To assess the accuracy of ultrasound-guided fine-needle aspiration biopsy in the differential diagnosis of gastrointestinal stroma cell tumors (GIST) from other submucosal tumors, using both cytology ...and histology.
We conducted a prospective study from May 2005 to September 2008 in all patients presenting with upper gastrointestinal submucosal tumors. Only patients in whom surgical resection was carried out were included in the final analysis. In cases of mesenchymal tumor, immunocytochemistry was attempted for further differentiation between GIST and non-GIST. Surgical histopathology served as the gold standard.
A total of 47 patients were analyzable, with a final histologic diagnosis of 35 mesenchymal tumors. Sufficient tissue for conventional cytologic diagnosis was obtained only in the 35 patients with mesenchymal tumors; in this subgroup, immunocytochemistry was possible in 46 %. If and only if enough material was available for immunocytochemistry, the sensitivity for (correct recognition of) GIST tumors was 93 %. In all 12 patients with nonmesenchymal tumors and lesions, cytology was nondiagnostic and the diagnosis had to be based on clinical suspicion and the appearance on endoscopy and endoscopic ultrasound (EUS). On an intention-to-diagnose basis, endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) had a positive predictive value for mesenchymal tumors of 100 %, but no value for the diagnosis of other lesions; using immunocytochemistry, a GIST tumor was recognized among the mesenchymal tumors with a sensitivity of 58 % and a specificity of 8 %.
EUS-FNA-based cytology is safe and has only limited value for the differential diagnosis of submucosal tumors, mainly because insufficient material is harvested. Better tissue acquisition techniques are necessary for better differential diagnosis.
The demographic development will lead to a disproportionate increase of older people and to a significant increase of functional gastrointestinal disorders including dysphagia due to motility and ...reflux-related disorders, nausea and vomiting by gastrointestinal dysfunction and abdominal and pelvic pain caused by chronic obstipation, stool impaction and incontinence. This implies significant consequences with regard to the development of weight loss, anorexia, social disadvantages and increased mortality with serious socio-economic burden. Ageing processes are determined by differentiated neurogeneration of the myenteric plexus (cholinergic degeneration) through reactive oxygen and nitrogen species and alteration of protective and regenerative processes. Age-related gastrointestinal dysfunctions may be caused by the ageing gastrointestinal tract itself or by other age-related diseases such as tumour, neurological or inflammatory diseases, anatomic changes, therapeutic medication, polymorbidity or malnutrition. Because of the significant therapeutic options, differential diagnostic work-up is mandatory also in elderly patients.
Push enteroscopy, balloon-guided, and single- and double-balloon enteroscopy (DBE) are now well established techniques in gastrointestinal endoscopy for small-bowel imaging and therapy. There are no ...published prospective studies comparing DBE with spiral enteroscopy and so the aim of the current study was to compare the performance of the two techniques in patients undergoing diagnostic enteroscopy.
Between January and December 2009, 35 patients referred for diagnostic enteroscopy were prospectively assigned to either spiral enteroscopy (n=18) or DBE (n=17). The performance of the two techniques was compared.
The patients were comparable with regard to age, sex, and indication for enteroscopy. Investigation performance, as assessed by time of insertion into the pylorus, the depth of insertion, the duration of the enteroscopy, and the amount of sedoanalgesia required were not significantly different between spiral enteroscopy and DBE. In 40% of the investigations, enteroscopy could detect abnormalities in the intestinal mucosa, in particular inflammatory changes and ulcers and, to a lesser extent, angiodysplasia. No significant difference in pathological findings could be detected between the two groups; however, clinically, diagnostic yield appeared to be higher for DBE (47.1% vs. 33.4%; n.s.).
Although this small study appears to show that DBE has a clinically higher diagnostic yield than spiral enteroscopy, larger studies are needed to confirm this preliminary finding.
Colonoscopy is the accepted gold standard for screening of neoplastic colorectal lesions, but the substantial miss rate remains a challenge. Computed virtual chromoendoscopy with the Fujinon ...intelligent colour enhancement (FICE) system is a new dyeless imaging technique that might allow higher rates of adenoma detection.
This is a prospective randomised five tertiary care centre trial of colonoscopy in the FICE mode versus standard colonoscopy with targeted indigocarmine chromoscopy (control group) in consecutive patients attending for routine colonoscopy. Histopathology of detected lesions was confirmed by evaluation of endoscopic resection or biopsy specimens.
