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A double-duct sign is the combined dilatation of the common bile duct and pancreatic duct, often caused by cancer of the pancreas. We present a patient with colicky pain in the right upper quadrant of her abdomen. On radiological imaging and endosonography, she had a double-duct sign due to choledocholithiasis and no mass in the pancreatic head. A literature search was performed, which indicated that in selected patients with a higher likelihood of pancreas cancer (for example jaundice or pancreatic mass on radiological imaging) up to 85% of patients do indeed have a pancreatic cancer. In an unselected population, regardless of presenting symptoms, a double-duct sign on endoscopic retrograde cholangiopancreatography (ERCP) was caused by a pancreas malignancy in 58% of patients. In selected patients without jaundice but with a double duct sign, pancreas cancer was only seen in 6% of patients. The sensitivity and specificity of the double-duct sign observed by ERCP for pancreatic cancer varies between 50-76% and 63-80%, respectively. Our patient with symptomatic choledocholithiasis underwent an uncomplicated ERCP with stone extraction and papillotomy and was referred for a cholecystectomy.

The aim of this study was to evaluate the effect of dietician-delivered intensive nutritional support (INS) on postoperative outcome in patients with esophageal cancer. Approximately 50-80% of patients with esophageal cancer are malnourished at the time of diagnosis. Malnutrition enhances the risk of postoperative complications, resulting in delay of postoperative recovery and impairment of quality of life. Sixty-five patients with esophageal cancer were included. All patients who received surgery (n = 28) in the time frame between March 2009 and April 2010, the first year after the start of INS, were included in the INS intervention group. The control group (n = 37) consisted of patients who received surgery during the 3 years before the start of INS. Logistic regression analysis was used to compare differences in severity of postoperative complications using the Dindo classification. Linear regression was applied to evaluate differences in preoperative weight change. The adjusted odds ratio for developing serious complications after surgery of INS compared with the control group was 0.23 (95% confidence interval: 0.053-0.97; P = 0.045). Benefit was mainly observed in patients who received neoadjuvant therapy before esophagectomy (n = 35). The INS program furthermore resulted in a relative preoperative weight gain in comparison with the control group of +4.8% (P = 0.009, adjusted) in these neoadjuvant-treated patients. This study shows that dietician-delivered INS preserves preoperative weight and decreases severe postoperative complications in patients with esophageal cancer., (© 2012 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus.)

Goals and Background: Discriminating between patients with nonresponsive but otherwise uncomplicated celiac disease (CD) and patients with refractory celiac disease (RCD) and/or lymphoma is difficult, especially as many abnormalities encountered in complicated CD are not within reach of conventional gastroduodenoscopy. We aimed to describe video capsule endoscopy (VCE) findings in patients with CD and persisting or relapsing symptoms despite a gluten-free diet and to identify VCE findings associated with poor prognosis., Methods: We retrospectively analyzed 48 VCE studies performed in adult patients with CD because of persisting or relapsing symptoms despite adherence to a gluten-free diet. Patients with either uncomplicated CD or RCD type I were considered to have a good prognosis, whereas patients with either RCD type II or enteropathy-associated T-cell lymphoma were considered to have a poor prognosis. Multivariate analysis was performed to identify VCE findings independently associated with either good or poor prognosis., Results: Proximal focal erythema (odds ratio, 6.7; 95% confidence interval, 1.2-38.7; P=0.033) and absence of progression of the capsule to the distal intestine (odds ratio, 16.5; 95% confidence interval, 1.2-224.9; P=0.035) were independently associated with poor prognosis. Of the 28 patients with none of these 2 features, none died during follow-up, compared with 2 (13.3%) of the 15 patients with one of both features, and 4 (80.0%) of the 5 patients with both the features., Conclusions: VCE is a minimally invasive endoscopic modality that could be of use in identifying patients with nonresponsive CD who are at risk of poor prognosis.

