Search

[Purpose] Stenting as a bridge to surgery (SBTS) can transform an emergency surgery (ES) into an elective surgery in patients with symptomatic left-sided malignant colonic obstruction. Concerns have been raised regarding short-term morbidity and long-term oncologic outcomes, with contrasting results reported in the literature. Our main aim is to evaluate not only long-term oncologic outcomes but also short-term postoperative outcomes of stented patients who underwent elective surgery compared to those who had ES., [Methods] From January 2006 to May 2012, we retrospectively identified patients with confirmed left-sided colorectal cancer obstruction. This was done in two centers of reference of colorectal diseases in southern Spain with patients who were treated with curative intent either with ES or SBTS. The short- and long-term results were compared between both groups., [Results] There were 71 patients in the stenting group and 66 in the emergency surgery group, with similar demographic data. Initial stoma creation rates were lower in the SBTS group (16.9% vs. 54.5%, p, [Conclusions] The use of SBTS reduces ostomy rates in patients with obstructive colon malignancies. Long-term survival results are similar. Patients in the SBTS group with stage III AJCC status showed a higher 5-year recurrence-free survival rate than those in the ES group.

Immunosuppressed patients are susceptible to infections by opportunistic agents such as Leishmania that could cause visceral leishmaniasis with gastrointestinal involvement in up to 10 % of cases. We report a 41-year-old man with human immunodeficiency virus (HIV) infection stage C3 with CD4 lymphocytes 81/mm3, 4,070 leukocytes (47.2 % lymphocytes, 0.0 % eosinophils, rest of differential normal) treated with antiretroviral therapy (dolutegravir/abacavir/lamivudine) with good adherence. He also reported mesangiocapillary glomerulonephritis type-1, hepatocutaneous porphyria, and a 7-year history of recurrent visceral leishmaniasis treated with liposomal amphotericin B as secondary prophylaxis. Esophagogastroduodenoscopy and colonoscopy indicated for chronic diarrhea and anemia performed 5 years ago displayed antral erythema, mild nodular appearance in the duodenal mucosa, and normal colonic mucosa. Gastric, duodenal, and colonic biopsies revealed Leishmania spp despite treatment with liposomal amphotericin B. A video capsule endoscopy (VCE) was now indicated for persistent diarrhea. Enteropathy with atrophic and patchy, marked edema of the villus, and whitish nodularity with a “river bedrock” appearance ([Fig. 1 – 3]) in the duodenum and jejunum were identified ([Video 1]). Further gastric and duodenal biopsies showed an accumulation of macrophages in the lamina propria of the mucosa with intracytoplasmatic Leishmania spp ([Fig. 4]). Treatment with meglumine antimoniate was initiated owing to previous failure with liposomal amphotericin B, without response.

Background and study aims: Endoscopy plays an essential role in managing patients with ulcerative colitis (UC), as it allows us to visualize and assess the severity of the disease. As such assessments are not always objective, different scores have been devised to standardize the findings. The main aim of this study was to assess the interobserver variability between the Mayo Endoscopy Score (MES), Ulcerative Colitis Endoscopy Index of Severity (UCEIS) and Ulcerative Colitis Colonoscopy Index of Severity (UCCIS) analyzing the severity of the endoscopic lesions in patients with ulcerative colitis. Patients and methods: This was a single-cohort observational study in which a colonoscopy was carried out on patients with UC, as normal clinical practice, and a video was recorded. The results from the video were classified according to the MES, UCEIS and UCCIS by three endoscopic specialists independently, and they were compared to each other. The Mayo Endoscopy Score (MES) was used to assess the clinical situation of the patient. The therapeutic impact was analyzed after colonoscopy was carried out. Results: Sixty-seven patients were included in the study. The average age was 51 (SD ± 16.7) and the average MES was 3.07 (SD ± 2.54). The weighted Kappa index between endoscopists A and B for the MES was 0.8; between A and C 0.52; and between B and C 0.49. The intraclass correlation coefficient for UCEIS was 0.92 among the three endoscopists (CI 95 %: 0.83–0.96) and 0.96 for UCCIS among the three endoscopists (CI 95 % 0.94–0.97). A change in treatment for 34.3 % of the patients was implemented on seeing the results of the colonoscopy. Conclusions: There was an adequate, but not perfect, correlation between the different endoscopists for MES, UCEIS, UCCIS. This was higher with the last two scores. Thus, there is still some subjectivity to be minimized through special training, on assessing the seriousness of the endoscopic lesions in patients with UC.

