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Background and aim In presence of malignant dysphagia, in patients unfit for surgery, the placement of a self-expandable metal stent (SEMS) represents a safe and effective palliative treatment. Esophageal stents (ES) present an over-the-wire mechanism where the stent is deployed under X-ray control. Recently a through-the-scope (TTS) ES was launched. The aim of our retrospective study is to assess the technical and clinical success of the new TTS-ES. Materials and methods Patients with malignant dysphagia caused by esophageal cancer or ab-extrinsic compression, who underwent TTS esophageal stent in six Italian endoscopic referral centers, were retrospectively reviewed. Results A total of 40 patients were enrolled. TTS stent placement was successful in 39/40 patients (97.5%). 31 patients had an Ogilvie score of 4, nine an Ogilvie 3. After 2 weeks from stent placement 29 reported Ogilvie score of 0, eight a score of 1. None of the patients developed retrosternal pain requiring drugs. No patient experienced perforation, bleeding or migration. A total of seven patients (18%) developed dysphagia as late adverse event (AE). Conclusion Through-the-scope ES presented less AEs, in terms of bleeding and perforation, if compared to the previous published data. An anti-migration system could be helpful, especially when the stent is placed for "ab-extrinseco" malignant dysphagia.

Evidence from controlled trials and meta-analyses suggests that laparoendoscopic rendezvous (LERV) is preferable to sequential treatment in the management of common bile duct stones. With this retrospective analysis of a prospective database that included consecutive patients treated for cholecystocholedocholithiasis at our institution between January 2007 and July 2015, we compared LERV with sequential treatment. The primary endpoint was global cost, defined as the cost/patient/hospital stay, and the secondary end points were efficacy and morbidity. Fisher’s exact test or Mann–Whitney test was used. Of a total of 249 consecutive patients, 143 underwent LERV (group A) and 106 a two-stage procedure (group B). Based on an average cost of €613 for 1 day of hospital stay in the General Surgery Department, the overall median cost of treatment was €6403 for group A and €8194 for group B (p

Background and aims: Safety of propofol sedation in patients with liver cirrhosis undergoing colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP) remains to be studied. The aim of this study was to investigate whether the use of propofol is safe for endoscopic procedures more complex than gastroscopy in patients with liver cirrhosis in a prospective controlled study. Methods: Two hundred and fourteen consecutive patients, with or without cirrhosis, who underwent colonoscopy or ERCP with propofol sedation were recruited between January and June 2009. Administration of sedation was performed by anesthesiologists and outcome measures were recorded. Main outcomes were complication rates and recovery times. Results: Sixty-one (28.5%) cirrhotic patients and 153 (71.5%) noncirrhotic patients were included. The incidence of sedation-related complications did not significantly differ between the two populations (11.5 vs. 17.0%, respectively, P=0.31). The mean (±SD) dose of propofol administered (213±86 vs. 239±100 mg, P=0.07), the mean time to achieve adequate sedation (3.3±1.1 vs. 3.0±1.2 min, P=0.21), the mean total duration of the endoscopic procedure (24.5±10.6 vs. 27.4±11.8 min, P=0.08), the mean time to reach Observer's Assessment of Alertness and Sedation Scale 5 (17.2±4.4 vs. 18.4±5.6 min, P=0.15), the mean time from completion of the procedure to release (9.0±2.5 vs. 9.1±3.2 min, P=0.86), and the mean time to full recovery (42.2±7.3 vs. 42.3±7.8 min, P=0.88) were very similar between the two groups. The limitation of this study was lack of randomization, and a control group of cirrhotic patients using standard sedation with benzodiazepines and opioids. Conclusion: Propofol deep sedation administered by an anesthesiologist with appropriate monitorings seems to be a safe procedure during colonoscopy or ERCP in cirrhotic patients.