Purpose: To evaluate the diagnostic accuracy of MR enteroclysis and to compare it to video capsule endoscopy (VCE) in the analysis of suspected small-bowel disease., Methods: We performed a retrospective analysis of 77 patients who underwent both MR enteroclysis and VCE and compared the findings of these studies with the findings of enteroscopy, surgery, or with the results of clinical follow-up lasting ≥2 years., Results: Findings included malignant neoplasms (n = 13), benign neoplasms (n = 10), refractory celiac disease (n = 4), Crohn's disease (n = 2) and miscellaneous conditions (n = 10). Specificity of MR enteroclysis was higher than that of VCE (0.97 vs. 0.84, P = 0.047), whereas sensitivity was similar (0.79 vs. 0.74, P = 0.591). In 2/32 (6.3%) patients with both negative VCE and negative MR enteroclysis a positive diagnosis was established, compared to 5/11 (45.5%) patients in whom VCE was positive and MR enteroclysis was negative (likelihood ratio 8.1; P = 0.004), 9/11 (81.8%) patients in whom MR enteroclysis was positive and VCE was negative (likelihood ratio 23.5; P < 0.0001), and all 23 patients in whom both VCE and MR enteroclysis showed abnormalities (likelihood ratio 60.8; P < 0.0001)., Conclusions: VCE and MR enteroclysis are complementary modalities. In our study-population, MR enteroclysis was more specific than VCE, while both produced the same sensitivity.

Background and Aim: Little is known about the causes of overt obscure gastrointestinal bleeding (OGIB) in patients using anti-thrombotic therapy. We aimed to describe video capsule endoscopy (VCE) findings and to identify factors associated with positive findings in these patients., Methods: We carried out a retrospective study of 56 patients who underwent VCE for evaluation of previous overt OGIB during anti-thrombotic therapy. VCE studies were re-evaluated by a gastroenterologist blinded to clinical details. Clinical data included in the multivariate analysis were sex, age, indication for and type of anti-thrombotic therapy, hemodynamic instability on admission, type of blood loss, hemoglobin on admission, use of a proton pump inhibitor, NSAID use, time between bleeding episodes and VCE, and whether or not anti-thrombotic therapy was resumed before the VCE study., Results: A probable cause for gastrointestinal bleeding was identified in 28 (50%) of the 56 studies. Angiodysplasia was found in 19 patients. Twenty-two studies showed a possible cause in the small bowel. Multivariate logistic regression analysis showed that reinstitution of anti-thrombotic therapy before VCE was carried out was the only independent predictor of positive VCE findings (OR: 8.61, 95% CI: 1.20-60.42, P=0.032)., Conclusions: Small intestinal angiodysplasia was the most common cause for overt OGIB. Reinstitution of withdrawn anti-thrombotic drugs before the VCE examination was carried out was associated with positive VCE findings in multivariate analysis., (© 2011 The Authors. Digestive Endoscopy © 2011 Japan Gastroenterological Endoscopy Society.)

Background and Study Aims: Inadequate bowel preparation negatively influences the reliability of examinations by video capsule endoscopy (VCE). Currently, only subjective scales are available to describe mucosal visibility. We aimed to design a score that was derived directly from the VCE images., Patients and Methods: A computed assessment of cleansing score was developed based on color intensities of the tissue color bar. The feasibility of this score was retrospectively tested in 24 VCE studies. A prospective study was conducted using 40 VCE segments from 10 consecutive VCE studies. The computed scores were compared with three existing methods of assessing small-intestinal cleansing. Correlations between the existing scoring systems and the computed score were evaluated using the intraclass correlation coefficient and Spearman's rho correlation., Results: All computed measurements were obtained twice and resulted in exactly the same results. Both overall and segmental mucosal visibility could be assessed. The computed score and the 10-point quantitative index were significantly associated for both readers (Spearman's rho: 0.68 and 0.75, respectively; P < 0.001). The intraclass correlation coefficient for the 4-point qualitative evaluation and the computed score was 0.67 for reader 1 and 0.64 for reader 2. For reader 1, the mean computed score for segments assessed as either inadequately or adequately cleansed was 5.0 and 6.4 ( P = 0.001). For reader 2 these values were 4.0 and 6.3, respectively ( P = 0.005)., Conclusions: A computed assessment of small-bowel mucosal visibility based on the ratio of color intensities of the red and green channel of the tissue color bar is feasible and more reproducible than existing subjective scales. Such a computed scale could be integrated into VCE reading software. For this novel scoring system we propose the term Computed Assessment of Cleansing (CAC) score., (© Georg Thieme Verlag KG Stuttgart · New York.)

