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The role and utility of cholangioscopy for diagnosing indeterminate biliary strictures.

Gastrointestinal Intervention.2017;6(1):2-8. doi:10.18528/gii.160035

Biliary strictures are considered indeterminate when evaluation with imaging and standard tissue sampling during endoscopic retrograde cholangiopancreatography (ERCP) are non-diagnostic. Standard tissue sampling techniques include cytologic brushings, with or without fluorescence in situ hybridization (FISH), and endoscopic intraductal biopsies. These strictures are often clinically suspicious for malignancy. The management of these patients can vary substantially and relies on an accurate diagnosis of the lesion. Unfortunately, despite numerous modalities, the sensitivity of existing tissue sampling techniques remains low and can lead to delays in diagnosis and the need for additional procedures. Cholangioscopy has emerged as a means to visually inspect and obtain image-guided biopsies of the lesion in question, with improved sensitivity as well as a high specificity and accuracy for diagnosing the etiology of indeterminate biliary strictures. The types of cholangioscopy systems and a summary of the pertinent literature are discussed in this review.
Bile Duct Diseases ; Biopsy ; Cholangiocarcinoma ; Cholangiopancreatography, Endoscopic Retrograde ; Cholangitis, Sclerosing ; Constriction, Pathologic* ; Diagnosis ; Fluorescence ; Humans ; Image-Guided Biopsy ; In Situ Hybridization ; Sensitivity and Specificity

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Greetings from the Guest Editor.

Jeffrey H LEE

Gastrointestinal Intervention.2017;6(1):1-1. doi:10.18528/gii.17000

No abstract available.

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How to manage gastric polyps.

Gandhi LANKE ; Atin AGARWAL ; Jeffrey H LEE

Gastrointestinal Intervention.2016;5(3):159-169. doi:10.18528/gii.2016.5.3.159

Gastric cancer is the second leading cause of cancer related death in the world. In United States, gastric polyps are found in approximately 6% of upper endoscopy. The incidence of gastric polyps increased with widespread use of esophagogastroduodenoscopy and more liberal use of proton pump inhibitors. They are usually asymptomatic, but infrequently cause symptoms of bleeding, pain and gastric outlet obstruction. It is important to distinguish premalignant conditions and mimickers of malignancy. Helicobacter pylori eradication therapy leads to regression of hyperplastic polyps but it is not clear for adenoma. Endoscopy plays key role not only in diagnosis but also in surveillance. With narrow band imaging and chromo endoscopy, we are much better today in detecting and discerning these. Also, with endoscopic mucosal resection and endoscopic submucosal dissection, we can manage these better. In this review article we will discuss the various diagnostic tools and therapeutic options for hyperplastic polyp, fundic gland polyp, gastrointestinal stromal tumor, adenoma, neuroendocrine tumor, linitis plastica, and intestinal metaplasia.
Adenoma ; Carcinoid Tumor ; Diagnosis ; Endoscopy ; Endoscopy, Digestive System ; Endosonography ; Gastric Outlet Obstruction ; Gastrointestinal Stromal Tumors ; Helicobacter pylori ; Hemorrhage ; Incidence ; Linitis Plastica ; Metaplasia ; Narrow Band Imaging ; Neuroendocrine Tumors ; Polyps* ; Proton Pump Inhibitors ; Stomach Neoplasms ; United States

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Endoscopic intervention for persistent bile leakage after cholecystectomy.

Hong Joo KIM

Gastrointestinal Intervention.2016;5(3):224-225. doi:10.18528/gii160021

SUMMARY OF EVENT: Persistent greenish discharge with abdominal pain and fever were developed in the patient who had undergone laparoscopic cholecystectomy. For the endoscopic treatment of postoperative bile leak, endoscopic biliary sphincterotomy (EBST) with endoscopic retrograde biliary drainage (ERBD) was done and patient's symptoms and persistent discharge via surgical drain were resolved. TEACHING POINT: A high grade bile leak suggests a large defect and EBST alone may be insufficient to allow healing of the defect, and thus, ERBD with or without EBST is proposed as the preferred initial endoscopic treatment.
Abdominal Pain ; Bile* ; Cholecystectomy* ; Cholecystectomy, Laparoscopic ; Drainage ; Fever ; Humans

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Coil occlusion of anal cushions in severe lower gastrointestinal haemorrhage.