Anastomotic leaks and fistulae are well-known complications of esophagogastric surgery that occur after 10% to 30% of such operations.1-4 Treatment of these complications is challenging, surgical repair may be ineffective, and the mortality rate may be as high as 60% whatever the mode of treatment.5,6 Several endoscopic methods have been proposed as alternative, noninvasive methods of fistula closure.7-9 Placement of expandable metal stents in the esophagus has become a major method of palliation for obstructing malignant lesions and fistulas.10-12 Placement of these stents, both covered and uncovered, has occasionally been described for the management of benign esophageal strictures and fistulae.13 A case is reported here of successful treatment of an anastomotic esophagomediastinal fistula, a complication of distal esophagectomy with total gastrectomy for adenocarcinoma of the cardia, by temporary placement of a new polyester, silicone-covered, expandable stent.

The use of angiotensin II antagonists in the treatment of portal hypertension remains controversial. Our aims were to assess the effect of Irbesartan on portal pressure and to evaluate its safety in cirrhotic patients with portal hypertension. Twenty-five cirrhotic patients were treated in a pilot study with Irbesartan 300 mg orally once daily for 60 days. Hemodynamic evaluations and biochemical tests were performed before therapy and after two months of treatment. Three patients (12%) discontinued treatment for symptomatic arterial hypotension (mean arterial pressure −26.% ± 3.1 versus basal). In the 18 responders, the hepatic venous pressure gradient diminished by a mean of 18.1% ± 10.5 from baseline (p = 0.02); the gradient decreased by 20% or more in only 5 patients (23%). The mean arterial pressure decreased significantly during therapy (92 ± 7 vs 109 ± 25 mm Hg, P < 0.001). In conclusions, Irbesartan induced a marginal reduction in portal pressure and its safety was limited by the pronounced effects on arterial pressure.

IgG antibodies against Mycobacterium paratuberculosis protoplasmic antigen were looked for by an enzyme immunosorbent assay in patients with Crohn's disease, Ulcerative colitis, active pulmonary tuberculosis, past pulmonary tuberculosis, and in healthy controls. Serum reactivity for these antibodies was not correlated to PPD skin test positivity without history of mycobacterial disease. A cutoff based on the mean absorbance value of a pool of healthy blood donors was chosen. Positive values were found in 12/24 (50%) patients with active pulmonary tuberculosis and 2/10 (20%) skin-test-positive subjects with past pulmonary tuberculosis as expected, because antigenic sharing is common among different mycobacteria. The control group of blood donors showed borderline positivities in 3/149 cases (2.01%). Positive values were found in 4/108 (3.70%) patients with Crohn's disease and 2/40 (5%) with ulcerative colitis. We conclude that our data do not support a causal relationship between the M. paratuberculosis and Crohn's disease, but occasional patients with inflammatory bowel diseases show unexpected positivities for these mycobacterial antibodies.

The role of angiotensin II (AT-II) type I receptor antagonists in the treatment of portal hypertension remains controversial. We tested the efficacy of Irbesartan (Irb) vs. Propranolol (Pro) in reducing portal pressure and evaluated its systemic haemodynamic effects.Thirty-four patients were randomly assigned to receive either Irb 300 mg/day (19 patients) or Pro 40-120 mg/day (15 patients) for 2 months.Irb was discontinued in five patients (26%). No major side effect occurred in the Pro group. On an average, the portal pressure gradient decreased significantly more in the Pro than in the Irb group (median -19.5%, range -11/-31% vs. -4.8%, +2.5/-10%, P0.001). A clinically significant decrease was seen in one (7%) of the patients given Irb vs. five (33%) given Pro (P0.02). The fall in mean arterial pressure was significantly higher with Irb than with Pro (median -29%, range -15/-45% vs. -4.9%, +8/-19%, P0.02). Irb significantly modified the blood creatinine clearance (median -29 ml/m, range +9/-61 ml/m, -30, -24/-35% P0.0001 vs. basal).Irb offers no advantage over Pro in the control of portal hypertension. Moreover, its therapeutic profile is limited by important side effects.