Endoscopic ultrasound (EUS)-guided drainage is now the treatment of choice in cases of pancreatic pseudocysts and walled-off necrosis, especially in the absence of luminal bulging and in patients with portal hypertension. Malignant refractory ascites usually heralds a poor prognosis and substantially impairs the quality of life of patients because of the symptoms experienced and the need for repeated paracentesis. EUS-guided placement of lumen-apposing, fully covered, self-expandable metal stents (FCSEMS) has been reported for the drainage of malignant ascites. Herein, we present the results of EUS-guided placement of plastic pigtails stents for the drainage of refractory malignant ascites in three patients. The aim was to improve symptoms and minimize the possible drawbacks of large-caliber FCSEMS. In this preliminary experience, EUS-guided placement of plastic stents was feasible and avoided further paracentesis.

The slow progression of chronic hepatitis C (CHC) infection requires long observation periods to detect clinical changes. We compare the incidence of clinical events, hepatocellular carcinoma (HCC), overall mortality, liver-related mortality, and fibrosis progression between patients with a sustained virological response (SVR) and nonresponders (NR) after a 13-year follow-up period.One hundred and eighty-two CHC patients, who received interferon and ribavirin treatment between 1996 and 2000, were included. Clinical events were evaluated during follow-up. At the end of follow-up, transient elastography was used to assess fibrosis progression.Of the 182 patients, 46.7% (n=85) achieved an SVR. Twenty-seven patients developed hepatic decompensation (one SVR) and 15 developed HCC (three SVR). Twenty-nine patients died (eight SVR). Twelve of the 29 deaths were liver related (two SVR). Independent factors associated with hepatic decompensation were NR to treatment [hazard ratio (HR)=23.35; 95% confidence interval (CI): 2.90-189.25; P=0.003], advanced fibrosis at baseline (HR=9.11; 95% CI: 4.13-20.09), and treatment delay after diagnosis (HR=1.02; 95% CI: 1.00-1.03; P=0.012). Only the latter two were associated with HCC development and liver-related mortality. An assessment of liver fibrosis was performed on 125 patients (66 SVR). Fibrosis values were significantly lower in SVR patients, showing less progression to advanced stages of fibrosis [SVR: 6.6 (2.8); 95% CI: 5.8-7.3] than NR [NR: 14.0 (11.1); 95% CI: 11.1-16.9; P0.001].In patients with CHC, SVR is durable and reduces clinical events. The risk of HCC development is lower, but not eliminated. Sustained responders showed fibrosis stabilization or improved fibrosis values.

Pyoderma gangrenosum is a serious cutaneous complication seen in approximately 1 % of patients with inflammatory bowel disease (IBD). Oral corticosteroids are the mainstay treatment, although the evidence supporting their use is weak. The purpose of this study was to investigate the characteristics of pyoderma gangrenosum associated with Crohn’s disease or ulcerative colitis and which treatments are prescribed in Spanish clinical practice. In this retrospective, observational study, the medical records from all patients with IBD and a diagnosis of pyoderma gangrenosum attended by the gastroenterology departments of 12 Spanish hospitals were reviewed. Data on patient demographics and characteristics, underlying IBD and treatment, and pyoderma gangrenosum characteristics, treatment, and outcome were collected and analyzed. The data from 67 patients were analyzed (41 [61.2 %] women, 41 [61.2 %] with Crohn’s disease, 25 [37.3 %] with ulcerative colitis, and 1 [1.5 %] with indeterminate disease). The underlying disease was in remission in approximately one-third of patients at the time of presentation of pyoderma gangrenosum. Healing was achieved in all patients (in 3 without any systemic therapy). Oral corticosteroids were taken by 51 patients (76.1 %), almost always as first-line treatment, although definitive healing was attained in 19 (28.4 %). Biologic agents such as infliximab and adalimumab were taken by 31 patients (46.3 %) at some point (first-line in 6 patients [9.0 %]), with definitive healing in 29 patients (93.5 %). Oral corticosteroid therapy remains the most common treatment for pyoderma gangrenosum associated with inflammatory bowel disease. Biologic therapies such as infliximab and adalimumab should also be considered.

