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BACKGROUND The large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times. AIM To evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB). METHODS We compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB (n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry (n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment. RESULTS Patients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently (P < 0.001). CONCLUSION Endoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Background and Aim: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. Methods: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. Results: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7–12). The median Rockall score was 8 (IQR, 7–9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P

INTRODUCTION: With increasing advances in minimally invasive endoscopic therapies and endoscopic resection techniques for luminal disease, there is an increased risk of post-procedure bleeding. This can contribute to significant burden on patient’s quality of life and health resources when reintervention is required. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder licensed for gastrointestinal bleeding. The aim of this single-arm, prospective, non-randomised multicentre international study is to look at outcomes in patients with upper gastrointestinal bleeds following elective endoscopic therapy treated with Hemospray to achieve haemostasis. METHODS: Data was prospectively collected on the use of Hemospray from 16 centres (January 2016–November 2019). Hemospray was used during the presence of progressive intraprocedural bleeding post-endoscopic therapy as a monotherapy, dual therapy with standard haemostatic techniques or rescue therapy once standard methods had failed. Haemostasis was defined as the cessation of bleeding within 5 min of the application of Hemospray. Re-bleeding was defined as a sustained drop in haemoglobin (>2 g/l), haematemesis or melaena with haemodynamic instability after the index endoscopy. RESULTS: A total of 73 patients were analysed with bleeding post-endoscopic therapy. The median Blatchford score at baseline was five (interquartile range 0–9). The median Rockall score was six (interquartile range 5–7). Immediate haemostasis following the application of Hemospray was achieved in 73/73 (100%) of patients. Two out of 57 (4%) had a re-bleed post-Hemospray, one was following oesophageal endoscopic mucosal resection and the other post-duodenal endoscopic mucosal resection. Both patients had a repeat endoscopy and therapy within 24 h. Re-bleeding data was missing for 16 patients, and mortality data was missing for 14 patients. There were no adverse events recorded in association with the use of Hemospray. CONCLUSION: Hemospray is safe and effective in achieving immediate haemostasis following uncontrolled and progressive intraprocedural blood loss post-endoscopic therapy, with a low re-bleed rate.

Background and aim Acute gastrointestinal bleeding carries poor outcomes unless prompt endoscopic hemostasis is achieved. Mortality in these patients remains significant. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites. We report the largest dataset of patient outcomes after treatment with Hemospray from an international multicenter registry. Patients and methods Prospective data (Jan 2016-May 2018) from 12 centers across Europe were collected. Immediate hemostasis was defined as endoscopic cessation of bleeding within 5 min after application of Hemospray. Rebleeding was defined as subsequent drop in hemoglobin, hematemesis, persistent melena with hemodynamic compromise post-therapy. Results Three hundred and fourteen cases were recruited worldwide (231 males, 83 females). Median pretreatment Blatchford score was 11 (IQR: 8-14) and median complete Rockall score (RS) was 7 (IQR: 6-8) for all patients. Peptic ulcer disease (PUD) was the most common pathology (167/314 = 53%) and Forrest Ib the most common bleed type in PUD (100/167 = 60%). 281 patients (89.5%) achieved immediate hemostasis after successful endoscopic therapy with Hemospray. Rebleeding occurred in 29 (10.3%) of the 281 patients who achieved immediate hemostasis. Seven-day and 30-day all-cause mortality were 11.5% (36/314) and 20.1% (63/314), respectively (lower than the predicted rates as per the RS). Similar hemostasis rates were noted in the Hemospray monotherapy (92.4%), combination therapy (88.7%) and rescue therapy (85.5%) groups. Conclusions These data show high rates of immediate hemostasis overall and in all subgroups. Rebleeding and mortality rates were in keeping/lower than predicted rates.

BACKGROUND: Hepatorenal syndrome (HRS) is associated with a poor prognosis. In HRS type 1, loss of renal function is rapidly progressive, while HRS type 2 is characterised by chronic ascites and more moderately elevated renal parameters. While treatment with terlipressin/albumin is well established in type 1, its effectiveness in chronic HRS is less clear. OBJECTIVE: The aim of this study was to evaluate the effectiveness of terlipressin/albumin treatment in patients with HRS type 2. METHODS: All patients with a first episode of HRS between April 2013 and February 2016 were included in this observational study. Relevant clinical and laboratory parameters were recorded and patients were followed. RESULTS: A total of 106 patients with HRS were included. With terlipressin therapy reversal of HRS types 1 and 2 was achieved in 48% and 46% of patients (p = 0.84) with relapse rates of 8% vs 50% (p = 0.001). Overall survival (OS) and survival free of liver transplantation (LTx) were similar in HRS types 1 and 2 (p = 0.69; p = 0.64). In multivariate analysis response to treatment was independently associated with better OS in HRS type 2, in addition to established risk factors such as lower Model for End-Stage Liver Disease score, absence of hepatic encephalopathy and eligibility for LTx. CONCLUSION: A terlipressin treatment course seems to be justified in selected patients with HRS type 2, especially in countries and settings with long transplant waiting lists. In addition treatment response might also help to identify HRS type 2 patients with a more favourable outcome.

Contains fulltext : 205162.pdf (Publisher’s version ) (Open Access) BACKGROUND AND AIMS: Colorectal cancer (CRC) is largely preventable with routine screening and surveillance colonoscopy; however, interval cancers arising from precancerous lesions missed by standard colonoscopy still occur. An increased adenoma detection rate (ADR) has been found to be inversely associated with interval cancers. The G-EYE device includes a reusable balloon integrated at the distal tip of a standard colonoscope, which flattens haustral folds, centralizes the colonoscope's optics, and reduces bowel slippage. The insufflated balloon also aims to enhance visualization of the colon during withdrawal, thereby increasing the ADR. METHODS: In this randomized, controlled, international, multicenter study (11 centers), patients (aged >/=50 years) referred to colonoscopy for screening, surveillance, or changes in bowel habits were randomized to undergo either balloon-assisted colonoscopy by using an insufflated balloon during withdrawal or standard high-definition colonoscopy. The primary endpoint was the ADR. RESULTS: One thousand patients were enrolled between May 2014 and September 2016 to undergo colonoscopy by experienced endoscopists; 803 were finally analyzed (standard colonoscopy n = 396; balloon-assisted colonoscopy n = 407). Baseline parameters were similar in both groups. Balloon-assisted colonoscopy provided a 48.0% ADR compared with 37.5% in the standard colonoscopy group (28% increase; P = .0027). Additionally, balloon-assisted colonoscopy provided for a significant increase in detection of advanced (P = .0033) flat adenomas (P < .0001) and sessile serrated adenomas/polyps (P = .0026). CONCLUSION: Balloon-assisted colonoscopy yielded a higher ADR and increased the detection of advanced, flat, and sessile serrated adenomas/polyps when compared with standard colonoscopy. Improved detection by the G-EYE device could impact the quality of CRC screening by reducing miss rates and consequently reducing interval cancer incidence. (Clinical trial registration number: NCT01917513.).