Purpose: To determine magnetic resonance (MR) enteroclysis findings in patients with uncomplicated celiac disease (CD), refractory CD (RCD) type I, and RCD type II, to develop and validate a scoring system to identify patients with RCD II and to determine the diagnostic accuracy of MR enteroclysis to detect CD-related malignancies., Materials and Methods: This study was performed with approval of the institutional review board. One radiologist blinded to clinical details retrospectively evaluated quantitative and qualitative criteria of 28 studies obtained in symptomatic patients with CD (uncomplicated CD, n = 10; RCD I, n = 8; RCD II, n = 10). A scoring system was developed by using parameters identified in multivariate analysis to be associated with RCD II, which two radiologists evaluated in a second group of 40 symptomatic patients with CD. Accuracy to detect malignancy was assessed in the total study group. Cumulative survival was evaluated in the total study group by using the Kaplan-Meier method., Results: MR enteroclysis could not be used to discriminate between uncomplicated CD and RCD I. The presence of less than 10 folds per 5 cm jejunum, mesenteric fat infiltration, and bowel wall thickening were associated with RCD II. A positive MR score was defined as the presence of two or more of these features. In the validation group, the MR score was positive in 13 of 15 patients with RCD II (sensitivity, 0.87) and negative in 24 of 25 patients without RCD II (specificity, 0.96). The 5-year survival rate was 95% in patients with a negative MR score and 56% in patients with a positive MR score (P < .0001). MR enteroclysis helped to identify the presence of seven of eight malignancies and to diagnose absence of malignancy in 58 of 60 studies., Conclusion: MR enteroclysis can be used to investigate the presence of RCD II or malignancy in symptomatic patients with CD., (© RSNA, 2011.)

Gallstone ileus is an uncommon cause of small bowel obstruction, affecting mainly elderly patients. We report a case of gallstone ileus in an 88-year old female patient. The correlation between computed tomography, double-balloon enteroscopy and intra-operative findings is discussed, as well as treatment strategies.

Background and Aims: Capsule endoscopy is applicable to several clinical conditions, but obscure gastrointestinal bleeding remains the main indication. This study aims at determining the diagnostic yield of capsule endoscopy for obscure gastrointestinal bleeding using a structured terminology in a large cohort in an academic hospital., Methods: In this retrospective study, 592 capsule endoscopy procedures performed in a tertiary hospital were analysed using the Capsule Endoscopy Structural Terminology. Main indications were gastrointestinal bleeding (n=142) and iron deficiency anaemia (n=240)., Results: Capsule endoscopy identified abnormalities in 44% of patients with iron deficiency anaemia and in 58% of patients with gastrointestinal bleeding, resulting in a diagnostic yield of 49% for obscure gastrointestinal bleeding. In 32 patients the cause was found in the stomach and in 8 in the colon., Conclusion: Capsule endoscopy evidenced a diagnostic yield of 49% for obscure gastrointestinal bleeding. Repeating endoscopy before capsule endoscopy should be considered since a reasonable proportion of lesions were found outside the small intestine.