espanolIntroduccion: el esofago de Barrett (EB) es una enfermedad adquirida definida por la presencia de metaplasia intestinal en el esofago distal. Su prevalencia se ha incrementado de forma alarmante en los ultimos anos. Objetivos: los objetivos primarios del presente trabajo fueron analizar el comportamiento del EB y del adenocarcinoma esofagico (ACE) en un area sanitaria espanola durante el seguimiento del periodo del estudio. Metodos: se analizaron caracteristicas sociodemograficas y el consumo de alcohol y tabaco. Tambien se valoro el comportamiento histologico asi como las causas de defuncion en cada uno de los grupos. Resultados: se incluyeron 430 pacientes, 338 con EB y 92 con ACE. La tasa de incidencia paso de 2,25 y 1,25 por 100.000 habitantes en 1996 a 6,5 y 4,75 en 2011, en EB y ACE, respectivamente. Hubo mas varones, mayor edad e ingesta etilica en el grupo adenocarcinoma respecto al grupo de Barrett. La supervivencia del ACE fue de 23 meses. Las principales causas de muerte en los pacientes con Barrett fueron el cancer no esofagico y la enfermedad cardiovascular. Conclusiones: existe una mayor incidencia y prevalencia tanto del EB como del ACE en los ultimos anos. Como factores de riesgo encontramos el sexo masculino, mayor edad y consumo de alcohol. El EB largo (> 3 cm) esta implicado en la progresion de la displasia. El diagnostico de ACE se hace, la mayor parte de las veces, con el debut de la enfermedad neoplasica y, en el menor de los casos, sobre un EB previo. La enfermedad cardiovascular y neoplasica no esofagica han sido las principales causas de mortalidad en los pacientes con EB. EnglishBackground: Barrett’s esophagus (BE) is an acquired disease defined by the presence of intestinal metaplasia with goblet cells in the distal esophagus. The prevalence of BE has increased dramatically over the last years. Aims: The primary aims of the study were to analyze the characteristics of BE and esophageal adenocarcinoma (EAC) in a Spanish health district during a follow-up period. Methodology: Sociodemographic factors, alcohol consumption and cigarette smoking were analyzed. We also studied the histological behavior and cause of death in each group. Results: In the present study 430 patients were included, 338 with BE and 92 with EAC. Incidence rates have risen from 2.25 and 1.25 per 100,000 inhabitants in 1996 to 6.5 and 4.75 per 100,000 in 2011, respectively. In the EAC group, male gender, age and alcohol consumption were higher in comparison to the BE group, and the overall survival was 23 months. In the BE group, the main causes of death were non-esophageal cancer and cardiovascular disease. Conclusions: The incidence and prevalence rates of AEC and BE have risen over the past years. Risk factors for these conditions were male gender, age and alcohol consumption. Long BE (> 3 cm) is involved in dysplasia progression. AEC diagnosis mainly occurs after neoplasia is detected and, in a few cases, due to a previous BE. Cardiovascular diseases and non-esophageal cancers have been found to be the main cause of death in BE patients.

Background and study aims: Colon capsules display images from the moment they are ingested, making the study of other extracolonic areas possible. The aim of this study was to analyze the significance of these extracolonic findings. Patients and methods: In this single-center, prospective study, 165 patients underwent colon capsule endoscopy (CCE) between September 2009 and October 2012 to rule out colonic pathology. Images were recorded, without interruptions, from the moment the capsule was ingested until its battery ran out. The study was deemed complete when the capsule had traveled from the esophagus to excretion or until the hemorrhoidal plexus was observed. Results: CCE was used for colorectal cancer (CRC) screening (81.2 %), to investigate for chronic diarrhea (9.7 %) and chronic iron deficiency anemia (6.1 %), and for patients with incomplete colonoscopy (3.0 %). The capsule returned findings in the esophagus in 52.1 % of patients, in the stomach in 45.5 % of patients, and in the small bowel in 70.7 % of patients, with the findings being considered relevant in 4.9 %, 9.7 %, and 22.6 % of patients, respectively. The whole extent of the digestive tract was fully recorded in 86.1 % of patients and the Z line could be fully observed in 57.6 % of patients. There were no adverse events. Conclusions: CCE allows the recording of images from almost the whole extent of the digestive tract in most patients, enabling relevant pathologies to be identified in extracolonic areas, particularly the small bowel. Technical and procedural improvements are still necessary in order to achieve better observation of the stomach and esophagus.

