiro Itoh1, Yoshiki Hirooka1, Osamu Watanabe1, Takafumi Ando1, Hidemi Goto1,2 1 Department of Gastroenterology, Nagoya Univesity Graduate School of Medicine,Nagoya,Japan, Nagoya, Japan; 2Endoscopy, Nagoya Univesity Hospital, Nagoya, Japan Background/Aims: Double-balloon enteroscopy (DBE) has enabled precise diagnosis and endoscopic intervention deep within the small bowel. In this study, we determine the role of DBE in the diagnosis of postoperative lesions including anastomosis and in the endoscopic balloon dilatation (EBD) for strictures in patients with Crohn’s jejunoileitis. Methods: Of 844 patients who underwent DBE between June 2003 and August 2011,80 consecutive patients (62 men and 18 women, 37⫾13 years of age) with Crohn’s jejunoileitis were enrolled. Of these 80 patients, 46 (38 men and 8 women) had undergone smallbowel resection previously and anastomotic sites were evaluated by Rutgeerts’ endoscopic scoring. Multiple logistic regression analysis was performed to assess the relation of Rutgeerts’ scores to variables such as gender, operative procedure (resection or stricutureplasty), usage of corticosteroids, immunomodulators, antiTNF antibody, and elemental diet, postoperative period, and previous surgical history. The indications for EBD were strictures with their length ⬍ 5cm and obstructive symptoms, and without active inflammations such as ulcers, abscess, and fistulae. EBD was performed at DBE in 27 patients (20 men and 7 women) with Crohn’s strictures (11 with anastomotic strictures, 8 with primary strictures, 8 with both strictures) within the small bowel except ileocolonic anastomosis. Results: In 46 patients who underwent 128 DBE examinations to evaluate the lesions including anastomosis, Rutgeerts’ grade 4 (n⫽23) was significantly associated with abdominal symptoms such as pain, abdominal distension, nausea, and vomiting, when compared with Rutgeerts’ grades 0-3 (n⫽23) (P⬍0.0001). Endoscopic recurrence with Rutgeerts’ grades 2-4 was not associated with any variables, but clinical recurrence with Rutgeerts’ grades 4 was associated with non- use of anti-TNF antibody (P⫽0.011) and use of immunomodulators (P ⫽ 0.011). Cumulative relapse rate after EBD was 32 % in 12 months and 64% in 36 months over the follow-up period (median: 52 months). When obstructive symptoms relapsed, repeated EBD was performed if strictures were indicated. Cumulative surgery-free rate was 80 % in 12 months and 72% in 36 months over the postdilation follow-up period. Conclusion: DBE was useful for accurate diagnosis of small-bowel lesions after surgery and endoscopic treatment for Crohn’s strictures, thereby possibly obviating the need for surgery. Anti-TNF antibody may help to decrease the postoperative recurrence rate of Crohn’s disease.
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Sa1710 Long-Term Outcomes After Single Balloon Enteroscopy in Patients With Obscure Gastrointestinal Bleeding Vladimir M. Kushnir*, Michael Tang, Thomas G. Hollander, Christine E. Hovis, Dayna S. Early, Daniel Mullady, Faris Murad, Riad R. Azar, Sreenivasa S. Jonnalagadda, Steven A. Edmundowicz, Chien-Huan Chen Gastroenterology, Washington University School of Medicine, St. Louis, MO Background: The small bowel (SB) is the most common source of blood loss in patients with obscure gastrointestinal bleeding (OGIB). Without specific therapy 60-75% of patients with OGIB experience continued GI blood loss. The rate of recurrent OGIB after double balloon enteroscopy (DBE) has been reported to be 40% at 30 months of follow up. The impact of single balloon enteroscopy (SBE) on the long-term outcomes of patients with OGIB has not been established. Aim: Determine the outcomes of patients with OGIB undergoing SBE. Methods: A retrospective review of the medical records of patients undergoing SBE at a single tertiary care hospital between 2007 and 2011 was performed. Patients were invited to participate in a telephone interview in order to obtain follow-up data. Clinical parameters, interventions and outcome were compared. Results: 150 patients underwent SBE for OGIB during the study period; follow up information was available on 104 [45.2% male, mean age (⫾SD) 70.9⫾11.3 years old]. The mean follow-up duration was 20.4⫾10.8 months. OGIB was overt in 53 (51%) and occult in 51 (49%) cases. All patients underwent anterograde SBE, and 4 patients underwent retrograde SBE. Mean procedure duration was 78⫾23 minutes. The probable source of OGIB was identified with SBE in 72 (69.2%) patients: 56 (53.8%) vascular malformations (VM), 4 tumors (3.8%; 2 GIST, 1 lymphoma, and 1 carcinoid tumor), 5 SB ulcer (4.8%) and previously undetected gastroesophageal pathology in 6 (5.7%. 