Introduction Lower Gastrointestinal bleeding (LGIB) accounts for 20% of GI bleeds, with significant mortality in the elderly and those with comorbidities. There is limited data on the use of Hemospray in LGIB’s. The primary aim was to look at its safety and efficacy in the treatment of LGIB’s. Methods Data was prospectively collected on the use of Hemospray in LGIB’s in 16 Centres in the UK, USA, Germany, France and Spain (January 2016 – November 2019). Hemospray was used as a monotherapy, combination therapy or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of Hemospray application. Results 24 patients with LGIB’s were recruited (16 male, 8 female). The cause of bleeding included malignancy (6/24,25%), post procedure (polypectomy/ESD)(5/24,21%), inflammation/angiodysplasia (7/24, 29%). The median lesion diameter was 20 mm (IQR, 25–50). 9/24 (38%) patients were on antiplatelets/anticoagulants. Immediate haemostasis was achieved in 22/24 (92%) patients. 2/19 (11%) had a re-bleed within 7 days, 4/19 (21%) had a re-bleed within 30 days. 2/21 (10%) died within 30 days (all cause mortality). The two patients that failed treatment had surgery. In combination Hemospray was always used as a second or third modality. There was a 78% haemostasis rate in patients on anticoagulants/antiplatelets, 100% immediate haemostasis on patients on no anticoagulants. There were no adverse events associated with Hemospray. Outcomes in the Hemospray treatment subgroups (table 1). Conclusions Hemospray is safe and effective in LGIB’s with 92% haemostasis rates, with better outcomes as a Monotherapy. Anticoagulants have an effect on haemostasis rates (78% vs 100%). Lower GI bleeds are difficult to treat. Hemospray is an effective alternative in situations where access is difficult and there is a large surface of bleeding.

Introduction Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity. The aim was to look at outcomes in patients with non-variceal UGIBs of all causes treated with Hemospray. Methods Data was collected prospectively (Jan’ 16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during endoscopy as a monotherapy, dual therapy or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of Hemospray application. Results 512 patients with non-variceal UGIBs were recruited (343 male, 169 female). The most common cause was peptic ulcers (236/512, 46%). Immediate haemostasis was achieved in 473/512 (92%) patients. Median Blatchford was 11 (IQR, 8–14), median Rockall was 7 (IQR, 6–8). Re-bleeding occurred in 59/404 (15%) patients. There was a 7-day mortality (all cause) of 9% (42/444), 30-day mortality (all cause) was 19% (85/444). The highest haemostasis rates were in the Hemospray monotherapy group (95%). 39 patients did not achieve haemostasis (69% were peptic ulcer related). 14/39 (36%) of these patients had CT embolization, 7/39 (18%) managed conservatively and 3/39 (8%) had surgery. Outcomes in different UGI pathologies (table 1). Conclusion There were high immediate haemostasis rates following treatment of non-variceal UGIBs. The better outcomes were when Hemospray was used in UGIB’s post endotherapy, malignancy and Angiodysplasia. In malignancies it can bridge towards surgery/chemoradiotherapy, and post endotherapy it can provide definitive haemostasis with low re-bleed rates.

Introduction Early treatment for variceal bleeding is recommended within 12 hours to improve outcomes. Endoscopic therapy in acute variceal bleeding can be technically difficult and not always successful and a bridge is sometimes required towards definitive therapy. Aim of this study was to look at outcomes in patients with upper gastrointestinal bleeds (UGIB’s) secondary to varices. Methods Data was collected prospectively (Jan’16- Nov’19) from 16 centres in the USA, UK, Germany, France and Spain. Hemospray was used during emergency endoscopy for a variceal UGIB as a monotherapy, dual therapy or rescue therapy once standard methods have failed. Haemostasis was defined as cessation of bleeding within 5 minutes. Results 12 patients had Hemospray treatment following a variceal UGIB (10 male, 2 female). 10 oesophageal varices, 2 gastric varices. The median Rockall was 8 (IQR, 7–8). The median Blatchford was 15 (IQR, 13–17). The immediate haemostasis rate was 75%. There were no re-bleeds. 4 patients were treated with Hemospray monotherapy, 3 with combination therapy and 5 with rescue therapy. Hemospray was always given after oesophageal banding/injection sclerotherapy in the combination/rescue therapy cohorts. 4/9 patients died within 7 days, 3 out of these 4 patients did not achieve initial haemostasis with Hemospray. Outcomes in the Hemospray subgroups (table 1). Conclusions The immediate haemostasis rate was 75% in variceal UGIBs following treatment with Hemospray. In this cohort there is no re-bleeding. This suggests that Hemospray may play a role as bridging therapy in variceal bleeds which are difficult to control, towards repeat definitive therapy.

Background Upper gastrointestinal bleeding (UGIB) is a leading cause of morbidity and is associated with a 2 % – 17 % mortality rate in the UK and USA. Bleeding peptic ulcers account for 50 % of UGIB cases. Endoscopic intervention in a timely manner can improve outcomes. Hemostatic spray is an endoscopic hemostatic powder for GI bleeding. This multicenter registry was created to collect data prospectively on the immediate endoscopic hemostasis of GI bleeding in patients with peptic ulcer disease when hemostatic spray is applied as endoscopic monotherapy, dual therapy, or rescue therapy. Methods Data were collected prospectively (January 2016 – March 2019) from 14 centers in the UK, France, Germany, and the USA. The application of hemostatic spray was decided upon at the endoscopist’s discretion. Results 202 patients with UGIB secondary to peptic ulcers were recruited. Immediate hemostasis was achieved in 178/202 patients (88 %), 26/154 (17 %) experienced rebleeding, 21/175 (12 %) died within 7 days, and 38/175 (22 %) died within 30 days (all-cause mortality). Combination therapy of hemostatic spray with other endoscopic modalities had an associated lower 30-day mortality (16 %, P Conclusions This is the largest case series of outcomes of peptic ulcer bleeding treated with hemostatic spray, with high immediate hemostasis rates for bleeding peptic ulcers.

