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Su1257 Small Bowel Malignancies Diagnosed at Enteroscopy: An Improved outcome?
Abstracts
Su1255 Enteroscopy With a Confocal Laser Endomicroscope Detects Early Changes Related to Acute Gastrointestinal Graft-Versus-Host Disease in the Jejunum - A Prospective Study Involving 23 Consecutive Patients After Hematopoietic Stem Cell Transplantation Werner Dolak*1, Yumiko Kamogawa1, Werner Rabitsch2, Maximilian Schöniger-Hekele1, Peter Kalhs2, Barbara Tribl1, Michael H. Trauner1, Michael Häfner1, Andreas Püspök1 1 Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; 2Bone Marrow Transplant Unit, Medical University of Vienna, Vienna, Austria Introduction: Graft-versus-host disease (GvHD) is a major cause of morbidity and mortality in patients after allogeneic hematopoietic stem cell transplantation (HSCT). Confocal laser endomicroscopy (CLE) provides in-vivo histology of gastrointestinal pathology and has recently been investigated for diagnosing acute GvHD of the colon. Aims and Methods: This prospective study aimed to evaluate GvHDassociated changes in the upper GI tract (including the proximal jejunum) by CLE. Consecutive patients with clinical suspect of acute gastrointestinal GvHD after HSCT underwent upper GI enteroscopy with an endoscope-based confocal laser endomicroscope (Pentax EC-3870CIFK, working length 150 cm). Findings on white light endoscopy and endomicroscopy were evaluated on site regarding the probability of a positive diagnosis of acute GvHD. Histological evaluation of conventional biopsies taken from the jejunum, duodenum, stomach and esophagus served as reference standard. Results: Within a two-years period 23 patients (13 male, 10 female, median age 46 years, range 20-65 years) were studied. Acute myeloic leukemia was the most frequent underlying disease (in 10/23 cases). CLE was performed 45 days after HSCT in median. The mean procedure time was 34.5 6.4 minutes. According to histology, 8/23 patients suffered from acute gastrointestinal GvHD of different severity. The jejunum was the most frequent site of pathology being involved in 7/8 GvHD positive cases. Findings on white light endoscopy varied from mild erythema up to massive ulceration. Endomicroscopic findings included a higher density of intramucosal vessels, cellular infiltrates and leakage of contrast agent as typical signs of inflammation up to complete loss of normal tissue structure. For diagnosing GvHD, sensitivity and specificity were 38% and 53% for white light endoscopy and 88% and 86% for CLE. During follow-up, two patients in whom acute GvHD was initially restricted to the jejunum showed also involvement of other gastrointestinal sites including the stomach and the colon. Conclusions: In this prospective trial, confocal laser endomicroscopy showed an excellent diagnostic accuracy for predicting the histological diagnosis of acute graft-versus-host disease in the upper gastrointestinal tract. The jejunum was involved in almost all GvHD-positive cases. Upper gastrointestinal endomicroscopy also involving the jejunum could be a valuable option for early detection of acute GvHD in order to minimize invasive procedures and speed up diagnostic workflow in patients after hematopoietic stem cell transplantation, ClinicalTrials.gov identifier: NCT01583712.
