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Background & Aims We aimed to compare the incidence of aerodigestive cancers in persons with negative results from colonoscopies and positive vs negative results from multitarget stool DNA tests for colorectal cancer and vs expected incidence. Methods We performed a retrospective cohort study of 1216 subjects with comprehensive patient records and/or cancer registry data from 3 medical centers in North America. Subjects had no neoplasia or only nonadvanced adenomas, based on screening colonoscopy, and either negative results (concordant with colonoscopy, n = 1011) or positive results (discordant colonoscopy, n = 205) from the multitarget stool DNA test. Outcomes included aerodigestive cancers in discordant vs concordant groups and comparison of observed aerodigestive cancer incidence between the groups and compared with expected incidence for the population, based on the Surveillance, Epidemiology, and End Results (SEER) data. Results Median follow-up times were comparable between subjects in the discordant (5.3 y; interquartile range, 3.5–5.8 y) and concordant (5.4 y; interquartile range, 3.7–5.8 y) groups. Aerodigestive cancers developed in 5 subjects in the discordant group vs 11 subjects in the concordant group (crude risk ratio, 2.3; 95% CI, 0.8–6.6; adjusted risk ratio, 2.2; 95% CI, 0.8–6.2; P = .151). The incidence of aerodigestive cancer was lower in the concordant group than the expected incidence based on SEER data (risk ratio, 0.4; 95% CI, 0.2–0.6; P = .0008). The incidence of aerodigestive cancer was not significantly greater in the population in the discordant group than the expected incidence based on SEER data (risk ratio, 0.8; 95% CI, 0.3–1.9; P = .599). Conclusions In a retrospective study with a median follow-up time of 5.4 years, incident aerodigestive cancers were uncommon among subjects with negative findings from colonoscopies, regardless of discordant or concordant results from multitarget stool DNA tests. Patients with negative results from high-quality colonoscopies therefore should not undergo further testing.

Immune checkpoint inhibitors (ICPIs) are novel therapeutic agents targeting a variety of cancers by enhanced T cell activation. Immune-related adverse events (irAEs) commonly occur with ICPI use and can affect multiple organ systems including the gastrointestinal tract. Due to irAEs, the use of ICPIs is limited in autoimmune diseases. We present a case of microscopic colitis diagnosed after the initiation of nivolumab and a case of ipilimumab colitis and Clostridium difficile in the setting of Crohn’s colitis.

Background: Studies of colorectal cancer screening by multitarget stool DNA (MT-sDNA) show false-positive (FP) rates of 7% to 13%. It is unclear whether FP patients are at increased long-term risk of adverse outcomes. Methods: We compared subsequent clinical events among patients with apparent FP MT-sDNA with those in patients reported as true negative (TN). This was a retrospective cohort study of participants in pre-FDA approval MT-sDNA studies having nonadvanced or negative baseline colonoscopy findings from a single referral center. Per-protocol and calibrated cutoffs defined FP and TN groups. From the time of stool collection, we measured differences between FP and TN groups in time to death, subsequent cancer diagnosis, and onset of alarm symptoms. Results: Of 1,050 eligible patients, only 6 were lost to follow-up. Median age was 65.6 years [interquartile range (IQR), 56.8–72.3]; 54% were female. Median follow-up time was 4 years (IQR, 3.5–5.3). Eight aerodigestive (lung and gastrointestinal tract) cancers occurred. FP status by calibrated, but not per-protocol, cutoffs was associated with subsequent aerodigestive cancer; however, cumulative incidence did not exceed SEER expectations from the general population. By any cutoff method, FP status was not associated with mortality or alarm symptoms. Conclusions: Although FP status was associated with long-term aerodigestive cancers, new cases were not temporally related and did not exceed incidence estimates from general population. Impact: These observations do not justify aggressive follow-up evaluation for patients with FP MT-sDNA at this time. Larger studies are needed to confirm these early findings. Cancer Epidemiol Biomarkers Prev; 26(4); 614–21. ©2016 AACR.

Factitious disorder is a rare psychiatric illness characterized by the willful and deceptive induction of illness for the purpose of assuming the sick role. It presents a substantial diagnostic challenge, as patients often go to great lengths to conceal their deception. Accordingly, its presence in the full spectrum of gastrointestinal diseases is likely underappreciated. While factitious gastrointestinal bleeding, abdominal pain and diarrhea are relatively common, factitious non-gastrointestinal symptoms in the setting of gastrointestinal illness have been infrequently reported. We present the case of a patient with Crohn's disease with recurrent pancytopenia attributed to the surreptitious ingestion of 6-mercaptopurine. In patients with possible access to immunomodulatory drugs, a high suspicion for and early identification of factitious disorder may improve patient outcomes and avoid invasive and costly diagnostic evaluations.

Preview Certain populations, particularly the elderly, are vulnerable to complications from the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Rates of hospital admission for perforated ulcer are rising in these patients, who have an associated risk of gastrointestinal hemorrhage and death. Studies have shown that some NSAIDs cause less harm to the stomach and duodenum than others and that prostaglandin E analogues given concomitantly may protect the mucosa.

Eosinophilic granulomatosis with polyangiitis (EGPA), formerly named Churg-Strauss syndrome, is a rare systemic small- and medium-sized-vessel vasculitis, characterized by the presence of severe asthma as well as blood and tissue eosinophilia. Gastrointestinal (GI) symptoms, like diarrhea and abdominal pain, are common; however, there are few reports of histologic evidence of GI involvement. We report the case of a patient on treatment for EGPA who presented with recurrent small bowel obstruction and choledocholithiasis. Biopsies of the esophagus, small bowel and common bile duct showed diffuse eosinophilia, with clear EGPA in the GI tract. Improved awareness of GI EGPA may allow for timely management of this disorder.