2 Cameron lesions, 3 gastric ulcer, 2 gastric VMs). Endoscopic therapy was performed in 57 (54.8%) patients; 2 of whom subsequently required surgery due to refractory bleeding from SB VM. Pharmacologic therapy was altered based on SBE findings in 12 (11.5%) patients. 3 patients underwent surgery for tumors found on SBE. Overall, 64 (61.5%) patients had no recurrence of OGIB during follow up. For patients who had a bleeding source identified on SBE, OGIB resolved in 45 out of 72 (62.5%) following SBE directed therapy. Of the patients with normal findings on SBE, OGIB spontaneously resolved in 19 out of 32 (59.4%). In 2 out of 32 patients with normal findings on SBE the etiology of OGIB was later identified (inflammatory bowel disease found on ileocolonoscopy and CT). Recurrence of OGIB was not associated with any demographic factors, comorbid medical conditions or endoscopic findings. The sole SBE complication was a SB microperforation which was successfully treated without surgery. Conclusions: SBE established etiologies and guided treatments in 69.2% of patients with OGIB. At 20 months follow up after SBE, 61.5% of patients experienced no further bleeding. The long term outcomes observed in our study suggest that SBE is an effective method for diagnosing and treating OGIB.
Sa1711 Efficacy of Video Capsule Endoscopy With Flexible Spectral Imaging Color Enhancement at Setting 3 for Differential Diagnosis of Red Spots in the Small Bowel Mitsunori Maeda*, Kazunari Kanke, Takako Sasai, Kastuo Morita, Masaya Terauchi, Mina Hoshino, Takeshi Sugaya, Akira Terano, Hideyuki Hiraishi Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan Background: Red spots, flat or slightly elevated red lesions that range in size from 1 to 10mm, are diagnosed as small bowel angioectasias, enteritis and so on. Red spots identified as small bowel angioectasias requires patients with obscure gastrointestinal bleeding (OGIB) to undergo endoscopic hemostasis or angiographic embolization. Red spots are identified as enteritis requires conservative treatment. However, it is often difficult to identify red spots as angioectasias or enteritis by conventional capsule endoscopy (CE). Aim: The aim of this study is to clarify whether CE with flexible spectral imaging color enhancement (FICE) at setting 3 (3) improves the detection of red spots in patients with OGIB. Methods: Twenty-six patients with OGIB identified as red spots by CE underwent double balloon endoscopy (DBE) at Dokkyo Medical University Hospital between February 2007 and November 2011. The patients were divided into Group A (13 patients with red spots identified as angioectasias by DBE), Group E (13 patients identified with red spots as enteritis by DBE). The E group was compared to the A group with regard to: 1) 3 levels of red spot in color at CE-FICE3, 2) the presence of blue sign, which is defined as a blue area around the red spot at CE-FICE3. The data were analyzed statistically by using Student’s t test, and the criterion for statistical significance was the 0.05 level. Results: There were no statistically significant difference in the levels color in the red spot between group A and group E (2.69⫾0.48 vs. 2.69⫾0.63, p ⫽0.359). Blue sign was more frequently observed in group A than group E (92.3⫾27.7% vs.15.4⫾37.6%, P⬍0.001). Although CE-FICE3 showed the blue sign, CE-FICE 1, 2 and conventional CE did not show the sign. Conclusions: CE-FICE3 may therefore help to identify red spots such as those associated with angioectasias or enteritis.