The most commonly missed polyps in colonoscopy are those located behind haustral folds. The G-EYE system is a standard colonoscope consisting of re-processable balloon at its distal tip. The G-EYE balloon improves the detection of polyps by straightening the haustral folds. In our back-to-back tandem study, we aimed to determine whether and to what extent the G-EYE system could reduce adenoma miss rates in screening colonoscopy. Patients referred to colonoscopy were randomized into 2 groups. Group A underwent a standard colonoscopy (SC) followed by balloon colonoscopy (BC), and Group B underwent BC followed by SC. In this randomized tandem study, the investigator's level of training and the endoscopists themselves were changed after each withdrawal. Each endoscopist was blinded to the results of the first withdrawal. Fifty-eight patients were enrolled and randomized into 2 groups with similar baseline characteristics. Nine patients were excluded from the study. Twenty-five patients underwent SC followed by BC while 24 underwent BC followed by SC. The adenoma miss rate for SC was 41 %, with an additional detection rate of 69 % for BC (ratio 1.69). The overall miss rate for polyps was 60 % for SC, with an additional detection rate of 150 % for BC (ratio 2.5). Experienced investigators who used BC were able to identify an additional 7 polyps while inexperienced investigators. Although our results could not clearly confirm that BC improves adenoma detection, the investigator's experience appears to be a major determinant of the adenoma detection rate. Die meisten übersehenen Polypen im Darm liegen verborgen hinter Kolonfalten. Das G-EYE Ballonkoloskop ist ein Standardkoloskop an dessen Spitze ein aufblasbarer Ballon angebracht ist, der die Falten des Kolons glättet und somit die Detektion von Polypen im Kolon verbessern kann. In unserer back-to-back Tandemstudie untersuchten wir daher die Wirksamkeit des G-EYE Systems in Hinblick auf eine Verbesserung der Detektionsraten von Polypen und Adenomen während einer diagnostischen Koloskopie mit unterschiedlichen Untersuchern. Die Patienten für eine diagnostische Koloskopie wurden in zwei Gruppen randomisiert. In Gruppe A erfolgte eine Standardkoloskopie (SC) gefolgt von einer Ballonkoloskopie (BC) und Gruppe B erhielt der Patient erst die BC mit anschließender SC. In dieser randomisierten Tandemstudie wurden nach jedem Rückzug die Untersucher gewechselt. Zudem hatten die Untersucher unterschiedliche Erfahrungslevel und waren für die Ergebnisse des Voruntersuchers verblindet. 58 Patienten wurden in zwei Gruppen randomisiert. Neun Patienten wurden aus der Studie ausgeschlossen. 25 Patienten begannen mit der SC gefolgt von der BC, während 24 in umgekehrter Reihenfolge untersucht wurden. Die Missrate für Adenome für SC betrug 41 %, mit einer zusätzlichen Detektionsrate von 69 % für die BC (ratio 1,69). Die gesamte Missrate für Polypen betrug 60 % mit der SC und einer zusätzlichen Detektionsrate von 150 % für die BC (ratio 2,5). Erfahrenere Untersucher konnten mit dem BC im Mittel 7 Polypen mehr finden als unerfahrene Untersucher. Auch wenn unsere Ergebnisse nicht eindeutig belegen, dass der Einsatz des BC mehr Adenome findet, so zeigt die Arbeit, dass die Erfahrung des Untersuchers einer der wichtigsten Indikatoren für die Adenomdetektionrate zu sein scheint.

Introduction Patients with tumour related upper gastrointestinal bleeds (UGIBs) are challenging to treat. Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder for GI bleeding. The primary aim was to look at outcomes of UGIBs secondary to tumours who had Hemospray therapy in 13 centres. Methods Data was prospectively collected on the use of hemospray from specialist centres in the UK, France, Germany (Jan’16-September’18). Hemospray was used for UGIBs secondary to tumours as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as the cessation of bleeding within 5 minutes of the application of hemospray. Results 75 patients with tumoural UGIBs were recruited (51 males, 24 females, 22/75 (29%) oesophageal, 49/75 (65%) gastric, 4/75 (5%) doudenal). The median rockall score was 8 (IQR,7–9). Immediate haemostasis was achieved in 73/75 (97%) of patients, 7/65 (11%) had a rebleed, 12/65 (18%) died within 30 days (all-cause mortality). Based on the baseline average total rockall score, the expected rebleed rate is 25–40%, and expected mortality rate was 40–45% in our cohort. 100% immediate haemostasis was achieved in duodenal and gastric tumours, and 91% in oesophageal tumours. Outcomes with mono/combination therapy and rescue therapy (table 1) Conclusions Hemospray is effective for achieving immediate haemostasis in UGIBs secondary to upper GI tumours, which are considered difficult to treat. When considering average rockall score the rebleed and mortality rate is better than predicted rates. Haemostasis is achieved in the majority allowing for patient stabilization and providing time for surgery/radiotherapy.

Introduction Peptic ulcers are the commonest cause of upper Gastrointestinal bleeding (UGIB). Hemospray (Cook Medical, North Carolina, USA) is a novel haemostatic powder aimed to treat UGIB. The aim of this study is to look at outcomes in patients with peptic ulcer GI bleeds treated with hemospray in 13 centres. Methods Data was prospectively collected on hemospray use in UGIBs in the UK, France and Germany (Jan’16-Sept’18). Hemospray was used for peptic ulcer UGIBs as a monotherapy, dual-therapy with standard haemostatic techniques or rescue therapy. Haemostasis was defined as cessation of bleeding within 5 minutes of hemospray application. Results 196 patients with UGIBs secondary to peptic ulcers were recruited (133 M, 63 F, 123/196(63%) duodenal, 44/196(22%) gastric, 29/196(15%) oesophageal). Immediate haemostasis was achieved in 171/196(87%) patients. The median rockall score was 7 (IQR, 6–8). Rebleeding rates were significantly lower in forrest 2a relative to current predicted rebleeding rates based on forrest classifications, 2/21(10%, P Outcomes with different Forrest classifications (table 1) Conclusions Hemospray is effective in achieving immediate haemostasis in peptic ulcer UGIBs. The baseline Blatchford/rockall scores in our cohort are high with patients recruited from tertiary centres with high-risk cases. The rebleeding and mortality rates are in keeping/below the predicted rate based on the scores. The best outcome with hemospray was with forrest 2a ulcers.