Turnaround time is an important component of endoscopy unit efficiency. Any reduction in the total time from patient arrival in the endoscopy room to departure from the recovery area may translate into better endoscopy unit efficiency.To evaluate the effects on endoscopy unit efficiency of a change in narcotic choice for moderate sedation in patients undergoing EGD at an ambulatory surgery center.Prospective, comparative, quality-improvement project.Endoscopy unit of a tertiary-care academic medical center.We enrolled consecutive patients (n = 1963) who underwent outpatient EGD by 1 of 5 endoscopists between November 2008 and November 2010.Moderate sedation with midazolam plus fentanyl versus meperidine.Sedation-dependent endoscopy unit efficiency and total procedure time (induction-to-intubation, intubation-to-extubation, and extubation-to-discharge).Fentanyl was associated with reduced total procedure time by 10.1 minutes resulting from both shorter induction-to-intubation time and extubation-to-discharge time (P.001). The mean (± SD) sedation-dependent endoscopy unit efficiency was 3.2 (± 1.9) procedures per hour for the meperidine group and 3.9 (± 2.7) procedures per hour for the fentanyl group (P = .012); this would translate into possibly increasing the endoscopy suite efficiency by 22%. Based on dosage equivalency conversion, equal doses of fentanyl and meperidine were used. No sedation-related complications or need for reversal agents were recorded.No randomization was performed.Compared with meperidine, fentanyl in combination with midazolam was associated with significantly shorter total procedure time. By improving the turnaround time, sedation-dependent endoscopy unit efficiency may be improved by 22%.

Background Cyclooxygenase (COX)-2 inhibitors such as celecoxib were designed to preserve anti-inflammatory activity without inhibiting COX-1. Downregulation of COX-2 inhibits colorectal carcinogenesis. Methods The Selenium and Celecoxib Trial was a randomized, placebo-controlled trial of once-daily selenium 200 µg and celecoxib 400 mg, alone or together, for colorectal adenoma prevention. Men and women between age 40 and 80 years were eligible following colonoscopic removal of adenomas. The primary outcome was development of new adenomas. Celecoxib was suspended early because of cardiovascular toxicity in other trials. Accrual to selenium or placebo continued. Before suspension, 824 participants were randomly assigned to celecoxib or placebo, of whom 712 (86.4%) were available for analysis. All statistical tests were two-sided. Results In the placebo and celecoxib arms of 356 participants each, adenoma detection was 47.5% and 49.7% (relative risk [RR] = 1.04, 95% confidence interval [CI] = 0.90 to 1.21, P = .58), respectively, after median periods of 13.6 and 14.2 months on intervention. Among participants colonoscoped within 12 months of discontinuing intervention (n = 244), overall adenoma recurrence (RR = 0.69, 95% CI = 0.48 to 0.98, P = .04) and recurrence with advanced adenomas (RR = 0.23, 95% CI = 0.07 to 0.80, P = .02) were reduced with celecoxib. Reduction of adenoma recurrence was greatest in participants with previous advanced adenomas. Celecoxib increased risk of hypertension in participants with pre-existing cardiovascular risk factors compared with placebo (hazard ratio = 2.19, 95% CI = 1.07 to 4.50, P = .03). Conclusions Limited-duration celecoxib prevents adenoma recurrence in patients with prior high-risk adenomas, in whom strategies to minimize cardiovascular toxicity might be feasible.

Background Selenium supplementation may help to prevent colorectal cancer; as precursors of colorectal cancer, colorectal adenomas are a surrogate for colorectal cancer. Selenium supplementation may increase risk of type 2 diabetes (T2D). Methods The Selenium and Celecoxib (Sel/Cel) Trial was a randomized, placebo controlled trial of selenium 200 µg daily as selenized yeast and celecoxib 400 mg once daily, alone or together, for colorectal adenoma prevention. Men and women between age 40 and 80 years were eligible following colonoscopic removal of colorectal adenomas. The primary outcome was adenoma development. Celecoxib was suspended because of cardiovascular toxicity in other trials, but accrual continued to selenium and placebo. A total of 1621 participants were randomly assigned to selenium or placebo, of whom 1374 (84.8%) were available for analysis. All statistical tests were two-sided. Results In the respective placebo and selenium arms of 689 and 685 participants, adenoma detection after medians of 33.6 (range = 0.0-85.1 months) and 33.0 months (range = 0.0-82.6 months) were 42.8% and 44.1% (relative risk [RR] = 1.03, 95% confidence interval [CI] = 0.91 to 1.16, P = .68). In participants with baseline advanced adenomas, adenoma recurrence was reduced by 18% with selenium (RR = 0.82, 95% CI = 0.71 to 0.96, P = .01). In participants receiving selenium, the hazard ratio for new-onset T2D was 1.25 (95% CI = 0.74 to 2.11, P = .41), with a statistically significantly increased risk of selenium-associated T2D among older participants (RR = 2.21; 95% CI = 1.04 to 4.67, P = .03). Conclusions Overall, selenium did not prevent colorectal adenomas and showed only modest benefit in patients with baseline advanced adenomas. With limited benefit and similar increases in T2D to other trials, selenium is not recommended for preventing colorectal adenomas in selenium-replete individuals.

