A longer myotomy for the treatment of achalasia is associated with worse gastroesophageal reflux disease despite palliating dysphagia. Recently, clinical outcomes have been correlated to the distensibility of the distal esophagus, which is measured intra-operatively using an endoscopic functional luminal image probe (EndoFLIP). We aimed to determine the minimum per oral endoscopic myotomy (POEM) length to allow for adequate distensibility index (DI). A 6-cm myotomy conducted in 2-cm increments during POEM was performed for patients with achalasia I and II from 2017 to 2019. The EndoFLIP was used to measure the DI intra-operatively: (1) prior to intervention, (2) following creation of the submucosal tunnel, (3) following transection of the high-pressure zone (HPZ), (4) following the distal extension, and (5) following the proximal esophageal extension. A total of 16 patients underwent POEM. Ages ranged from 21 to 78 years, 10 were male, and 13 had type II achalasia. The median DI was 2.7 (1.4–3.6) mm2/mmHg prior to intervention; 2.4 (1.4–3.3) mm2/mmHg following the submucosal tunnel; 3.2 (1.6–4.4) mm2/mmHg following transection of the HPZ; 3.8 (2.6–4.5) mm2/mmHg following the gastric extension; and 4.5 (3.3–7.1) mm2/mmHg following the proximal extension. Our target range DI was achieved for 50% of patients after transection of the HPZ. Distensibility changed with each myotomy increment and fell within the target range for most patients following a 2–4-cm myotomy. This suggests that a shorter myotomy may be appropriate for select patients, and the use of the EndoFLIP intra-operatively may allow for a tailored myotomy length.

The challenge of esophagogastric myotomy for the treatment of achalasia is to strike a balance between obstruction relief and the development of reflux. Despite its importance, the length of myotomy has varied significantly during per oral endoscopic myotomy (POEM) to treat achalasia I and II. Distensibility index (DI) is measured using an endoscopic functional luminal imaging probe (EndoFLIP) placed across the gastroesophageal junction. Healthy volunteers have exhibited a DI range of 4.9-6.7 mm2/mmHg, while a minimum DI of 2.8 mm2/mmHg has been shown to be a strong predictor of achieving a post-POEM Eckardt score <3. We hypothesized that performing POEM in incremental lengths could aid in determining a minimum myotomy length using the EndoFLIP to measure DI. Between 2017 and 2019, patients were treated for primary achalasia I and II using a standard length POEM completed in a stepwise fashion (3 stages). Using a balloon volume of 40 ml, the EndoFLIP was used to measure the DI (defined as the minimum cross-sectional area divided by the pressure) at 5 points: (1) prior to any intervention, (2) following creation of the submucosal tunnel, (3) following a 2 cm myotomy including the high pressure zone (HPZ) and gastroesophageal junction (GEJ), (4) following the 2 cm distal gastric myotomy, and (5) following completion of the 6 cm myotomy. A total of 14 patients underwent a stepwise myotomy. Ages ranged from 33-78 years, 8 were male, and 11 had type II achalasia. At baseline, the median DI was 2.7 mm2/mmHg. Following creation of the submucosal tunnel, the median DI was 2.65 mm2/mmHg. After performing a 2 cm myotomy involving the GEJ and proximal esophagus, the median DI was 3.6 mm2/mmHg. After completion of a 2 cm distal or gastric myotomy, the median DI was 3.5 mm2/mmHg. After completion of a 2 cm proximal esophageal myotomy for a total 6 cm myotomy length, the DI was 5.1 mm2/mmHg (p=0.05). During POEM, the minimal threshold DI of greater than 2.8 mm2/mmHg is achieved after completion of the submucosal tunnel and performing a 2 cm myotomy proximal to and including the GEJ (Figure 1). Comparatively, distal extension of the myotomy 2 cm on to the stomach did not yield a significant change in DI but completion of the 6 cm myotomy proximally resulted in a DI within the normal range. This raises the possibility that a 2 cm myotomy of the GEJ/HPZ may be all that is necessary to treat achalasia by POEM.