Introduction Acute gastrointestinal bleeding (AGIB) carries poor outcomes unless prompt endoscopic haemostasis is achieved. Hemospray is a novel intervention that creates a mechanical barrier over bleeding sites when applied endoscopically. Primary aim of this international prospective multicentre registry is to collect outcomes of patients with AGIB after endoscopic Hemospary application. Secondary outcomes of rebleeding, disease and procedure specific outcomes are also collected. Method Prospective data (Jan2016-Jan2018) from 11 centres across UK, France and Germany collected. Hemospray used as mono therapy, dual-therapy with standard haemostatic techniques or rescue therapy once standard methods failed. Immediate haemostasis defined as cessation of bleeding within 5 min after application of Hemospray. Rebleeding defined as subsequent drop in Hb (>2 g/L), haematemesis, persistent melaena with haemodynamic compromise post therapy. Results 275 cases recruited worldwide(203 M and 72 F). Median pretreatment Blatchford score (BS) 11 for all cases. 246 patients (89%) achieved immediate haemostasis after endoscopic therapy with Hemospray (table 1). Similar haemostasis rates noted in the Hemospray monotherapy (92%), combination therapy (90%) and rescue therapy (85%) group. Peptic ulcer bleed was the most common pathology (53%) and forrest Ib the most common lesion type (66%). 29 patients did not achieve immediate haemostasis.Median BS was higher in this group at 13 (IQR 11–16, p Conclusion These data show high rates of immediate haemostasis (89%). Forrest Type 1b lesions have a higher rate of unsuccessful haemostais and increased risk of rebleeding after therapy. Patients with rebleeding and unsuccessful treatment had higher BS at baseline. The expansion of this international registry will provide data on the efficacy of Hemospray in various disease and patient types over the coming years.

Suspected gastrointestinal (GI) bleeding is a common initial diagnosis in emergency departments. Despite existing endoscopic scores to estimate the risk of GI bleeding, the primary clinical assessment of urgency can remain challenging. The 5-step Manchester Triage System (MTS) is a validated score that is often applied for the initial assessment of patients presenting in emergency departments. All computer-based records of patients who were admitted between January 2014 and December 2014 to our emergency department in a tertiary referral hospital were analyzed retrospectively. The aim of our retrospective analysis was to determine if patient triage using the MTS is associated with rates of endoscopy and with presence of active GI bleeding. In summary, 5689 patients with a GI condition were treated at our emergency department. Two hundred eighty-four patients (4.9 %) presented with suspected GI bleeding, and 165 patients (58 %) received endoscopic diagnostic. Endoscopic intervention for hemostasis was needed in 34 patients (21 %). In patients who underwent emergency endoscopy, triage into MTS categories with higher urgency was associated with higher rates of endoscopic confirmation of suspected GI bleeding (79 % of patients with MTS priority levels 1 or 2, 53 % in level 3 patients, and 40 % in levels 4 or 5 patients; p = 0.024). The MTS is an established tool for triage in emergency departments and could have a potential to guide early clinical decision-making with regards to urgency of endoscopic evaluation in patients with suspected GI bleeding. Eine gastrointestinale Blutung ist eine der häufigsten gastroenterologischen Verdachtsdiagnosen in einer Notaufnahme. Obwohl diverse Scores zur Einschätzung der schwere einer gastrointestinalen Blutung existieren, kann die primäre notfallmedizinische Einschätzung dieser Patienten dennoch herausfordernd sein. Das Manchester Triage System (MTS) ist ein validierter Score, der für Patienten unabhängig von diagnostischen Befunden zur Triage bei der initialen Aufnahme in einer Notaufnahme von nicht ärztlichem Personal angewandt wird. Alle Akten von gastroenterologischen Patienten die zwischen Januar 2014 und Dezember 2014 in unserer Notaufnahme eines Maximalversorgers behandelt wurden, wurden retrospektiv analysiert. Das Ziel unserer retrospektiven Analyse war es zu untersuchen, ob die Anwendung des MTS mit der endoskopischen Diagnostik und dem Befund einer aktiven gastrointestinalen Blutung korreliert. Insgesamt wurden 5689 Patienten in einem Jahr mit einer gastrointestinalen Symptomatik in unserer Notaufnahme behandelt. Bei 284 Patienten (4,9 %) wurde eine gastrointestinale Blutung vermutet. 165 Patienten (58 %) erhielten akut oder im Verlauf eine endoskopische Diagnostik. Dabei war eine endoskopische Intervention bei 34 Patienten (21 %) notwendig. Patienten die in höheren MTS Notfallkategorien klassifiziert waren, zeigten höhere Raten an endoskopisch bestätigten gastrointestinalen Blutungen. (79 % mit MTS Level 1 oder 2, 53 % in Level 3 und 40 % in Level 4 oder 5; p = 0,024). Das MTS ist ein etabliertes Triage System in Notaufnahmen. Es kann angenommen werden, dass dieses einfach zu bedienende System auch das Potential hat, klinische Entscheidungen für eine Notfallendoskopie bei Patienten mit dem Verdacht auf eine gastrointestinale Blutung zu unterstützen.

