Introduction

​Routine mucosal sampling from pre-defined anatomical sites is recommended during pediatric upper gastrointestinal endoscopy regardless of macroscopic appearance, but evidence for this recommendation remains limited. We investigated this issue in a large and well-defined patient cohort.

Aims & Methods

Concordances between endoscopic and histologic findings and their association to the diagnosis after the first endoscopy was studied in 1181 consecutive children undergoing endoscopy with systematic biopsy sampling during years 2007-2014. Furthermore, the associations between endoscopic and histologic findings and a gastrointestinal diagnosis received during follow-up up to 11 years were studied.

Results

Systematic sampling was conducted in 98.4% of the children in esophagus, 99.3% in stomach, and 98.8% in duodenum. Any endoscopic findings were reported in 51.7% and histologic abnormalities in 59.3% of the children. The Cohen’s k coefficient between endoscopic and histologic findings was 0.272 overall, 0.190 in esophagus, 0.148 in stomach, and 0.520 in duodenum. The most common diagnoses were celiac disease (26.0%), inflammatory bowel disease (11.2%) and gastroesophageal reflux disease (5.2%). Significant association between endoscopic abnormalities and presence of a diagnosis was seen in any endoscopic site and in duodenum, but not in esophagus or stomach, while histologic abnormalities associated with a diagnosis in each biopsy location (Table 1.). Histologic abnormalities were seen in 146 (25.4%) children without diagnosis at the first endoscopy, the most common being chronic inactive gastritis (7.5%) and mild chronic esophagitis (5.8%). Furthermore, in patients without initial diagnosis histologic abnormalities were associated with a follow-up diagnosis (odds ratio 2.59, 95% confidence interval 1.40-4.79), whereas endoscopic abnormalities did not (OR 0.61, 95% CI 0.31-1.18).

Conclusion

The low concordance between endoscopic and histologic findings supports systematic biopsy sampling in pediatric upper gastrointestinal endoscopy. Histologic findings are strongly associated with initial gastrointestinal diagnosis and to a lesser extent with a follow-up diagnosis.

Disclosure

Author has no conflict of intrest

Introduction

The increasing accessibility of upper gastrointestinal endoscopy has led to a rise in its prescription. However, its overuse and inappropriate indications result in environmental and economic costs, potential iatrogenesis, and a paradoxical reduction in access. This study aims to assess the indications for elective diagnostic upper gastrointestinal endoscopy (UGE) requested in the hospital setting.

Aims & Methods

A retrospective analysis was conducted on elective diagnostic UGE requests from both outpatient and inpatient settings. The appropriateness of the requests was classified according to the recommendations of the American Society for Gastrointestinal Endoscopy and the European Society of Gastrointestinal Endoscopy.

Results

A total of 314 requests were analyzed over a three-month period: 90.8% (n=285) from outpatient consultations and 7.6% (n=24) from inpatient settings. A previous UGE had been performed in 53.8% (n=169) of patients, with an average interval of 27.13 ± 2.12 months between requests. Overall, 59.6% (n=187) of the requests were deemed appropriate, with the most frequent indications being the need for biopsies (15%, n=28), gastrointestinal bleeding or anemia (14.4%, n=27), and post-endoscopic intervention surveillance (10.7%, n=20).
Clinical information indicated the presence of alarm symptoms in 27.7% (n=87) cases, the most frequent being gastrointestinal bleeding or anemia (33.3%, n=29), age >50 years with new-onset symptoms or suspected structural disease (21.8%, n=19), and progressive dysphagia (17.2%, n=15). Conversely, 40.4% (n=127) of requests were considered inappropriate, mainly due to non-compliance with guidelines and surveillance intervals. The most common inappropriate indications included symptoms attributed to disorders of the gut-brain axis (20.5%, n=26), surveillance of atrophic gastritis, fundic gland polyps, hyperplastic polyps, and gastric intestinal metaplasia (11.8%, n=15), as well as post-gastric surgery surveillance for benign conditions in asymptomatic patients (8.7%, n=11). Additionally, 39 (28.3%) UGEs were requested for gastric cancer screening.

Conclusion

This study identified a significant proportion of UGE requests lacking appropriate and timely indications. These findings emphasize the need for well-defined criteria to ensure the rational and optimized use of this resource.

Introduction

The timing of performing upper gastrointestinal endoscopy(EGD) in patients with acute upper GI bleeding remains controversial. Different recommendations exist regarding the ideal time interval between the first clinical presentation of acute upper GI bleeding and EGD, assuming no postponement before patient arrival at the hospital. While it is generally agreed that upper gastrointestinal endoscopy should be performed within 24 hours of the first clinical presentation of acute upper GI bleeding, this recommendation poses a significant challenge for medical staff during weekends and healthcare centres with fewer resources than major hospitals.