COX inhibitors reduce colorectal adenoma recurrence by up to 45% and selenium supplementation may prevent colorectal cancer. Following colonoscopic adenoma resection, 1,600 men and women, ages 40 to 80 years, were randomized to celecoxib (400 mg daily), a selective COX-2 inhibitor, and/or selenium (200 μg daily as selenized yeast), or double placebo. The trial was initiated in November 2001. The primary trial endpoint is adenoma recurrence in each intervention group compared with placebo, as determined by surveillance colonoscopy conducted three to five years after baseline. Randomization was stratified by use of low-dose aspirin (81 mg) and clinic site. Following reports of cardiovascular toxicity associated with COX-2 inhibitors, the celecoxib arm was discontinued in December 2004 when 824 participants had been randomized. Accrual continued with randomization to selenium alone or placebo. Randomization of the originally planned cohort (n = 1,621) was completed in November 2008. A further 200 patients with one or more advanced adenomas (denoting increased risk for colorectal cancer) were accrued to enhance statistical power for determining intervention efficacy in this higher-risk subgroup. Accrual of the total cohort (n = 1,824) was completed in January 2011. Baseline cohort characteristics include: mean age 62.9 years; 65% male; body mass index (BMI) 29.1 ± 5.1; 47% taking low-dose aspirin while on trial; 20% with three or more adenomas; and 38% with advanced adenomas. Intervention effects on adenoma recurrence will be determined, and their modification by genetic background and baseline selenium level. The effect of selenium supplementation on risk for type II diabetes will also be reported. Cancer Prev Res; 5(12); 1381–93. ©2012 AACR.

Eosinophilic enteritis is a rather rare condition that can manifest anywhere from esophagus to rectum. Its description in the literature is sparse, but associations have been made with collagen vascular disease, malignancy, food allergy, parasitic or viral infections, inflammatory bowel disease, and drug sensitivity. We present the case of a 41-year-old male diagnosed with ulcerative colitis who underwent proctocolectomy with ileal pouch anal anastomosis and loop ileostomy formation utilizing Seprafilm®, who later developed eosinophilic enteritis of the loop ileostomy site. This is the first report of eosinophilic enteritis and its possible link to the use of bioabsorbable adhesion barriers.

Crohn's disease (CD) and Takayasu's arteritis (TA) are inflammatory granulomatous autoimmune disorders. Simultaneous occurrence of CD and TA in the same individual is rare. We report two cases treated with biologic agents. Case 1: A 16-year-old male presented with abdominal pain, nausea, vomiting. CT angiogram showed thickening of the terminal ileum, wall thickening and narrowing of multiple large and medium arteries including aorta and left common carotid. Colonoscopy with biopsy of the stenotic ileocecal valve confirmed CD. Resected carotid artery pathology was consistent with TA. Treatment was initially begun with prednisone, then methotrexate was started followed by infliximab. Due to side effects, methotrexate was switched to azathioprine. He remained asymptomatic. Case 2: A 38-year-old male with well-characterized Crohn's ileocolitis for 15 years, who had been treated with prednisone, mesalamine, sulfasalazine, and azathioprine presented with chest, upper back and abdominal pain. CT angiogram showed vasculitis of large and medium arteries, with stenosis of the right renal artery, and wall thickening of the sigmoid colon. He was diagnosed with TA. He underwent treatment with infliximab and adalumimab on different occasions, which were later discontinued due to fever, bacteremia and complications from sepsis. He remained on prednisone and azathioprine. In these two patients with both CD and TA the diagnoses were confirmed by imaging and pathologic findings. Both patients developed vascular complications. Tumor necrosis factor inhibitor therapy was effective in one patient but discontinued in the other due to infection. Further research into the association of CD and TA may provide clues to their etiologies and guide effective interventions.

Colorectal cancer can be prevented via screening by the detection and removal of colorectal adenomas. Few data exist on screening capacity by rural/urban areas. Therefore, the aims of this work were to evaluate current colorectal cancer endoscopy screening capacity and to estimate potential volume for rural and urban regions in Arizona. Gastroenterologists and colorectal surgeons practicing in Arizona completed a survey (n = 105) that assessed current colonoscopy and sigmoidoscopy screening and estimated future capacity. Resources needed to increase capacity were identified, and differences between rural and urban regions were examined. Responders were more likely to practice in an urban region (89.5%). Physicians reported performing 8,717 endoscopic procedures weekly (8,312 in urban and 405 in rural regions) and the vast majority were colonoscopies (91% in urban and 97% in rural regions). Urban physicians estimated being able to increase their capacity by 35.7% (95% confidence interval 34.7-35.7) whereas rural physicians estimated an increase of 53.1% (95% confidence interval 48.1-58.0). The most commonly cited resource needed to increase capacity was a greater number of physicians in urban regions (52.1%); while the top response in rural areas was appropriate compensation (54.6%). Lastly, 27.3% of rural physicians noted they did not need additional resources to increase their capacity. In conclusion, Arizona has the ability to expand colorectal cancer screening endoscopic capacity; this potential increase was more pronounced in rural as compared to urban regions.

Background Colonoscopy is considered the primary procedure for colorectal cancer screening and prevention. However patient acceptance of this procedure has been poor. A major deterrent for patients is the need for a large-volume (4-l) preprocedure colonic preparation (polyethylene glycol [PEG] solution) that can be associated with a bad taste. Aim To determine patient preference and acceptance of the NaP tablet preparation in patients who have previously used PEG solutions for their prior colonoscopy exams. Methods Patients who had used a standard 4-l PEG solution preparation for a colonoscopy within the past 12 months and who were scheduled for a repeat colonoscopy were invited to participate in this study. A preprocedural questionnaire was administered to the patients. The primary outcome measure was whether the patient indicated a preference for the NaP tablet preparation over the previous PEG solution. Results Thirty-five of 53 participants (66%) who completed the study preferred the NaP tablet preparation over 4-l PEG. A majority of patients also indicated that they would use the NaP tablet preparation again and would like to have a choice of preparation for their next colonoscopy. Conclusions Among patients who previously used a 4-l PEG preparation for colon cleansing and participated in this study, 66% of patients preferred the NaP tablet preparation over the PEG preparation for their colonoscopy.

