Search

Petroleum is commonly used as a solvent, and primary intrathecal administration or secondary diffusion and subsequent clinical management has not been reported. We report the case of a male patient with intrathecal petroleum diffusion following accidental lumbar infiltration. After the onset of secondary myeloencephalopathy with coma and tetraparesis, continuous cranio-lumbar irrigation using an external ventricular and a lumbar drain was established. Cranial imaging revealed distinct supra- and infratentorial alterations. The patient improved slowly and was referred to rehabilitation. Intrathecal petroleum leads to myeloencephalopathy and continuous cranio-lumbar irrigation might be a safe treatment option.

PurposeGlioma patients face a limited life expectancy and at the same time, they suffer from afflicting symptoms and undesired effects of tumor treatment. Apart from bone marrow suppression, standard chemotherapy with temozolomide causes nausea, emesis and loss of appetite. In this pilot study, we investigated how chemotherapy-induced nausea and vomiting (CINV) affects the patients' levels of depression and their quality of life.MethodsIn this prospective observational multicentre study (n = 87), nausea, emesis and loss of appetite were evaluated with an expanded MASCC questionnaire, covering 10 days during the first and the second cycle of chemotherapy. Quality of life was assessed with the EORTC QLQ-C30 and BN 20 questionnaire and levels of depression with the PHQ-9 inventory before and after the first and second cycle of chemotherapy.ResultsCINV affected a minor part of patients. If present, it reached its maximum at day 3 and decreased to baseline level not before day 8. Levels of depression increased significantly after the first cycle of chemotherapy, but decreased during the further course of treatment. Patients with higher levels of depression were more severely affected by CINV and showed a lower quality of life through all time-points.ConclusionWe conclude that symptoms of depression should be perceived in advance and treated in order to avoid more severe side effects of tumor treatment. Additionally, in affected patients, delayed nausea was most prominent, pointing toward an activation of the NK1 receptor. We conclude that long acting antiemetics are necessary totreat temozolomide-induced nausea.

BACKGROUND Recent studies have analyzed the potential of advanced endoscopic imaging techniques for differentiating hyperplastic and adenomatous colorectal lesions. Latest endoscopic resection techniques now also allow for treatment of more advanced staged lesions including treatment of early cancerous lesions. AIMS To assess the potential of the i-scan technology to differentiate between adenomatous polyps and advanced staged neoplasia. METHODS Consecutive patients undergoing colonoscopy at a tertiary referral center were included. After a dedicated training, participating endoscopists underwent a review of 298 unknown images of colonic lesions to assess colorectal lesion histology. RESULTS Overall accuracy for prediction of advanced staged neoplasia was 92.2% (sensitivity: 94.2%, specificity 90.9%). The positive and negative predictive values were calculated as 87.5% and 95.9%, respectively. The κ-value for differentiating adenomatous polyps and advanced staged neoplasia was 0.8193 (0.7894 to 0.8492). Intraobserver agreement was calculated with a κ-value of 0.9301 (0.8875 to 0.9727). CONCLUSIONS Accurate interpretation of i-scan images for prediction of advanced colorectal neoplasia can successfully be performed even by nonexpert endoscopists with a high overall accuracy and excellent interobserver agreements.

New oral anticoagulants are increasingly used instead of vitamin K antagonists or low molecular weight heparins. Hence, more individuals treated with new oral anticoagulants will seek travel medicine advice. Travel medicine experts should therefore become familiar with new oral anticoagulants and with their impact and role in travel medicine. This review summarizes pharmacological characteristics and approved indications of dabigatran, rivaroxaban and apixaban, and highlights their relevance for travellers on permanent oral anticoagulation and for the prophylaxis of travellers' thrombosis. Compared to vitamin K antagonists, the new oral anticoagulants have many advantages: they do not have interactions with food, they have lower potential for drug-drug interactions and do not require regularly performed laboratory tests. The oral administration, obviating the need to carry needles and syringes during travel may give the new oral anticoagulants a further advantage over low molecular weight heparins. Clinical experience with the new oral anticoagulants, however, is still rather limited and there is concern regarding the clinical management of patients treated with new oral anticoagulants who suffer from severe bleeding or who need urgent invasive procedures. Overall, it remains an individual decision based on a risk/benefit analysis as to whether or not patients on long-term treatment with vitamin K antagonists should be switched to new oral anticoagulants for intended travel. Further caution is also indicated so that the availability of orally administered new anticoagulants should not lead to undifferentiated and unjustified prescription of anticoagulants for the prophylaxis of traveller's thrombosis.