Anamnese: Eine 66-jahrige Frau stellte sich bei ihrem Hausarzt mit zunehmender Verschlechterung des Allgemeinzustandes bei laborchemischem Nachweis einer hypochromen, mikrozytaren Anamie vor. Untersuchungen: Die ambulante nicht invasive (Hamoccult-Test: positiv) und invasive (OGD) Diagnostik wurde bei Nachweis multipler Kolonpolypen (Koloskopie) durch eine Kapselendoskopie erganzt. Bei Verdacht auf ein Ulkus im oberen Dunndarm erfolgte die stationare Aufnahme zur Doppelballonenteroskopie. Die endoskopische Diagnostik ergab die Diagnose eines Adenokarzinoms des Jejunums. Therapie und Verlauf: Das Tumorstaging mit explorativer Laparotomie zeigte eine lokal fortgeschrittene Tumorerkrankung, sodass eine palliative Chemotherapie analog zur Therapie des Kolonkarzinoms durchgefuhrt wurde. Folgerung: Bei vorhandener Polyposis des Kolons und unklarer Atiologie der Anamie sollte auch eine Dunndarmdiagnostik erfolgen. Bei Polyposis oder positiver Familienanamnese sollte auf ein adenomatoses Polyposis-Syndrom getestet werden.

Overt or occult gastrointestinal bleeding is a frequently observed condition in routine gastroenterological practice. Occult gastrointestinal bleeding is usually a purely incidental finding, based on the discovery of iron deficiency anemia in the laboratory or blood in stool (a positive Hemoccult test). However, overt bleeding accompanied by the clinical features of tarry stool, hematemesis, or hematochezia may be a life-threatening condition, calling for immediate emergency management. In contrast to traumatology, algorithms of emergency and intensive medicine are not sufficiently validated yet for acute life-threatening bleeding. The purpose of this review was to present all established and new endoscopic hemostasis techniques and to evaluate their efficacy, as well as to provide the treating endoscopist with practical advice on how he/she could incorporate these procedures into acute medical management. The recommendations are based on inspection of the study results in the recent published literature, as well as emergency medicine algorithms in traumatology.

Hintergrund und Fragestellung | Das hepatorenale Syndrom (HRS) ist eine schwere, potenziell reversible Komplikation bei Patienten mit Leberzirrhose. Unbehandelt ist die Prognose sehr schlecht. Fur eine Behandlung mit Terlipressin in Kombination mit Humanalbumin wurde in mehreren randomisiert-kontrollierten Studien eine Verbesserung der Nierenfunktion demonstriert, der Einfluss dieser Therapie auf die Gesamtprognose bleibt allerdings unklar. Im Rahmen der vorliegenden Observations-Studie sollte der Effekt einer Terlipressin-Behandlung bei HRS auf Nierenfunktion, Gesamtuberleben sowie dialyse- und transplantationsfreiem Uberleben untersucht werden. Patienten und Methodik | Uber einen Zeitraum von 12 Monaten wurden in unserem Zentrum alle Patienten mit HRS und Terlipressin-Therapie prospektiv erfasst. Klinisch relevante Parameter, Therapiecharakteristika, Ansprechen, Gesamtuberleben, Dialyseeinleitung und Lebertransplantation (LTx) wurden ausgewertet. Ergebnisse | Insgesamt wurden 57 Patienten uber einen medianen Zeitraum von 65 Tagen prospektiv beobachtet. Bei der Mehrzahl der Patienten lag ein fortgeschrittenes Zirrhose-Stadium vor (Child-Pugh C: 46; 81 %). Die kumulative Terlipressin-Dosis bzw. -Behandlungsdauer betrug im Median 20 mg bzw. 5 Tage. Ein komplettes oder partielles Ansprechen auf Terlipressin im Sinne einer HRS-Ruckbildung wurde in 29 bzw. 3 von 57 Patienten beobachtet (51 %; 5 %). Patienten mit Terlipressin-Ansprechen zeigten mit einem medianen Gesamtuberleben von 167 vs. 27 Tagen bzw. einem dialyse- und LTx-freiem Uberleben von 81 vs. 4 Tagen eine signifikant bessere Gesamtprognose als Patienten mit Nicht-Ansprechen. In einer uni- und multivariaten Analyse war eine hohe Ausgangs-Serum-Bilirubin-Konzentration mit dem Nicht-Ansprechen assoziiert. Folgerung | Terlipressin in Kombination mit Humanalbumin ist eine effektive Therapie beim HRS. Das Terlipressin-Ansprechen ist dabei mit einem signifikanten Uberlebensvorteil assoziiert.

Lower gastrointestinal bleeding is common and occurs often in elderly patients. In rare cases it is associated with hemorrhagic shock. A large number of such bleedings, which are often caused by colon diverticula, subside spontaneously. Alternatively they can be treated by endoscopic procedures successfully. Given the aging population of our society, the rising incidence of lower gastrointestinal tract bleeding and new anticoagulant therapies, some of the bleedings tend to be severe. Colonoscopy is the established standard procedure for the diagnosis and treatment of lower gastrointestinal bleeding. However, a small number of patients experience re-bleeding or shock; their bleeding does not resolve spontaneously and cannot be treated successfully by endoscopic procedures. In such patients, interventional radiology is very useful for the detection of bleeding and the achievement of hemostasis. Against this background we performed a literature search using PubMed to identify all relevant studies focused on the endoscopic and radiological management of lower gastrointestinal bleeding and present recent conclusions on the subject.

Gastrointestinal bleeding (GIB) can occur at different locations and different intensities throughout the intestine. Gastrointestinal bleeding is subdivided based on the location (upper, lower, middle GIB). The upper GI tract comprises the esophagus, stomach, and duodenum (up to the papilla of Vateri). Middle GIB relates to that part of the GI tract located below the papilla Vateri up to the terminal ileum. Lower GIB is defined as a bleeding within the colon and rectum.

Multimodality imaging is an essential aspect of endoscopic surveillance for the detection of neoplastic lesions, such as dysplasia or intramucosal cancer, because it improves the efficacy of endoscopic surveillance and therapeutic procedures in the gastrointestinal tract. This approach reveals mucosal abnormalities that cannot be detected by standard endoscopy. Currently, these imaging techniques are divided into those for primary detection and those for targeted imaging and characterization, the latter being used to visualize areas of interest in detail and permit histological evaluation. This Review outlines the use of virtual chromoendoscopy, narrow-band imaging, autofluorescence imaging, optical coherence tomography, confocal endomicroscopy and volumetric laser endomicroscopy as new imaging techniques for diagnostic investigation of the gastrointestinal tract. Insights into use of multimodal endoscopic imaging for early disease detection, in particular for pre-malignant lesions, in the oesophagus, stomach and colon are described.