Renal failure secondary to hepatorenal syndrome or to organic renal disease occurs frequently in cirrhotic patients with portal hypertension. The present prospective study investigates the usefulness of terlipressin in both the diagnostic and the therapeutic approach to cirrhotics with renal failure.Sixteen patients were studied: 11 with hepatorenal syndrome type 2 (group 1) and five with organic renal disease (group 2). All received terlipressin (1 mg/4 h intravenously) for 7 days. Subsequently, 12 patients (nine from group 1 and three from group 2) underwent a transjugular intrahepatic portosystemic shunt.Terlipressin significantly improved renal function (serum creatinine, 1.8 +/- 0.8 versus 2.4 +/- 0.9 mg/dl; blood creatinine clearance, 53 +/- 8 versus 21.3 +/- 8.7 ml/min; P0.05) in group 1 [8/11 patients (73%) versus 1/5 (20%) of group 2; P0.05]. The only patient in group 2 who responded to terlipressin had a mixed renal dysfunction. Renal function improved significantly after transjugular portosystemic shunt in all patients who responded to terlipressin.Terlipressin administration significantly improves renal function in cirrhotic patients with hepatorenal syndrome type 2 but not in organic kidney failure. By providing the critical information that a patient's kidney function is (or is not) reversible, a trial with terlipressin may be useful when selecting cirrhotic patients with renal failure as candidates for a transjugular intrahepatic portosystemic shunt or liver transplantation.

Background. Endoscopic therapy is a safe and effective method for treating non-variceal upper gastrointestinal bleeding. However, failure of therapy, in terms of continuing bleeding or rebleeding, is seen in up to 20%. Cyanoacrylate is a tissue glue used for variceal bleeding that has occasionally been reported as an alternative haemostatic technique in non-variceal haemorrhage. Aim. To retrospectively describe personal experience using cyanoacrylate injection in the management of bleeding ulcers after failure of first-line endoscopic modalities. Patients and methods. Between January 1995 and March 1998, 18 (12 M/6 F, mean age 68.1 years) out of 176 patients, referred to our Unit for non-variceal upper gastrointestinal bleeding, were treated with intralesional injection of adrenaline plus undiluted cyanoacrylate. Persistent bleeding after endoscopic haemostasis or early rebleeding were the indications for cyanoacrylate treatment. Results. Definitive haemostasis was achieved in 17 out of 18 patients treated with cyanoacrylate. One patient needed surgery. No early or late rebleeding occurred during the follow-up. No complications or instrument lesions related to cyanoacrylate were recorded. Conclusions. In our retrospective series, cyanoacrylate plus adrenaline injection was found to be a potentially safe and effective alternative to endoscopic haemostasis when conventional treatment modalities fail in controlling bleeding from gastroduodenal ulcers.

Background: Metal stents have been reported as an effective alternative to surgery for the palliation of patients with colorectal neoplastic obstruction. Because most of the published series describe the use of uncovered stents, the purpose of our study was to prospectively evaluate the effectiveness, feasibility, safety, and outcome of covered stents for the palliative treatment of malignant colorectal strictures. Methods: Sixteen patients with advanced distal colorectal cancer underwent placement of 10 and 12 cm long, 23 mm diameter covered stents under fluoroscopic and endoscopic control. Clinical and endoscopic follow-up was scheduled at 3- to 6-week intervals. Results: Stent insertion was successful in 15 of 16 patients (93%). Perforation occurred in one patient during stent placement requiring colostomy. Relief of bowel obstruction was documented in all successfully treated patients. The median follow-up was 21 weeks (range 1 to 46). No recurrence of obstruction was observed during the follow-up period. Stent migration occurred in 2 patients, 7 and 21 days after stent placement. Conclusions: Covered stents may provide safe and effective palliation of patients with malignant rectosigmoid strictures. Prolonged luminal patency and sealing of fistulous tracts are potential advantages of covered versus uncovered stents in the palliative treatment of colorectal malignancies. (Gastrointest Endosc 2000;52:735-40).