Solitary rectal ulcer syndrome (SRUS) is an uncommon disorder which can present in patients being evaluated for defecatory disorders or which can present as a primary process often involving hematochezia, rectal pain and tenesmus. Unfortunately the diagnosis of this disorder is often delayed due to misdiagnosis and/or physician unfamiliarity with the condition. We present a 24-year-old female who presented with 6 months of bloody diarrhea and weight loss. She had been receiving treatment for a presumed diagnosis of inflammatory bowel disease (IBD) due to an endoscopic picture of rectal thickening, edema and ulceration and had been on prednisone for 2 months prior to presentation without relief of her symptoms. After further testing including repeat endoscopy with biopsies, defecography and anorectal manometry, the diagnosis of SRUS was made and treatment was changed. Medical management was unsuccessful and she ultimately required surgical intervention. This case highlights the difficulty in diagnosing SRUS due to its resemblance to other gastrointestinal diseases and should serve as a reminder that if a patient is not responding to IBD therapy, another etiology should be considered.

The purpose of our study was to determine whether imaging changes of Crohn's disease at sequential CT enterography examinations correlate with disease progression or regression.Forty CT enterography examinations in 20 patients (12 women, eight men; mean age, 55.5 years) with known Crohn's disease were retrospectively evaluated by a radiologist who was blinded to the clinical history. One radiologist determined whether imaging findings of Crohn's disease were present and, if so, whether the findings progressed, regressed, or remained stable between examinations. CT enterography findings were then compared with disease progression or regression based on symptoms and clinical follow-up. Direct comparison of CT enterography and endoscopy was also performed when available.Disease progression or regression by CT enterography correlated with symptoms in 16 of 20 (80%) patients. Specifically, CT enterography and symptoms agreed in 12 patients with clinical disease progression, two patients with clinical regression, and two with clinically stable disease. In four of 20 (20%) patients, symptoms progressed although CT enterography findings were negative (n = 2) or improved (n = 2). No treatment change was initiated; and at follow-up, three of four patients were improved and the remaining patient was stable symptomatically. Sixteen ileoscopies were attempted in 12 patients; however, four examinations did not reach the ileum. In the remaining examinations, endoscopy correlated with CT enterography in all cases (12/12, 100%) and with symptoms in nine of 12 (75%) cases. The weighted kappa statistic, which measures the chance-adjusted agreement between CT enterography and symptoms, was 0.57 (95% CI, 0.20-0.94).This preliminary study indicates that imaging changes between CT enterography examinations have excellent potential for reliably monitoring Crohn's disease progression or regression.

Background In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. Objective We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. Methods We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. Conclusions Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

A Single-Center Experience of 260 Consecutive Patients Undergoing Capsule Endoscopy for Obscure Gastrointestinal Bleeding

To determine whether an association exists between relapse in inflammatory bowel disease and use of nonsteroidal anti-inflammatory drugs (NSAIDs), a retrospective records review was conducted of patients with Crohn's disease, ulcerative colitis, or indeterminate colitis examined at an outpatient tertiary care center between July 17, 2000, and November 1, 2001. Extracted data collected during the patient's last visit included medication use, maintenance therapy, disease activity, and smoking status. Use of NSAIDs was defined as a daily dose or more of any type the month before relapse. Of 60 patients (22, relapse; 38, remission), 9 (41%) in relapse and 10 (26%) in remission used NSAIDs. Maintenance therapy varied from 68% (relapse) to 92% (remission). The adjusted odds ratio between medication use and relapse was 6.31 (95% confidence interval, 1.16-34.38; P = .03). Use of NSAIDs was associated with relapse. A prospective cohort study that corrects for maintenance therapy is needed to evaluate this relationship.

A Meta-Analysis of the Yield of Capsule Endoscopy Compared to Other Diagnostic Modalities in Patients with Obscure Gastrointestinal Bleeding

Capsule endoscopy (CE) has been shown to have a high diagnostic yield in patients with obscure gastrointestinal bleeding (OGIB). It is not known if repeating CE improves diagnostic yield or changes patient management when the initial CE is negative or nondiagnostic. The aims of this study are (1) to understand the reasons for repeat CE, (2) to determine the diagnostic yield of repeat CE, and (3) to establish if findings on repeat CE resulted in a change in patient management.Between August 2001 and October 2003, we performed 391 capsule studies. Of these, 24 were repeat studies in patients with OGIB. We retrospectively reviewed the charts of these 24 patients.The reasons for repeat CE were: recurrent gastrointestinal bleeding (13), limited visualization on first exam due to poor prep or blood (10), complication (1) (capsule impaction at cricopharyngeus). Eighteen of 24 (75%) repeat capsule studies revealed additional findings (7 arteriovenous malformations, 2 gastropathy, 2 erosions, 2 masses, 1 ulcer, 2 red spots, 1 linear streak, 1 erythema). These findings led to changes in patient management in 15 of the 24 (62.5%) cases.Indications for repeat CE most commonly include recurrent gastrointestinal bleeding and limited visualization on initial study. Repeat CE results in a high yield of new findings that lead to changes in patient management. Repeat CE should be considered in patients with persistent OGIB when the initial study is negative or inconclusive.

Capsule endoscopy is a revolutionary new diagnostic tool for the detection of small bowel disease. As the name implies, capsule endoscopy makes use of a swallowable video capsule; as such, it is the only technique that allows noninvasive endoscopic examination of the entire small bowel without sedation. Obscure gastrointestinal bleeding is the most common indication for capsule endoscopy, which commonly depicts arteriovenous malformations, small bowel tumors, and ulcers missed at standard endoscopy and imaging examinations. However, capsule endoscopy is not optimal for the localization of small bowel lesions. In addition, lesions can be missed due to poor bowel preparation, rapid or delayed small bowel transit, or orientation of the camera away from a lesion. Computed tomography and barium examinations are useful for detecting these missed lesions and for localizing lesions detected at capsule endoscopy. Other limitations of capsule endoscopy are the inability to treat lesions and its limited use in patients with small bowel strictures or obstruction. Nevertheless, this new technique is easy to perform, is well tolerated by patients, and, for the first time, allows noninvasive endoscopic evaluation of the entire small bowel.