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
AB251
upper endoscopic procedures (OR 1.15, 95%CI 1.04 - 1.27), diabetes with end organ damage (OR 1.89, 95%CI 1.07 - 3.35), connective tissue disease (OR 2.09, 95%CI 1.1 - 4.0), Charlson comorbidity index (OR 1.11, 95%CI 1.02 - 1.20), and increasing transfusion requirements (3-9 units OR 1.72, 95%CI 1.13 - 2.63; ⱖ10 units OR 2.85, 95%CI 1.89 - 4.30) were significantly associated with positive findings on CE (all p ⬍ 0.027). Following multivariable analysis, only increasing transfusion requirements (3-9 units OR 1.63, 95%CI 1.04 - 2.56; ⱖ10 units OR 2.63, 95%CI 1.62 - 4.26) and connective tissue disease (OR 2.18, 95%CI 1.09 4.31) remained significant (all p ⬍ 0.033). Conclusions: While a number of trends were seen in the univariable analysis, only transfusion requirements and the presence of connective tissue disease were identified as significant factors associated with positive outcomes in the multivariable analysis. The low number of positive predictors limits our ability to utilize demographic and clinical factors as a tool to improve efficiency in selecting patients for CE.
Change to selective COX-2 inhibitor Reduced number of medications Continuation of the same medications Follow-up duration, months, mean ⴞ SD Rebleeding, number (%)
Total (nⴝ53)
Continuation of causative medications (nⴝ31)
Discontinuation of causative medications (nⴝ22)
4 (7.5)
0 (0.0)
4 (18.2)
4 (7.5)
4 (12.9)
0 (0.0)
27 (50.9)
27 (87.1)
0 (0.0)
24.5 ⫾ 12.7
26.7 ⫾ 11.5
21.5 ⫾ 14.0
0.142
11 (20.8)
2 (6.5)
9 (40.9)
0.002
p value
NSAID, non-steroidal anti-inflammatory drug; CE, capsule endoscopy.
Sa1706 Cessation of Potentially Causative Medications Decreases Rebleeding Rate in Patients of Obscure GI Bleeding Without Definite Lesions on Capsule Endoscopy Soung Min Jeon*, Bae Hwan Kim, Jeong Eun Shin, Hyun Deok Shin, Suk Bae Kim, Sung Hoon Moon, Hong-Ja Kim, Il Han Song Internal Medicine, Dankook University College of Medicine, Cheonan, Republic of Korea Background and Aims: In patients of obscure GI bleeding (OGIB) without definite findings on capsule endoscopy(CE), rebleeding is a difficult-to-predict problem and a treatment of choice to prevent their rebleeding is not clear. The aim of this study was to assess whether, in patients without diagnostic findings in CE, discontinuation of potentially causative medications decreased rebleeding rate, or not. Methods: This retrospective study involved a total of 53 patients who had undergone CE for OGIB, but discharged without subsequent therapeutic enteroscopy because of non-diagnostic findings of CE between January 2008 and February 2011 at Dankook University Hospital (DKUH). In 31 patients among them, potentially causative medications were discontinued. However, in 22 patients, the medications should be continuous due to the risk of cardiovascular attack or severe symptoms. The prevalence of recurrent bleeding was compared between two groups and risk factors of rebleeding were analyzed with a few variables including continuation of causative medications. Results: The basic characteristics including age, sex, initial symptoms of OGIB, initial level of hemoglobin, and findings of CE were not different significantly between two groups. However, patients (n⫽22) whose medications should be continuous had more underlying diseases and took more causative medications (mean number of underlying diseases, 1.9⫾0.8 vs 1.3⫾0.5, p⫽0.002; mean number of causative medications, 1.7⫾0.6 vs 1.1⫾0.3, p⬍0.001). During mean follow-up period of 24.5⫾12.7 months, rebleeding rates were 40.9% in cases whose medications could not be ceased and 6.5% in patients whose causative medications were discontinued, respectively (p⫽0.002). On multivariate analysis of risk factors for rebleeding after discharge in patients of OGIB without definite lesions on capsule endoscopy, continuation of medication was uniquely a significant risk factor (odds ratio, 8.987; 95% confidence interval, 1.035-78.072; p⫽0.047). Conclusions: In patients with non-diagnostic CE results, cessation of potentially causative medications is a treatment of choice in terms of prevention of recurrent bleeding of OGIB. If it is impossible to discontinue potentially causative medications due to risk of cardiovascular events and severe symptoms, further diagnosis and therapy such as enteroscopy as well as close observation should be considered for significantly higher rebleeding rate. Table. Potentially causative medications, findings of capsule endoscopy and rebleeding rates during follow-up period