Background Increased vascular permeability and angiogenesis play a crucial role in the pathogenesis of inflammatory bowel disease (IBD). Aim was to determine whether computed virtual chromoendoscopy has the potential to enhance assessment of disease severity and extent in patients with mild or inactive IBD in comparison to high-definition white-light endoscopy. Methods Consecutive patients with IBD were randomly assigned at a 1:1 ratio to undergo colonoscopy with high-definition white light (group A) or computed virtual chromoendoscopy (group B). The mucosal vascular pattern and any mucosal abnormalities were recorded. Subsequent to endoscopic characterization targeted, biopsies were obtained from every segment for subsequent histopathological analysis of disease activity. Results Overall, 100 patients were screened to participate in this study of whom 78 patients (high-definition white light, n = 39; computed virtual chromoendoscopy, n = 39) completed the study protocol thereby matching the previously calculated sample size. Average duration of the examination was 18 minutes in group A and 20.5 minutes in group B that was not statistically significant. When comparing the endoscopic prediction of inflammatory extent and activity with the histological results, an overall agreement of 48.71% and 53.85% (group A) and 92.31% and 89.74% (group B) was found, respectively. These differences were statistically significant (P = 0.0009 and P = 0.066). Conclusions This study indicates that computed virtual chromoendoscopy significantly improves the diagnosis of the severity and extent of mucosal inflammation in patients with IBD. This newly developed imaging technique may therefore have important implications for therapeutic interventions in patients with IBD.

We read with interest the paper by Moussata et al and the GI snapshot by Neufert et al , published in recent issues of Gut .1 ,2 The authors described in these outstanding articles the potential of confocal laser endomicroscopy (CLE) to either image intramucosal bacteria in vivo in patients with inflammatory bowel diseases and also to visualise disease specific findings (‘foamy macrophages’) in a patient with Mycobacterium avium intracellulare infection. CLE was recently introduced as a new emerging endoscopic imaging modality which due to its inherent capability of providing in vivo images of microscopic tissue changes at 1000-fold …

The prevalence of deafness and complement deficiencies in association with meningococcal disease caused by uncommon serogroups of meningococci was studied in 30 patients (Group A) and 30 controls with Serogroup B disease (Group B). In Group A 8 patients (26.6%) had hearing impairment in contrast to only 1 patient (3.3%) in Group B (P < 0.01). Complement deficiency was detected in 8 patients (26.6%) of Group A whereas none of the Group B patients showed a defect in the complement system (P < 0.01). Association between complement deficiencies and meningococcal disease was detected for Serogroups Y (n = 5; 16.6%) and W135 (n = 3; 10.0%). Localization of the defects revealed only complement deficiencies of the classical pathway (C8-beta or C7 defects). The levels of Ig and IgG subclasses were found to be within the normal range for all patients. Our results suggest that meningococcal diseases caused by uncommon serogroups are more often associated with deafness and late complement component defects.

Introduction Device assisted enteroscopy is the standard technique to explore the deep small bowel. However, continuous insufflation of air often significantly distends the small intestine and hampers subsequent advancement of the enteroscope, resulting in distension related abdominal discomfort that can compromise the completion of the procedure and its diagnostic and therapeutic yield. We aimed at developing a novel water infusion technique to reduce small bowel distension and to facilitate enteroscopic procedures. Method We have performed enteroscopies with water infusion in patients who underwent prior wireless capsule enteroscopy that yielded pathologic findings which required further evaluation and/or treatment. Once the enteroscope was passed through the pylorus CO 2 insufflation was switched off. Subsequent advancement of the scope was performed with water infusion whenever necessary to visualise the intestinal lumen. Push-and-pull enteroscopy was performed as per the standard technique. The primary study end points were: system preparation time, rates of successful deep small bowel enteroscopy, procedure duration, diagnostic and therapeutic yield, rate of adverse events. The secondary endpoints included subjective evaluations by the patients concerning the discomfort associated with the procedure and by the endoscopist concerning the ease of performing the procedure. Results Water infusion enteroscopies were performed in 4 patients. The median age of the patients included in the study was 62 (range 36–72). Median time to prepare the system was 2 min (Range 2–3). Enteroscopy was performed successfully in all cases. The estimated median small bowel intubation depth – past the ligament of Treitz- was 160 cm (Range 145–220 cm). Median time of the procedure was 14 min (Range 14–16). All the procedures provided diagnostic elements or enabled treatment. No complications occurred during or after the procedure. Endoscopic findings and treatments are described in the table. Patients reported no significant discomfort during and after the procedure, and endoscopists were able to complete the procedure with ease in all patients. Endoscopic findings and treatments Conclusion The newly introduced water infusion technique allows for deep small bowel enteroscopy within a relatively short period of time. This procedure is relatively safe and well tolerated. Further studies are needed to assess the efficacy and safety of Disclosure of interest None Declared.