Su1256 A Clinical Update on the Yield of Double Balloon Enteroscopy for Recurrent Partial Small Bowel Obstructions Monia E. Werlang*1, Michael J. Bartel2, Lady Katherine Mejia-Perez3, Bhaumik Brahmbhatt2, Andree H. Koop1, Abhishek Bhurwal2, Mark Stark2, Frank Lukens2 1 Internal Medicine, Mayo Clinic, Jacksonville Beach, FL; 2 Gastroenterology, Mayo Clinic, Jacksonville, FL; 3Universidad de Los Andes, Bogota, Colombia The etiology of symptomatic recurrent partial small bowel obstruction (pSBO) is often unclear. Imaging can provide information about the location of suspected culprit lesions, however tissue sampling and direct visualization are required for exact diagnosis. We investigated the outcome of consecutive patients undergoing diagnostic double balloon enteroscopy (DBE) for symptomatic recurrent pSBO with and without abnormal imaging. A total of 50 patients were identified who underwent DBE for workup of pSBO between 2/2009 and 6/2014. Symptoms leading to DBE indication were recurrent abdominal pain with nausea, vomiting and abdominal distention in all cases. Demographics, comorbidities, NSAID use, contrast enhanced cross-sectional imaging, video capsule endoscopy (VCE), DBE findings, pathology reports and long-term outcomes were abstracted by retrospective chart review. Primary outcome was to identify the etiology of recurrent pSBO and secondary outcome to define predictors for culprit lesions on DBE. Fifty patients (mean age 60.1 years, SD 14, 70% female) underwent 73 DBE (42 upper DBE and 31 lower DBE), with total enteroscopy achieved in 64% of attempted cases. pSBO symptoms were present over a mean of 61 months (SD 94). All previous EGD (nZ30) and colonoscopies (nZ38) were unrevealing. VCE showed strictures and ulcers in 74%.
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Cross-sectional imaging was performed 103 days (mean) prior to DBE and showed normal results in 33%. The remaining results were unspecific small bowel dilation in 55% whereas strictures were present only in 5% of cases. A culprit for pSBO was identified by DBE in 78% of patients: non-specific ulcerated strictures (16%), suspected adhesions (16%), NSAID strictures (10%), radiation induced changes (10%), anastomotic strictures (8%), suspected motility disorder (8%), lymphoma (2%) and other (8%). Overall, strictures were found in 21 patients (42%), with dilation performed in 10 patients to allow passage of DBE scope. On univariate analysis, only odds ratio (OR) of VCE findings (40.6) significantly predicted DBE findings, whereas cross-sectional imaging, duration of symptoms, presence of weight loss or anemia, underlying surgery or inflammatory bowel disease, radiation therapy and NSAID use did not. None of the factors predicted DBE findings independently on multivariate analysis. Of patients with available follow up (nZ31), most patients (74%) had no improvement following DBE and eventually required surgical resection for the identified culprit lesion. None of the patients followed up after normal DBE required surgery. The yield of DBE was 78% identifying a culprit lesion in patients with long standing pSBO. CT, MRI, VCE findings, amongst other laboratory values did not predict independently the presence of small bowel pathology. Most patients eventually required surgical resection for small bowel pathology identified on DBE.
Su1257 Small Bowel Malignancies Diagnosed at Enteroscopy: An Improved outcome? Simran Sidhu, Hui Yann Lee, Robert P. Willert* Gastroenterology, Manchester Royal Infirmary, Cheshire, ENG, United Kingdom Background: Device assisted enteroscopy is commonly used to visualise & biopsy abnormalities that have been detected on radiological investigations or capsule endoscopy (CE). Small bowel malignancies are uncommon worldwide and account for only 1-2% of all gastrointestinal malignancies1. However there is evidence of a rising incidence of small bowel malignancies through the last decades2-3. We therefore investigated the number of small bowel malignancies diagnosed by double balloon enteroscopy (DBE) and the 1 year outcomes at our institution. Methods: We retrospectively reviewed all DBEs performed at our UK tertiary centre from 2009-2015. Demographics, indications for DBE, prior investigations, DBE findings & 12 month mortality were analysed. Results: 294 DBEs were performed with 19 small bowel cancers found (11 male). Mean age at diagnosis was 61 (Range 33 to 74 year). Presenting symptoms were anaemia (83.3%, nZ15), vomiting (11.1%, nZ2), & weight loss (5.6%, nZ1). All patients underwent radiological imaging (76.5%, nZ13) or CE (58.8%, nZ10) prior to DBE. In 33.3% (nZ6) both radiological imaging & CE had been performed. Indication for DBE was abnormal capsule (41.2%, nZ7), abnormal imaging (52.9%, nZ9) or both (5.9%, nZ1). Histology findings were jejunal adenocarcinoma in 52.9% (nZ9), distal duodenal adenocarcinoma in 29.4% (nZ5), jejunal GIST in 11.8% (nZ2) & enteropathy associated T cell lymphoma in 5.9% (nZ1). 