Pavan Singh NAJRAN ; Malcom WILSON ; Damian MULLAN

Gastrointestinal Intervention.2016;5(3):221-223. doi:10.18528//gii160004

Coil occlusion of colonic vessels is uncommon due to a risk of colonic ischemia and perforation, and should only be performed as a bridge to emergent surgery. Colonic haemorrhage can occur in haemorrhoidal disease which is managed conservatively in most cases. Endovascular management of haemorrhoids has been described in a non acute setting with effective results and little complications. We present a case of a 46-year-old male admitted with haemorrhage secondary to abnormal vascular rests within the anal cushions, similar to that described in haemorrhoidal disease. Both clinical and endoscopic examination did not identify haemorrhoids; however, catheter angiogram identified ectatic distal rectal arteries with arterial blush demonstrating a haemorrhagic focus. This was subsequently embolised. The patient experienced no ischemic complications or further haemorrhage. Endovascular management in this setting has both a diagnostic and therapeutic benefit allowing rapid effective management of the patient.
Arteries ; Catheters ; Colon ; Humans ; Ischemia ; Male ; Middle Aged

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Development of a new reagent for endoscopic ultrasound-guided celiac plexus neurolysis and tumor ablation therapy.

Kazuo HARA ; Kenji YAMAO ; Nobumasa MIZUNO ; Susumu HIJIOKA ; Hiroshi IMAOKA ; Masahiro TAJIKA ; Tutomu TANAKA ; Makoto ISHIHARA ; Takamitu SATO ; Nozomi OKUNO ; Nobuhiro HIEDA ; Tukasa YOSHIDA ; Niwa YASUMASA

Gastrointestinal Intervention.2016;5(3):216-220. doi:10.18528/gii150025

BACKGROUND: Both endoscopic ultrasound-guided celiac plexus neurolysis (EUS-CPN) and tumor ablation using ethanol are very common procedures, and the utility of these therapies has already been reported in prominent journals. However, their effectiveness appears temporary and insufficient, especially EUS-CPN. We therefore have to consider new reagents for improving the results. The present study examined the best concentration of ethanol and povidone iodine mixed with atelocollagen for more effective therapies. METHODS: The effects of the new reagents were confirmed in three live pigs. At first, we injected three kinds of reagents (including indigo carmine) in three separate areas of para-aortic tissue under EUS guidance in one pig. At more than 4 hours after injection, we checked ethanol injection sites after dissection. In next study, we performed EUS-guided injection of a total of six kinds of reagents (two kinds of ethanol, three kinds of povidone iodine, and control atelocollagen) into the livers of two living pigs. After 2 weeks, we examined tissue damage to the liver in the two pigs. RESULTS: The 75% ethanol (absolute ethanol 3.75 mL + 1% atelocollagen 1.25 mL + a very small amount of indigo carmine) was seen like blue gel, and still remained in the para-aortic tissue. Brownish areas of povidone iodine mixed with 3% atelocollagen exhibited clear, regular borders with greatly reduced infiltration into surrounding tissue compared to others. CONCLUSION: We concluded that 75% ethanol mixed with 1% atelocollagen appears optimal for EUS-CPN. Povidone iodine mixed with 3% atelocollagen may be suitable for small tumor ablation therapy.
Celiac Plexus* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Endosonography ; Ethanol ; Indicators and Reagents ; Indigo Carmine ; Liver ; Povidone-Iodine ; Swine

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Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for diagnosis of solid pancreatic lesions.

Rapat PITTAYANON ; Pradermchai KONGKAM ; Rungsun RERKNIMITR

Gastrointestinal Intervention.2016;5(3):212-215. doi:10.18528/gii160025

An accurate diagnosis of solid pancreatic lesions (SPLs) is important because pancreatic cancer cannot be ignored if curative treatment is possible. Prompt and reliable diagnostic procedures are greatly needed for patients presenting with SPLs, particularly where resection is possible for a malignant mass. Several endoscopic ultrasound (EUS)-related technologies including a novel EUS-guided needle-based confocal laser endomicroscopy (EUS-nCLE) can provide real-time images at the cellular level (1,000-fold magnification). A 19-gauge EUS-guided fine needle aspiration (EUS-FNA) needle is recommended because its channel is large enough for the 0.85-mm diameter nCLE miniprobe. The procedure is performed by standard EUS-FNA techniques with either pre- or post-loading technique. Ten percent fluorescein sodium (2.5–5 mL) is used as an enhancing agent and is intravenously injected immediately before puncturing the lesion. Only a few studies have used the technique and reported results. A recent study from 19 malignant and 3 benign SPLs classified EUS-nCLE findings according to 4 signs: dark clumps, and dilated vessels (predominantly seen in malignant SPLs) and fine white fibrous bands and normal acini (predominantly seen in benign SPLs). Using these criteria, researchers correctly diagnosed 18 of the malignant SPLs (94.7%). Another study described 2 lesions as having “dark cells aggregates with pseudo-glandular aspects, and straight hyperdense elements more or less thick corresponding to tumoral fibrosis” in 17 of 18 malignant SPLs. Thus far, no large and systematic study has been performed to evaluate the potential clinical use of EUS-nCLE for diagnosing SPLs. However, based on available information from a few studies and the current limitations of EUS-FNA, EUS-nCLE can potentially provide a complementary role in diagnosing such lesions. Nevertheless, more studies are certainly needed.
Biopsy, Fine-Needle ; Diagnosis* ; Endoscopic Ultrasound-Guided Fine Needle Aspiration ; Fluorescein ; Humans ; Needles ; Pancreatic Neoplasms ; Ultrasonography