Potentially causativ medications, number of cases*(%) Low-dose aspirin NSAID Wafarin Clopidogrel Cilostazole Others(herbal medications, etc.) Findings of CE Negative** Suspicious*** Adjustment of medications, number (%) Discontinuation of all medications
Total (nⴝ53)
Continuation of causative medications (nⴝ31)
Discontinuation of causative medications (nⴝ22)
33 (62.3) 17 (32.1) 4 (7.5) 12 (22.6) 4 (7.5) 2 (3.8)
17 (54.8) 12 (38.7) 0 (0.0) 2 (6.5) 1 (3.2) 2 (6.5)
16 (72.7) 5 (22.7) 4 (18.2) 10 (45.5) 3 (13.6) 0 (0.0)
22 (41.5) 31 (58.5)
15 (48.4) 16 (51.6)
7 (31.8) 15 (68.2)
p value
0.186 0.219 0.014 0.001 0.157 0.225 0.228
⬍0.001 18 (34.0)
0 (0.0)
18 (81.8)
*Number of cases can be counted several times in a patient using multiple drugs. **Negative result denotes normal small-bowel mucosa on CE. ***Suspicious findings include suspicious mucosal changes, such as small isolated vascular ectasia, red spots, and single small erosion, but without definite relationship with bleeding.
Sa1707 Cyp2c9*3 Genetic Polymorphism and the Clinicopathologic Characteristics of Small-Intestinal Injury Caused by Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)/Low-Dose Aspirin (LDA) Makoto Ishihara*1, Naoki Ohmiya1, Kei Ohara1, Koji Yamada1, Asuka Nagura1, Ryoji Miyahara2, Osamu Watanabe1, Takafumi Ando1, Eizaburo Ohno2, Hiroki Kawashima1, Akihiro Itoh1, Yoshiki Hirooka2, Hidemi Goto1,2 1 Gastroenterology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Endoscopy, Nagoya University Hospital, Nagoya, Japan Background/Aims: Since the advent of videocapsule endoscopy and doubleballoon endoscopy (DBE), NSAIDs/LDA-induced small-intestinal injuries have been frequently observed. As both drugs are being prescribed increasingly due to longevity, precise diagnosis at enteroscopy is necessary because these injuries can cause overt bleeding, anemia, and small bowel obstruction. In this study, we determine the clinicopathologic characteristics of NSAIDs/LDA-induced smallintestinal injuries in our hospital, and further determined the genetic effect of CYP2C9*3 on the development and the severity of these injuries. Methods: A total of 109 NSAIDs/LDA users (LDA 48, NSAIDs 48, and both 13; 67.6 ⫾ 10.8 years of age, 59 men and 50 women) who underwent DBE at our hospital between June 2003 and September 2011 were enrolled. CYP2C9*3 genetic polymorphism was analyzed by using TaqManPCR assay. Results: The indications for DBE were obscure gastrointestinal bleeding (n⫽92), small bowel obstruction (n⫽10), and the others (n⫽7). Small-intestinal lesions were observed at DBE in 78 patients, 40 of which had ulcerative lesions, 21 of which had vascular disease, and 17 of which had neoplastic lesions. Of 40 ulcerative lesions, 30 (LDA 5, NSAIDs 16, and both 9) were diagnosed as NSAIDs/LDA injuries. Loxoprofen caused injuries less than diclofenac and meloxicam. Of 30 patients with NSAIDs/ LDA injuries, 8 had diaphragm-like strictures, in whom endoscopic balloon dilation was performed at DBE (n⫽7) or at laparotomy (n⫽1). As 5 of these 8 cases had taken meloxicam, meloxicam was significantly associated with diaphragm-like strictures. Histologic diagnosis such as apoptotic body by using biopsy specimens at DBE was positive in 3 of 21 patients (14%). There were no significant association of CYP2C9*3 genetic polymorphism with overall NSAIDsinduced small-intestinal injuries, but CYP2C9*3 carrier was significantly associated with NSAIDs-induced diaphragm-like strictures, when compared with 856 controls without obscure gastrointestinal bleeding (adjusted OR 8.2; 95% CI, 1.5-43.4). Conclusions: DBE was useful for diagnosis and treatment of NSAIDs/ LDA-induced small-intestinal injuries. This study provides evidence supporting the association of CYP2C9*3 genetic polymorphism and meloxicam with NSAIDsinduced diaphragm-like strictures.