Objective: To summarise available evidence on diagnostic tests that might help primary care physicians to identify patients with an increased risk for colorectal cancer among those consulting for non-acute lower abdominal symptoms., Data Sources: PubMed, Embase, and reference screening. Study eligibility criteria Studies were selected if the design was a diagnostic study; the patients were adults consulting because of non-acute lower abdominal symptoms; tests included signs, symptoms, blood tests, or faecal tests. Study appraisal and synthesis methods Two reviewers independently assessed quality with a modified version of the QUADAS tool and extracted data. We present diagnostic two by two tables and pooled estimates of sensitivity and specificity. We refrained from pooling when there was considerable clinical or statistical heterogeneity., Results: 47 primary diagnostic studies were included. Sensitivity was consistently high for age >or=50 (range 0.81-0.96, median 0.91), a referral guideline (0.80-0.94, 0.92), and immunochemical faeces tests (0.70-1.00, 0.95). Of these, only specificity of the faeces tests was good. Specificity was consistently high for family history (0.75-0.98, 0.91), weight loss (0.72-0.96, 0.89), and iron deficiency anaemia (0.83-0.95, 0.92), but all tests lacked sensitivity. None of these six tests was (sufficiently) studied in primary care., Conclusions: Although combinations of symptom and results of immunochemical faeces tests showed good diagnostic performance for colorectal cancer, evidence from primary care is lacking. High quality studies on their role in the diagnostic investigation of colorectal cancer in primary care are urgently needed.

Background: Capsule retention in the small bowel is a known complication of small-bowel video capsule endoscopy. Surgery is the most frequently used method of capsule retrieval., Objective: To determine the incidence and causes of capsule retention and to describe double-balloon endoscopy (DBE) as the primary technique used for capsule retrieval., Design: Retrospective analysis of all video capsule studies was performed at our center, and evaluation of the outcome of DBE was the first method used to retrieve entrapped video capsules., Setting: Tertiary referral center., Patients: A total of 904 patients who underwent small-bowel video capsule endoscopy., Interventions: Capsule retrieval by DBE., Main Outcome Measurements: The number of patients in whom capsule retention occurred and the number of patients in whom an entrapped capsule could be retrieved by using DBE., Results: Capsule retention occurred in 8 patients (incidence 0.88%; 95% CI, 0.41%-1.80%) and caused acute small-bowel obstruction in 6 patients. All retained capsules were successfully removed during DBE. Five patients underwent elective surgery to treat the underlying cause of capsule retention. One patient required emergency surgery because of multiple small-bowel perforations., Limitations: Retrospective design., Conclusions: In our series, the incidence of capsule retention was low. DBE is a reliable method for removing retained capsules and might prevent unnecessary surgery. If surgery is required, preoperative capsule retrieval allows preoperative diagnosis, adequate staging in case of malignancy, and optimal surgical planning., (2010 American Society for Gastrointestinal Endoscopy. Published by Mosby, Inc. All rights reserved.)

Purpose: To evaluate the diagnostic accuracy and interobserver variance of magnetic resonance (MR) enteroclysis in the diagnosis of small-bowel neoplasms, with small-bowel endoscopy, surgery, histopathologic analysis, and follow-up serving as standards of reference, and to identify MR enteroclysis characteristics capable of enabling discrimination between benign and malignant small-bowel neoplasms., Materials and Methods: This study was performed in accordance with the guidelines of the institutional review board, and the requirement for informed consent was waived. MR enteroclysis studies of 91 patients (43 women, 48 men; age range, 18-83 years) were retrospectively evaluated by two radiologists blinded to clinical details. Only studies explicitly performed to investigate or exclude the presence of small-bowel neoplasms were included. Radiologic findings were compared with findings of double-balloon endoscopy (n = 45), surgery (n = 18), esophagogastroduodenoscopy (n = 3), ileocolonoscopy (n = 2), autopsy (n = 2), and clinical follow-up for more than 18 months (n = 21). Efficacy parameters were calculated with 95% confidence intervals. Tumor characteristics were compared with the Student t test and the Fisher exact test., Results: Readers 1 and 2 interpreted 31 and 33 studies, respectively, as depicting a small-bowel neoplasm and 19 and 17 studies, respectively, as depicting small-bowel malignancy. In 32 patients, the presence of small-bowel neoplasm was confirmed. In 19 of these patients, the neoplasm was malignant. Sensitivity and specificity in the diagnosis of small-bowel neoplasms was 0.91 and 0.95, respectively, for reader 1 and 0.94 and 0.97, respectively, for reader 2; the kappa value was 0.95. Factors associated with malignancy were the presence of longer solitary nonpedunculated lesions, mesenteric fat infiltration, and enlarged mesenteric lymph nodes., Conclusion: Eighty-six of 91 studies were correctly interpreted, resulting in an overall diagnostic accuracy of 0.95 for MR enteroclysis in the detection of small-bowel neoplasms., Supplemental Material: http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.09090828/-/DC1., ((c) RSNA, 2010)