High definition endoscopy is the accepted standard in colonoscopy. However, an important problem is missed polyps.Our objective was to assess the additional adenoma detection rate between high definition colonoscopy with tone enhancement (digital chromoendoscopy) vs. white light high definition colonoscopy.In this prospective randomized trial patients were included to undergo a tandem colonoscopy. The first exam was a white light colonoscopy with removal of all visualized polyps. The second examination was randomly assigned in a 1:1 ratio as either again white light colonoscopy (Group A) or colonoscopy with tone enhancement (Group B). Primary endpoint was the adenoma detection rate during the second withdrawal (sample size calculation - 40 per group).67 lesions (Group A: n=34 vs. Group B: n=33) in 80 patients (mean age 61 years, male 64%) were identified on the first colonoscopy. The second colonoscopy detected 78 additional lesions: n=60 with tone enhancement vs. n=18 with white light endoscopy (p0.001). Tone enhancement found more additional adenomas (A n=20 vs. B n=6, p=0.006) and identified significantly more missed adenomas per subject (0.5 vs. 0.15, p=0.006).High definition plus colonoscopy with tone enhancement detected more adenomas missed by white light colonoscopy.

Die gastrointestinale Blutung (overt oder okkult) ist ein haufiges Krankheitsbild in der taglichen klinischen Praxis. Dabei treten Symptome entsprechend der Blutungslokalisation auf. Die overte Blutung ist charakterisiert durch Teerstuhl, Hamatemesis oder Hamatochezie. Okkulte gastrointestinale Blutungen fallen in Zufallsbefunden durch Anamie im Labor oder positive Stuhltests auf. Neben einer notfall- und intensivmedizinischen Versorgung bei der akuten Blutung spielt die gastrointestinale Endoskopie die wichtigste Rolle bei Diagnostik und Therapie der gastrointestinalen Blutung. Neue technische Entwicklungen haben in den letzten Jahren zu einer deutlichen Verbesserung der interventionell endoskopischen Versorgung dieser Patienten gefuhrt. So sind neben Injektionsverfahren, auch mechanische und thermische Anwendungen weiterentwickelt worden, um die Effektivitat der Blutstillung zu verbessern. Diese neuen Verfahren werden im Rahmen dieses Reviews vorgestellt.

a b s t r a c t Background: Endomicroscopy allows in vivo microscopic investigation of enteral mucosa during endo- scopic examinations. The aim of this study was to determine interobserver variability in the evaluation of endomicroscopic pictures of several organs by groups of investigators composed of confocal experts, pathologists and students. Methods: Twenty-five selected representative endomicroscopic pictures of the colon, stomach and oesophagus (total number, 75) were evaluated based on tissue, inflammatory and neoplastic changes (secondary endpoints). The endomicroscopic presence of neoplastic features was the primary endpoint and correlated with the final histological diagnosis. Results: The kappa values for experts examining colon, stomach, and oesophagus pictures were 0.80, 0.91, and 0.488, respectively; for students 0.74, 0.684, and 0.527 and for pathologists 0.749, 0.633, and 0.346, respectively. Neoplasia was accurately diagnosed in 67-97% of patients with no significant differences between the 3 groups. Tissue differentiation was determined best by pathologists, whereas the degree of inflammation was better diagnosed by experts and students. In all 3 groups the diagnosis of oesophageal diseases was the most difficult. Conclusions: Endomicroscopic images can be interpreted with high concordance. In our study, the diag- nostic reliability was not different between students, endomicroscopic experts, and pathologists. Thus, endomicroscopy could be an additional and reliable imaging modality for diagnosing mucosal neoplasia of the gut. © 2013 Editrice Gastroenterologica Italiana S.r.l. Published by Elsevier Ltd. All rights reserved.

Background and Aims: Despite increasingly sensitive and accurate blood tests to detect liver disease, liver biopsy remains very useful in patients with atypical clinical features and abnormal liver tests of unknown etiology. The aim was to determine those elevated laboratory liver parameters that cause the clinician to order a biopsy, and whether laboratory tests are associated with pathological findings on histology. Methods: 504 patients with unclear hepatopathy, admitted to the outpatient clinic of a university hospital between 2007 and 2010, were analyzed with respect to laboratory results, clinical data, and the results of liver biopsies. Results: Aspartate aminotransferase (AST) and glutamate dehydrogenase (GLDH) levels above the normal range significantly increased the likelihood of recommending a liver biopsy by 81% [OR with 95% CI 1.81 (1.21-2.71), p = 0.004] and 159% [OR with 95% CI 2.59 (1.70-3.93), p < 0.001], respectively. AST values above normal were associated with fibrosis (63 vs. 40% for normal AST, p = 0.010). Elevated ferritin levels pointed to a higher incidence of steatosis (48 vs. 10% for normal ferritin, p < 0.001) and inflammation (87 vs. 62% for normal ferritin, p = 0.004). Conclusions: Our results indicate that elevated AST and GLDH were associated with a greater likelihood of recommending liver biopsy. Elevated AST and ferritin levels were associated with steatosis, inflammation and fibrosis on liver biopsies. Thus, AST and ferritin may be useful non-invasive predictors of liver pathology in patients with unclear hepatopathy., OA-Komponente aus Allianzlizenz

Durchfallerkrankungen sind haufige Erkrankungen des Gastrointestinaltrakts und eine der 5 haufigsten Todesursachen weltweit. Obwohl genaue epidemiologische Angaben fehlen, spielen Diarrhoen auch in entwickelten Landern eine zunehmende Rolle. Dabei werden akute von chronischen Diarrhoen unterschieden. Die haufigsten Ursachen fur eine akute Enteritis infectiosa sind virale und bakterielle Erreger. Im Fall einer bakteriellen Dysenterie sind antibiotikaassoziierte Durchfalle durch Clostridium difficle eine haufige nosokomiale Manifestation der Erkrankung. Bei den viralen Erregern sind Noroviren in etwa 90 % der Falle Ausloser einer akuten, innerhalb von 48-72 Stunden meist selbstlimitierenden Diarrho. Bakterielle Dysenterien werden, wenn notwendig, mit Antibiotika behandelt, wobei bei einigen Erregern zunehmende Resistenzentwicklungen zu beachten sind. Eine weiterfuhrende mikrobiologische oder endoskopische Diagnostik ist nicht immer notwendig. Die Therapie orientiert sich an den klinischen Symptomen und berucksichtigt im Allgemeinen die Pravention sekundarer Komplikationen.