Aims & Methods

This study was conducted at the Department of Internal Medicine, Gastroenterology Division, at Aleppo University Hospital between July 2018 and June 2020. The study included patients who were admitted due to acute upper gastrointestinal bleeding. The clinical manifestation of upper gastrointestinal bleeding, its duration, and the interval between the first upper gastrointestinal bleeding and the GI endoscopy were determined. Patients were divided into three groups: Group I underwent urgent endoscopy within less than 24 hours of the first bleeding; Group II underwent endoscopy between 24 and 72 hours from the first bleeding; and Group III underwent endoscopy after 72 hours or more of bleeding.

Results

234 patients were included in the study who were admitted to the hospital and underwent upper gastrointestinal endoscopy. Among them, 58.55% were male and 41.45% were female. The average age of the patients was 57.15.
The most common manifestation of acute upper gastrointestinal bleeding was melena, which was observed in 67.59% of cases, followed by hematemesis (52.99%) and epigastric pain (30.34%). The rate of normal esophageal endoscopy findings was 40% in the first group, 54.84% in the second group, and 64.4% in the third group. Hiatal hernia was observed in 30.77% of patients in the first group, 29.03% in the second group, and 28.89% in the third group. Reflux esophagitis was diagnosed in 10.77% of patients in the first group, 10.48% in the second group, and 20% in the third group. Esophageal varices were diagnosed in 10.77% of patients in the first group, 9.68% in the second group, and 13.33% in the third group.
There was no statistically significant difference in the rates of esophageal endoscopy findings among the study groups, except for the presence of blood-filled esophagus, which was significantly more common in the first group (P < 0.05). The highest rate of normal findings in upper gastrointestinal endoscopy was observed in the third group, which was statistically significant (P < 0.05). Blood in the stomach and erosive gastritis were most frequently observed in the first group, with a statistically significant difference in their favor.
The rates of observing gastric ulcers, gastric erosions, hypertensive gastropathy, gastric varices, gastric tumors, portal hypertensive gastropathy, and diffuse mucosal bleeding were similar among the three study groups without a significant statistical difference . The upper gastrointestinal endoscopy was normal in the duodenum in the highest percentage among patients in group three, with a statistically significant difference (P < 0.05). Blood in the duodenum and duodenal edema were observed with the highest rate in patients of the first group with a statistically significant difference compared to the other two groups (P < 0.05). The evaluation of the duodenum among patients of the first group could not be achieved with a higher rate compared to the other two groups, and the statistical difference was significant.
The percentage of observing esophageal ulcers, esophageal biopsies, adherent thrombus, and vascular distortion were similar among the three groups without a significant statistical difference (P > 0.05). The cause of bleeding was identified with certainty by visualizing the bleeding lesion in 32.31% of patients in the first group, 9.68% of patients in the second group, and 4.44% of patients in the third group. There was a statistically significant difference between the groups in favor of the first group.

Conclusion

Our research revealed no significant variance in endoscopic results in patients who underwent endoscopy at distinct time intervals. However, performing early endoscopy, within 24 hours of the first clinical presentation of acute upper GI bleeding, had a higher incidence of detecting the bleeding lesion and identifying the cause of bleeding in comparison to delayed endoscopy. Our study emphasizes the significance of early endoscopy in patients with acute upper GI bleeding to enhance the possibility of identifying the cause of bleeding and administering timely interventions to minimize complications and mortality.

References

1. Acute upper gastrointestinal bleeding: management. London: National Institute for Health and Clinical Excellence: Guidance; 2012.
2. Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2010;152(2): 101e13.
3. Gralnek IM, Dumonceau JM, Kuipers EJ, Lanas A, Sanders DS, Kurien M, et al. Diagnosis and management of nonvariceal upper gastrointestinal hemorrhage: European society of gastrointestinal endoscopy (ESGE) guideline. Endoscopy 2015;47(10):a1e46.
4. Hwang JH, Fisher DA, Ben-Menachem T, Chandrasekhara V, Chathadi K, Decker GA, et al. The role of endoscopy in the management of acute nonvariceal upper GI bleeding. Gastrointest Endosc 2012;75(6):1132e8
5. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012;107(3):345e60. quiz 61. 6 Stanley AJ, Ashley D, Dalton HR, Mowat C, Gaya DR, Thompson E, et al. Outpatient management of patients with low-risk upper-gastrointestinal hemorrhage: multicenter validation and prospective evaluation. Lancet 2009;373(9657):42e7

Introduction

Capsule endoscopy (CE) is an important non-invasive diagnostic modality for the evaluation of small bowel and colon. However, in patients with gastrointestinal tract anatomy altered by surgical interventions, there can be a higher risk of incomplete examination of small bowel and colon.