commercially available at that time, we adapted a selfexpanding covered nitinol Esophageal Ultraflex stent (Microvasive Endoscopy, Boston Scientific Corp., Natick, Mass.) usually used for esophageal strictures. The stent was 10 cm long (7 cm covered in the central part and 1.5 cm uncovered in the distal and proximal end) and 23 mm in diameter when deployed and was compressed onto a 90 cm long, flexible, wireguided delivery catheter. The distal margin of the stricture was marked by intramucosal injection of Lipiodol. Then a 0.035-inch guidewire (Zebra, Microvasive) was inserted under fluoroscopic guidance through the stricture, and after removing the endoscope the sheath of the stent was mounted over the guidewire and inserted beyond the stricture under fluoroscopic and direct vision with the endoscope positioned alongside the stent catheter. Deployment began proximally and progressed in a distal manner. The stent was easily placed without encountering technical problems and its correct positioning with partial expansion was immediately observed by fluoroscopy. Dilations were performed to obtain full expansion. Intestinal decompression with passage of feces was observed shortly after the procedure while restoration of the normal bowel gas pattern and complete expansion of the stent were evident on a plain x-ray film obtained 48 hours later. Fecaluria, pneumaturia, and vaginal passage of feces stopped a few hours after the stent insertion. A barium enema performed 1 week later confirmed occlusion of the fistulous tracts and effective restoration of bowel patency by the covered stent (Fig. 2). The patient died 13 weeks after endoscopic palliation without recurrence of symptoms related to the obstruction or to the genitourinary fistulas. During the last 3 weeks of life she developed severe diarrhea probably due to the formation of a new neoplastic fistula between the colon and small intestine.

BACKGROUND AND STUDY AIMS The lack of uniformity in defining the stigmata of hemorrhage in patients with bleeding ulcers is suggested by the wide range among published studies in prevalence and rebleeding rates for the same stigmata. Moreover there is, in published trials of endoscopic hemostasis, little standardization of definitions of stigmata of hemorrhage. The aim of this study was to assess the interobserver agreement among endoscopists from the same area (Piedmont and Valley of Aosta). PATIENTS AND METHODS A workshop for 47 expert endoscopists was organized in order to evaluate their agreement in the diagnosis of stigmata of recent hemorrhage, according to Forrest's classification. During the meeting 25 videotapes from endoscopic examinations of patients with recent non-variceal bleeding were shown to the 47 endoscopists, who were asked to classify every lesion. RESULTS The overall and beyond chance interobserver agreement was calculated by means of the kappa statistic. The overall agreement among endoscopists was highly significant (p < 0.001, kappa=0.60), while the beyond chance agreement varied from excellent to good for lesions with active bleeding (kappa=0.76 and kappa=0.61 for FIA and FIB lesions respectively), whereas for lesions with stigmata of recent hemorrhage kappa varied from 0.44 to 0.49. CONCLUSIONS These data suggest the need for better knowledge of endoscopic criteria, in order to evaluate the results of endoscopic therapy and to assess new treatments.

Among colorectal polyps, those of the sessile and villous type are said to bear a high frequency cancer degeneration. While surgery is considered the cure, alternative choices are to be offered in the presence of contraindications or lack of an informed consent. We analyzed the results of the "combined therapy" that requires the use of the ND-YAG laser following the ablation of the lesion with diathermic snare. We used an EV laser 132 with double wavelength to allow the ablation of flat lesions and minimize the risk of perforation. We included 12 patients with sessile colorectal polyps. In 9/12 complete eradication was obtained over a follow-up 11 months; of the remaining 3, 2 dropped out, 1 did not respond. Owing to the small series, the relationship between the successful eradication and the size of the polyp cannot be evaluated. We conclude that the treatment of sessile colorectal polyps with this combined approach may be a promising one.

A dosage of 4 mg/kg/day intravenous cyclosporine as an adjunct to high-dosage hydrocortisone has been recommended to avoid colectomy in acute steroid-resistant ulcerative colitis. In treating eight such patients, four of whom presented with toxic megacolon, we immediately tapered the steroid dosage and infused a lower dosage of only 2 mg/kg cyclosporine for 15 days to fit a therapeutic range of 60-240 ng/ml, as previously designed for a kidney transplant program. Seven of the eight (87.5%), including three with megacolon, went into remission and started the chronic phase of treatment; the eighth patient underwent colectomy. Of the seven, one died on day 3 of the chronic phase because of pulmonary embolism while in clinical remission, and another discontinued treatment. The other five (62.5%) remain in remission on 6 mg/kg oral cyclosporine, or have already switched from cyclosporine to azathioprine. Two episodes of reversible nephrotoxicity appeared in the chronic phase only. These results emphasize the efficacy and safety of cyclosporine in acute ulcerative colitis, but there is still a need for further dose-response and drug association relationship studies.