Sa1708 Endoscopic Resection Outcomes of Duodenal Brunner’s Gland Adenoma Mingyan Cai*, Ping-Hong Zhou, Liqing Yao Endoscopic Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China Objectives: Duodenal Brunner’s gland adenoma is a rare duodenal neoplasm. Because it usually locates in the mucosal and submucosal layer, it is thought can be treated with endoscopic surgery with good outcomes. We describe the outcomes of those tumors with endoscopic resection, including endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD). Methods:
AB250 GASTROINTESTINAL ENDOSCOPY Volume 75, No. 4S : 2012
www.giejournal.org
Abstracts
We retrospectively review the database for patients who underwent endoscopic resection of duodenal Brunner’s gland adenoma between 2006 and March 2011. Clinical and pathological features and long-term outcomes are described. Results: All the 25 duodenal duodenal Brunner’s gland adenomas underwent endoscopic resection successfully. 22 tumors were located in the duodenal bulb and 3 in the descending part of duodenum. 19 lesions were sessile and 6 pedunculated. There were 10 male patients and 15 females. The average age was 53 years (range, 35 - 69 years). The average tumor size was 1.6cm (range, 0.5 - 7.0cm). 13 lesions were treated by EMR, 10 by ESD and 2 by piecemeal EMR (EPMR). All margins were tumor free. No perforation occurred. One patient with a large size tumor (7cm) who received EPMR had a volume of 200ml blood loss during procedure. The bleeding was successfully managed by closing the wound with clips and a nylon loop after tumor removal. One patient underwent EPMR had delayed bleeding on postoperative day 2. The bleeding was controlled by endoscopic haemostasis. There was no difference between groups in age (p⫽0.08) and tumor size (p⫽0.178). However, the mean operation time of EMR group was significantly shorter than that of ESD group [(8.0⫾5.4 min for EMR), (21.7⫾17.1 min for ESD), p⫽0.002]. No recurrence or metastasis was found during follow-up time (mean, 18 months; range; 7-38 months). There was no difference in the mean follow-up time [17.9⫾10.3 months for EMR; 20.0⫾7.4 months for ESD; p⫽0.60] between groups of EMR and ESD. Conclusion: Both EMR and ESD are efficacious endoscopic methods for the removal of duodenal Brunner’s gland adenoma. However, the use of EPMR for treating larger lesions should be carried out with caution because of the possibility of operative bleeding or delayed bleeding. The operation time of EMR group was significantly shorter than ESD group. No difference of recurrence or metastasis was found between groups. The outcome of endoscopic methods for treating duodenal Brunner’s gland adenoma is satisfactory.