Aim Esophageal capsule endoscopy is a well tolerated procedure that does not require sedation and has proved its value for the study of the esophagus. The aim of our study was to assess the feasibility, accuracy, safety and acceptability of esophageal capsule endoscopy for the study of gastroesophageal reflux disease and esophageal varices in patients who refused conventional upper gastrointestinal endoscopy. Patients and methods Thirty consecutive examinations performed in 28 patients (15 men/13 women; mean age: 58.5+/-12.4 years; range: 23-87 years) were reviewed. Twenty-five examinations were performed in 23 patients presenting with chronic gastroesophageal reflux disease symptoms and the remaining five were carried out in patients with cirrhosis for screening of esophageal varices. The procedures were done with the new PillCam ESO that harbors two viewing cupules and takes a total of 14 frames/s. Technical data (total recording time, esophageal transit time and Z-line visualization), clinical findings (Savary-Miller grade; presence and characteristics of esophageal varices or portal hypertension gastropathy), and patient's opinion (quality and comfort questionnaire) were analyzed. Results All the patients ingested and excreted the capsule without complications. Two examinations in the gastroesophageal reflux disease group were repeated; one was issued as a follow-up and the other because no images were recorded in the first capsule endoscopy. From the former, only the satisfaction questionnaire was analyzed. Mean total recording time and esophageal transit time were 1224 and 243.79 s, respectively (range: 2-1192 s). Complete study of the Z-line was possible in 23 examinations (23/29; 79.3%). Esophageal erosions were seen in 58.33% (14/24) of the examinations carried out in patients with gastroesophageal reflux disease. Nine out of 14 patients (64.29%) presented with grade I esophagitis and the other five (35.71%) with grade II esophagitis. Among the five patients with cirrhosis, small varices were visualized in one (1/5; 20%), while large varices with red spots were evidenced in the remaining three (3/5; 60%). All four patients showing esophageal varices were found to have portal hypertension gastropathy. In most examinations, patients found the capsule easy to swallow (28/30; 93.33%), asymptomatic (29/30; 96.66%), evaluated the procedure as comfortable (29/30; 96.66%), and would repeat it if necessary (30/30; 100%). Conclusions Esophageal capsule endoscopy is an adequate alternative diagnostic method for the study of gastroesophageal reflux disease and for the screening of esophageal varices in patients refusing to undergo conventional upper gastrointestinal endoscopy.

Objective Colon capsule endoscopy (CCE) is a new endoscopic technique that is minimally invasive and allows evaluation of the colon mucosa without pain, sedation, and gas insufflation. To date, few studies have investigated the use of CCE in patients with ulcerative colitis (UC). This study compares the ability of CCE and a conventional colonoscopy to assess mucosal disease activity and the extent of inflammatory mucosa in patients with UC. Methods Forty-two patients (27 men, mean age 48.5 years) with known UC and indication for colonoscopy were enrolled in this single-blind, prospective study. All patients underwent CCE, followed by a colonoscopy. The activity and extent of the disease was assessed using Mayo scores and Montreal scores, respectively. Results There was a good correlation between CCE and colonoscopy in disease severity (κ=0.79; 95% confidence interval: 0.62-0.96) and extent of inflammation (κ=0.71; 95% confidence interval: 0.52-0.90) observed. The ability of CCE to assess a broad segment of distal ileum led to a change in the diagnosis of UC to ileocolonic Crohn's disease in three patients. Bowel preparation was considered adequate in 80% of the patients and no serious adverse events related to the CCE procedure or bowel preparation were reported. Conclusion CCE is a safe and useful method for the evaluation of patients with UC. The ability of CCE to assess distal ileum provides an advantage to colonoscopy as CCE can identify patients who have been incorrectly diagnosed with UC, resulting in a change in their diagnosis to Crohn's disease.