Objective The Glasgow-Blatchford Bleeding Score (GBS) was designed to identify patients with upper gastrointestinal bleeding (UGIB) who do not require hospitalisation. It may also help stratify patients unlikely to benefit from intensive care.Design We reviewed patients assigned a GBS in the emergency room (ER) via a semiautomated calculator. Patients with a score ≤7 (low risk) were directed to an unmonitored bed (UMB), while those with a score of ≥8 (high risk) were considered for MB placement. Conformity with guidelines and subsequent transfers to MB were reviewed, along with transfusion requirement, rebleeding, length of stay, need for intervention and death.Results Over 34 months, 1037 patients received a GBS in the ER. 745 had an UGIB. 235 (32%) of these patients had a GBS ≤7. 29 (12%) low-risk patients were admitted to MBs. Four low-risk patients admitted to UMB required transfer to MB within the first 48 hours. Low-risk patients admitted to UMBs were no more likely to die, rebleed, need transfusion or require more endoscopic, radiographic or surgical procedures than those admitted to MBs. No low-risk patient died from GIB. Patients with GBS ≥8 were more likely to rebleed, require transfusion and interventions to control bleeding but not to die.Conclusion A semiautomated GBS calculator can be incorporated into an ER workflow. Patients with a GBS ≤7 are unlikely to need MB care for UGIB. Further studies are warranted to determine an ideal scoring system for MB admission.

Introduction: Dengue infection is a common disease in tropical and subtropical regions and is characterized by fever, headache, arthralgia and joint and muscle pain.Occasionally, patients develop abdominal and gastrointestinal symptoms, however, little information exists regarding the occurrence of these events.Objective: The aim of this study was to determine the frequency of gastrointestinal signs and symptoms in a cohort of patients with Dengue fever.Material and Methods We performed a retrospective review of 1463 adult patients with a diagnosis of Dengue fever during the 2016 epidemic to determine the frequency of abdominal and gastrointestinal symptoms.All of the patients were attended in the Outpatient Department in a Public Hospital in Buenos Aires-Argentina Statistics Analysis: A descriptive statistic was performed using X2 test and Fisher `s exact test with a significance level of p<0.005.Results: Abdominal and gastrointestinal symptoms were present in 64% of patients.The most frequent symptoms was abdominal pain (n=1024,70%), followed by nausea (n= 877, 60%), vomiting (n=468, 32%), diarrhea (n=159, 17%), hepatomegaly (n=18,2%), gastrointestinal bleeding (n=9, 1%), splenomegaly (n=5, 0,5%) and ascites (n=1, 0,1%).Hospitalization was required in 99 patients (n=6,77%), all of them (100%) (p<0.00001) had some abdominal and gastrointestinal symptoms.In this group the most frequent symptoms were abdominal pain (n=99, 100%), followed by nausea (n=89, 90%), vomiting (n= 75, 76%), diarrhea (n=60, 61%), hepatomegaly (n=17, 18%), gastrointestinal bleeding (n= 9, 10%), splenomegaly (n=5, 5%) and ascites (n=1,1%) Conclusions: Our findings suggest a high frequency of gastrointestinal symptoms in patients with dengue fever.These symptoms were significantly more frequent in patients who were hospitalized, this suggests a relation of gastrointestinal symptoms with the severity of dengue infection and their presence should be considered by the decision-making health team for appropriate patients management.The differential diagnosis of an acute febrile syndrome with abdominal pain or gastrointestinal symptoms in patients living in endemic areas or who have recently travelled to certain regions should include dengue infection.

Per oral endoscopic myotomy (POEM) is performed by accessing the submucosal space of the esophagus. This space may be impacted by prior interventions such as submucosal injections, dilations or previous myotomies. These interventions could make POEM more difficult and may deter surgeons during their initial experience. We sought to determine the impact of prior interventions on our early experience.

Upper GI bleeding is the most common GI cause for hospitalization in the US and costs over $5 billion/year. Numerous studies have tried to identify areas for cost reduction with varying success. Risk stratification using the Glasgow Blatchford Bleeding Score has identified low risk patients who could be treated as outpatients. We report the use of the GBBS to help direct bed assignment in a large urban hospital.