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Endoscopic ultrasound-guided biliary drainage.

Majid A ALMADI ; Nonthalee PAUSAWASDI ; Thawee RATANCHUEK ; Anthony Yuen Bun TEOH ; Khek Yu HO ; Vinay DHIR

Gastrointestinal Intervention.2016;5(3):203-211. doi:10.18528/gii150019

Endoscopic ultrasound-guided biliary drainage (EUS-BD) is emerging as a safe and effective alternative for endoscopic BD. The advantage of multiple access points from stomach and duodenum allows EUS-BD in patients with altered surgical anatomy and duodenal stenosis. EUS-BD is also useful in patients with failed endoscopic retrograde cholangiopancreatography or difficult biliary cannulation. Depending on the access and exit route of the stent, a variety of EUS-BD procedures have been described. Trans-papillary as well as trans-luminal stent placements are possible with EUS-BD. Recent studies have shown a clinical success rate in excess of 90% and complication rates of < 15%. Prospective studies are needed to know the long-term results and relative efficacy of this technique.
Bile Duct Diseases ; Biliary Tract Neoplasms ; Catheterization ; Cholangiopancreatography, Endoscopic Retrograde ; Constriction, Pathologic ; Drainage* ; Duodenum ; Endosonography ; Humans ; Jaundice, Obstructive ; Prospective Studies ; Stents ; Stomach

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Development of the Asian EUS Group consensus in pancreatic pseudocyst drainage.

Anthony Yuen Bun TEOH ; Vinay DHIR ; Zhen Dong JIN ; Mitsuhiro KIDA ; Dong Wan SEO ; Khek Yu HO

Gastrointestinal Intervention.2016;5(3):199-202. doi:10.18528/gii160016

Drainage of pseudocyst and walled-off pancreatic necrosis has traditionally been achieved by surgical means. Recently, there has been a progressive shift in paradigm to performing endoscopic drainage for these conditions. Endoscopic ultrasound (EUS)-guided drainage is the preferred approach for drainage of pancreatic pseudocyst. However, many controversies still exist on the optimal management and wide variations in techniques exist. There is a pressing need for establishment of a consensus for safe practices in EUS-guided pseudocyst drainage.
Asian Continental Ancestry Group* ; Consensus* ; Drainage* ; Humans ; Necrosis ; Pancreatic Pseudocyst* ; Ultrasonography

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Is endoscopic necrosectomy the way to go?.

James Weiquan LI ; Tiing Leong ANG

Gastrointestinal Intervention.2016;5(3):193-198. doi:10.18528/gii.2016.5.3.193

Pancreatic necrosis with the formation of walled-off collections is a known complication of severe acute pancreatitis. Infected necrotic pancreatic collections are associated with a high mortality rate. Open necrosectomy and debridement with closed drainage has traditionally been the gold standard for treatment of infected pancreatic necrosis, but carries a high risk of perioperative complications. Direct endoscopic necrosectomy has emerged as a safe and effective modality of treatment for this condition. Careful patient selection and gentle meticulous debridement is important to optimize clinical success. Bleeding is the commonest associated complication with the procedure but most cases can be managed conservatively. Air embolism, although rare, is potentially fatal. The use of fully covered large diameter lumen apposing self-expandable metal stents has further simplified the procedure. These stents optimize drainage, and facilitate endoscopic necrosectomy because repeat insertion of the endoscope into the necrotic cavity can be easily achieved.
Debridement ; Drainage ; Embolism, Air ; Endoscopes ; Endosonography ; Hemorrhage ; Mortality ; Necrosis ; Pancreatitis ; Patient Selection ; Stents

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