871 patients were enrolled, and 764 patients (344 female, mean age 64 years) were subjected to final analysis (368 in the FICE group, 396 in the control group). In total, 236 adenomas (mean of 0.64 per case) were detected in the FICE group and 271 adenomas (mean of 0.68 per case) in the control group (p = 0.92). There was no statistically significant difference in the percentage of patients with >or=1 adenoma between the control group (35.4%) and the FICE group (35.6%) (p = 1.0). For the differential diagnosis of adenomas and non-neoplastic polyps, the sensitivity of FICE (92.7%) was comparable with that of indigocarmine (90.4%) (p = 0.44).
At colonoscopy, adenoma detection rates are not improved by virtual chromoendoscopy with the FICE system compared with white light endoscopy with targeted indigocarmine spraying. However, FICE can effectively substitute for chromoscopy concerning the differentiation of neoplastic and non-neoplastic lesions.
Irritable bowel syndrome (IBS) is a gut‐brain disorder in which symptoms are shaped by serotonin acting centrally and peripherally. The serotonin transporter gene SLC6A4 has been implicated in IBS ...pathophysiology, but the underlying genetic mechanisms remain unclear. We sequenced the alternative P2 promoter driving intestinal SLC6A4 expression and identified single nucleotide polymorphisms (SNPs) that were associated with IBS in a discovery sample. Identified SNPs built different haplotypes, and the tagging SNP rs2020938 seems to associate with constipation‐predominant IBS (IBS‐C) in females. rs2020938 validation was performed in 1978 additional IBS patients and 6,038 controls from eight countries. Meta‐analysis on data from 2,175 IBS patients and 6,128 controls confirmed the association with female IBS‐C. Expression analyses revealed that the P2 promoter drives SLC6A4 expression primarily in the small intestine. Gene reporter assays showed a functional impact of SNPs in the P2 region. In silico analysis of the polymorphic promoter indicated differential expression regulation. Further follow‐up revealed that the major allele of the tagging SNP rs2020938 correlates with differential SLC6A4 expression in the jejunum and with stool consistency, indicating functional relevance. Our data consolidate rs2020938 as a functional SNP associated with IBS‐C risk in females, underlining the relevance of SLC6A4 in IBS pathogenesis.
Background and aims: Histamine is known as a regulator of gastrointestinal functions, such as gastric acid production, intestinal motility, and mucosal ion secretion. Most of this knowledge has been ...obtained from animal studies. In contrast, in humans, expression and distribution of histamine receptors (HR) within the human gastrointestinal tract are unclear. Methods: We analysed HR expression in human gastrointestinal tissue specimens by quantitative reverse transcription-polymerase chain reaction and immunostaining. Results: We found that H1R, H2R, and H4R mRNA were expressed throughout the gastrointestinal tract, while H3R mRNA was absent. No significant differences in the distribution of HR were found between different anatomical sites (duodenum, ileum, colon, sigma, and rectum). Immunostaining of neurones and nerve fibres revealed that H3R was absent in the human enteric nervous system; however, H1R and H2R were found on ganglion cells of the myenteric plexus. Epithelial cells also expressed H1R, H2R and, to some extent, H4R. Intestinal fibroblasts exclusively expressed H1R while the muscular layers of human intestine stained positive for both H1R and H2R. Immune cells expressed mRNA and protein for H1R, H2R, and low levels of H4R. Analysis of endoscopic biopsies from patients with food allergy and irritable bowel syndrome revealed significantly elevated H1R and H2R mRNA levels compared with controls. Conclusions: We have demonstrated that H1R, H2R and, to some extent, H4R, are expressed in the human gastrointestinal tract, while H3R is absent, and we found that HR expression was altered in patients with gastrointestinal diseases.
Propofol sedation is applied as moderate sedation for almost all diagnostic and interventional endoscopies. Propofol sedation bears the risk of complications such as respiratory as well as ...cardiopulmonary insufficiency including sedation-induced death. According to recent guidelines, non-anesthesiologist-administered propofol (NAAP) should be performed by an additional person who has NAAP as their sole task.
In a prospective multicentre survey involving 191,142 patients, clinically relevant endoscopy-associated complications were registered from 02/2010 to 01/2012.