Sa1709 Usefulness of Endoscopic Diagnosis of Postoperative SmallBowel Lesions and Balloon Dilation for Strictures in Patients With Crohn’s Disease at Double-Balloon Enteroscopy Koji Yamada*1, Naoki Ohmiya1, Asuka Nagura1, Makoto Ishihara1, Kei Ohara1, Eizaburo Ohno2, Hiroki Kawashima1, Ryoji Miyahara2, Akihiro Itoh1, Yoshiki Hirooka1, Osamu Watanabe1, Takafumi Ando1, Hidemi Goto1,2 1 Department of Gastroenterology, Nagoya Univesity Graduate School of Medicine,Nagoya,Japan, Nagoya, Japan; 2Endoscopy, Nagoya Univesity Hospital, Nagoya, Japan Background/Aims: Double-balloon enteroscopy (DBE) has enabled precise diagnosis and endoscopic intervention deep within the small bowel. In this study, we determine the role of DBE in the diagnosis of postoperative lesions including anastomosis and in the endoscopic balloon dilatation (EBD) for strictures in patients with Crohn’s jejunoileitis. Methods: Of 844 patients who underwent DBE between June 2003 and August 2011,80 consecutive patients (62 men and 18 women, 37⫾13 years of age) with Crohn’s jejunoileitis were enrolled. Of these 80 patients, 46 (38 men and 8 women) had undergone smallbowel resection previously and anastomotic sites were evaluated by Rutgeerts’ endoscopic scoring. Multiple logistic regression analysis was performed to assess the relation of Rutgeerts’ scores to variables such as gender, operative procedure (resection or stricutureplasty), usage of corticosteroids, immunomodulators, antiTNF antibody, and elemental diet, postoperative period, and previous surgical history. The indications for EBD were strictures with their length ⬍ 5cm and obstructive symptoms, and without active inflammations such as ulcers, abscess, and fistulae. EBD was performed at DBE in 27 patients (20 men and 7 women) with Crohn’s strictures (11 with anastomotic strictures, 8 with primary strictures, 8 with both strictures) within the small bowel except ileocolonic anastomosis. Results: In 46 patients who underwent 128 DBE examinations to evaluate the lesions including anastomosis, Rutgeerts’ grade 4 (n⫽23) was significantly associated with abdominal symptoms such as pain, abdominal distension, nausea, and vomiting, when compared with Rutgeerts’ grades 0-3 (n⫽23) (P⬍0.0001). Endoscopic recurrence with Rutgeerts’ grades 2-4 was not associated with any variables, but clinical recurrence with Rutgeerts’ grades 4 was associated with non- use of anti-TNF antibody (P⫽0.011) and use of immunomodulators (P ⫽ 0.011). Cumulative relapse rate after EBD was 32 % in 12 months and 64% in 36 months over the follow-up period (median: 52 months). When obstructive symptoms relapsed, repeated EBD was performed if strictures were indicated. Cumulative surgery-free rate was 80 % in 12 months and 72% in 36 months over the postdilation follow-up period. Conclusion: DBE was useful for accurate diagnosis of small-bowel lesions after surgery and endoscopic treatment for Crohn’s strictures, thereby possibly obviating the need for surgery. Anti-TNF antibody may help to decrease the postoperative recurrence rate of Crohn’s disease.
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Sa1710 Long-Term Outcomes After Single Balloon Enteroscopy in Patients With Obscure Gastrointestinal Bleeding Vladimir M. Kushnir*, Michael Tang, Thomas G. Hollander, Christine E. Hovis, Dayna S. Early, Daniel Mullady, Faris Murad, Riad R. Azar, Sreenivasa S. Jonnalagadda, Steven A. Edmundowicz, Chien-Huan Chen Gastroenterology, Washington University School of Medicine, St. Louis, MO Background: The small bowel (SB) is the most common source of blood loss in patients with obscure gastrointestinal bleeding (OGIB). Without specific therapy 60-75% of patients with OGIB experience continued GI blood loss. The rate of recurrent OGIB after double balloon enteroscopy (DBE) has been reported to be 40% at 30 months of follow up. The impact of single balloon enteroscopy (SBE) on the long-term outcomes of patients with OGIB has not been established. Aim: Determine the outcomes of patients with OGIB undergoing SBE. Methods: A retrospective review of the medical records of patients undergoing SBE at a single tertiary care hospital between 2007 and 2011 was performed. Patients were invited to participate in a telephone interview in order to obtain follow-up data. Clinical parameters, interventions