Hintergrund und Fragestellung: Die Bereitschaft zur Organspende ist in Deutschland nach wie vor unzureichend und bei Weitem erhalten nicht alle Patienten auf den Wartelisten rechtzeitig ein geeignetes Spenderorgan. So wird angenommen, dass die inadaquate Verfugbarkeit von Spenderorganen Ausdruck mangelnder Kenntnis und nachfolgender Unsicherheit in der Bevolkerung ist. Die Einstellung und das Wissen junger Menschen zur Organspende sind bislang wenig untersucht. Methodik: 4000 Fragebogen wurden uber die Schulen an alle Schulerinnen und Schuler der 11. und 12. Klasse (n = 2422) in der rheinland-pfalzischen Landeshauptstadt Mainz versandt. Die Beantwortung von 12 Fragen erfolgte unter Aufsicht eines Lehrers sowie ohne Hilfsmittel und war freiwillig. Ergebnisse: 1155 Umfragebogen wurden ausgewertet. 11,3 % aller antwortenden Teilnehmer besasen einen Organspendeausweis. In 48,9 % der Falle waren Hirntod und Organspende in den eigenen Familien bereits thematisiert worden. 37,0 % der Schuler waren im Falle ihres Hintodes nicht mit einer Organspende einverstanden und geben hierfur in 72,4 % ein Informationsdefizit als Grund an. Schuler mit auslandischer Staatsburgerschaft lehnen die Organspende haufiger ab als Deutsche (43,4 % vs. 36,2 %). Folgerungen: Mehr als die Halfte der Jugendlichen zwischen 14 und 20 Jahren befurworten die Organspende. Allerdings fuhren junge Menschen nur selten einen Organspendeausweis. Diese regionalen Ergebnisse zeigen, dass ein Informationsdefizit der Hauptgrund fur die Ablehnung zur Organspendebereitschaft ist. Eine Intensivierung der Aufklarung im Schulalter sollte zu einer Verbesserung dieser Situation fuhren.

A 66-year-old woman suffering from skin paleness and weakness presented an increasing hypochromic, microcytic anemia. Diagnostic: In an ambulant setting a capsule endoscopy of the small intestine was carried out because of multiple polyps of the colon (colonoscopy) in addition to non-invasive (Hämoccult-Test) and invasive (gastroscopy) diagnostic. The patient was then admitted to hospital to clarify a suspicious ulcer of the small bowl. According to biopsies taken via balloon enteroscopy, an adenocarcinoma of the small intestine was diagnosed.After staging and exploratory laparotomy, histology findings showed an advanced tumour stage. A palliative chemotherapy, analogue to colon cancer treatment, was conducted.Small bowel diagnostics should be carried out if the aetiology of an anemia is not certain with an existing polyposis of the colon. Individuals with personal or family history of cumulative colorectal adenomas should undergo assessment for an adenomatous polyposis syndrom.

Hepatorenal syndrome (HRS) is a severe but potentially reversible complication in patients with cirrhosis. Untreated it is associated with a poor prognosis. Several randomized controlled trials (RCT) demonstrated that treatment with terlipressin and albumin improves renal function. However the effect on overall survival is unclear. Aim of the study was to gain further insight into the effect of terlipressin treatment in patients with HRS on renal function, overall survival and survival without liver transplantation or renal replacement.All patients presenting with HRS and treated with terlipressin in our tertiary referral liver and transplantation center between April 2013 and April 2014 were included. Clinically relevant parameters such as response to therapy, overall survival and transplant- and renal-replacement-free-survival were prospectively investigated.Overall 57 patients were prospectively followed over a median of 65 days. In the majority of patients cirrhosis was in an advanced stage (Child-Pugh C: 46; 81%). Median cumulative terlipressin dosage and treatment duration were 20 mg and 5 days, respectively. Complete or partial response to terlipressin with recovery from HRS was observed in 20 and 3 out of 57 patients (51%; 5%). Median overall survival was significantly better in patients with response to terlipressin than in patients with non-response (167 vs. 27 days; p0.0001), as well as median survival free of liver transplantation and renal-replacement-therapy (81 vs. 4 days; p0.0001). In uni- and multivariate analysis, non-response was associated with a high baseline serum-bilirubin-concentration.Terlipressin in combination with albumin is effective in the majority of patients with HRS. Response to therapy is associated with improved survival.

AIM: To investigate the impact of JetPrep cleansing on adenoma detection rates. METHODS: In this prospective, randomized, crossover trial, patients were blindly randomized to an intervention arm or a control arm. In accordance with the risk profile for the development of colorectal carcinoma, the study participants were divided into high-risk and low-risk groups. Individuals with just one criterion (age > 70 years, adenoma in medical history, and first-degree relative with colorectal cancer) were regarded as high-risk patients. Bowel preparation was performed in a standardized manner one day before the procedure. Participants in the intervention arm underwent an initial colonoscopy with standard bowel cleansing using a 250-mL syringe followed by a second colonoscopy that included irrigation by the use of the JetPrep cleansing system. The reverse sequence was used in the control arm. The study participants were divided into a high-risk group and a low-risk group according to their respective risk profiles for the development of colorectal carcinoma. RESULTS: A total of 64 patients (34 men and 30 women) were included in the study; 22 were included in the high-risk group. After randomization, 30 patients were assigned to the control group (group A) and 34 to the intervention group (group B). The average Boston Bowel Preparation Scale score was 5.15 ± 2.04. The withdrawal time needed for the first step was significantly longer in group A using the JetPrep system (9.41 ± 3.34 min) compared to group B (7.5 ± 1.92 min). A total of 163 polyps were discovered in 64 study participants who underwent both investigation steps. In group A, 49.4% of the polyps were detected during the step of standard bowel cleansing while the miss rate constituted 50.7%. Group B underwent cleansing with the JetPrep system during the first examination step, and as many as 73.9% of polyps were identified during this step. Thus, the miss rate in group B was a mere 26.1% (P < 0.001). When considering only the right side of the colon, the miss rate in group A during the first examination was 60.6%, in contrast to a miss rate of 26.4% in group B (P < 0.001). CONCLUSION: JetPrep is recommended for use during colonoscopy because a better prepared bowel enables a better adenoma detection, particularly in the proximal colon.

