Faculty Bibliography

BACKGROUND AND AIMS: The advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories. METHODS: We performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position. RESULTS: A total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. The average advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. There were no procedural adverse outcomes reported in the 98 cases. CONCLUSIONS: The TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using a conventional colonoscope without the need for an overtube. Procedure time is shorter than that of other forms of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.

Introduction: Barrett's esophagus (BE) is a known precursor to esophageal adenocarcinoma. Endoscopic guidelines for BE and esophageal dysplasia (ED), rely on random four-quadrant forceps biopsies (FB) obtained every 1-2 cm in the BE segment, and are subject to sampling error. Wide area transepithelial brush biopsy combined with 3 dimensional computer image analysis of the sample (WATS^3D) previously has been shown to provide incremental value as an adjunct to FB in the detection of both BE and ED. Aims & Methods: A prospective multi-center, community-based trial utilizing WATS^3D testing was conducted during the period 2012-2014. Patents with symptoms of reflux, suspected BE, and known BE undergoing surveillance for ED were enrolled. A specially designed transepithelial WATS^3D biopsy brushes for tissue sampling in addition to forceps biopsies (FB) during the same endoscopy. WATS^3D and FB samples were sent to a central laboratory for analysis. In contrast to the standard 2 micron cut tissue slice, WATS^3D biopsy specimens also include an uncut direct smear of up to 150 microns in thickness to better capture the natural three dimensional appearance of the glandular tissue. Laboratory analysis of this uniquely thick tissue sample is aided by a computer based image processing system that integrates into a single three dimensional image information taken from up to 150 separate one micron focal planes. This information is then automatically reviewed by the systems image processing algorithms and neural networks which select and display to the pathologist the most suspicious cells that are found in every focal plane of the entire WATS^3D specimen. Results: There were 4203 patients enrolled in the study with adequate FB and WATS^3D specimens. The medianage was 59 yr with 43% being males. BE was diagnosed in 594 patients by FB and in 799 patients byWATS^3D. Of these 799 patients, 493 had no BE seen on FB. Thus, the addition WATS^3D tothe standard forceps biopsy protocol increased the detection of BE by 83.0% (493/594; 95%confidence interval 74%493%), This added detection of BE in 12% (493/ 4203) of all patients testedwith WATS^3D results in a number of patients needed to test (NNT) to obtain one additional BEpatient of 8.53. Esophageal dysplasia was diagnosed in 26 patients by FB and in 33 patients byWATS^3D. Of these 33 patients, 23 had no ED on FB. Thus, the addition of WATS^3D to the standardforceps biopsy protocol increased ED detection by 88.5% (23/26; 95% confidenceinterval 48%4160%). This augmented ED detection in 0.5% (23/4203) of all screening patients testedwith WATS^3D, results in an NNT to obtain one additional ED case of 182.7. There were no adverse events which resulted from use of WATS^3D. Conclusion: This multi-center trial demonstrates the benefit of WATS^3D use in daily community-based endoscopic practice. These results underscore previous data demonstrating the adjunctive benefit of adding WATS^3D to FB for augmented detection of both Barrett's metaplasia and dysplasia. (Table Presented)

Portal hypertensive gastropathy (PHG) is a painless condition of gastric mucosal ectasia and impaired mucosal defense, commonly seen in patients with elevated portal pressures. While it is typically asymptomatic and incidentally discovered on upper endoscopy, acute and chronic bleeding may occur. There are no definitive recommendations for treatment of asymptomatic PHG. Non-selective beta-blockers represent the mainstay of therapy for chronic bleeding, while somatostatin and vasopressin and their derivatives may be used in conjunction with supportive measures for acute bleeding. Salvage therapy with transjugular intrahepatic portosystemic shunt or rarely surgical shunt is appropriate when medical management fails. The role of endoscopic therapy for PHG is controversial. Liver transplantation should be considered as a final resort in cases of refractory bleeding due to PHG.

The Bellevue IBD clinic serves a radically different patient population than is treated in most US healthcare settings, represented in most clinical trials, or reflected in current management guidelines. Here we discuss the complexity of providing care to these individuals, areas of disparity in IBD care and resources to assist our patient population