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Tracheoesophageal fistula (TEF) is frequently congenital and requires surgical correction. TEF can also occur secondary to malignant esophageal tumors or benign diseases and these cases are managed by endoscopic means, such as closing the defect with metallic stents. Although esophageal injury can occur secondary to nonsteroidal anti-inflammatory drugs (NSAIDs), TEF secondary to chronic NSAIDs use has not been described in the literature. We report the case of a male patient with refractory migraine and chronic use of NSAIDs, with a history of esophageal stenosis presenting with acute-onset total dysphagia. Upper gastrointestinal endoscopy and CT-scan revealed TEF located at 25 cm from the incisors. An esophageal stent was placed endoscopically, and 6 weeks a second stent was placed in a stent-in-stent manner to allow removal of both stents. Endoscopic control after the removal of the stents showed the persistence of the fistula, so a third stent was placed as a rescue therapy. Against medical advice, the patient continued to use OTC painkillers and NSAIDs in large doses. Three months later, he was readmitted with total dysphagia and recent-onset dysphonia. CT scan revealed a new fistula above the already placed stent. A second metallic stent was endoscopically placed through the old stent to close the newly developed fistula. The patient was discharged on the third day with no complications and he remains well at 6 months follow-up. Due to small cases studies, recurrent TEF remains a therapeutic challenge. Endoscopic therapy is usually an effective solution, but complex cases might require multiple treatment sessions.

Background and aims. Colon polypectomy decreases the incidence of colorectal cancer and related mortality. Several factors such as the size, location and type of polyp as well as endoscopist experience have been shown to correlate with the risk of ensuing procedure-related complications. This study aims to evaluate the impact of polyp and endoscopist-related factors on the rate of postpolypectomy complication in a real-life setting. Methods. During the study period all polypectomies performed in our unit were reported on a standard form that included data on polyp type (flat, sessile, pedunculated), size, location in the colon, resection method, endoscopist volume and procedure-related complications arising up to 30 days. The main outcome was the complication rate of polypectomies. The factors that associated with a higher risk of complications were assessed on univariate and multivariate analysis. Results. 244 polyp resections from 95 patients were included in the analysis. 199 polyps were resected by low-volume endoscopists (44.7%) and 135 polypectomies were performed by highvolume endoscopists (55.3%). On multivariate analysis only polyp size correlated with the risk of procedure-related complications. Conclusion. Polyp size is the most important risk factor for procedure-related complications. Both high and low-volume endoscopists have a low overall rate of serious complications.

Background and study aims: In videocapsule endoscopy examination (VCE), subtle variations in mucosal hue or pattern such as those seen in ulcerations can be difficult to detect, depending on the experience of the reader. Our aim was to test whether virtual chromoendoscopy (VC) techniques, designed to enhance the contrast between the lesion and the normal mucosa, could improve the characterization of ulcerative mucosal lesions. Patients and methods: Fifteen trainees or young gastroenterologists with no experience in VCE were randomly assigned to evaluate 250 true ulcerative and 100 false ulcerative, difficult-to-interpret small bowel lesions, initially as white light images (WLI) and then, in a second round, with the addition of one VC setting or again as WLI, labeling them as real lesions or artifacts. Results: On the overall image evaluation, an improvement in lesion characterization was observed by adding any chromoendoscopy setting, especially Blue mode and FICE 1, with increases in accuracy of 13 % [95 %CI 0.8, 25.3] and 7.1 % [95 %CI – 17.0, 31.3], respectively. However, when only false ulcerative images were considered, with the same presets (Blue mode and FICE 1), there was a loss in accuracy of 10.7 % [95 %CI – 10.9, 32.3] and 7.3 % [95 %CI – 1.3, 16.0], respectively. The interobserver agreement was poor for both readings. Conclusions: VC helps beginner VCE readers correctly categorize difficult-to-interpret small bowel mucosal ulcerative lesions. However, false lesions tend to be misinterpreted as true ulcerative with the same presets. Therefore care is advised in using VC especially under poor bowel preparation.