11 patients (57.9%) had CE prior to DBE; CE failed to diagnose a malignancy in 3 patients (27.3%) who were subsequently found to have malignancy on DBE (2 patients with Jejunal GIST and 1 patient with Jejunal adenocarcinoma). In all these 3 patients the CE finding was reported as showing angiodysplasia. All the malignancies were deemed suitable for therapy by a multidisciplinary team. The treatment was surgery alone in 52.9% (nZ9), surgery and chemotherapy in 23.5% (nZ4) and chemotherapy alone in 17.6% (nZ3). The survival rate at 3 months was 88.2% and 66.7% at 1 year. In the patients with a diagnosis of adenocarcinoma the 1 year survival rate was 85.7%. Conclusions: The 1 year survival of 85.7% is significantly higher than previous reports (survival rate of 30% at 1 year from small bowel adenocarcinoma)4 and may potentially reflect the improved outcomes from earlier diagnosis using CE and DBE. DBE also aided in the diagnosis of tumors not seen on CE, as described in literature5. This would suggest that in patients with negative CE findings DBE should strongly be considered if a clinical suspicion of a small bowel tumour exists. References: 1. Chow JS, et aI. Int J Epidemiol 1996;35:722-728 2. Shack LG, et al. Aliment Pharmacol Ther. 2006;23:1297-306. 3. Haselkorn T, et al. Cancer Causes Control. 2005;16:781-7. 4. MH Farhat, et al. Journal of Oncology 2008. Article ID. http://dx.doi.org/10.1155/ 2008/212067 5. Chong AK, et al. Gastrointest Endosc. 2006;64:445-9.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB329
Su1255 Enteroscopy With a Confocal Laser Endomicroscope Detects Early Changes Related to Acute Gastrointestinal Graft-Versus-Host Disease in the Jejunum - A Prospective Study Involving 23 Consecutive Patients After Hematopoietic Stem Cell Transplantation Werner Dolak*1, Yumiko Kamogawa1, Werner Rabitsch2, Maximilian Schöniger-Hekele1, Peter Kalhs2, Barbara Tribl1, Michael H. Trauner1, Michael Häfner1, Andreas Püspök1 1 Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; 2Bone Marrow Transplant Unit, Medical University of Vienna, Vienna, Austria Introduction: Graft-versus-host disease (GvHD) is a major cause of morbidity and mortality in patients after allogeneic hematopoietic stem cell transplantation (HSCT). Confocal laser endomicroscopy (CLE) provides in-vivo histology of gastrointestinal pathology and has recently been investigated for diagnosing acute GvHD of the colon. Aims and Methods: This prospective study aimed to evaluate GvHDassociated changes in the upper GI tract (including the proximal jejunum) by CLE. Consecutive patients with clinical suspect of acute gastrointestinal GvHD after HSCT underwent upper GI enteroscopy with an endoscope-based confocal laser endomicroscope (Pentax EC-3870CIFK, working length 150 cm). Findings on white light endoscopy and endomicroscopy were evaluated on site regarding the probability of a positive diagnosis of acute GvHD. Histological evaluation of conventional biopsies taken from the jejunum, duodenum, stomach and esophagus served as reference standard. Results: Within a two-years period 23 patients (13 male, 10 female, median age 46 years, range 20-65 years) were studied. Acute myeloic leukemia was the most frequent underlying disease (in 10/23 cases). CLE was performed 45 days after HSCT in median. The mean procedure time was 34.5 6.4 minutes. According to histology, 8/23 patients suffered from acute gastrointestinal GvHD of different severity. The jejunum was the most frequent site of pathology being involved in 7/8 GvHD positive cases. Findings on white light endoscopy varied from mild erythema up to massive ulceration. Endomicroscopic findings included a higher density of intramucosal vessels, cellular infiltrates and leakage of contrast agent as typical signs of inflammation up to complete loss of normal tissue structure. For diagnosing GvHD, sensitivity and specificity were 38% and 53% for white light endoscopy and 88% and 86% for CLE. During follow-up, two patients in whom acute GvHD was initially restricted to the jejunum showed also involvement of other gastrointestinal sites including the stomach and the colon. Conclusions: In this prospective trial, confocal laser endomicroscopy showed an excellent diagnostic accuracy for predicting the histological diagnosis of acute graft-versus-host disease in the upper gastrointestinal tract. The jejunum was involved in almost all GvHD-positive cases. Upper gastrointestinal endomicroscopy also involving the jejunum could be a valuable option for early detection of acute GvHD in order to minimize invasive procedures and speed up diagnostic workflow in patients after hematopoietic stem cell transplantation, ClinicalTrials.gov identifier: NCT01583712.
