Colonoscopy is important to prevent colorectal cancer. Bowel preparation is essential for adequate mucosa visualization. Usually, patients are instructed to consume clear liquids the day before a colonoscopy. However, recent studies have suggested that using a low-residue diet is preferable. Our aim was to assess bowel preparation efficacy, tolerance and adverse effects of low-residue diet (LRD) versus clear liquid diet (CLD) on the day before colonoscopy. PubMed/MEDLINE, Cochrane databases, and CINAHL were searched (October 2019). Randomised control trials involving adult patients undergoing colonoscopy examination and that compared LRD versus CLD on the day before colonoscopy were included. Data extraction and assessment of methodological quality of included studies were independently performed by two authors. Our primary outcome was the rate of adequate bowel preparation measured with validated BBPS, Ottawa, or Aronchick scales. Adequacy was defined as a colonoscopy with a score of 2 or 3 points in each colon segments, Aronchick scale (good or very good) or with Ottawa scale (<6 points). A subgroup analysis for the primary outcome was performed based on timing of bowel preparation less than five hours and split doses. Our secondary outcomes were tolerability and adverse effects. Tolerability of the intestinal preparation was measured by assessing acceptability rate and patients rate who would choose the same preparation in the future. The incidence of adverse effects was measured by assessing the rate of nausea, vomits and abdominal discomfort. Grouped estimates of relative risk (RR) were used for dichotomous variables (adequate bowel preparations, tolerability, and adverse effect). Thirteen RCT studies were included (N = 2587). Patients who received a low residue diet compared to clear liquids showed no differences in adequate bowel preparations (RR 1.01; 95% CI, 0.98-1.04; I2 = 66%), and in adverse effects (RR 0.92; 95% CI, 0.81-1.05; I2 = 0%). Nevertheless, low residue diet compared to clear liquids demonstrated better tolerability (RR 1.15; 95% CI, 1.09-1.22; I2 = 81%). The subgroup analysis for the primary outcome showed no significant differences in adequate bowel preparations between LRD and CLD. (RR 1.01; 95% CI, 0.98-1.04; I2 = 25%). A low-residue diet, a day before the scheduled colonoscopy, improves patients' tolerance to the bowel preparation process without affecting preparation quality or causing more adverse effects compared to liquid diet.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Abstract Background Capsule endoscopy (CE) can detect small bowel (SB) lesions compatible of Crohn’s disease (CD) in patients with suggestive symptoms but with inconclusive results for the diagnostic workup. However, the clinical impact of CE in helping physicians to make decisions about patients with suspected CD is not currently well established. The aim of the study was to investigate the clinical impact of CE to confirm diagnosis of CD and also to evaluate whether the results of CE modify therapeutic decisions. Methods We conducted a single-centre retrospective cohort study. All consecutive adult’s patients submitted to CE for clinical suspected of CD, on period November 2012 to November 2018, were included. Data on demography, previous research, medications for IBD, CE procedures and follow-up were analysed. Multivariate logistic regression analysis was carried out to identify predictors of CD. Results A total of 329 CE protocols in adult’s patients were performed over the study period. Ninety were in IBD patients and were included in the analysis 63 CEs submitted for suspected of CD: Clinical suspected CD 54(86%) and colitis unclassified 9 (14%). The mean age was 41 years (range 17–77 years) and 54% were males. The CE reached the caecum in 58 cases (92%) and retention was observed in 5 (8%) with only one patient (1.6%) requiring surgical removal. Overall, 28 of 63 patients (44%) had CE findings consistent with the diagnosis of CD. The lesions identified by CE included ulcers 24 (86%), erythema and villous oedema 17(61%), aphthas and mucosal erosions 5 (18%), stenosis 2 (7%) and were distributed mainly in the distal part of the SB (third tertile) in 23 (82%), but in 14 (50%) cases the proximal SB (first and second tertiles) was also affected. The mean Lewis Score (LS) was 903 (112–4356). Significant inflammatory activity (LS ≥ 135) was detected in 17 (27%) and was moderate or severe (LS > 790) in 7 (11%). CE visualise normal SB mucosa in 34 (54%) of patient’s, which rules out CD. Therapeutic started in 23 (36%) of patients, initiating a new IBD medication in most cases in the 3 months after the CE. On logistic regression analysis, male (p = 0.02) and findings in ileocolonoscopy (p = 0.004) were independents predictors of CD. Conclusion In our cohort, CE in suspected CD confirm diagnosis in 44% of cases. Male gender and findings in ileocolonoscopy appear to be independents predictors of CD. CE is a useful tool in suspected CD, since it adds relevant information for diagnosis and had a great impact on therapeutic decisions.