Per oral endoscopic myotomy (POEM) is increasingly utilized to treat patients with achalasia. Early results have demonstrated significant improvement of symptoms, but there are concerns about postoperative reflux. With only limited comparative data available, we sought to compare POEM to laparoscopic Heller myotomy (LHM) with partial fundoplication.

Background: Per Oral Endoscopic Myotomy (POEM) is a novel treatment for achalasia that is being increasingly utilized.Early results have demonstrated significant improvements in the patient's ability to swallow, but there is concern and evidence that patients undergoing POEM may have significant reflux postoperatively.Currently, there is only limited comparative data to laparoscopic Heller myotomy (LHM) to provide context to these concerns.We sought to compare our short term outcomes with POEM to laparoscopic Heller myotomy with partial fundoplication.Methods: We retrospectively reviewed outcomes from a prospectively maintained database of consecutive patients with achalasia undergoing primary myotomy.Data on 32 POEM (2014POEM ( -2015) ) and 120 LHM (2003LHM ( -2015) ) patients was reviewed and matched based on the Chicago classification subtype, Eckardt score, QOLRAD, GERD-HRQL and Dysphagia scores.Analyses were conducted at the 6-12 month follow up using the outcomes of quality of life, Eckardt scores, PPI use, pH scores and endoscopic esophagitis.Results: We matched 25 POEM patients to 25 LHM patients according to achalasia subtypes I (5/5), II (14/14), and III (6/6).Gender distribution (M/F), mean age and BMI for POEM was 14/11, 54.8 years and 27.8 and for LHM was 10/15, 51.7 years and 24.6, these were comparable.In the LHM group 20 Dor and 5 Toupet fundoplications were performed.Compared to preoperative values the postoperative Eckhardt scores, QOL metrics and swallowing ability significantly improved in both groups (Table 1).The postoperative values were also comparable between the groups (Table 1).However in the POEM group, DeMeester scores were numerically higher, EGD revealed esophagitis in 53.3% of POEM patients and 26.7% LHM patients and PPI use was 36.9% (POEM) and 21.7% (LHM).Conclusion: Patients with achalasia undergoing POEM or LHM achieve significant improvement in quality of life and Eckhardt scores along with palliation of their swallowing function in early clinical follow up.Although objective testing appears similar between the groups, the presence of esophagitis and higher PPI use in the POEM group suggests that ongoing and longer term follow up is required.Table

Background: Double-balloon enteroscopy (DBE) is effective in visualizing the small bowel to perform biopsy sampling and interventions. Few studies have evaluated the utility of DBE in patients with known or suspected Crohn's disease (CD).Objective: To evaluate the use of DBE in the diagnosis and impact on patient management in known and suspected CD and to compare capsule endoscopy (CE) with DBE findings.Design: Retrospective study from August 2004 to August 2009 of DBE procedures.Setting: Five academic, tertiary U.S. centers.Patients: Patients with known or suspected CD.Main Outcome Measures: Diagnostic yield, impact on patient management, and comparison of DBE to CE findings in patients with known and suspected CD.Results: We analyzed 98 DBE procedures performed in 81 patients (38 with known CD and 43 with suspected CD). For patients with CD, common indications were abdominal pain and bleeding/anemia. The diagnostic yield was 87% (33/38 patients). The impact on subsequent management decisions was 82% (31/38). Common indications for DBE in patients with suspected CD were abnormal CE or other imaging. The diagnostic yield was 79% (34/43 patients). The impact on subsequent management decisions was 77% (33/43). In 17% of patients (14/81), DBE failed to reach the target lesion. There was 1 perforation, 3 strictures dilated, and 1 of 2 retained capsules recovered. When CE was followed by DBE, 46% of lesions were confirmed on DBE.Limitations: Retrospective analysis, imperfect criterion standard.Conclusions: DBE is an effective technique for assessment of the small bowel in known and suspected CD and affects management. Failure to reach target areas with DBE is not uncommon, and perforations can occur. There is poor correlation between CE and DBE.