CD is a chronic inflammatory disorder associated to mucosal and transmural inflammation of the bowel wall. It is well known that CD can affect the entire gastrointestinal. Therefore, ileocolonoscopy and biopsies of the terminal ileum as well as of each colonic segment to look for microscopic evidence of CD are the first-line procedures to establish the diagnosis. However, it has been observed that up to 30% of the patients have only small bowel involvement. Evaluation of the small bowel has been made with radiological procedures, barium radiography, and abdominal computed tomography or by ileocolonoscopy or enteroscopy, but they have many recognized limitations. CE is undoubtedly a very useful diagnostic tool proposed to observe small-bowel lesions undetectable by conventional endoscopy or radiologic studies. We review different studies that have been published reporting the use of CE in suspected and evaluation of the extension or the recurrence in CD and also its use in pediatric population and its complications.

Capsule endoscopy is nowadays the diagnostic technique of choice in the study of small bowel pathologies, allowing the non-invasive study of the entire mucosa. This has led, together with new technical advances, to the creation of two new models (PillCam ESO and PillCam Colon) for the study of esophageal and colonic diseases. These two new capsules offer an interesting alternative to conventional endoscopy in the study of the upper and lower digestive tracts, because traditional endoscopy is often unpleasant and uncomfortable for the patient, can be painful, often requires moderate or deep sedation and is not without complications (hemorrhage, perforation, etc.). PillCam Colon is particularly important for its usefulness in the diagnosis of colonic polyps, and is a potentially useful tool in cases of incomplete colonoscopy or in colorectal cancer screening, even more when most patients are reluctant to undergo screening programs due to the said disadvantages of conventional colonoscopy. This article discusses the advantages of capsule endoscopy over conventional endoscopy, its current application possibilities and indications in routine clinical practice. In the various sections of the work, we assess the application of endoscopic capsule in different sections of the digestive tract (esophagus, stomach, and colon) and finally the potential role of panendoscopy with PillCam Colon.

Therapy of gastric varices (GV) is still challenging. Cyanoacrylate (CYA) injection is the recommended treatment for bleeding GV, but has a known adverse event rate, which could be reduced if EUS is used for guidance. Otherwise, EUS-guided coil application (ECA) may be an alternative.To compare CYA and ECA embolization of feeding GV for feasibility, safety, and applicability.Retrospective analysis of a prospectively maintained database.Multicenter study, tertiary referral centers.Thirty consecutive patients with localized GV who received either CYA injection or ECA were included with follow-up for 6 months after treatment.There were 11 patients in the coil group and 19 patients in the CYA group. The GV obliteration rate was 94.7% CYA versus 90.9% ECA; mean number of endoscopy sessions was 1.4 ± 0.1 (range 1-3). Adverse events occurred in 12 of 30 patients (40%) (CYA, 11/19 [57.9%]; ECA, 1/11 [9.1%]; P.01); only 3 were symptomatic, and an additional 9 (CYA group) had glue embolism on a CT scan but was asymptomatic. No further adverse events occurred during follow-up. Six patients (20%) died unrelated to the procedures or bleeding.Nonrandomized; EUS expertise necessary.EUS-guided therapy for GV by using CYA or ECA is effective in localized GV. ECA required fewer endoscopies and tended to have fewer adverse events compared with CYA injection. Larger comparative studies are needed to prove these data.

Background: adalimumab, a human anti-TNF, is an effective induction and maintenance therapy for patients with moderate to severe Crohn s disease. It seems to be effective in patients with resistance to infliximab, too, though the experience is more limited. Aim: to evaluate the efficacy of adalimumab, in patients with Crohn s disease (CD) and failure to previous treatment with infliximab. Methods: twenty-five patients with CD and failure to previous treatment with infliximab were enrolled; they were treated with 160/80 (24 patients) and 80/40 (1 patient) induction doses. We analyze clinical response to treatment with adalimumab by the Crohn’s disease Activity Index (CDAI) and plasma concentration of C-reactive protein (CRP), steroid sparing and complete fistula closure at week 48. Results: eighteen out of twenty-five patients (72%) achieved clinical remission (CDAI score < 150) at week 24 and 15/25 (60%) patients at week 48. There was a statistically significant difference (p < 0.01) in CRP serum levels from 21 to 8 mg/dl at week 48. Nine out of fifteen patients (60%) treated with corticosteroids were able to discontinue steroids. Three out of eleven patients (27%) with fistulizing Crohn s disease had complete fistula closure after the treatment. Seventy two percent of the patients (18/25) needed to increase adalimumab to weekly dose, in order to maintain clinical response. Five out of twenty-five patients (20%) had adverse events; two of them (8%) with serious adverse events (tuberculous meningitis and abdominal abscess) that forced the withdrawal of treatment. Conclusions: according to these data, adalimumab provides a clinical and analytical improvement in patients with CD and failure to previous therapy with infliximab.