Colonoscopic identification of sessile serrated adenomas (SSAs) and tubular (TA) or tubulovillous adenomas (TVA) has important implications for preventing colorectal cancer. Acetic acid has a coloring effect on the mucous membranes, resulting in a visual effect called acetowhitening. SSAs show a distinctive acetowhitening pattern leading to a persistent white polyp surface, a reaction not seen in tubular or tubulo villous adenomas. However the diagnostic precision of this reaction is unknown.

Abstract Background Small bowel (SB) evaluation in established Crohn’s disease (eCD) is of paramount importance for planning therapy strategies. However, the utility of CE in helping physicians to make decisions in eCD is not currently well established. To investigate clinical impact of CE to assess activity and extension of eCD and to evaluate whether the results of CE modify therapeutic decisions. Methods We conducted a single centre retrospective cohort study. All consecutive adult’s patients submitted to CE for eCD were included from November 2012 to November 2018. Data on demography, previous research, medications for IBD and follow-up were analysed. Univariate analysis was carried out to identify CE features associated with changes in therapeutic management. Results A total of 329 CE protocols in adult′s patients were performed, of which 90 were in IBD. We included in the analysis 27 CEs submitted for eCD. The mean age was 35 years (range 15–75), 17 (63%) were males and median disease duration was 8 years. The CE reached the cecum in 26 cases (96%) and retention was observed in only one patient (4%) without necessity of surgical removal. At the time of CE, 5 patients (18%) had abnormal inflammatory biomarkers, anaemia in 4 (15%), abdominal pain in 18 (67%) and diarrhoea in 16 (59%). Thirteen of 27 patients (48%) had CE findings consistent with mucosal activity of CD. The lesions identified by CE included ulcers 11 (41%), erythema and villous enema 10 (37%), erosions 2 (7%), stenosis 2 (7%) and were distributed mainly in the distal part of the SB (3rd tertile) in 12 (44%), but in 4 (15%) the proximal SB (1st and 2nd tertile) was also affected. The mean Lewis Score (LS) was 784 (8–5392). Significant inflammatory activity (LS ≥ 135) was detected in 9 (33%) and was moderate or severe (LS > 790) in 2 (7%). CE has changed Montreal classification in 4 (15%) of patients and in 14 (52%) SB mucosal activity was ruled out. Indeed, CE has changed therapeutic management in 14 (52%) of patients within 3 months after the CE, as follows: 8 patients were started new biological therapy, 3 were optimised biological therapy, 2 were started on budesonide and 1 suspended azathioprine. Proximal SB affected, as compared with only distal SB affected, were more frequently associate with changes in therapeutic management (100% vs. 43%, p: 0.04). Significant inflammatory activity (LS ≥ 135), as compared with LS < 135, were also more frequently associate with changes in therapeutic management (82% vs. 25%, p: 0.004). Conclusion In our study, CE in patients with eCD added valuable clinical information and had a great impact on therapeutic decisions. Whether this approach will improve outcomes in eCD will require further investigation.

Sessile serrated adenomas/polyps (SSA/Ps) have a well-established malignant potential. Because of their subtle appearance, they pose a special diagnostic challenge for the endoscopist [1] [2].

Lung cancer is one of the leading causes of death worldwide. Pulmonary nodules located in the vicinity of the mediastinum. retrocardiac, near the aorta or pulmonary vessels. and in front of the spine, may be difficult to access through a percutaneous or bronchoscopic approach. Fine needle aspiration/biopsy guided by transesophageal echoendoscopy (EUS-FNA/FNB) is a minimally invasive method with low morbidity that could allow access to lesions in these places. We present the case of a patient with a solitary pulmonary nodule, in which the diagnosis of lung cancer was obtained by EUS-FNA/FNB.

Small bowel (SB) capsule endoscopy (CE) can detect lesions compatible of Crohn’s disease (CD) in patients with suggestive symptoms but with inconclusive results for the diagnostic work-up. However, the utility of CE in helping physicians to make decisions about patients with suspected CD is not currently well established.

