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Topical pharyngeal anesthesia as an adjunct to intravenous sedation to facilitate gastroscopy has been widely acknowledged; however, its efficacy has not been established when it is used in patients under deep sedation with propofol. To demonstrate the limited value of topical pharyngeal anesthesia in patients under moderate to deep sedation with propofol. One hundred and twenty-nine patients undergoing gastroscopy were prospectively randomized to receive 10 % lidocaine or distilled water topical spray as an adjunct to intravenous propofol via target-controlled infusion. Verbal and somatic responsiveness, presence of gag reflex and hiccup to esophageal intubation, and the overall ease of the procedure were evaluated by the anaesthetists and gastroenterologists. Hemodynamic parameters including peripheral oxygen saturation, systolic/diastolic blood pressure (SBP/DBP), heart rate (HR), bispectral index, and SBP × HR were compared at 5 time points: on arrival, after 5 spontaneous breaths, when estimated brain concentration of propofol, Ce, reached 3.5 μg/ml, on esophageal intubation, and on awakening. No statistical difference was observed between the lidocaine and distilled water group in verbal or somatic responses, gag reflex or hiccups on esophageal intubation. Similarly, BIS, SBP, DBP, and HR showed no significant difference between the groups. The use of topical pharyngeal anesthesia in combination with target-controlled infusion with propofol in the performance of diagnostic gastroscopy might be eliminated without adversely affecting patient care or outcomes.

Diagnosing and treating patients with obscure gastrointestinal bleeding is clinically challenging. Most lesions responsible for the origin of obscure gastrointestinal bleeding are located in the small bowel. Double-balloon enteroscopy is a novel method for exploring the small intestine and has significant therapeutic potential. This study evaluated the value of double-balloon enteroscopy in diagnosing and managing obscure gastrointestinal bleeding. From October 2003 to January 2006, a total of 20 patients (6 men, 14 women; mean age, 55.2 years old) with obscure gastrointestinal bleeding (18 obscure overt bleeding, 2 obscure occult bleeding) were investigated by double-balloon enteroscopy. A total of 29 procedures (15 via oral approach and 14 via rectal approach) were performed. The diagnostic yield, endoscopic therapeutic procedures, complications, and outcome were then assessed. Small bowel lesions potentially responsible for the bleeding were identified in 15 (75%) of 20 patients, including 9 angiodysplasias, 2 gastrointestinal stromal tumors (GISTs), 2 ulcers, 1 jejunal granulation polyp, and 1 Peutz-Jeghers polyposis. Endoscopic treatments including heater probe coagulation, polypectomy, and endoscopic mucosal resection were performed in 11 patients. Two patients with GISTs received surgical intervention. Two patients with angiodysplasias that endoscopic treatment failed underwent laparoscopic resections following tattooing. There were no complications and the procedures were tolerated well. Among the 15 patients who had a lesion identified with subsequent treatment, rebleeding occurred in 3 (20%) patients with angiodysplasias. Of the five patients in whom no definite lesion was detected, rebleeding developed in four (80%). For patients with an identified lesion that was further treated, the rebleeding rate was lower than for those with "persistent" obscure gastrointestinal bleeding (P=0.031). We conclude that double-balloon enteroscopy offers a safe and effective method for diagnosing and managing patients with obscure gastrointestinal bleeding.

The purpose of this study was to estimate the sex- and age-specific incidence rates of inflammatory bowel diseases (IBD) in Taiwan. Site-specific cancer occurred in patients with IBD would be reported, too. A retrospective study by analyzing the data from the National Health Insurance Research Database of Taiwan. Between 2000 and 2010, the overall incidence rate of Crohn’s disease (CD) and ulcerative colitis (UC) was 0.208 and 0.838 per 100,000 person-years. For male, the incidence rate of CD was 0.195 (95 % CI 0.113–0.276) per 100,000 persons in 2000 and increased to 0.318 (95 % CI 0.216–0.421) per 100,000 persons in 2010. For female, the incidence rate of CD was 0.092 (95 % CI 0.035–0.149) per 100,000 persons in 2000 and increased to 0.210 (95 % CI 0.128–0.293) per 100,000 persons in 2010. For male, the incidence rate of UC was 0.690 (95 % CI 0.537–0.843) per 100,000 persons in 2000 and increased to 1.351 (95 % CI, 1.140–1.562) per 100,000 persons in 2010. For female, the incidence rate of UC was 0.386 (95 % CI 0.269–0.503) per 100,000 persons in 2000 and increased to 0.858 (95 % CI 0.691–1.024) per 100,000 persons in 2010. Among the CD patients, 0.19 % had colorectal cancers (1/519). Among the UC patients, 0.24 % had colorectal cancers (5/2098). This nationwide population-based longitudinal epidemiological study of IBD in Taiwan provides data for future global comparisons.