Background: There are no formal guidelines regarding sedation for endoscopy in cirrhotic patients (CP). The use of propofol has been shown to be effective and safe for gastroscopy but its use for prolonged endoscopic procedure remains to be studied. Aim: To evaluate the efficacy and safety of propofol in CP undergoing prolonged endoscopic procedures compared with non-cirrhotic patients (NCP). Methods: Twenty-nine consecutively collected inpatients (mean age 58±SD7, M/F=18/11) with known liver cirrhosis (Child–Pugh class A=12, B=9, C=8) undergoing colonoscopy (21) or ERCP (8) received propofol by an anesthetist; the outcome measures studied (induction and recovery times, efficacy and safety of sedation, return to baseline function) were compared with those recorded among 68 consecutively collected NCP (mean age 61±SD8, M/F=41/27) undergoing the same endoscopic procedures (colonoscopy: 49, ERCP: 19). Results: The mean dose of propofol administered in CP was 242mg (SD±38, range 100–350) compared with 260mg (SD±8, range 120–380) in NCP (p = 0.2). The mean time to achieve sedation was 2.8min (SD±1.1) in CP and 3.1 (SD±1.2) in NCP (p = 0.9). The mean time to reach a maximal level of alertness on the Observer’S Assessment of Alertness and Sedation Scale (OAASS) in CP was 13.8min (SD±4.2) compared with 12.7 (SD±4) in NCP (p = 0.7). Time to full recovery was 28.6min (SD±9.1) in CP compared with 26.2min (SD±8) in NCP (p = 0.72). Procedures times between the groups were similar: 26min (SD±12) in CP vs 29min (SD±14) in NCP (p = 0.8). No significant complication related to sedation was observed in the 2 groups. Conclusions: Propofol sedation is efficacious, safe and well tolerated in CP undergoing prolonged endoscopic procedures.

The potential role of digestive endoscopy as a mode for transmission of hepatitis C virus (HCV) is controversial.To evaluate the role of digestive endoscopy in transmitting HCV by comparing the incidence of HCV infection in a cohort of patients undergoing endoscopy and in a cohort of blood donors.Prospective cohort study.3 endoscopic units and 2 blood banks in northwestern Italy.The potentially exposed cohort consisted of 9188 outpatients consecutively recruited from 3 endoscopic units. Of 9008 patients negative for antibody to HCV (anti-HCV), 8260 (92%) were retested for anti-HCV 6 months after endoscopy. The unexposed cohort consisted of 51,230 healthy, anti-HCV-negative persons who donated blood at 2 blood banks in the same area and during the same time period; 38,280 of them (75%) were tested again for anti-HCV 6 to 48 months after the first blood donation (95,317 person-years of observation).Differences in the anti-HCV seroconversion rate between the exposed cohort (patients undergoing endoscopy) and the unexposed cohort (blood donors). Seroconversion was evaluated by a third-generation enzyme immunoassay for anti-HCV; persons positive for anti-HCV were tested for HCV RNA by polymerase chain reaction.All 8260 persons undergoing endoscopy remained negative for anti-HCV 6 months after the procedure (risk per 1000 persons, 0 [95% CI, 0 to 0.465]); in particular, none of the 912 patients who underwent endoscopy with the same instrument previously used on HCV carriers showed anti-HCV seroconversion (risk per 1000 persons, 0 [CI, 0 to 4.195]). Four blood donors became positive for anti-HCV and HCV RNA (mean follow-up, 2.49 years; 0.042 case per 1000 person-years [CI, 0.011 to 0.107 case per 1000 person-years]); each had undergone minor surgery before the second test.In the endoscopy cohort, 8.3% of patients were lost to follow-up.These findings support the hypothesis that properly performed digestive endoscopy is not a major risk factor for the transmission of HCV.