Patients with long-standing extensive chronic inflammatory bowel disease (IBD) have an increased risk of developing intraepithelial neoplasia and colitis-associated cancer (CAC) compared to the average risk population. In 2003, the first randomized, controlled trial was published evaluating lesions in the colon according to a modified Pit-Pattern classification after pan-chromoendoscopy with methylene blue (0.1 %). Chromoendoscopy enabled unmasking dysplastic lesions and clarifying the borders between neoplastic and normal tissue. This has led to the “smart biopsy” concept, where more targeted biopsies become possible after enhanced endoscopy (chromoendoscopy). In addition, confocal laser endomicroscopy (CLE) has revealed in vivo tissue changes in vessel, connective tissue and cellular-subcellular structures.

Background Unlike metastatic colorectal cancer (CRC) there are to date few reports concerning the predictive value of molecular biomarkers on the clinical outcome in stage II/III CRC patients receiving adjuvant chemotherapy. Aim of this study was to assess the predictive value of proteins related with the EGFR- and VEGFR- signalling cascades in these patients. Methods The patients' data examined in this study were from the collective of the 5-FU/FA versus 5-FU/FA/irinotecan phase III FOGT-4 trial. Tumor tissues were stained by immunohistochemistry for VEGF-C, VEGF-D, VEGFR-3, Hif-1 α, PTEN, AREG and EREG expression and evaluated by two independent, blinded investigators. Survival analyses were calculated for all patients receiving adjuvant chemotherapy in relation to expression of all makers above. Results Patients with negative AREG and EREG expression on their tumor had a significant longer DFS in comparison to AREG/EREG positive ones (p< 0.05). The benefit on DFS in AREG-/EREG- patients was even stronger in the group that received 5-FU/FA/irinotecan as adjuvant treatment (p=0.002). Patients with strong expression of PTEN profited more in terms of OS under adjuvant treatment containing irinotecan (p< 0.05). Regarding markers of the VEGFR- pathway we found no correlation of VEGF-C- and VEGFR-3 expression with clinical outcome. Patients with negative VEGF-D expression had a trend to live longer when treated with 5-FU/FA (p=0.106). Patients who were negative for Hif-1 α, were disease-free in more than 50% at the end of the study and showed significant longer DFS-rates than those positive for Hif-1 α (p=0.007). This benefit was even stronger at the group treated with 5-FU/FA/irinotecan (p=0.026). Finally, AREG-/EREG-/PTEN+ patients showed a trend to live longer under combined treatment combination. Conclusions The addition of irinotecan to adjuvant treatment with 5-FU/FA does not provide OS or DFS benefit in patients with stage II/III CRC. Nevertheless, AREG/EREG negative, PTEN positive and Hif-1 α negative patients might profit significantly in terms of DFS from a treatment containing fluoropyrimidines and irinotecan. Our results suggest a predictive value of these biomarkers concerning adjuvant chemotherapy with 5-FU/FA +/− irinotecan in stage II/III colorectal cancer. Electronic supplementary material The online version of this article (doi:10.1186/s13046-014-0083-8) contains supplementary material, which is available to authorized users.

Endomicroscopy is a new imaging tool for gastrointestinal endoscopy. In vivo histology becomes possible at subcellular resolution during ongoing colonoscopy. Panchromoendoscopy with targeted biopsies has become the method of choice for surveillance of patients with inflammatory bowel disease. Endomicroscopy can be added after chromoendoscopy to clarify whether standard biopsies are needed. This smart biopsy concept can increase the diagnostic yield of intraepithelial neoplasia and substantially reduce the need for biopsies. Clinical acceptance is increasing because of a multitude of positive studies about the diagnostic value of endomicroscopy. Smart biopsies, functional imaging, and molecular imaging may represent the future for endomicroscopy.

AIM: To evaluate the diagnostic yield (inflammatory activity) and efficiency (size of the biopsy specimen) of SpyGlassTM-guided biopsy vs standard brush cytology in patients with and without primary sclerosing cholangitis (PSC). METHODS: At the University Medical Center Mainz, Germany, 35 consecutive patients with unclear biliary lesions (16 patients) or long-standing PSC (19 patients) were screened for the study. All patients underwent a physical examination, lab analyses, and abdominal ultrasound. Thirty-one patients with non-PSC strictures or with PSC were scheduled to undergo endoscopic retrograde cholangiography (ERC) and subsequent peroral cholangioscopy (POC). Standard ERC was initially performed, and any lesions or strictures were localized. POC was performed later during the same session. The Boston Scientific SpyGlass SystemTM (Natick, MA, United States) was used for choledochoscopy. The biliary tree was visualized, and suspected lesions or strictures were biopsied, followed by brush cytology of the same area. The study endpoints (for both techniques) were the degree of inflammation, tissue specimen size, and the patient populations (PSC vs non-PSC). Inflammatory changes were divided into three categories: none, low activity, and high activity. The specimen quantity was rated as low, moderate, or sufficient. RESULTS: SpyGlassTM imaging and brush cytology with material retrieval were performed in 29 of 31 (93.5%) patients (23 of the 29 patients were male). The median patient age was 45 years (min, 20 years; max, 76 years). Nineteen patients had known PSC, and 10 showed non-PSC strictures. No procedure-related complications were encountered. However, for both methods, tissues could only be retrieved from 29 patients. In cases of inflammation of the biliary tract, the diagnostic yield of the SpyGlassTM-directed biopsies was greater than that using brush cytology. More tissue material was obtained for the biopsy method than for the brush cytology method (P = 0.021). The biopsies showed significantly more inflammatory characteristics and greater inflammatory activity compared to the cytological investigation (P = 0.014). The greater quantity of tissue samples proved useful for both PSC and non-PSC patients. CONCLUSION: SpyGlassTM imaging can be recommended for proper inflammatory diagnosis in PSC patients. However, its value in diagnosing dysplasia was not addressed in this study and requires further investigation.