A 34-year-old patient with diabetes insipidus after removal of a hypothalamic tumor, developed difficulties with his treatment and presented with hypernatremia. On admission his blood pressure was normal, he was confused, had polyuria and secondary hyperaldosteronism, and his serum [Na+] was 162 mmol/l. We lowered the serum [Na+] with free water and desmopressin so that after 13 days his serum [Na+] was 141 mmol/l and his symptoms were improved. We reviewed the patient's charts and discovered that his body weight was 79.0 kg with hypernatremia, and 78.5 kg after correction of his serum [Na+] and aldosterone.

differences in polyp detection, need for abdominal compression, sedation use, or insertion time. Three minor adverse events were reported in each study arm, with one perforation in the SC group. Conclusions: The use of magnetic endoscopic imaging for routine colonoscopy appears to increase cecal intubation. Acknowledgements: Supported in part by a Resident Research Award from the Canadian Association of Gastroenterology and Takeda Canada. References: 1. Rostom A, Ross ED, Dube C, et al. Development and validation of a nurse-assessed patient comfort score for colonoscopy. Gastrointest Endosc. 2013 Feb;77(2):255-61.

491 Retrograde Single-Balloon Enteroscopy: a Single-Center Experience of 107 Patients Kaci E. Christian*, Karan Kapoor, Eric M. Goldberg University of Maryland Medical Center, Baltimore, MD Background: Single-balloon enteroscopy (SBE) represents a novel approach to diagnose and treat small bowel disease. The small bowel can be deeply intubated via the anterograde (mouth) or retrograde (anus) approach depending on the probable location of the suspected lesion. Single balloon enteroscopy has different performance characteristics depending upon the route chosen, but most studies combine the information. This study constitutes the largest published cohort to date of retrograde single-balloon enteroscopy (RSBE). Objectives: To evaluate the technical success, diagnostic yield and therapeutic potential of RSBE. Design: Single tertiarycare referral center, retrospective study. Setting: University of Maryland Medical Center, Baltimore, MD. Patients: A total of 105 patients were referred for RSBE between July 2007 and September 2013. Results: A total of 107 procedures were performed. The mean age of patients was 57 years, 51.4% were female and 79.4% of procedures were performed on an outpatient basis. Indications included gastrointestinal bleeding, suspected or confirmed inflammatory bowel disease (IBD), imaging suggestive of pathology other than bleeding or IBD and other. Pre-procedural imaging was performed in 67.3% of patients with a 33.3% concordance of imaging and endoscopic findings. Mean insertion depth was 105.4 cm proximal to the ileocecal (IC) valve and mean procedure length was 39.9 minutes. There was a diagnostic yield of 43.9%, with an additional 12.1% of cases exhibiting colonic pathology. In 19.6% of cases, the endoscopist performed a therapeutic intervention, and in 34.6% of cases a tissue sample was obtained. There were no complications. Limitations: Single-center, retrospective design Conclusions: RSBE exhibited a high diagnostic yield for a seemingly safe and effective procedure, allowing for diagnostic and therapeutic interventions for a variety of small bowel diseases. Patient demographics and pre-procedural considerations. Age, years 57.3 16.2

Virtual Chromoendoscopy With I-SCAN for Real Time Diagnosis of Colorectal Cancer In Vivo Helmut Neumann*, Michael Vieth, Martin Grauer, Dane Wildner, JuRgen Siebler, Markus F. Neurath Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany; Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany Introduction: Colorectal cancer is the third most commonly diagnosed cancer in the world and colonoscopy still remains the gold standard for surveillance. i-scan was recently introduced as a new endoscopic imaging technique, enabling virtual chromoendoscopy during ongoing endoscopy that may allow better distinction and characterization of intestinal tissue in vivo. Aims: Main study objective was to assess the potential of i-scan for prediction of histology during screening colonoscopy for colorectal cancer. Material & Methods: Consecutive patients underwent screening or surveillance colonoscopy and were evaluated using a high-definition endoscope with i-scan capability. Circumscript lesions were examined by i-scan before taking biopsy specimens or performing polypectomy. i-scan images were graded according to the Kudo pit pattern classification and vascular changes and correlated with conventional histopathology in a prospective and blinded fashion. Results: i-scan yielded highquality images in all cases. Overall, 152 colorectal lesions were identified. 28% of lesions were neoplasic and 72% were non-neoplastic. Based on pit pattern and vasculare alterations i-scan could predict the presence of neoplastic changes with high sensitivity (95.2%), specificity (97.3%) and accuracy (96.7%). Positive and negative predictive values of i-scan for in vivo diagnosis of colorectal cancer were 98.2% and 93.0%, respectively. Conclusion: i-scan is a novel diagnostic tool which allows the real-time prediction of neoplasic changes with high accuracy. This may be of crucial importance in clinical practice and could lead to an optimized and rapid diagnosis of neoplasic changes during ongoing endoscopy.