Goals: We sought to determine the yield of stool analysis for bacterial culture, ova and parasites, and Clostridium difficile toxin in suspected relapses of inflammatory bowel disease (IBD). Background: The diagnostic yield of such stool studies has not been examined recently in the United States. Study: The medical records of consecutive IBD patients who underwent stool testing for relapses at our institution between July 1, 2000, and November 25, 2001, were abstracted for demographics, stool test results, recent antibiotic exposure, and hospitalization. Results: Fifty-four patients were evaluated during 62 relapses with 99 stool samples. Twelve stool tests were positive. C. difficile accounted for the majority of positive tests (10/12). Of these, 9 (90%) were associated with antibiotic use in the prior month versus 10 (22%) in the C. difficile-negative group (P < 0.001). Hospitalization, prednisone use, or sulfasalazine use did not differ significantly with C. difficile status. Eight C. difficile-positive patients improved clinically with targeted antibiotic therapy. Two bacterial cultures (4%) were positive for Campylobacter jejuni and Plesiomonas shigelloides. Conclusion: Stool studies yielded a pathogen, mainly C. difficile, in 20% of the relapsing IBD patients. Antibiotic use was significantly associated with a positive C. difficile toxin. Toxin-positive patients improved clinically with targeted antibiotics.

Diaphragm disease of the small intestine is part of the spectrum of diseases associated with injury to the gastrointestinal tract induced by nonsteroidal anti-inflammatory drugs. Standard endoscopy or contrast studies of the small intestine rarely identify these lesions. The diagnosis usually is established at the time of surgery. We report the case of a 72-year-old woman with obscure gastrointestinal bleeding and intermittent obstruction of the small intestine who had had multiple hospitalizations and extensive testing. The patient had been treated with nonsteroidal anti-inflammatory drugs for osteoarthritis. A radiograph of the small intestine with barium contrast revealed no abnormalities, so capsule endoscopy was performed. Capsule endoscopy showed multiple small intestinal strictures beyond which the capsule could not pass. After the patient experienced continued symptoms suggestive of intermittent partial obstruction of the small intestine, computed tomography showed the capsule within a dilated loop of intestine adjacent to a stricture. After 9 days of conservative medical therapy and worsening symptoms, the patient required an exploratory laparotomy. The capsule was located in a 12-cm segment of intestine with 4 diaphragm-like lesions. Pathologic study found submucosal lesions with features identical to those of neuromuscular and vascular hamartoma (eg, mature, reactive tissue elements of smooth muscle, dense fibrous tissue, and nerve tissue bundles with scattered ganglion cells and vessels). No manifestations of Crohn disease were evident. This case represents the first diagnosis with capsule endoscopy of diaphragm disease of the small intestine with pathologic features of neuromuscular and vascular hamartoma.

Background Patients with familial adenomatous polyposis (FAP) are known to have an increased risk for gastric adenomas. The clinical features of gastric adenomas in FAP have not been well characterized, and there is a lack of standardized approaches to the management of these lesions. Aims To study the endoscopic appearance, risk factors, clinical course, and response to therapy of gastric adenomas in patients with FAP. Methods We retrospectively reviewed the records of 97 patients with FAP who underwent esophagogastroduodenoscopy (EGD) at Mayo Clinic (Florida, Rochester and Arizona) between 2004 and 2013. Results Nine patients (9%) had biopsy-proven gastric adenomas. Adenomas were located in the antrum (five patients), in the body and fundus in the setting of background fundic gland polyps (FGP) (three patients), and in the body not associated with FGP (one patient). Adenoma size was 3–40 mm and the number of adenomas per patient ranged from one to 20. Adenomas in the antrum were flat and subtle, whereas those in the gastric body or fundus were polypoid and difficult to differentiate from the cystic FGPs seen in patients with FAP. The performing endoscopists reported difficulty with identifying adenomas, and six patients had at least one EGD within the previous three years where gastric adenomas were not reported. Adenomas were classified as tubular in eight patients and tubulovillous in one patient. High grade dysplasia was noted in one patient. After a median follow-up of 63 months (interquartile range: 20–149 months), no patient in our entire cohort (with or without gastric adenomas) developed gastric cancer. The patients in whom gastric adenoma developed, compared to those without gastric adenoma, were more likely to be younger [36 ± 12 vs. 48 ± 15 years, p = 0.02], have concomitant chronic gastritis [22% vs. 0%, p = 0.008], and have desmoid tumors [5 (56%) vs. 19 (22%), p = 0.04]. Conclusions Gastric adenomas are not uncommon in patients with FAP and are often difficult to identify endoscopically. Endoscopists should have a high degree of suspicion for gastric adenomas in these patients and a low threshold to biopsy. Given the benign clinical course, recommended initial management is conservative with endoscopic therapy and periodic surveillance.