Su1256 A Clinical Update on the Yield of Double Balloon Enteroscopy for Recurrent Partial Small Bowel Obstructions Monia E. Werlang*1, Michael J. Bartel2, Lady Katherine Mejia-Perez3, Bhaumik Brahmbhatt2, Andree H. Koop1, Abhishek Bhurwal2, Mark Stark2, Frank Lukens2 1 Internal Medicine, Mayo Clinic, Jacksonville Beach, FL; 2 Gastroenterology, Mayo Clinic, Jacksonville, FL; 3Universidad de Los Andes, Bogota, Colombia The etiology of symptomatic recurrent partial small bowel obstruction (pSBO) is often unclear. Imaging can provide information about the location of suspected culprit lesions, however tissue sampling and direct visualization are required for exact diagnosis. We investigated the outcome of consecutive patients undergoing diagnostic double balloon enteroscopy (DBE) for symptomatic recurrent pSBO with and without abnormal imaging. A total of 50 patients were identified who underwent DBE for workup of pSBO between 2/2009 and 6/2014. Symptoms leading to DBE indication were recurrent abdominal pain with nausea, vomiting and abdominal distention in all cases. Demographics, comorbidities, NSAID use, contrast enhanced cross-sectional imaging, video capsule endoscopy (VCE), DBE findings, pathology reports and long-term outcomes were abstracted by retrospective chart review. Primary outcome was to identify the etiology of recurrent pSBO and secondary outcome to define predictors for culprit lesions on DBE. Fifty patients (mean age 60.1 years, SD 14, 70% female) underwent 73 DBE (42 upper DBE and 31 lower DBE), with total enteroscopy achieved in 64% of attempted cases. pSBO symptoms were present over a mean of 61 months (SD 94). All previous EGD (nZ30) and colonoscopies (nZ38) were unrevealing. VCE showed strictures and ulcers in 74%.
www.giejournal.org
Cross-sectional imaging was performed 103 days (mean) prior to DBE and showed normal results in 33%. The remaining results were unspecific small bowel dilation in 55% whereas strictures were present only in 5% of cases. A culprit for pSBO was identified by DBE in 78% of patients: non-specific ulcerated strictures (16%), suspected adhesions (16%), NSAID strictures (10%), radiation induced changes (10%), anastomotic strictures (8%), suspected motility disorder (8%), lymphoma (2%) and other (8%). Overall, strictures were found in 21 patients (42%), with dilation performed in 10 patients to allow passage of DBE scope. On univariate analysis, only odds ratio (OR) of VCE findings (40.6) significantly predicted DBE findings, whereas cross-sectional imaging, duration of symptoms, presence of weight loss or anemia, underlying surgery or inflammatory bowel disease, radiation therapy and NSAID use did not. None of the factors predicted DBE findings independently on multivariate analysis. Of patients with available follow up (nZ31), most patients (74%) had no improvement following DBE and eventually required surgical resection for the identified culprit lesion. None of the patients followed up after normal DBE required surgery. The yield of DBE was 78% identifying a culprit lesion in patients with long standing pSBO. CT, MRI, VCE findings, amongst other laboratory values did not predict independently the presence of small bowel pathology. Most patients eventually required surgical resection for small bowel pathology identified on DBE.