Technical challenges have obstructed the diagnosis and treatment of small intestine disease. An innovative form of enteroscopy-the double balloon method-permits visualization of the complete small intestine, to-and-fro examination of an area of interest, and biopsy and endoscopic procedures which are safer, faster, and less painful than earlier methods. From October 2003 to May 2004, a total of 10 patients with obscure gastrointestinal bleeding received 12 enteroscopic examinations, 8 per oral and 4 per rectal examinations, while 2 patients received per oral enteroscopy first and further per rectal procedures 2 days later. Two cases with intestinal submucosal tumors were discovered by per oral enteroscopy, one with a 5-cm SMT with reddish mucosa at the jejunum and another with a 4-cm SMT and surface ulceration, in which the biopsy showed GIST. Both patients received an operation later. Four patients were found to have intestinal angiodysplasia in jejunum(per oral) and one in ileum (per rectal), and after local therapy bleeding stopped. Multiple angiodysplasias were observed in a patient who was operated on for active bleeding from the ileum after Indian ink tattooing. The two patients who received per oral and per rectal procedures did not display definite small intestinal lesions. All patients underwent the procedures satisfactorily without any complications, and the examination times varied from 90 to 360 min. Double balloon enteroscopy permits deep insertion of an endoscope into the small intestine without excessive stretching of the intestinal tract. This method can use either an oral or an anal approach. To-and-fro observation of almost the complete small intestine is possible, as are interventions.

To analyze the efficacy and outcome of colonoscopic resection for colorectal neoplastic lesions, we retrospectively reviewed 338 colorectal lesions from 232 patients regarding the clinical profiles, colonoscopic findings, histological findings, complications, and outcome. Morphologically, these lesions were classified into three categories: pedunculated (n = 140), sessile (n = 176); and flat (n = 22). Histological findings of lesions included adenoma (n = 248), carcinoma in situ (n = 17), submucosal carcinoma (n = 2), hyperplastic polyp (n = 57), and inflammatory polyp (n = 14). Neoplastic lesions are generally larger than nonneoplastic lesions (χ2 test, P < 0.05). The incidence of carcinoma was 5.6% of 338 resected lesions. The rate of cancer or high-grade dysplasia in flat polyps was greater than in pedunculated and sessile polyps (13.6 vs 4.54 vs 5.71%; P < 0.05). There were no perforations or deaths after colonoscopic treatment, and only mild bleeding occured in two patients. To date, 19 patients with early colorectal cancer were treated successfully by endoscopy with no recurrence or metastasis. To reduce the incidence and mortality of colorectal cancer, colonoscopic resection is a simple and safe procedure for removing neoplastic lesions. Detailed histological examinations are essential to decide the indications of surgery.

Peutz-Jeghers syndrome (PJS) is a very rare disease that often causes severe complications such as bowel obstruction or gastrointestinal tract bleeding. In the past, it was usually treated by using surgical intervention despite the associated complications. Balloon-assisted enteroscopy (BAE) has been documented as an effective and safe method for the diagnosis and treatment of small bowel lesions. Hence, we conducted this study to verify whether BAE is useful for patients with PJS. To evaluate the safety and efficacy of BAE with prophylactic polypectomy in patients with PJS. From August 2005 to February 2010, 6 consecutive patients were diagnosed with PJS after pathological and clinical examination, and underwent BAE examination and polypectomy at Chang Gung Memorial Hospital, an academic tertiary referral center. Six consecutive patients (4 men and 2 women) diagnosed with PJS underwent BAE with polypectomy. BAE was performed 17 times for complete examination of the entire small bowel. The range of the diameter of the removed polyps was 1–6 cm. No immediate complications such as hemorrhage or hollow organ perforation were noted during the procedure, and no patient developed intussusception during the follow-up period (32 ± 17.5 months). BAE with polypectomy is useful for patients with PJS in order to reduce the complications of the condition.

Double-balloon enteroscopy (DBE) is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. The aim is to describe how outcomes differ with patient setting (with DBE diagnosis and intervention, with DBE diagnosis but without intervention, and without DBE diagnosis), and thus demonstrate the value of endoscopic intervention when encountering potential bleeder during DBE. From November 2003 to January 2008, 90 patients with obscure gastrointestinal bleeding presented with DBE at our tertiary referral center. A total of 113 DBE procedures were carried out. Overall diagnostic yield was 75.6% (68/90). Endoscopic intervention was performed in 58 (85.3%) of the 68 patients with potential bleeder. The 90 patients were divided into three settings: with endoscopic diagnosis and intervention (n = 58), with endoscopic diagnosis but without intervention (n = 10), and without endoscopic diagnosis (n = 22). Rebleeding rates for the three groups were 22.4%, 60%, and 22.7%, respectively. For the 35 patients diagnosed with vascular lesions, the rebleeding rates in patients with and without endoscopic intervention, were 38.5% (10/26) and 66.7% (6/9), respectively. One (0.9%) severe adverse event occurred during the 113 procedures, and the patient died. DBE is an effective tool for diagnosing and treating obscure gastrointestinal bleeding. DBE involves relatively safe procedures and has an acceptable complication rate. When potential bleeders are encountered during the procedure, especially for vascular lesions, therapeutic intervention should be attempted, since the intervention-related complication rate is acceptable, and such intervention can reduce the rebleeding rate and enhance the cost-effectiveness of DBE.