Objectives Precursors to 1/3 of colorectal cancer (CRC), serrated polyps have been under-detected by screening due to their inconspicuous, non-hemorrhagic, and proximal nature. A new multi-target stool DNA test (multi-target sDNA) shows high sensitivity for both CRC and advanced adenomas. Screen detection of serrated polyps by this approach requires further validation. We sought to assess and compare noninvasive detection of sessile serrated polyps (SSP) ≥1 cm by sDNA and an occult blood fecal immunochemical test (FIT). Methods In a blinded prospective study, a single stool sample used for both tests was collected from 456 asymptomatic adults prior to screening or surveillance colonoscopy (criterion standard). All 29 patients with SSP≥1 cm were included as cases and all 232 with no neoplastic findings as controls. Buffered stool samples were processed and frozen on receipt; Exact Sciences performed sDNA in batches using optimized analytical methods. The sDNA multi-marker panel targets methylated BMP3 (mBMP3) and NDRG4, mutant KRAS, β-actin, and hemoglobin. FIT (Polymedco OC-FIT Check) was performed in separate lab ≤2 days post defecation and evaluated at cutoffs of 50 (FIT-50) and 100 ng/ml (FIT-100). Results Median ages: cases 61 (range 57–77), controls 62 (52–70), p = NS. Women comprised 59% and 51%, p = NS, respectively. SSP median size was 1.2 cm (1–3 cm), 93% were proximal, and 64% had synchronous diminutive polyps. Among multi-target sDNA markers, mBMP3 proved highly discriminant for detection of SSP≥1 cm (AUC = 0.87, p

Melanocytosis of the digestive tract is defined as the presence of melanocytes at the interface between the epithelium and the lamina propria, without evidence of cytologic or architectural atypia. Esophageal melanocytosis is rarely identified endoscopically. This report describes a case of esophageal melanocytosis in a patient with known Addison’s disease. Esophageal melanocytosis is rare and this case suggests the possibility of a relationship to Addison’s disease.

Background Capsule endoscopy, a new technology, allows visualization of the entire small intestinal mucosa. The main indication for capsule endoscopy at present is the evaluation of GI bleeding of obscure origin. Studies to date suggest that capsule endoscopy is safe and is associated with few adverse events. One concern, which has not been studied, is the potential effect of the capsule on cardiac pacemakers and other electromedical devices. The primary aims of this study were to evaluate the safety of capsule endoscopy in patients with cardiac pacemakers who are being evaluated for GI bleeding of obscure origin and to determine whether pacemakers have any effect on the images captured by the capsule endoscope. Methods Patients with cardiac pacemakers referred for evaluation of GI bleeding of obscure origin were entered into the study. Before the procedure, an electrocardiogram was obtained, and pacemaker functions were checked. Capsule endoscopy was performed in a hospital setting to allow closer monitoring, instead of the outpatient clinic, which is our routine. Cardiac rhythm was assessed simultaneously during capsule endoscopy with a Holter monitor. Post-procedure pacemaker function was again checked for any disturbance. When the capsule endoscopy studies were reviewed, observations were made with particular reference to technical difficulty or interference with imaging. Observations Five consecutive patients (4 men, 1 woman; mean age, 73 years, range 56-92 years) with cardiac pacemakers were studied. In all patients, the indication for capsule endoscopy was GI bleeding of obscure origin. A cardiologist and pacemaker nurse specialist reviewed the Holter monitor recordings and evaluated pacemaker function after the procedure for each patient. No arrhythmia or other adverse cardiac event was noted during capsule transmission. No pacemaker-induced interference on the capsule endoscopy images was observed. Conclusions Capsule endoscopy appears to be safe in patients with cardiac pacemakers and does not appear to be associated with any significant adverse cardiac event. Pacemakers do not interfere with capsule imaging.

Background and Study Aims. The presence of an implantable electromechanical cardiac device (IED) has long been considered a relative contraindication to the performance of video capsule endoscopy (CE). The primary aim of this study was to evaluate the safety of CE in patients with IEDs. A secondary purpose was to determine whether IEDs have any impact on images captured by CE.Patients and Methods.A retrospective chart review of all patients who had a capsule endoscopy at Mayo Clinic in Scottsdale, AZ, USA, or Rochester, MN, USA, (January 2002 to June 2010) was performed to identify CE studies done on patients with IEDs. One hundred and eighteen capsule studies performed in 108 patients with IEDs were identified and reviewed for demographic data, method of preparation, and study data.Results.The most common indications for CE were obscure gastrointestinal bleeding (77%), anemia (14%), abdominal pain (5%), celiac disease (2%), diarrhea (1%), and Crohn’s disease (1%). Postprocedure assessments did not reveal any detectable alteration on the function of the IED. One patient with an ICD had a 25-minute loss of capsule imaging due to recorder defect. Two patients with LVADs had interference with capsule image acquisition.Conclusions.CE did not interfere with IED function, including PM, ICD, and/or LVAD and thus appears safe. Additionally, PM and ICD do not appear to interfere with image acquisition but LVAD may interfere with capsule images and require that capsule leads be positioned as far away as possible from the IED to assure reliable image acquisition.

Preview Certain populations, particularly the elderly, are vulnerable to complications from the use of nonsteroidal anti-inflammatory drugs (NSAIDs). Rates of hospital admission for perforated ulcer are rising in these patients, who have an associated risk of gastrointestinal hemorrhage and death. Studies have shown that some NSAIDs cause less harm to the stomach and duodenum than others and that prostaglandin E analogues given concomitantly may protect the mucosa.

Afternoon colonoscopies have recently been reported to be associated with lower adenoma detection rate (ADR), which was attributed to physician fatigue resulting from the same endoscopist performing procedures throughout the day. The aim of our study was to assess ADR in morning compared with afternoon colonoscopy performed in half-day blocks with different physicians. We evaluated the primary hypothesis that morning and afternoon ADRs would not differ significantly when performed in half-day blocks by different endoscopists.Data on all colonoscopies performed between January 2009 and December 2009 were obtained from our endoscopy database. All patients who underwent colonoscopies in 2009 for screening, surveillance, and family history of colon cancer/polyps were included in the study. Morning colonoscopies were defined as those that were performed from 0800 to 1200 hours. Afternoon colonoscopies were defined as those that were performed from 1300 to 1700 hours. Colonoscopies in each block were performed either by different endoscopists working in half-day (morning or afternoon) block schedules or by the same endoscopist working a full-day schedule.A total of 4,665 patients were included in the study. For endoscopists working the full-day, the afternoon ADR was significantly lower than the morning ADR (21 vs. 26.1%; odds ratio (OR)=0.75; 95% confidence interval (CI) 0.59, 0.96; P=0.02). Conversely, in the half-day group, there was no significant difference in ADR between afternoon and morning (27.6 vs. 26.6%; OR=1.05; 95% CI 0.88, 1.26; P=0.56).Performing colonoscopies in half-day blocks by different endoscopists increases the detection of adenomas in afternoon procedures, probably by reducing physician fatigue.