Recently the incidence of oesophageal carcinoma has increased predominantly due to a rise in the incidence of adenocarcinoma. A relationship with the increasing prevalence of Barrett's oesophagus plays an important role. Diagnosis and staging should include oesophago-gastro-duodenoscopy, transoesophageal endo-echography and computer tomography. A higher sensitivity and specificity for distant metastases may possibly be achieved by adding positron emission tomography. In patients with adenocarcinoma neoadjuvant chemoradiotherapy followed by surgery has been associated with better survival. This effect is less convincing in squamous cell carcinomas. Distal and gastro-oesophageal tumours are particularly suitable for a transhiatal approach. Intrathoracic tumours are suitable for a transthoracic resection. There is no difference in survival after the transhiatal or the transthoracic approach, despite the less extensive lymph node dissection in the transhiatal procedure. Minimally invasive oesophagectomy seems to be associated with a lower morbidity and a shorter hospital stay. Randomized trials are needed to substantiate these results.

The field of radiological small bowel imaging is changing rapidly, as is small bowel enteroscopy. New techniques allow the depiction of intraluminal, mural, and extraintestinal features of various small bowel disorders, such as Crohn disease, small bowel polyposis syndromes, small intestinal malignancies, and celiac disease. For patients requiring repeated small bowel imaging, modalities that do not use ionizing radiation, such as ultrasound or magnetic resonance imaging, should be considered.

We describe initial experience with the use of a new fixation method (Wiesbaden rein), which has been developed to prevent dislodgement of feeding tubes in the gastrointestinal tract. The Wiesbaden rein has been used in three patients without complication. In none of the patients was dislodgement or malfunction of the feeding tube observed. Therefore, the use of the Wiesbaden rein might prevent dislodgement of feeding tubes. Clinical trials are required before this new method can be recommended for general use.

Aim: To perform a single-center analysis of all double balloon endoscopy (DBE) related cases of pancreatitis identified prospectively from a recorded DBE-complication database., Methods: From November 2003 until January 2007, 603 DBE procedures were performed on 412 patients, with data on complications recorded in a database. The setting was a tertiary care center offering DBE. DBE was performed from the antegrade or retrograde route. Outcome measurements included age, gender, medication, indication, DBE-endoscope type, insertion depth, procedure duration, findings, interventions, post-procedural abdominal pain, and post-procedural hospitalization., Results: This is the largest single-center study reporting on post-DBE pancreatitis prospectively. Six patients (1.0%) developed post-DBE pancreatitis, all after antegrade DBE. There was no association with gender, duration of the procedure or type of endoscope. The mean age was 51.9 years (range 25-78). Four patients had severe pancreatitis. Of these, two had inflammatory signs in the body-tail region, one had pancreatitis in the tail region, and the total pancreas was involved in one., Conclusion: The incidence of post-DBE pancreatitis in our series is higher than previously reported. We found no relation with DBE-endoscope type. The inflammatory changes occurred in the body-tail region of the pancreas, suggesting that post-DBE pancreatitis is caused by repetitive mechanical strain on the pancreas.