OBJECTIVE To evaluate the type, frequency, and severity of macroscopic small bowel mucosal injury after chronic NSAID intake as assessed by capsule endoscopy (CE), as well as to correlate the severity of gastroduodenal and intestinal damage in these patients. MATERIAL AND METHODS A prospective, endoscopist-blind, controlled trial. Sixteen patients (14F/2M; age: 57.06 +/- 10.16 yrs) with osteoarthritis (OA) on chronic therapy with NSAIDs underwent CE and upper gastrointestinal endoscopy (UGE). Seventeen patients with OA (9F/2M; age: 57.47 +/- 9.82 yrs) who did not take NSAIDs were included as a control group. A scale ranging from 0 to 2 (0 = no lesions, 1-minor = red spots or petechiae, denuded areas and/or 1-5 mucosal breaks; 2-major = > 5 mucosal breaks and/or strictures, or hemorrhage) was designed to assess the severity of small bowel mucosal injuries. RESULTS CE found intestinal lesions in 75% (12/16) of patients in the study group and in 11.76% (2/17) of controls (p < 0.01). Seven out of 16 NSAID consumers (43.75%) and none in the control group (0%) had a major small bowel mucosal injury (p < 0.01). The percentages of patients with grade 1 and 2 gastroduodenopathy in the study group, as assessed by UGE, were 37.14 and 23.81%, respectively. There was no significant difference in the rate of major enteropathy between patients with none or minor gastroduodenal injury, and those with major gastroduodenopathy (43.75 vs. 40%; p = N.S.). CONCLUSIONS Chronic NSAID intake is associated with a high rate of small bowel mucosal injuries. Our data have failed to demonstrate a relationship between the severity of gastroduodenal and intestinal injury.

Small bowel strictures can be missed by current diagnostic methods. The Patency capsule is a new non-endoscopic dissolvable capsule which has as an objective of checking the patency of digestive tract, in a non-invasive manner. The available clinical trials have demonstrated that the Patency© capsule is a good tool for assessment of the functional patency of the small bowel, and it allows identification of those patients who can safely undergo a capsule endoscopy, despite clinical and radiographic evidence of small-bowel obstruction. Some cases of intestinal occlusion have been reported with the Patency© capsule, four of them needed surgery. So, a new capsule with two timer plugs (Agile© capsule) has been recently developed in order to minimize the risk of occlusion. This new device stars its dissolution process earlier (30 h after ingestion) and its two timer plugs have been designed to begin the disintegration even when the device is blocked in a tight stricture.

Background Bleeding from gastric varices can be challenging because of its high mortality and recurrent bleeding rates. Endoscopic therapy with tissue adhesives can control acute hemorrhage, but recurrent bleeding could appear if obliteration is not achieved, and endoscopic vision could be troublesome in the case of massive hemorrhage. The glue injected could be responsible for embolic phenomena and local complications. EUS has proved useful in minimizing the risk of recurrent bleeding from gastric varices, accurately showing if they are obturated or not. The presence of perforating veins detected by EUS has been reported as a risk factor for recurrent bleeding from esophageal varices. Objective To assess the efficacy of EUS-guided cyanoacrylate injection in gastric varices at the entrance of the perforating veins to obtain variceal obturation. Design Open-basis case series study. Setting Tertiary care, academic medical center, Seville, Spain. Patients Five consecutive patients with gastric varices were enrolled from May 2005 through May 2006. Interventions We injected cyanoacrylate-lipiodol in gastric varices with 22-gauge needles by EUS guidance. Main Outcome Measurements To analyze the obliteration of gastric varices, the recurrent bleeding rate, and safety of EUS-guided cyanoacrylate-lipiodol injection. Results EUS-guided injection of the perforating veins by using cyanoacrylate-lipiodol was successful in eradicating gastric varices in the 5 patients treated, without recurrent bleeding or other complications during the study follow-up. Limitation This is a single-center nonrandomized study. Conclusions EUS-guided injection of cyanoacrylate at the level of the perforating veins in the treatment of gastric varices seems to be a safe, efficient, and accurate approach. Further controlled studies are warranted.