Background: Increased vascular permeability and angiogenesis play a crucial role in the pathogenesis of inflammatory bowel disease (IBD). Previously, magnifying endoscopy and chromoendoscopy have been shown to be reliable tools for predicting histological assessment of severity in patients with mild or even inactive disease. i-scan (Pentax, Tokyo, Japan) was recently introduced as a novel computed virtual chromoendoscopy technique which enables a clear visualization of the mucosal vascular pattern within the gastrointestinal tract. Aim was to determine whether i-scan has the potential to enhance assessment of disease severity and extent in patients with mild or inactive IBD in comparison to high-definition white light endoscopy (HD-WL). Methods: Consecutive patients with IBD were randomly assigned at a 1:1 ratio to undergo colonoscopy with HD-WL (Group 1) or i-scan (Group 2). The mucosal vascular pattern and any mucosal abnormalities were recorded. Inflammation in ulcerative colitis was recorded according to Mayo ulcerative endoscopic score and in Crohn’s disease according to Crohn’s Disease Endoscopic Index of Severity (CDEIS). Subsequent to endoscopic characterization targeted biopsies were obtained from every segment for subsequent histopathological analysis of disease activity. Results: Overall, 100 patients were screened to participate in this study of whom 78 patients (HD white light, n = 39; i-scan, n = 39) completed the study protocol thereby matching the previously calculated sample size. Average duration of the examination was 18 minutes in group A and 20.5 minutes in group B which was not statistically significant. When comparing the endoscopic prediction of inflammatory extent and activity with the histological results an overall agreement of 51.28% and 56.41% (group A) and 92.31% and 89.74% (group B) was found, respectively. These differences were statistically significant (p = 0.0009 and p = 0.011). Conclusions: The present study indicates that i-scan significantly improves the diagnosis of the severity and extent of mucosal inflammation in patients with IBD. This newly developed imaging technique will therefore have important implications for diagnostic and therapeutic interventions in patients with IBD.

Confocal Laser Endomicroscopy (CLE) Enables Accurate In Vivo Differentiation Between Microscopic Colitis and Quiescent Ulcerative Colitis a Longitudinal Case Study Helmut Neumann*, Cord Langner, Martin Grauer, Raja Atreya, Jonas Mudter, Claudia Gunther, Michael Vieth, Markus F. Neurath Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany; Institute of Pathology, Medical University of Graz, Graz, Austria; Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany Introduction: Both microscopic colitis and quiescent ulcerative colitis (UC) do not show any mucosal abnormalities during endoscopy. Therefore, only histopathology can correctly diagnose both conditions. CLE enables real-time in vivo histology during ongoing endoscopy with a magnification level up to 1000-fold. Aims: Aim of the present study was to prospectively evaluate if CLE has the potential to differentiate between microscopic colitis and quiescent UC. Material & Methods: Consecutive patients with diarrhea were included and underwent ileocolonoscopy in combination with fluorescein aided CLE. Patients with visible mucosal lesions, Crohn’s disease and infectious colitis were excluded. Subsequent to the confocal diagnosis, targeted biopsies were taken for additional histopathological diagnosis. Results: Overall, 150 patients were prospectively screened to participate in the study. Of those, 36 had UC and 3 microscopic colitis (2 collagenous, 1 lymphocytic). CLE readily identified thickened collagenous bands or increased lymphocytic infiltration within the lamina propria. Moreover, CLE could readily identify mild crypt abnormalities and changes of the microvasculature in UC. Theses architectural differences between UC and microscopic colitis were highly specific (100%) for the respective disease entity. Conclusion: CLE allowed accurate in vivo differentiation between microscopic colitis and UC during ongoing endoscopy. It is now planned to confirm these findings in a larger cohort of patients in order to clarify the role of CLE in the clinical setting.