Sulindac, atorvastatin, or prebiotic dietary fiber may reduce colorectal cancer (CRC) risk. However, clinical trial data are currently limited. We conducted a randomized, phase II chemoprevention trial involving subjects 40 years or older, with previously resected colon cancer or multiple/advanced colorectal adenomas. Magnification chromoendoscopy (MCE) was performed to identify and characterize rectal aberrant crypt foci (ACF); eligibility criteria required five or more rectal ACFs at baseline. Intervention assignments were as follows: (a) atorvastatin 20 mg qd; (b) sulindac 150 mg bid; (c) oligofructose-enriched inulin (as ORAFTI®Synergy1) 6 gm bid; or (d) control (maltodextrin) 6 gm bid, for 6 months. Percent change in rectal ACF number (%ΔACF) within arm was the primary endpoint. Secondary endpoints included changes in proliferation (Ki67) and apoptosis (caspase-3), as measured from normal mucosa biopsy samples. Among 85 eligible randomized subjects, 76 (86%) completed the trial per protocol. The median (range) of rectal ACF was 9 (5–34) and 8 (0–37) at baseline and postintervention, respectively. The median (SD) for %ΔACF was 5.6 (−69% to 143%), −18.6 (−83% to 160%), −3.6 (−88% to 83%), and −10.0 (−100% to 117%) in the atorvastatin, sulindac, ORAFTI®Synergy1 and control arms, respectively. Neither within-arm (P = 0.12–0.59) nor between-arm (P = 0.30–0.92) comparisons of %ΔACF were statistically significant. The active and control interventions also seemed to have similar effects on mucosal proliferation and apoptosis (P > 0.05 for each comparison). Data from this multicenter, phase II trial do not provide convincing evidence of CRC risk reduction from 6-month interventions with atorvastatin, sulindac, or ORAFTI®Synergy1, although statistical power was limited by the relatively small sample size. Cancer Prev Res; 4(2); 259–69. ©2011 AACR.

Afternoon colonoscopies have higher failure rates, due primarily to poor bowel cleansing. Hypothesizing that the time of administration influences the quality of bowel cleansing, we compared the quality of bowel cleansing for afternoon colonoscopies in patients completing the preparation on the same day vs. the day before colonoscopy.Data on afternoon colonoscopies performed between July 2008 and April 2009 were obtained from our endoscopy database. Bowel-preparation options were 4L polyethylene glycol (PEG) or 2L PEG plus four bisacodyl tablets. Patients could take the preparation on the same day as the procedure or the day prior, or consume half the day prior and half the same day. Bowel-cleansing quality was reported as excellent, good, fair-adequate, inadequate, or poor. Multivariate logistic regression analysis evaluated the association between quality of bowel cleansing and time of preparation administration.Bowel cleansing was reported as poor or inadequate in 7% of patients, adequate in 63%, and good or excellent in 30%. Afternoon colonoscopies using the same-day 4L PEG preparation were 3.14 times more likely to have fair-adequate cleansing and 7.03 times more likely to have good or excellent cleansing when compared with the other options.Same-day 4L PEG preparation for afternoon colonoscopy confers better-quality cleansing than prior-day preparation.

Background The patency capsule (PC) is used before capsule endoscopy (CE) in patients with known or suspected small-bowel (SB) strictures or obstruction (SBO) to avoid CE retention. False-positive PC examination results can occur in patients with delayed transit without obstruction, precluding the use of CE. Radiological tests are another option to evaluate the presence of SBO before CE. Objectives Comparison of the PC and radiological examinations to detect clinically significant SB strictures. Main Outcome Measurements Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of the PC, and radiological tests for detecting significant strictures. Results Forty-two patients underwent a PC study and radiological examinations. Both of the examinations showed similar sensitivity (57% vs 71%; P = 1.00) and specificity (86% vs 97%; P = .22). The receiver-operating characteristic curves evaluating combined sensitivity and specificity were also similar in both the PC and radiological examinations (0.71 vs 0.84, respectively; P = .46). Pooling results from both the PC and radiological tests had the highest sensitivity and NPV (100%, 100%). False-positive results occurred in 5 PC examinations and 1 radiological examination. The PC examination had 3 false-negative results (9%), whereas radiological tests had 2 (6%). Limitations Retrospective study. Conclusions The NPV for the PC and radiological tests were not significantly different, suggesting that if findings on either test are negative before CE, the patient will most likely pass the capsule without incident. Radiological tests can be used to minimize PC study false-positive results by confirming or excluding the presence of a significant stricture suspected by the PC and to localize the PC if passage is delayed.