UGI bleeding is a frequent cause for hospitalization. Admission to ICU versus floor bed is usually based on subjective criteria. A more objective tool may help prevent errors in placement that delay needed care or waste resources. The Glasgow-Blatchford bleeding score (GBBS) has been shown to predict hospital mortality and the need for interventions in patients admitted with non-variceal UGI bleeding. Using the GBBS at admission may help stratify patients appropriate for floor care versus intermediate care (IMCU) or ICU.

Colonoscopy is considered the criterion standard for detecting colorectal cancer; adequate preparation is crucial for an effective colonoscopy but definitive data on the optimal preparation are lacking.The authors' aim was to assess the efficacy of split versus non-split preparations, the rate of adequate preparation according to type and dose of laxatives, the role of "runway-time" (the interval time between the last drink and the beginning of colonoscopy), and to evaluate compliance as an additive risk factor for colon cleansing.This was a series of meta-analyses of controlled studies.Published trials comparing split versus non-split preparation in adults undergoing colonoscopy were selected by using MEDLINE, the Cochrane Central Register of Controlled Trials, clinical trial.gov,ISI Web of Science, and Scopus.The authors included 29 studies.Overall, an adequate preparation was obtained in 85% of patients in the split-dose group and in 63% in the non-split-dose group (rate difference 22%).The heterogeneity was caused by 5 factors: the runway time (the longer, the worse the cleansing), type of diet, male sex, use of polyethylene glycol 4L and the Jadad score.Compliance was significantly higher in the split-dose group.Dr. Bucci and colleagues concluded that they had provided further evidence of the superiority of split-dose regimen over a non-split-dose regimen and that, regardless of type and dose, the superiority of split-dose regimens remains valid if the "golden 5 hours" rule is preserved.

BACKGROUND:The over-the-scope clip (OTSC) provides more durable and full-thickness closure as compared with standard clips. Only case reports and small case series have reported on outcomes of OTSC closure of GI defects. OBJECTIVE:To describe a large, multicenter experience with OTSCs for the management of GI defects. Secondary goals were to determine success rate by type of defect and type of therapy and to determine predictors of treatment outcomes. DESIGN:Multicenter, retrospective study. SETTING:Multiple, international, academic centers. PATIENTS:Consecutive patients who underwent attempted OTSC placement for GI defects, either as a primary or as a rescue therapy. INTERVENTIONS:OTSC placement to attempt closure of GI defects. MAIN OUTCOME MEASUREMENTS:Long-term success of the procedure. RESULTS:A total of 188 patients (108 fistulae, 48 perforations, 32 leaks) were included. Long-term success was achieved in 60.2% of patients during a median follow-up of 146 days. Rate of successful closure of perforations (90%) and leaks (73.3%) was significantly higher than that of fistulae (42.9%) (P < .05). Long-term success was significantly higher when OTSCs were applied as primary therapy (primary 69.1% vs rescue 46.9%; P = .004). On multivariate analysis, patients who had OTSC placement for perforations and leaks had significantly higher long-term success compared with those who had fistulae (OR 51.4 and 8.36, respectively). LIMITATIONS:Retrospective design and multiple operators with variable expertise with the OTSC device. CONCLUSION:OTSC is safe and effective therapy for closure of GI defects. Clinical success is best achieved in patients undergoing closure of perforations or leaks when OTSC is used for primary or rescue therapy. Type of defect is the best predictor of successful long-term closure.

Technological advances in endoscopic devices have significantly increased success of endoscopic closure of gastrointestinal (GI) defects, including perforations, fistulae, and anastomotic leaks. Conventional treatment of these defects is with surgical management, which is associated with significant morbidity and mortality. The over-the-scope clip (OTSC) provides more durable closure than standard clips because of its wider mouth and ability to grasp larger amounts of tissue. In addition, full-thickness closure is achievable due to greater compressive force. However, only case reports and small case series have reported on outcomes of OTSC closure of GI defects.