Aim For many physicians who ordinarily treat patients with colonic diseases, colonoscopy is considered a prime study interest. Developments in colonoscopic equipment and methods have led to larger numbers of endoscopic diagnoses and treatments for colorectal neoplasms. The purpose of this investigation is to evaluate the efficacy and outcomes of endoscopic treatment for colorectal neoplastic lesions and the development of colorectal cancers after colonoscopic therapy. Materials and methods From September 1999 to May 2005, 19,815 consecutive colonoscopic examinations in 16,318 patients were gathered, totaling 9,534 endoscopic treatments for colorectal neoplasms. Macroscopic characteristics of the neoplasms were classified into protruded (N = 7,455), sessile (N = 1,569), lateral spreading tumor (N = 201), depressed lesions (N = 21), and flat lesions (N = 288). Snare polypectomy was conducted in 7,536 lesions, hot forceps removal in 1,545 lesions, and endoscopic mucosal resection in 353 lesions. Results Histological diagnoses were 8,333 neoplastic lesions (8,246 adenomas with low/high-grade dysplasia and 87 invasive adenocarcinomas) and 1,201 non-neoplastic lesions (1,186 hyperplastic and 15 inflammatory polyps). For the adenocarcinoma group, all had received further operations, while 73 surgical specimens discovered no residual tumors. Four perforations and 146 bleedings were found following endoscopic treatment. No procedure-related mortality was found and no recurrent malignancy was found after 6-71 months follow-up. Conclusion To lower the incidence and mortality of advanced colorectal cancer, endoscopic treatment for colorectal neoplasms is a simple and safe procedure.

This study describes the feasibility of magnifying colonoscopy with indigo carmine dye contrast to distinguish neoplastic and nonneoplastic colonic polyps. This study sampled consecutive patients undergoing colonoscopy using an Olympus CF240ZI from January to October 2000 at Chang-Gung Memorial Hospital, Lin-Kou Medical Center. This study analyzed a total of 270 polyps. Indigo carmine (0.2%) was sprayed directly on the mucosa surface before observing the crypts using a magnifying colonoscope (1.5×–100×). The pit patterns were described using the classification proposed by Kudo. Finally, polypectomy or biopsy was performed for histological diagnosis. The study identified 155 adenomas, 99 hyperplastic polyps, 9 adenocarcinomas, and 7 other nonneoplastic lesions (harmatoma, inflammatory polyps, and mucosal tag). The pit pattern was analyzed for all lesions. Further classification into neoplastic (adenoma and adenocarcinoma) and nonneoplastic (hyperplastic and others) polyps revealed 156 neoplastic and 14 nonneoplastic polyps among the type III to type V pits and 92 nonneoplastic and 8 neoplastic polyps among the type I and II pits. The sensitivity of type III to type V pits in detecting neoplastic polyps was 95.1%, with a specificity of 86.8% and diagnostic accuracy of 91.9%. The positive likelihood ratio was 7.3, and the negative likelihood ratio was 0.06. Magnifying colonoscopy with indigo carmine dye contrast provides morphological detail that correlates well with polyp histology. Small flat lesions with typical type II pit pattern should have minimal neoplastic risk, thus endoscopic resection is not necessary.

Background Esophageal endoscopic submucosal dissection (ESD) has rarely been reported for the treatment of cirrhotic patients. Aim To report the results of ESD treatment of superficial esophageal neoplasms (SENs) for cirrhotic patients. Methods Forty patients with 50 consecutive SENs undergoing 46 sessions of ESD were retrospectively reviewed. The cirrhotic group included eight patients (11 SENs) with liver cirrhosis consisting of six patients classified as Child-Pugh class A liver cirrhosis and two patients classified as class B liver cirrhosis. Four patients (6 SENs) had coexisting esophageal varices. Parameters were compared between the cirrhotic patients and the non-cirrhotic controls (32 patients, 39 SENs). Results Platelet counts of the cirrhotic group were significantly lower, while international normalized ratio was significantly higher. When the cirrhotic group and non-cirrhotic group were compared, the mean tumor length (4 vs. 3.7 cm, p = 0.56) and median procedure time (15.1 vs. 11.5 min/cm2, p = 0.30) were similar. The en bloc resection rates were 81.8 and 89.7 % (p = 0.60). Within the cirrhotic group, both lesions without en bloc resection were patients with esophageal varices. The rates of submucosal disease for the cirrhotic group and non-cirrhotic groups were 54.5 and 25.6 % (p = 0.064), respectively, while the R0 resection rates were 77.8 and 94.3 % (p = 0.16), respectively. The two lesions without R0 resection in cirrhotic group had positive vertical but not horizontal margins due to submucosal invasion. Intraprocedural bleeding occurred more frequently in cirrhotic patients than non-cirrhotic patients (18.2 vs. 0 %, p = 0.045). None of the patients suffered from esophageal perforation, postoperative bleeding, or death that was related to the ESD. Conclusion Esophageal ESD seems to be safely and can be effectively performed on cirrhotic patients, particularly those without severe liver dysfunction.