Background and aim: Dysphagia occurs in the last phase of the course of ASL and is associated with an adverse prognosis. PEG has been proposed as symptomatic treatment of dysphagia in patients with both bulbar and spinal ASL. The aim of our study was to evaluate the effects of PEG placement and to describe long-term nutritional status and survival of ASL patients. Methods : Since January 1993, 49 patients (19M/30F), mean age 61.7 years (range 33-77) with bulbar (25) and spinal (24) ASL were enrolled in the study and underwent PEG after a median time of 163 from dysphagia onset. Forced Vital Capacity (FVC), Norris scale, weight loss (WL), body mass index (BMI), serum prealbumin, albumin, trasnferrin, daily energy and protein intake were evaluated every two months in the follow-up period. Results : PEG was successfully placed in all patients. Three patients received a 9 Fr enteral tube, 38 a 14 Fr and 8 a 20 Fr.There were no procedure-related complications or 30-day mortality. The median body weight improved from 54.4+Kg at the time of PEG to 62.5+.8 Kg at six months follow-up. The median survival after PEG was 185 days (range 31-1080 days). Death was always related to respiratory failure. In univariate analysis factors influencing the survival after PEG were WL% (WL>10% median survival 116 days, WL 65% median survival 241 days, p=0.04). No statistically significant differences were observed in terms of survival in patients with bulbar and spinal ASL. In patients in whom PEG was placed within six months from the onset of dysphagia there was a trend toward a longer survival in comparison with patients who had PEG six months later than the onset of dysphagia. Conclusions : PEG represents a safe and effective method for the management of ASL patients who develop dysphagia. WL >10% and FVC

Purpose: EUS can be of value in evaluating gastroesophageal signs of PH. The aim of our study was to show that EUS may add usefull information to the endoscopic diagnosis of gastroesophageal complications of PH and it can be more sensitive than endoscopy at gastric level. Methods: 149 patients (pts) (105 men, mean age 55±12 years) with endoscopic signs of PH underwent EUS with a rotating sector scanner (Olympus GFUM3/UMQ130). 107 pts were endoscopically treated after bleeding until obtaining oesophageal eradication in 104. Afterward they underwent EUS within 1 month. 109 pts were followed up by endoscopy. Results: gastric varices were diagnosed in 14 of the 109 followed up pts (13%) by endoscopy and in 32 (29%) by EUS. Of the 95 pts without gastric varices at endoscopy 21 (22%) were positive at EUS and 2/21 (9%) developed them during the follow-up. Conversely 3/74 pts without gastric varices at endoscopy and EUS developed them successively (4%). About junctional varices 18/109 (16%) pts were positive at endoscopy, 54/109 (50%) at EUS. Of the 91 pts without junctional varices at endoscopy 43 resulted positive at EUS (47%) and 11/43 (26%) developed them during the follow-up versus 2/48 pts (4%) without junctional varices at EUS (Fisher exact test P=0.026). 111/148 showed EUS features described as typical for congestive gastropathy (CG), while only 61/148 were positive at endoscopy (Chi-square P=0.023). Conversely 37/148 pts did not show any typical signs of CG at EUS versus 87/148 at endoscopy (Chi-square P=0.001). Conclusion: according to the literature in our study EUS detected more gastric and junctional varices than endoscopy. EUS supplied usefull information to predict the development of new junctional varices during the follow-up of pts previously endoscopically negative. Unluckily the number of pts is still too small for any statistically significant meaning of EUS in predicting the development of new gastric varices. Furthermore EUS seems to have a very high positive and an even higher negative predictive value in detecting CG compared to endoscopy.

Background and aim: Acute large bowel obstruction is an emergency situation usually requiring surgical intervention. A new colonic, throughthe-scope metal stent has been described as effective in the treatment of obstructing colorectal cancer. Aim of our study was to evaluate the feasibility, efficacy and safety of emergency enteral stent placement for the preoperative management of neoplastic acute bowel obstruction. Methods: Sixteen consecutive patients (10M/6F, mean age 72, range 58- 89) with clinical and radiologic signs of acute colonic obstruction were included in the study. Before stent placement a CT scan was performed in order to evaluate the nature and the site of obstruction. The site of obstruction was rectum in 3 patients, sigmoid in 6 , descending in 3, splenic flexure in 1, trasversum in 1, hepatic flexure in 1 and a colorectal anastomotic recurrence in 1. Enteral stents (22 mm diameter and 6 or 9 cm in lenght) were used in all patients. A guide wire and a 5 Fr ERCP catheter were used to pass through the stricture and to inject contrast in order to visualise the proximal and distal extension of the tumor. Stent placement was then performed under endoscopic and fluoroscopic control advancing the stent over the guide wire. Results: Stent placement was successful in 14 out of 16 patients (87%). In one patient with a splenic flexure we were not able to pass with the guide wire over the stricture. In 1 patient the stent could not be advanced through a tortuous, fixed sigmoid stricture. No complications were observed. Thirteen patients recovered from mechanical obstruction and could receive bowel cleansing (in 1 patient bowel occlusion did not relieve after stent placement). In 4 patients the stent placement was considered to be a definitive palliative treatment. After a median time of 4 days (range 3-7) nine patients underwent a single stage surgery with end-to-end anastomosis without complications. Conclusion: Preoperative enteral placement seems a safe and effective technique to manage patients with acute large bowel malignant obstruction. It allows to perform a single stage curative resection even in patients admitted to emergency room for acute colonic obstruction. In patients with advanced neoplastc disease diagnosed after relief of bowel occlusion, the enteral stent could be considered a definitive palliative treatment alternative to defunctioning colostomy.