and outcome were compared. Results: 150 patients underwent SBE for OGIB during the study period; follow up information was available on 104 [45.2% male, mean age (⫾SD) 70.9⫾11.3 years old]. The mean follow-up duration was 20.4⫾10.8 months. OGIB was overt in 53 (51%) and occult in 51 (49%) cases. All patients underwent anterograde SBE, and 4 patients underwent retrograde SBE. Mean procedure duration was 78⫾23 minutes. The probable source of OGIB was identified with SBE in 72 (69.2%) patients: 56 (53.8%) vascular malformations (VM), 4 tumors (3.8%; 2 GIST, 1 lymphoma, and 1 carcinoid tumor), 5 SB ulcer (4.8%) and previously undetected gastroesophageal pathology in 6 (5.7%. 2 Cameron lesions, 3 gastric ulcer, 2 gastric VMs). Endoscopic therapy was performed in 57 (54.8%) patients; 2 of whom subsequently required surgery due to refractory bleeding from SB VM. Pharmacologic therapy was altered based on SBE findings in 12 (11.5%) patients. 3 patients underwent surgery for tumors found on SBE. Overall, 64 (61.5%) patients had no recurrence of OGIB during follow up. For patients who had a bleeding source identified on SBE, OGIB resolved in 45 out of 72 (62.5%) following SBE directed therapy. Of the patients with normal findings on SBE, OGIB spontaneously resolved in 19 out of 32 (59.4%). In 2 out of 32 patients with normal findings on SBE the etiology of OGIB was later identified (inflammatory bowel disease found on ileocolonoscopy and CT). Recurrence of OGIB was not associated with any demographic factors, comorbid medical conditions or endoscopic findings. The sole SBE complication was a SB microperforation which was successfully treated without surgery. Conclusions: SBE established etiologies and guided treatments in 69.2% of patients with OGIB. At 20 months follow up after SBE, 61.5% of patients experienced no further bleeding. The long term outcomes observed in our study suggest that SBE is an effective method for diagnosing and treating OGIB.
Sa1711 Efficacy of Video Capsule Endoscopy With Flexible Spectral Imaging Color Enhancement at Setting 3 for Differential Diagnosis of Red Spots in the Small Bowel Mitsunori Maeda*, Kazunari Kanke, Takako Sasai, Kastuo Morita, Masaya Terauchi, Mina Hoshino, Takeshi Sugaya, Akira Terano, Hideyuki Hiraishi Department of Gastroenterology, Dokkyo Medical University, Mibu, Japan Background: Red spots, flat or slightly elevated red lesions that range in size from 1 to 10mm, are diagnosed as small bowel angioectasias, enteritis and so on. Red spots identified as small bowel angioectasias requires patients with obscure gastrointestinal bleeding (OGIB) to undergo endoscopic hemostasis or angiographic embolization. Red spots are identified as enteritis requires conservative treatment. However, it is often difficult to identify red spots as angioectasias or enteritis by conventional capsule endoscopy (CE). Aim: The aim of this study is to clarify whether CE with flexible spectral imaging color enhancement (FICE) at setting 3 (3) improves the detection of red spots in patients with OGIB. Methods: Twenty-six patients with OGIB identified as red spots by CE underwent double balloon endoscopy (DBE) at Dokkyo Medical University Hospital between February 2007 and November 2011. The patients were divided into Group A (13 patients with red spots identified as angioectasias by DBE), Group E (13 patients identified with red spots as enteritis by DBE). The E group was compared to the A group with regard to: 1) 3 levels of red spot in color at CE-FICE3, 2) the presence of blue sign, which is defined as a blue area around the red spot at CE-FICE3. The data were analyzed statistically by using Student’s t test, and the criterion for statistical significance was the 0.05 level. Results: There were no statistically significant difference in the levels color in the red spot between group A and group E (2.69⫾0.48 vs. 2.69⫾0.63, p ⫽0.359). Blue sign was more frequently observed in group A than group E (92.3⫾27.7% vs.15.4⫾37.6%, P⬍0.001). Although CE-FICE3 showed the blue sign, CE-FICE 1, 2 and conventional CE did not show the sign. Conclusions: CE-FICE3 may therefore help to identify red spots such as those associated with angioectasias or enteritis.
Volume 75, No. 4S : 2012
GASTROINTESTINAL ENDOSCOPY
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