Background: Confocal laser endomicroscopy (CLE) allows microscopic imaging within the mucosal layer of the gut during ongoing endoscopy. Different studies have addressed the potential of CLE for in vivo diagnosis of ulcerative colitis and microscopic colitis. However, there are no data on the utility of CLE for in vivo diagnosis of Crohn’s disease (CD). The aim was to assess the clinical utility of CLE in patients with CD and to determine whether disease activity can be graded using CLE.

second in a 360-degree-panorama-view for the first 2 hours and 3fps for the rest of time. This enables a side view like with ERCP. A motion detector allows the video capsule to take photographs more frequently when the video capsule is moving more rapidly. The device does not employ wireless technology. SV1 saves the data on the on-board flash memory when it traverses through the bowel. The capsule is retrieved, opened by the docking station where the data are transferred by USB to the reviewing workstation. 19 patients (12 F and 7 M, mean age 42 y) in whom evaluation of the small bowel was indicated swallowed SV1 either after colonoscopy or after a preparation with 2 l of a PEG solution in the afternoon before the examination. The patients swallowed 20 mg of metoclopramide and 170 mg of simethicone 30 min before swallowing the capsule. They were allowed to eat after 6 hours. Results: The capsules were retrieved in 17 of 19 patients forming the study population. The indication was Crohn’s disease (after exclusion of stenoses) in 3, undefined chronic inflammatory disease in 1, NSAR use in 2, Anemia in 5, duodenal polyp after polypectomy in 1, chronic diarrhea in 2, tumor of unknown origin in 1, and unexplained abdominal discomfort in 2 patients. The mean time to pass the stomach was 26 min and the small bowel 243 min. The duodenal papilla was identified in 11 of 17 patients (65%). We further detected mucosal breaks/ulcers in 3 patients with Crohn’s disease, in 1 patient with NSAR use and in 1 patient with anemia. No adverse effects were detected. Discussion: Compared to capsules with cameras at the end, SV1 with a 360 degree imaging detects the duodenal papilla in a higher proportion which constitutes an advantage for the diagnosis of neoplasms of the papilla and duodenum. We also detected pathologic findings in the lower part of the small bowel. Every capsule reached the ileocecal valve. Small bowel capsule endoscopy with SV1 is a safe procedure. The panoramic imaging capsule seems to have an advantage in small bowel.

Confocal Laser Endomicroscopy for In Vivo Diagnosis of Clostridium Difficile Associated Colitis Helmut Neumann, Michael Vieth, Martin Grauer, Raja Atreya, Jonas Mudter, Christoph Becker, Nadine Wittkopf, Markus F. Neurath Department of Medicine 1, University of Erlangen-Nuremberg, Erlangen, Germany; Institute of Pathology, Klinikum Bayreuth, Bayreuth, Germany Background: Clostridium difficile infection (CDI) is one of the most clinically significant causes of hospital-acquired diarrhea and associated with significant morbidity and mortality. Endomicroscopy (CLE) has recently risen as a new emerging endoscopic imaging modality enabling real time in vivo histology during ongoing endoscopy. Aims: Main objective was to investigate whether CLE has the capability for the in vivo diagnosis of CDI. Second objective of our study was to proof the presence of intramucosal bacteria using CLE. Material & Methods: Prospectively, seventy-eight consecutive patients with diarrhea were included of whom eight patients were diagnosed with CDI based on toxigenic culture. CLE was performed after intravenous injection of fluorescein. Additionally, in three patients topical application of acriflavine hydrochloride was performed. In order to validate the presence of intramucosal bacteria ex vivo CLE was performed in pure C. difficile culture; in addition fluorescence in situ hybridization (FISH) was made. Finally, endomicroscopy with fluorescence labelled eubacterial oligonucleotide probes specific for C. difficile was performed in order to prove the presence of intramucosal bacteria. Results: Overall, 80 lesions were examined using endomicroscopy. CLE could readily identify CDIassociated histological changes in vivo. In early CDI, CLE revealed small surface erosions of the superficial colonic crypts and an increased cellular infiltrate. Microvessels within the lamina propria were slightly dilated but showed no leakage. In advanced CDI, CLE demonstrated massively dense cellular infiltrate. Normal colonic appearance was nearly completely abolished and fragile vessels with leakage became visible. Furthermore, a plaque of loosely cells, fibrin and debris covered the mucosal surface. Sensitivity and specificity of CLE in predicting CDI was 75% and 92.9%, respectively. In addition, intramucosal bacteria were visualized using CLE. The presence of these bacteria could also be proven by CLE with fluorescein-labelled specific C. difficile probes and by using the FISH-technique. Sensitivity and specificity for the presence of intramucosal bacteria on endomicroscopy and afterwards confirmed with FISH was 100%. No adverse events regarding the procedure or the use of fluorescence agents were observed. Conclusions: CLE has the potential for the in vivo diagnosis of CDI associated colitis thus enabling accelerated diagnosis and improved patient management. In addition, CLE enabled the detection of intramucosal bacteria in vivo which could open a plethora of new indications in the near future.