followed by a prior history of the event and sex.In the decision model we included the following thirteen individual NSAIDs: aceclofenac, celecoxib, diclofenac, etoricoxib, ibuprofen, indometacin, ketoprofen, ketorolac, meloxicam, naproxen, nimesulide, piroxicam, and rofecoxib.In general, the 'preferred' drugs based on their GI and CV safety profile were aceclofenac and celecoxib, followed by nimesulide and ibuprofen.Two NSAIDs (piroxicam and ketorolac) consistently ranked lowest.Conclusion: The SOS consortium provided an integrated GI and CV safety decision model for new NSAID users, incorporating thirteen individual NSAIDs, which may aid physicians in decision making.Risk of upper gastrointestinal complication, ischemic stroke, myocardial infarction, and heart failure hospitalization with individual NSAIDs UGIC: upper gastrointestinal complications;

Background. Endoscopic therapy (ablation +/- mucosal resection) for esophageal high-grade dysplasia (HGD) or intramucosal carcinoma has demonstrated promising results. Little is known about patients who have persistent or progressive disease despite endotherapy. We compared patients who had successful eradication of their disease with those in whom endotherapy failed to try to identify factors predictive of failure and outcomes after salvage therapy.Methods. We performed a single-institution retrospective review of patients treated with endotherapy from 2007 to 2012.Results. Thirty-eight patients underwent endotherapy: 28 had successful eradication of their disease and endotherapy failed in 10 patients. Patients in whom endotherapy failed were more likely to have high-grade dysplasia (HGD) on initial endoscopy, nodules or ulcers, multifocal dysplasia, and persistent nondysplastic Barrett's metaplasia. Patients in whom endotherapy failed also underwent significantly more endotherapy sessions. Seven patients had persistent dysplasia or progression to cancer, and 3 patients had complete eradication of HGD but presented with intramucosal carcinoma an average of 15 months after eradication. The 10 patients in whom endotherapy failed underwent salvage therapy with esophagectomy (7 patients), definitive chemoradiotherapy (1 patient), and endotherapy (2 patients). Patients treated with esophagectomy were disease free at a mean of 25 months postoperatively.Conclusions. HGD on initial endoscopy, multifocal dysplasia, mucosal abnormalities, and failure to eradicate nondysplastic Barrett's metaplasia were associated with failure of endotherapy. Patients with these characteristics should be considered at higher risk for treatment failure, and earlier consideration should be given to esophagectomy if there is persistent, progressive, or recurrent neoplasia. Clinical outcomes are good, even after salvage therapy. Continued endoscopic surveillance is mandatory after successful endotherapy because of the risk of recurrent disease.

Background/Aims: Double balloon enteroscopy (DBE) allows both diagnosis and therapeutic maneuvers in the small bowel. Its use was pioneered in Europe and Asia but there remains a relative paucity of literature from North America. Our aim in this study was to determine diagnostic and therapeutic yield in a North American setting. Methods: A five-year retrospective analysis of all patients undergoing DBE at a single tertiary care North American hospital was performed. Results: Four-hundred fifty-seven procedures, 265 anterograde and 192 retrograde, were performed on 335 patients. The most common indications were obscure gastrointestinal bleeding, small bowel obstruction, and suspected masses and mucosal abnormalities. Total enteroscopy was achieved in 19 of the 89 patients who had both anterograde and retrograde procedures. Overall diagnostic yield in the determination of cause of symptoms or previous imaging was 52%. The most common causes of obscure bleeding were small bowel ulcers (10%), vascular lesions (25%) and neoplasms (10%). The most common causes of small bowel obstruction were strictures, some of which underwent dilation. Other therapeutic interventions included polypectomy, retrieval of retained capsules, stent retrievals and percutaneous enteral jejunostomy tube placement. Overall complication rates were very low (0.6%) and included medication reaction (n=1), scope dysfunction (n=1) and perforation (n=1). Conclusions: DBE can be performed safely and with good diagnostic yield in a single referral center in North America.

Double balloon enteroscopy (DBE) and video capsule endoscopies (VCE) have both been used in recent years in the evaluation of obscure GI bleed (OGIB). The studies are often complementary and most often performed sequentially, with VCE being performed first and DBE being performed thereafter.

Pancreato-biliary GI practice increasingly utilizes ERCP and EUS. These skills have only recently been taught together during advanced training. Many tertiary endoscopists have proficiency in only one of these disciplines. Formal retraining can be prohibitively time consuming and impractical for most practicing gastroenterologists.