Aims & Methods

The aim of our study was to evaluate the rate of complete examination and diagnostic yield of CE, in patients with previous gastrointestinal surgery, as well as the impact of endoscopic placement of CE using the AdvanCE device.
Retrospective, cohort study, including patients submitted to CE of the small bowel or colon, detailing patients with previous gastrointestinal surgeries and with endoscopic placement of CE.

Results

A total of 642 patients was included, 17 with previous gastrointestinal surgery (2.6%), from which 9 with gastric bypass and Y-de-Roux (with 3 having esophagojejunostomy and 6 gastrojejunostomy), 3 patients with Bilroth II, 2 with Bilroth I e 3 patients with sleeve gastrectomy.
Endoscopic placement of CE was performed at the discretion of the responsible gastroenterologist and occurred in 8 patients (1.2%). It was 13.3 times more likely to be performed in patients with previous gastrointestinal surgery (11.8% vs 1.0%, p=0.017).
In patients without endoscopic placement of CE, the rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was comparable between those with and without previous gastrointestinal surgery: 86.7% vs 85.3% (p=1.000), 73.3% vs 78.1% (p=0.751) e 40% vs 38% (p=0.875), respectively.
In patients with gastrointestinal surgery, the rate of complete examination of the gastrointestinal tract was comparable between patients with and without endoscopic placement of CE: 50.0% vs 86.7% (p=0.331). The rate of complete examination of the gastrointestinal tract, adequate bowel preparation and diagnostic yield was not influenced by the different types of surgery, considering patients with gastric bypass vs Y-de-Roux vs Bilroth II: 75.0% vs 80.0% vs 66.7% (p=0.915), 50.0% vs 60.0% vs 66.7% (p=0.902) e 25.0% vs 20.0% vs 66.7% (p=0.363), respectively.

Conclusion

CE is effective, even in patients with previous gastrointestinal surgery, with diagnostic yield and rate of complete examination of the gastrointestinal tract similar to other patients, regardless of the type of surgery. Endoscopic placement of CE with AdvanCE device does not seem to improve outcomes in patients with previous gastrointestinal surgery.

Introduction

Appropriate tissue sampling is vital for lesion diagnosis during endoscopy. We have previously found an association between higher biopsy rates and reduced compliance with national biopsy recommendations (e.g. from ulcers) with higher rates of post endoscopy upper gastrointestinal cancers (PEUGIC).

Aims & Methods

The aim of this study was to examine biopsy practice in the UK, along with comparing results to the recommendations set out by the European Society of Gastrointestinal Endoscopy.

Upper gastrointestinal (UGI) endoscopies between 01/01/2019 and 29/02/2020 were analysed from the National Endoscopy Database (NED). Surveillance endoscopies were excluded. Logistic regression analysis examined associations with biopsy rate, biopsies from gastritis or duodenitis and biopsies from ulcers.

Results

638,280 UGI endoscopies were analysed. 289,156 (45.3%) involved biopsies: esophagus 17.1%, stomach 18.0%, duodenal bulb (D1) 3.9%, second part of the duodenum (D2) 19.4%.
Biopsy rate was associated with: clinical endoscopists OR 1.31 (95% CI 1.29-1.33) and surgeons OR 0.84 (95% CI 0.90-0.95), compared to gastroenterologists; patient age 70-79 OR 1.12 (95% CI 1.05-1.19); male patients OR 1.07 (CI 95% 1.06-1.08); urgent endoscopy OR 1.38 (CI 95% 1.35-1.39); emergency endoscopy OR 0.37 (95% CI 0.36-0.39); and therapy during endoscopy OR 0.25 (95% CI 0.24-0.27) .

During endoscopy for dysphagia with a normal appearance, only 5232 (36.3%) had biopsies to exclude eosinophilic esophagitis, with usually too few biopsies taken (mean 4.5 (SD±2.0)). When the endoscopic diagnosis was reportedly normal (excluding dysphagic indications), 35% involved potentially unnecessary biopsies (263557 biopsies). Biopsies were commonly taken from uncomplicated inflammatory conditions: 31% of endoscopic gastritis (58765 biopsies) and 31% of endoscopic duodenitis (15580 biopsies). Biopsies for gastritis/duodenitis were associated with surgeons OR 1.36 (95% CI 1.26-1.46) and clinical endoscopists OR 1.38 (95% CI 1.31-1.45), compared to gastroenterologists.