Colonoscopy may fail to detect neoplasia located on the proximal sides of haustral folds and flexures. The Third Eye Retroscope (TER) provides a simultaneous retrograde view that complements the forward view of a standard colonoscope.To evaluate the added benefit for polyp detection during colonoscopy of a retrograde-viewing device.Open-label, prospective, multicenter study evaluating colonoscopy by using a TER in combination with a standard colonoscope.Eight U.S. sites, including university medical centers, ambulatory surgery centers, a community hospital, and a physician's office.A total of 249 patients (age range 55-80 years) presenting for screening or surveillance colonoscopy.After cecal intubation, the disposable TER was inserted through the instrument channel of the colonoscope. During withdrawal, the forward and retrograde video images were observed simultaneously on a wide-screen monitor.The number and sizes of lesions (adenomas and all polyps) detected with the standard colonoscope and the number and sizes of lesions found only because they were first detected with the TER.In the 249 subjects, 257 polyps (including 136 adenomas) were identified with the colonoscope alone. The TER allowed detection of 34 additional polyps (a 13.2% increase; P.0001) including 15 additional adenomas (an 11.0% increase; P.0001). For lesions 6 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 18.2% and 25.0%, respectively. For lesions 10 mm or larger, the additional detection rates with the TER for all polyps and for adenomas were 30.8% and 33.3%, respectively. In 28 (11.2%) individuals, at least 1 additional polyp was found with the TER. In 8 (3.2%) patients, the polyp detected with the TER was the only one found. Every polyp that was detected with the TER was subsequently located with the colonoscope and removed. For all polyps and for adenomas, the additional detection rates for the TER were 9.7%/4.1% in the left colon (the splenic flexure to the rectum) and 16.5%/14.9% in the right colon (the cecum to the transverse colon), respectively.There was no randomization or comparison with a separate control group.A retrograde-viewing device revealed areas that were hidden from the forward-viewing colonoscope and allowed detection of 13.2% additional polyps, including 11.0% additional adenomas. Additional detection rates with the TER for adenomas 6 mm or larger and 10 mm or larger were 25.0% and 33.3%, respectively. (NCT00657371.).

Background Video capsule endoscopy has been shown to be the single most effective endoscopic procedure for identifying the source of obscure GI bleeding (OGIB). Objective Our purpose was to report on the Food and Drug Administration pivotal trial in which the Endocapsule (EC) (Olympus America, Allentown, Pa) was compared with the Pillcam SB (PSB) (Given Imaging, Yoqneam, Israel) in patients with OGIB. Design A novel trial design was used in which the EC and the PSB were swallowed by the same patient 40 minutes apart, in randomized order. Setting Four academic medical centers. Patients Patients with OGIB aged 18 to 85 years who had either been transfused or who had a hematocrit of Interventions Both video capsules were swallowed in random order. Videos from the PSB were read locally for patient management. All videos were then read by at least 2 independent readers for normal versus abnormal categorization, a diagnosis, capsule transit time, reading time, and a subjective assessment of image quality. Main Outcome Measurement Categorization of videos as either normal or abnormal. Results Data from 51 of 63 enrolled patients were analyzed. Nine patients were excluded for technical reasons and 3 for protocol violations. Twenty-four videos were read as normal and 14 as abnormal from both capsules. Disagreement occurred in 13. No adverse events were reported for either capsule. Overall agreement was 38 of 51 (74.5%) with a κ of 0.48, P = .008. Limitations Although ingestion order was randomized, the videos could not be read blind owing to a different shape of the image margin. Conclusions (1) Both devices were safe and had a comparable diagnostic yield within the range previously reported. (2) There was a subjective difference in image quality favoring the EC. (3) This study design provided unique information about capsule movement in the small intestine and the lack of electromechanical interference between 2 different capsules.

Background Retention of the video capsule is the most significant complication associated with capsule endoscopy (CE). There are limited data on incidence, risk factors, and outcomes of capsule retention. Objective We aimed to determine the incidence of capsule retention and to investigate the causes and clinical outcomes of capsule retention. Setting Single tertiary referral medical center. Patients All patients who underwent CE for suspected small bowel disease from June 2002 to March 2006. Methods Retrospective case series. Results Capsule retention occurred in 1.4% of our patients (14/1000). Eleven patients failed to pass the capsule because of nonsteroidal anti-inflammatory drug (NSAID) enteropathy (diaphragm disease). One patient had capsule retention from an obstructing carcinoid tumor. Metastatic ovarian cancer with invasion of the ileum was the cause of retention in another patient. One patient who did not have surgical removal of the capsule because of loss of follow-up had retention caused by a small-bowel tumor suspicious for carcinoid tumor on CT enterography. All patients remained "asymptomatic" from the retained capsules. Thirteen patients underwent elective partial small-bowel resection and capsule removal. No deaths were associated with these surgeries. Eleven patients recovered promptly, whereas 2 patients had mild postoperative ileus. Limitation Retrospective study. Conclusion Retention of the capsule endoscope appears to be infrequent. The most common cause is diaphragm disease resulting from NSAIDs in this study population. In most cases, capsule retention is asymptomatic, and it usually leads to surgical removal, which appears safe and also identifies and treats the underlying small-bowel condition.

Background Many factors impacting cecal intubation rates have been examined in detail; however, little information exists regarding the effect of the timing of the procedure. We sought to examine any difference in cecal intubation rates between morning and afternoon colonoscopies and identify factors contributing to a discrepancy. Methods Retrospective, single-center study comparing cecal intubation rates for colonoscopies performed in the morning (begun prior to 12 noon) and colonoscopies performed in the afternoon (begun after 12 noon) over an approximately 12 month period. Univariate and multivariate analyses were performed evaluating patient demographics, procedure indication(s), endoscopist, bowel preparation type and quality, and participation by a gastroenterology fellow. Results 6087 colonoscopies were evaluated in this study. Colonoscopies (n = 3729) performed in the morning were compared to colonoscopies performed in the afternoon (n = 2358). The crude completion rate to the cecum was 95.0% in the morning group while the completion rate to the cecum was 93.6% of the afternoon exams (p = 0.02). The morning colonoscopies had better bowel preparation quality (p < 0.001). The multivariate analyses demonstrated that gender, age, and bowel preparation quality impacted completion rates. After correcting for these factors, there was no significant difference in completion rates in the morning versus afternoon. Conclusion Uncorrected cecal intubation rates were lower in the afternoon compared to the morning in outpatients undergoing colonoscopy. Bowel preparation quality was worse in the afternoon compared with the morning. Efforts at improving afternoon bowel preparation may improve the outcome of afternoon colonoscopies.