In less than 5 years capsule endoscopy (CE) has become the first technique elected for the study of small bowel disease. This is a non-invasive technique that allows visualising the whole mucosa of the small bowel and has shown its effectiveness in patients with obscure digestive haemorrhage [1] and also in other intestinal pathologies such as Crohn’s disease, N-said enteropathy, intestinal diseases specific in elder patients or polyposis syndromes [2–5]. However, this new technique has limitations in that it does not permit biopsies to be taken, nor therapeutic procedures. Although these problems may be difficult to solve, it would not be surprising that, in short or medium term, the new technologies will allow their partial resolution. On this basis, some authors have suggested that non-medical staff (a well-trained nurse) could pre-check a recorded video, indicating abnormal or doubtful images found, and then a practitioner would interpret them [6–9] (Bossa, Levinthal, Niv, Fern´ andez-Uri´

hospital setting, the success rate for eradication of EAC using EMR and RFA is 78%, with 39% free of intestinal metaplasia at a median of 5 months follow up. This study shows that EMR with RFA is a successful and safe option for treating many patients diagnosed with EAC who are deemed high risk for esophagectomy. Therefore, EMR with RFA should be considered a viable treatment option for patients with Barrett’s esophagus and early stage EAC.

Recombinant Activated Factor VII (rFVIIa) in the Treatment of 19 Patients with Severe and Active Bleeding Esophageal Varices: A 3-Years Experience Rafael Romero-Castro, Francisco Pellicer-Bautista, Manuel Jimenez-Saenz, Manuel Gomez-Parra, Angel Caunedo-Alvarez, Maria Dolores Guerrero-Aznar, Juan Manuel Herrerias-Gutierrez Objectives: To analyse the hemostatic efficacy of rFVIIa in active and severe bleeding esophageal varices (BEV). Methods. From May 2001 to October 2004, we studied in an open basis, the hemostatic effect of a single intravenous dose of 4.8 mg of rFVIIa (Novoseven; Novo Nordisk A/S, Bagsvaerd, Denmark) given in a bolus in 3 minutes, average dose of 73 G 8 ig/kg bw (50-100). The drug was administered in a compassionate protocol use. All the patients had active BEV at endoscopy. Hemostasis was determined by endoscopy, hemodynamic, hematologic parameters and transfusional requirements. Patients with failure to control bleeding (clinical significant) or early rebleeding (according to Baveno III criteria), uncontrolled by pharmacological or endoscopic therapy or balloon tamponade, were considered candidates for rFVIIa treatment. There were 19 patients, mean age 66.5G8 years (24-80). Alcoholic liver cirrhosis 12, postHCV cirrhosis 3, PBC 2, steatohepatitis 1 and autoimmune cirrhosis 1 . Child-Pugh-class A: 4, B: 10 and C: 5. In 13 cases had oozing BEV, 3 spurting BEV and 3 oozing bleeding from ulcers secondary to sclerosis and banding. Results: Hemostasis was achieved in 17 out 19 cases (89%), about 10 minutes after rFVIIa infusion. Formation of hemostatic and firm clots at the site of the bleeding point or endoscopic procedure were observed, that persisted several days (1-8). A transiently normalization or shortening in previously lenghtened prothrombin time was observed. The mean lowest hemoglobin value was 6.9G2.6 g/dl (normal 12-16). An average of 4.5G2 U of packed RBCs were transfused before rFVIIa administration and 1.2G1 U later. The one-month mortality was 31,5% (3 patient in Child B class and 3 in C class). One patient died from multiorgan failure, 1 from sepsis, 2 from oozing BEV unresponsive to rFVIIa and, 2 from spurting BEV unresponsive to endoscopic sclerosis, without furher administration of rFVIIa. The remain 13 patients (68.5%) have a mean follow-up of 19G4 months (2-42), four Child A, seven Child B and 2 Child C. Ten patients are in endoscopic secondary prohylaxis, two recieved a TIPS and one an OLT. Conclusions: rFVIIa seems to be effective and safe achieving hemostasis in these cases of severe BEV. Endoscopic complications of portal hypertension therapy were managed with rFVIIa successfully. These results encourage for prospective studies to confirm the efficacy, safety, optime dosing and cost-effectiveness of rFVIIa in active BEV. S1203 The Meaning of G3CMH in the Barrett’s Esophagus From a New Point of View Hitoshi Satodate, Haruhiro Inoue, Shin-ei Kudo Introduction: Long-segment Barrett’s esophagus is the occurrence of intestinal metaplasia in glandular mucosa above gastroesophageal junction 3 cm level in the distal tubular esophagus. For a long time this was the only accepted definition of Barrett’s esophagus. Recent realization has resulted in the definition of two other entities: (a) short-segment Barrett’s esophagus, which is the presence of intestinal metaplasia in ‘‘normal’’ glandular mucosa in the distal 3 cm of the esophagus; and (b) intestinal metaplasia of the gastric cardia, which is the presence of intestinal metaplasia in cardiac mucosa of the proximal stomach. But it is difficult to believe that there is a clear and accurate understanding of what the meaning of the ‘‘3 cm’’ is. Aims & Methods: The aim of this study is to investigate the meaning of ‘‘3 cm’’ in the Barrett’s esophagus. There are several definitions of gastroesophageal junction. The most common definition uses the proximal limit of the gastric rugal folds. But, in the Japanese classification of the esophagus, the distal end of the esophagus is defined as lower end of palisade venous zone with the endoscopic findings. Then we directed the attention to the vascular architecture of the distal esophagus. In this study, the length of the palisade venous zone at the distal end of the esophagus is measured with surgically resected specimen. A silicon rubber compound (Microfil) injection method with a methyl salicylate clearing technique was used in 5 resected esophageal specimens. The maicrovascular architecture was clearly observed under the stereomicroscope, and the length of palisade venous zone was measured. The mean length was 2.9 cm. Results & Conclusion: Above mentioned 2.9 cm is well correlated with ‘‘3 cm’’ of the accepted definition of Barrett’s esophagus and short-segment Barrett’s esophagus. In other words, it could be said that Barrett’s esophagus is the presence of intestinal metaplasia above the palisade venous zone. We believe this can be a new concept of definition of the Barrett’s esophagus. This study is now advanced with the magnifying endoscopic examination of the Barrett’s esophagus.