Su1257 Small Bowel Malignancies Diagnosed at Enteroscopy: An Improved outcome? Simran Sidhu, Hui Yann Lee, Robert P. Willert* Gastroenterology, Manchester Royal Infirmary, Cheshire, ENG, United Kingdom Background: Device assisted enteroscopy is commonly used to visualise & biopsy abnormalities that have been detected on radiological investigations or capsule endoscopy (CE). Small bowel malignancies are uncommon worldwide and account for only 1-2% of all gastrointestinal malignancies1. However there is evidence of a rising incidence of small bowel malignancies through the last decades2-3. We therefore investigated the number of small bowel malignancies diagnosed by double balloon enteroscopy (DBE) and the 1 year outcomes at our institution. Methods: We retrospectively reviewed all DBEs performed at our UK tertiary centre from 2009-2015. Demographics, indications for DBE, prior investigations, DBE findings & 12 month mortality were analysed. Results: 294 DBEs were performed with 19 small bowel cancers found (11 male). Mean age at diagnosis was 61 (Range 33 to 74 year). Presenting symptoms were anaemia (83.3%, nZ15), vomiting (11.1%, nZ2), & weight loss (5.6%, nZ1). All patients underwent radiological imaging (76.5%, nZ13) or CE (58.8%, nZ10) prior to DBE. In 33.3% (nZ6) both radiological imaging & CE had been performed. Indication for DBE was abnormal capsule (41.2%, nZ7), abnormal imaging (52.9%, nZ9) or both (5.9%, nZ1). Histology findings were jejunal adenocarcinoma in 52.9% (nZ9), distal duodenal adenocarcinoma in 29.4% (nZ5), jejunal GIST in 11.8% (nZ2) & enteropathy associated T cell lymphoma in 5.9% (nZ1). 11 patients (57.9%) had CE prior to DBE; CE failed to diagnose a malignancy in 3 patients (27.3%) who were subsequently found to have malignancy on DBE (2 patients with Jejunal GIST and 1 patient with Jejunal adenocarcinoma). In all these 3 patients the CE finding was reported as showing angiodysplasia. All the malignancies were deemed suitable for therapy by a multidisciplinary team. The treatment was surgery alone in 52.9% (nZ9), surgery and chemotherapy in 23.5% (nZ4) and chemotherapy alone in 17.6% (nZ3). The survival rate at 3 months was 88.2% and 66.7% at 1 year. In the patients with a diagnosis of adenocarcinoma the 1 year survival rate was 85.7%. Conclusions: The 1 year survival of 85.7% is significantly higher than previous reports (survival rate of 30% at 1 year from small bowel adenocarcinoma)4 and may potentially reflect the improved outcomes from earlier diagnosis using CE and DBE. DBE also aided in the diagnosis of tumors not seen on CE, as described in literature5. This would suggest that in patients with negative CE findings DBE should strongly be considered if a clinical suspicion of a small bowel tumour exists. References: 1. Chow JS, et aI. Int J Epidemiol 1996;35:722-728 2. Shack LG, et al. Aliment Pharmacol Ther. 2006;23:1297-306. 3. Haselkorn T, et al. Cancer Causes Control. 2005;16:781-7. 4. MH Farhat, et al. Journal of Oncology 2008. Article ID. http://dx.doi.org/10.1155/ 2008/212067 5. Chong AK, et al. Gastrointest Endosc. 2006;64:445-9.
Volume 83, No. 5S : 2016 GASTROINTESTINAL ENDOSCOPY AB329