Background & Aims Extrahepatic complications of cirrhosis increase the risk for decompensation of the liver disease and death. Previous studies show common pathogenetic mechanisms involved in the development of hepatopulmonary syndrome and cirrhotic cardiomyopathy. We aimed to assess the link between these entities and their effect on disease-related patient morbidity and mortality. Methods Seventy-four consecutive cirrhotic patients without prior history of cardiovascular and pulmonary disease were included in a prospective observational study. Routine blood work, arterial blood gas analysis, pulse oximetry measurements, N-terminal pro-brain natriuretic peptide levels and contrast enhanced echocardiography examination with tissue Doppler imaging were performed in all patients. Patients were followed up for a median of 6 months and disease-related adverse events and death were the main outcomes tested. Statistical analysis was conducted according to the presence of hepatopulmonary syndrome or cirrhotic cardiomyopathy. Results Hepatopulmonary syndrome was diagnosed in 17 patients (23%) and cirrhotic cardiomyopathy in 30 patients (40.5%). There was no association between the presence of cirrhotic cardiomyopathy and the existence of mild or moderate hepatopulmonary syndrome. No echocardiographic parameters were useful in predicting the presence of hepatopulmonary syndrome. N-terminal pro-brain natriuretic peptide levels and length of QT interval did not aid in diagnosis of cirrhotic cardiomyopathy. Neither entity had significant influence on disease-related outcomes in the follow-up period. Conclusions Hepatopulmonary syndrome and cirrhotic cardiomyopathy are independent complications arising in cirrhosis and have a limited influence on morbidity and mortality on a pre-liver transplantation population.

Purpose of review Bowel preparation for colonoscopy is a key quality indicator that impacts on all aspects of the procedure, such as patient comfort, diagnostic yield, and adverse events. Although most laxative regimens currently employed have been compared in a multitude of settings, the optimal preparation regimen still remains an open question. Recent findings Recent studies have focused on developing new regimens by modifying dosage, timing of administration or by combining laxatives with synergic mechanisms of action with the purpose of increasing patient tolerability while maximizing bowel cleansing. Several low-volume preparations and combinations of laxatives and adjunctive medication have shown promise in delivering both adequate preparation of the colon and good patient tolerability. Also, we have gained a better understanding of the influence of patient-related factors such as health literacy and education on the quality of bowel preparation. Summary Although several novel regimens have been tested in recent trials, it remains unclear which, if any, of these bowel preparations can replace the standard bowel cleansing regimens in clinical practice. Also, further data are required on how to improve bowel cleansing by choosing the appropriate regimen for the individual patient.

The role of prophylactic antibiotherapy prior to elective endoscopic retrograde cholangiopancreatography (ERCP) is unclear. We aimed to determine whether patients receiving systemic antibiotics prior to ERCP had lower morbidity and mortality rates as well as shorter hospitalization compared to patients who did not receive antibiotic prophylaxis.We conducted a prospective study of all patients undergoing ERCP in our unit. Antibiotic use, postERCP cholangitis rates, 30-day mortality and hospital stay were studied. Also, bacteriological examination of bile aspirates from these patients was conducted and antibiotic susceptibility was determined for the isolated pathogens.One hundred-thirty eight consecutive ERCPs conducted in our unit in a 9 month period were included. Cholangitis developed in 3 (4.6%) cases in the antibiotics groups and 3 (4%) cases in the control group (p=0.8). Hospital stay did not differ significantly between the two study groups (p=0.58). There was only one procedure-related death which was the result of postERCP pancreatitis in a patient with severe associated illnesses. Bile aspirates showed bacterial growth in 75% of the cases where bile was obtained, with E. coli being the most frequently isolated microorganism. No differences in bacteriological profiles were noted between the two study groups.There seems to be no influence on patient-related outcome of antibiotic prophylaxis prior to elective ERCP.

BACKGROUND Endocan is a marker of angiogenesis previously studied in various types of cancer and inflammatory conditions. Its expression is influenced by vascular endothelial growth factor A (VEGF A) and tumor necrosis factor alpha (TNF alpha), cytokines involved in pathogenetic pathways in inflammatory bowel disease (IBD). The aim of this study was to determine whether serum endocan levels were increased in IBD patients. METHODS We conducted an exploratory pilot study. Serum endocan levels were determined in a group of 33 consecutive IBD patients from an observational cohort study ongoing at Colentina Hospital and compared to levels determined in two control groups: healthy controls and stage IV cancer patients. RESULTS Endocan levels were significantly higher in the IBD group as compared to both healthy controls (p < 0.001) and cancer patients (p < 0.01). There was no correlation found between endocan levels and disease activity as assessed by clinical or endoscopical activity scores. CONCLUSIONS There is a potential role for endocan in future biomarker studies in IBD patients.

A 72-year old man presented with a 6-month history of weight oss (approximately 27 kg), diarrhoea (up to 12 loose stools/day) nd bloating. He was severely malnourished and had moderate retibial pitting oedema. On examination of the abdomen borboygmi and succussion splash were noted. Blood work revealed mild ormocytic normochromic anaemia, hypoalbuminemia and a low holesterol level. The stool test showed undigested muscle fibres nd starch but no neutral fat or fatty acid crystals. Endoscopy showed a large uncomplicated diverticulum in he second part of the duodenum (Fig. 1). Colonoscopy was nremarkable and computed tomography showed air–fluid levels nd dilatation of intestinal loops. Extensive diverticulosis with