The majority of propofol sedations were applied without additional persons for NAAP. Overall endoscopy-related complication rate was 0.0022 % (n = 424) and sedation-related complications 0.00 042 % (n = 82). Variability over time and between the clinics was low and not influenced by the number of endoscopies performed during the investigation period. Sedation-related death occurred in 6 patients (0.00 003 %), 50 % during emergency endoscopies. In all sedation-associated deaths the patients had ASA class 3 before endoscopy. All fatal complications occurred in the presence of an additional trained person for NAAP.
This large prospective survey shows that propofol sedation in gastrointestinal endoscopy is a safe procedure with a low potential of risk in daily routine. However, high risk patients (ASA ≥ 3) should be identified, especially before emergency endoscopies and managed by additional persons for NAAP and under intensive care surveillance.
Non cardiac chest pain (NCCP) are recurrent angina pectoris like pain without evidence of coronary heart disease in conventional diagnostic evaluation. The prevalence of NCCP is up to 70 % and may be ...detected in this order at all levels of the medical health care system (general practitioner, emergency department, chest pain unit, coronary care). Reduction of quality of life in NCCP is comparable, partially even higher compared to cardiac chest pain. Reasons for psychological strain are symptom recurrence in app. 50 %, nonspecific diagnosis with resulting uncertainty and insufficient integration of other medical disciplines in diagnostic work-up. Managing of patients with NCCP has to be interdisciplinary because non cardiac causes of chest pain may be found frequently. Especially gastroenterological expertise is required because in 50 - 60 % of cases gastroesophageal reflux disease (GERD), in 15 - 18 % hypercontractile esophageal motility disorders with nutcracker, jackhammer esophagus or distal esophageal spasmus or achalasia and in 32 - 35 % other esophageal alterations (e. g. infectious esophageal inflammation, drug-induced ulcer, rings, webs, eosinophilic esophagitis) as cause of chest pain may be detected. This implicates that regular interdisciplinary round wards and management of chest pain units are mandatory.
Symptoms suspicious of extraesophageal reflux (SSEER) include globus, chronic cough, mucous obstruction and hoarseness. Reports of conventional esophageal function tests and measurement of ...extraesophageal reflux (EER) in these patients are spare providing conflicting results.
In a prospective study we evaluated 60 patients with SSEER by esophageal function tests (esophageal manometry, combined 24 h pH - metry - impedance and oropharyngeal pH measurement, Dx - pH measurement) and esophagogastroduodenoscopy (EGD). The patients were stratified into 2 groups according to their accompanying reflux symptoms. Group 1, n = 23, comprised patients with SSEER solely and group 2, n = 37 patients with SSEER and reflux symptoms. The patients were compared to patients with reflux symptoms solely (group 3, n = 14).
There were no significant differences between the groups according to age, sex and BMI. Patients with SSEER and reflux symptoms (group 2) showed significantly increased proportion of pathological acid reflux, de Meester Score, pH < 4 overall and in upright positon and hypotensive lower esophageal sphincter pressure compared to patients with SSEER solely (group 1) but no significant difference to patients with reflux symptoms solely (group 3). All the other parameters of esophageal testing including non-acid reflux and EER were not significantly different between the three groups.
The results of the present study do not support a causal link between SSEER and esophageal motility disorders, acid or non-acid reflux and EER as measured by conventional esophageal function tests and oropharyngeal pH measurement.
Although colonoscopy is the standard procedure in the diagnosis of colorectal neoplasia, a significant number of clinical relevant lesions may be missed even by experienced endoscopists using current ...technology. A transparent cap mounted at the tip of a colonoscope may be an easy way to extend the visual field during colonoscopy and may improve the detection rate of mucosal lesions.
The significance of cap assisted (CAC) vs. conventional colonoscopy (CC) on polyp detection rate was evaluated in a prospective randomized controlled trial in 504 patients.
CC and CAC detected polyps in 39.3 % and 31.8, not significantly different. There was also no significant difference between CAC and CC according to age, sex, indication for colonoscopy, diverticulosis, sedation, bowel cleansing, withdrawal time, time/number of attempts to intubate the cecal walve, number, localization, size or histology of polyps,. However, the time to reach the cecal floor and the overall time of colonoscopy were significantly lower for CAC (1 minute).
CAC was without clinical impact on polyp detection rate or performance of colonoscopy.
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