Background: Vimentin is a type III intermediate filament protein that stabilises cell architecture, but might be more active involved in intestinal inflammation during Crohn's disease (CD) and ulcerative colitis (UC).In lamina propria vimentin is found fibroblast and myofibroblasts, but are also produced by activated macrophages in inflammatory diseases.Protein fragments from vimentin turnover can be measured by competitive enzyme-linked immunosorbent assay (ELISA) targeting MMP-2 and -8 degraded and citrullinated-vimentin (VICM) and thereby maybe act as a serological biomarker of intestinal inflammation.The aim of this study is to evaluate how VICM correlates to clinical and endoscopic disease activity in CD and UC.Methods: We included 63 CD patients, 107 UC patients and 20 healthy controls in a prospective biomarker evaluation study.35% (n=24) of CD patients and 49% (n=52) of UC patients had active disease.We recorded Harvey-Bradshaw Index (HBI) or Simple Clinical Colitis Activity Index (SCCAI), and measured VICM, C-reactive protein (CRP) and faecal calprotectin (FC).17 CD and 63 UC patients underwent sigmoidoscopy or colonoscopy and were scored with Simple Endoscopic Score for Crohn's disease (SES-CD) or Endoscopic Mayo Score.Results: VICM was significantly elevated in CD and UC patients compared to healthy controls (p=0.0001).VICM correlated positively to SES-CD, SCCAI and Endoscopic Mayo Score (Fig. 1B, Fig. 2A andB), and had a tendency to correlate to HBI (Fig. 1A).VICM had a stronger correlation to the endoscopic scores than CRP (Fig. 1B, 1D, 2B, 2D), but not as strong a correlation as FC (Fig. 1A,1E,2A,2E).Conclusion: VICM is significantly elevated in IBD patients in remission and IBD patients with active disease compared to healthy controls.Furthermore, VICM correlates significantly to endoscopic disease activity in CD and to clinical and endoscopic activity in UC.VICM has a higher correlation to the endoscopic scores compared to CRP.As VICM is produced locally in the inflamed gut and CRP is a systemic inflammation marker produced in the liver.Thus VICM might act as a serological biomarker of inflammation in the intestinal wall in IBD.

Colonoscopy has become the preferred modality for colorectal cancer (CRC) screening in many countries. However, it is well recognized that colonoscopy is not perfectly sensitive for the detection of neoplasia and that CRC can be diagnosed within a short interval following a colonoscopy in which no cancer was detected. These cancers are also known as interval post-colonoscopy colorectal cancers (PCCRCs). Several clinical and endoscopy-related risk factors have been associated with the risk of developing PCCRC.

Endoscopic ultrasound-fine needle aspiration(EUS-FNA) is a reliable tool for the diagnosis of pancreatic lesions, especially in high-volume centers (HVC) where the reported sensitivity(SE) is around 95%.

Introduction:The effectiveness of screening colonoscopy is unclear, particularly for right colon cancer.Most of available evidence comes from administrative dataset analysis; therefore, information about patients' clinical details and colonoscopy characteristics is scarce.Aim: To evaluate the association between screening colonoscopy(SCC) and incident colorectal cancer(CRC), and to determine whether the effect of colonoscopy differs according to CRC anatomic location, endoscopists characteristics and colonoscopy quality.Methods: We conducted a nested case-control study.Eligible patients were affiliated to a health insurance company that provides health-care to 41.000 adults and centralizes medical care in one tertiary hospital.Individuals between 55 and 90 years old on their CCR diagnosis date during 2010-2017 were matched, using diagnosis(reference) date, to randomly selected controls, on age and sex.Patients at average risk for CCR and with at least 5 years of health plan enrolment duration were included.SCC exposure was defined as having occurred between 6 months and up to 5 years before the reference date.Indication for colonoscopy, pre-assessment interview details, and colonoscopy characteristics were assessed based on electronic medical records.Completeness of colonoscopy assessed by written report and photo-documentation of cecal landmarks.Bowel preparation was classified according to Aronchick scale.Using conditional regression analysis, the association between screening colonoscopy in the 5-year period before the reference date and diagnosis of colorectal cancer was evaluated adjusting for Charlson comorbidity score.Subgroup analysis were performed for CRC location, endoscopists specialty(Colorectal surgeon vs Gastroenterologist), and for high-quality colonoscopy(complete and with satisfactory bowel preparation).Results: We analyzed 134 eligible patients with invasive CRC and 670 colorectal cancer-free controls.Having received a SCC was associated with a 77% reduction in the risk of developing any CRC(adjusted odds ratio(AOR) = 0.23, CI 0.13-0.39).SCC was associated with a 91% reduction in the risk of presenting a left CRC(AOR=0.09,CI 0.03-0.23),but no statistically significant reduction in the risk of presenting a right CRC was observed(AOR=0.55,CI 0m.27-1.13).Patients who received a high-quality SCC had a larger reduction in the risk of developing any CRC(81%)(AOR=0.19,CI 0.09-0.41)or left CRC(92%)(AOR=0.08,CI 0.02-0.34),and was associated with a 63%reduction in the risk of right CRC(AOR=0.37,CI 0.14-0.97).The risk of developing CRC was not influenced by the endoscopists specialty(AOR=0.51,CI0.13-2.03)(Fig1).Conclusion: Screening colonoscopy significantly reduced left CRC incidence.Only high-quality screening colonoscopies were associated with a lower incidence of right CRC. Mo1619