Mean number of biopsies from esophageal ulcers was 3.7 (SD±2.1) and from gastric ulcers 3.8 (SD±2.4).Biopsies of gastric or esophageal ulcers were associated with clinical endoscopists OR 1.51 (95% CI 1.37-1.65) and surgeons OR 0.53 (95% CI 0.50-0.56), compared with gastroenterologists; outpatient procedures OR 1.40 (95% CI 1.27-1.53); and emergency procedures OR 0.66 (95% CI 0.55-0.79).

Conclusion

Analysis of NED reveals a large number of apparently unnecessary biopsies for gastritis or duodenitis or during normal endoscopy. In contrast, in only 36% of normal endoscopies for dysphagia were biopsies taken to rule out eosinophilic esophagitis. Quality improvement efforts are needed to reduce unnecessary biopsies, increase appropriate biopsies, reduce costs and environmental impact.

References

Pouw RE, Barret M, Biermann K, Bisschops R, Czakó L, Gecse KB, de Hertogh G, Hucl T, Iacucci M, Jansen M, Rutter M, Savarino E, Spaander MCW, Schmidt PT, Vieth M, Dinis-Ribeiro M, van Hooft JE. Endoscopic tissue sampling - Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2021 Nov;53(11):1174-1188. doi: 10.1055/a-1611-5091. Epub 2021 Sep 17. PMID: 34535035.

Introduction

Acute upper gastrointestinal (UGI) bleeding is a common medical emergency among the elderly. There is limited data on the management and outcomes of non-variceal UGI bleeding in the elderly in India.

Aims & Methods

We aimed to study clinical presentation, endoscopic findings, and outcomes in elderly patients with acute non-variceal UGI bleeding. All elderly patients (≥ 60 years of age) who presented with acute UGI bleed and were admitted for the same from 2021 to 2022 were retrospectively analysed. Baseline characteristics, blood transfusions before and after endoscopy, endoscopic diagnosis and therapy, AIMS65 score, complete Rockall score, and outcomes such as in-hospital re-bleeding and mortality were recorded.

Results

Of the 399 patients who had acute non-variceal UGI bleed, 309 patients aged <60 years were excluded. Of the 90 patients studied, the mean age of presentation was 69.8 ± 7.35 years, with 81.1% males. The most common presentation was melena (30%). Forty-one (45.5%) patients had a history of antiplatelet and anticoagulant use. The most common endoscopic finding was gastric ulcer (54.4%), followed by duodenal ulcer (22.2%), gastroesophageal junction ulcer (7.7%), Mallory-Weiss tear (6.6%), duodenal diverticular bleed (2.2%). The majority of ulcers were Forrest III (43.3%), followed by Forrest IIa (23.3%) and IIc (18.3%). Around 65% of patients with non-variceal UGI bleeds did not require endotherapy. Dual endotherapy was done in 25.5.5% of patients. Triple endotherapy was done in two patients. AIMS65 score was 1 in 50% of patients and 2 in 24.5% of patients. The majority (81.1%) of patients had a complete Rockall score of 3-7, indicating a moderate risk of re-bleeding and mortality. All the 90 patients were discharged without any mortality.

Conclusion

Our study showed that gastric ulcer was the most common cause of acute non-variceal UGI bleeding in the elderly, and melena was the most common presentation. Early endoscopic therapy may reduce blood transfusion requirements, in-hospital re-bleeding, and mortality.

Introduction

The increasing availability of gastrointestinal (GI) interventions has raised the need to treat luminal defects. Endoscopic suturing (ES) is a minimally invasive technique, used for a wide range of indications.

Aims & Methods

This retrospective cohort study aimed evaluate the performance of ES in treating upper GI defects.Data from a tertiary centre were collected for patients undergoing ES to treat upper GI defects. The primary outcome was technical success, defined as the successful sutures’ deployment. Secondary outcomes included immediate clinical success (confirmation of closure at the time of the procedure), recurrence, long-term outcomes and complications. Descriptive statistics and x² test were used to calculate the rates of the outcomes and assess any link between independent variables and results.

Results

Forty-two procedures were performed on 25 patients between 2018 and 2023. The mean age was 55 (±16.2) years and 56% were female. The technical success rate was 88.1% (37/42) and immediate clinical success 91.9% (34/37), with only two (4.8%) adverse events. The overall recurrence rate was 61.8% (21/34), with a long-term clinical success rate of 69.6% (16/23). Technical success was higher in oesophagus (92.3%), and stomach (100%) (p=0.002), and immediate clinical success was more likely in patients with leak (88.9%) or fistula (95.2%) compared to perforation (50%; p=0.005).

Conclusion

ES demonstrated high rates of technical and immediate clinical success for defect closure in the upper GI tract, with low rates of complications. The benefit is most prominently seen among patients with leaks and fistulas in the stomach and oesophagus.