Introduction: several studies have pointed out the effectiveness of the PillCam© colon capsule endoscopy (CCE) compared with the colonoscopy in the study of the colonic pathology. Aims and methods: the objective of our study was to assess the agreement in the diagnosis of CCE with conventional colonoscopy as well as its sensitivity and specificity, and to describe the findings of the CCE in our clinical practice. Consecutive patients with abdominal symptoms were included in the study. The CCE was performed as previously reported (with PEG and sodium phosphate as laxative agents). The nature and location of the findings, colonic transit time, complications, cleanliness degree and consistency with diagnostic colonoscopy, when performed, were analyzed. Results: a total of 144 subjects (67 women and 77 men); (52.17±16.71 years) with the following indications were included: screening of Colorectal cancer (88 patients), control after polipectomy (24), incomplete colonoscopy (7), rectal bleeding (10), anemia (8), diarrhea (7). The CCE exploration was complete in 134/144 cases (93%), with no case of retention. The preparation was good-very good in 88/134 (65,6%), fair in 26/134 (19,4%) and poor in 20/134 (15%) of the cases. The average colonic transit was of 140.76 min (9-603). Any adverse effect was notified. In 44 cases a colonoscopy was carried out after CCE (results were hidden from another endoscopist). Compared to colonoscopy, the rate of agreement was 75,6%, the sensitivity was 84% and the specificity 62,5%, PPV was 77,7% and NPV was 71,4 %. The colonic findings in 134 CCE were: in 34 cases CCE it did not show lesions, diverticulosis in 63 explorations, polyps in 43, angiodysplasias in 15, Crohn's Disease in 9 and ulcerative colitis in other 8 cases. Conclusions: the CCE is an effective and reliable technique for the detection of lesions in colon, and because of its high agree-ment with the colonoscopy, it could be useful in clinical practice. Further studies with large seria and cost-effectiveness analysis are needed to confirm these data.