Informed consent was obtained verbally via telephone call from the patient and his family and this consent was documented in the electronic medical recordA 43-year-old male with history of asthma presented to his primary care physician with solid and liquid dysphagia. A barium esophagram revealed “free gastroesophageal reflux” and findings suspicious for ineffective esophageal motility. He was referred to gastroenterology, but did not establish care due to lack of insurance.

Background Single operator choledochoscopy is a platform used to assist in the confirmation of diagnosis of biliary lesions. However, there are little data regarding the interobserver agreement of imaging interpretation. Our objective was to assess the interobserver agreement in single operator choledochoscopy interpretation. Methods 38 De-identified SPY Choledochoscopy video clips were sent to 7 interventional endoscopists. They were asked to score the videos on presence of four criteria selected by the investigators: growth, stricture, hyperplasia, and ulceration. Observers also chose a final diagnosis from the categories of cancer, hyperplasia, inflammation, or normal. Kappa scores were calculated for the scoring of the four criteria and for the selection of the final diagnosis. Results The overall interobserver agreement was fair in scoring for the presence of a growth (K = 0.28, SE 0.035) and stricture (K = 0.32, SE 0.035). Scoring for ulceration was slight to fair (K = 0.17, SE 0.035). There was only slight agreement for the presence of hyperplasia (K = 0.11, SE 0.035); and presumed final diagnosis based on imaging (K = 0.18, SE 0.022). Conclusion The results of this study support the need for an effort to identify and validate cholangioscopy imaging criteria for biliary pathology. This may assist in improving the reliability of the diagnostic value of cholangioscopy as its use becomes more widespread.

Partially covered self-expanding metal stents (PCMS) have been extensively used for palliation of malignant distal biliary stricture. Many centers have been using them as a bridge to surgery (BTS) regardless of resectability with or without eventual neoadjuvant therapy. We analyzed the outcome of all patients receiving PCMS and subsequently referred for surgery in our institution.

Background: Percutaneous endoscopic gastrostomy (PEG) is an invasive procedure that can result in bleeding. Guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, before PEG. Serotonin reuptake inhibitors (SRIs) have been associated with an increased risk of GI bleeding.Objective: To determine whether there is an association between periprocedural aspirin, clopidogrel, or SRI use and bleeding in patients who underwent PEG tube placement.Design: Retrospective cohort study.Setting: Large quaternary-care academic medical center.Patients: A total of 990 patients (525 men) with a median age of 69.8 years who underwent PEG from January 1999 to April 2009.Interventions: PEG tube placement.Main Outcome Measurements: GI bleeding.Results: Sixteen patients (1.6%) had evidence of bleeding during the first 48 hours after PEG, and 12 patients (1.2%) had evidence of bleeding between 48 hours and 14 days after PEG. Thirty-six patients (3.6%) received high-dose aspirin (>325 mg), 27 patients (2.7%) received clopidogrel (75 mg), and 99 patients (10%) received an SRI before PEG. Twenty-four patients (2.4%) received high-dose aspirin, 25 patients (2.5%) received clopidogrel, and 130 patients (13.1%) received an SRI after PEG. Multivariate analysis demonstrated no association between periprocedural use of aspirin (at any close) or clopiclogrel and post-PEG bleeding. However. SRIs administered 24 hours or less before PEG were associated with a significantly higher odds of post-PEG bleeding (adjusted odds ratio 4.1; 95% CI, 1.1-13.4; P = .04).Limitations: Retrospective, single-center study with limited statistical power despite a relatively large cohort of patients.Conclusions: Use of aspirin or clopidogrel before or after PEG was not associated with procedure-related bleeding. SRI use in the 24 hours before PEG was associated with an increased risk of bleeding. (Gastrointest Enclose 2011;74:22-34.)

Single Operator Choledochoscopy (SOC) using the SpyGlassTM Direct Visualization System (Boston Scientific, Natick, MA) is a platform used to assist in the confirmation of diagnosis of biliary lesions. However, there is little data regarding the interobserver agreement of SPY imaging interpretation. There is currently no established scoring criteria for the cholangioscopic diagnosis of intraductal pathology. The objective of this pilot multicenter study was to assess the interobserver agreement and variance in interpretation of SOC. De-identified SPY Choledoschoscopy video clips were compiled and sent out to selected interventional endoscopists at academic medical centers in which cholangioscopy is frequently performed. The reviewers were asked to score the videos on presence and severity of four features: growth, stricture, hyperplasia, and ulceration. These criteria were chosen based on the prior experience of an independent investigator (MK) with an experience of greater than 400 choledochoscopies. Observers were also asked to choose a final diagnosis from the categories of cancer, hyperplasia, inflammation, or normal; and they graded the quality of the videos. The interobserver agreements for these scores were measured using the Fleiss' kappa statistic along with 95% CI. All calculations were peformed using SAS. K statistics were interpreted based on the convention by Landis and Koch: poor agreement; <=0 slight agreement; 0 to 0.20, fair agreement; 0.21 - 0.40, moderate agreement; 0.41 - 0.60, substantial agreement; 0.61 - 0.80, almost perfect agreement; 0.81 - 1.00. The accuracy of each observer's final diagnosis was also determined by comparing the scores to pathology and/or clinical follow-up for each patient represented in the video clips. Thirty-seven video clips were sent to 7 observers at 6 academic centers. Overall interobserver agreement was fair in scoring for the presence of a growth (K=0.28, SE 0.035) and stricture (0.32, SE 0.035). Scoring for ulceration was slight to fair (K=0.17, SE 0.035). There was only slight agreement for the presence of hyperplasia (K=0.11, SE 0.035). The observers also had only slight agreement on their presumed final diagnosis based on imaging (K 0.18, SE 0.022). There was slight to poor agreement on video quality. The mean accuracy of the raters was 36% (± 8.6%). Interobserver agreements of the proposed scoring categories of cholangioscopy images ranges from slight to fair. The average accuracy of determining a final diagnosis by cholangioscopic imaging by experienced users was less than 40%. The lack of agreement on specific features of imaging as well as the final diagnosis suggest that imaging criteria for malignancy need to be established and the training of these criteria should be addressed.

Serotonin is released from platelets in response to vascular injury and promotes vasoconstriction and platelet aggregation. Selective serotonin reuptake inhibitors (SSRIs) inhibit uptake of serotonin by platelets, which may lead to a reduced ability to form clots and a subsequent increase in the risk of bleeding.

Percutaneous endoscopic gastrostomy (PEG) has been classified as a high-risk procedure (ASGE guidelines, GIE 2005;61:189-194) and bleeding is a potential complication following PEG. These guidelines recommend discontinuing clopidogrel for 7 to 10 days, but not withholding aspirin, prior to high-risk procedures.