BACKGROUND AND AIM: 210 After endoscopic eradication of oesophageal varices by means of sclerotherapy or rubber-band ligation, varices recurrence remains a maior problem. Some studies suggested that in patients with endoscopic signs of varices obliteration, EUS may demostrate still patent residual lumina in the esophageal wall. The aim of our study was to assess if EUS can supply usefull information in the evaluation of endoscopic varices eradication in order to predict variceal recurrence and rebleeding.MATERIAL AND METHODS: 107 patients (74 men, mean age 56±11 years) bleeding from gastroesophageal varices underwent endoscopic treatment by means of sclerotherapy or rubber-band ligation until obtaining endoscopic eradication of oesophageal varices in 104 of them. Then they underwent EUS with a rotating sector scanner (Olympus GF-UM3/UMQ130) within 1 month from the treatment. Eighty-six of the 104 eradicated patients had an endoscopic follow-up (8.8 ± 7.1 months) to evaluate the recurrence of oesophageal varices. RESULTS: 56 of the endoscopically eradicated patients (65%) were not judged completely eradicated by EUS, because it made possible to identify still patent variceal lumina or just partially thrombosed vessels or some small residual anechoic structures in the oesophageal wall. Forty-one of them (73%) developed recurrence of oesophageal varices, while just 8 out of the remaining 30 patients (27%), judged eradicated by both endoscopy and EUS, showed oesophageal varices in the follow-up (Chi-square P=0.02). CONCLUSIONS: EUS detects more patent residual vessels in the esophageal wall than endoscopy after endoscopic variceal eradication by means of sclerotherapy or rubber-band ligation. These EUS findings may have a precise clinical impact: predicting variceal recurrence they can indicate the need of further endoscopic therapy.

The diagnostic accuracy of abdominal ultrasonography in inflammatory bowel disease (IBD) has been evaluated in a prospective, randomized, blind study. A total of 181 patients (89 with Crohn's disease, 57 ulcerative colitis and 35 controls) were examined. Sensitivity and specificity of diagnosis in Crohn's disease, corrected for prevalence, were 80.8 and 79.2%, respectively, and a very similar accuracy was found in the differential diagnosis of IBD. In conclusion, ultrasonography can play a role in detecting Crohn's disease and in the differential diagnosis of chronic IBD.

Colonoscopy is used in the differential diagnosis of inflammatory bowel disease but its accuracy and the "weight" of the various endoscopic signs have not been assessed. In a prospective study 357 patients with 606 colonoscopies, in whom the endoscopic appearances were those of ulcerative colitis, Crohn's colitis, or indeterminate colitis, were followed-up for an average period of 22 mo. A final, definite, endoscopy-independent diagnosis was reached by means of autopsy, surgery, or histology on biopsy in 71% of patients. Accuracy of colonoscopy was 89%, with 4% errors and 7% indeterminate diagnoses. Errors were more frequent in severe inflammatory activity (9%). The most useful endoscopic features in this differential diagnosis were discontinuous involvement, anal lesions, and cobblestoning of mucosa for Crohn's disease, and erosions or microulcers and granularity for ulcerative colitis. After selecting the endoscopic features with best predictive value, an "endoscopic score" was calculated by means of "likelihood ratios."