Most pancreatic cysts (PCs) found incidentally by CT and MRI scans might not be clinically important according to the Fukuoka guidelines, the American Gastroenterological Association (AGA) guidelines and European guidelines. To determine and compare the prevalence of incidental clinically important PCs (CIPCs). Abdominal contrast-enhanced CT or MRI scans performed during a one-year period were retrospectively reviewed to identify incidental PCs. CIPCs were defined as those cysts that would be capable of triggering further evaluation with endoscopic ultrasound, immediate surveillance (within 3–6 months) and/or surgery. Prevalence was calculated as the number of patients with CIPCs per 100 subjects imaged (%). Sixty patients (mean age 70±14 years) out of 565 were found to have incidental PCs, representing a prevalence of 8.7% (95% CI 6.3–11.5) in CT scans and 27.5% (95% CI 16–41) in MRI scans. Seven patients (11.6%, 95% CI 5–22) had CIPCs based on size ≥ 30 mm (n=5), size ≥ 30 mm and pancreatic duct (PD) dilation (n=1) and PD dilation and presence of solid component (n=1). Based on the Fukuoka guidelines, the prevalence of CIPCs was 1.2% (95% CI 0.4–2.5) in CT scans (6/507) and 1.7% (95% CI 0.1–9) in MRI scans (1/58). Based on the AGA and European guidelines, the prevalence of CIPCs was 0.2% (95% CI 0.1–1) in CT scans (1/507) and 1.7% (95% CI 0.1–9) in MRI scans (1/58). Patients with PCs initially classified as "AGA- or European-positive" had a higher surgical probability and this decision was taken earlier in the follow-up. In our cohort, the prevalence of important incidental pancreatic cysts was not negligible at around 1% according to current guidelines. La mayoría de los quistes de páncreas (PC) hallados incidentalmente en las tomografías (TC) y las resonancias magnéticas (RMN) podrían no ser clínicamente importantes de acuerdo con las actuales guías Fukuoka, American Gastroenterological Association (AGA) y europea. Determinar y comparar la prevalencia de PC incidentales clínicamente importantes (CIPCs). Se revisaron retrospectivamente las TC de abdomen con contraste y las RMN durante un período de un año para identificar PCs incidentales. Los CIPC se definieron como aquellos quistes que serían capaces de desencadenar una evaluación ulterior con ecoendoscopia, vigilancia en un corto intervalo (3-6 meses) y/o cirugía. La prevalencia se calculó como el número de pacientes con CIPC por cada 100 sujetos estudiados (%). Se encontró que 60 (edad media 70 ± 14 años) de 565 pacientes tenían PC incidentales, lo que representó una prevalencia de 8,7% (IC95% 6,3-11,5) en las TC y 27,5% (IC95% 16-41) en las RMN. Siete pacientes (11,6%, IC95% 5-22) tenían CIPC basados en el tamaño ≥30 mm (n=5), tamaño ≥30 mm y dilatación del conducto pancreático (PD) (n=1), y dilatación de PD y presencia de componente sólido (n=1). Basándonos en la guía Fukuoka, la prevalencia de CIPC fue de 1,2% (IC95% 0,4-2,5) en las TC (6/507) y 1,7% (IC95% 0,1-9) en las RMN (1/58). Basado en las guías AGA y europea, la prevalencia de CIPC fue de 0,2% (IC95% 0,1-1) en las TC (1/507) y 1,7% (IC95% 0,1-9) en las RMN (1/58). Los pacientes con PC inicialmente clasificados como "AGA o europea positivo" tuvieron una mayor probabilidad quirúrgica y esta decisión se tomó antes en el seguimiento. En nuestra cohorte, la prevalencia de quistes pancreáticos incidentales y relevantes no fue despreciable, siendo cercana al 1% según las guías actuales.

Fecal immunochemical testing (FIT) is increasingly used for colorectal cancer (CRC) screening. Further evaluation of the association between lesion characteristics and FIT results in a screening population would improve the understanding of the performance of FIT.

likely to continue to grow at a rapid rate beyond five years.

Patients with inflammatory bowel disease (IBD) and long-standing colitis have an increased risk of developing colonic neoplasia. Whether the endoscopist’s characteristics and surveillance technics can increase the detection of dysplasia in clinical practice is still unknown.

OBJECTIVES:The risk of developing metachronous advanced neoplastic lesions (ANLs) during surveillance after resection of sessile serrated adenomas (SSAs) has not been quantified. METHODS:Patients with sporadic SSAs resected between 1 April 2007 and 31 December 2009 who underwent surveillance colonoscopy in our institution were prospectively evaluated. Patients with low-risk adenomas (LRAs), high-risk adenomas (HRAs), and negative index colonoscopy (NIC) during the same period were identified using the pathology database and electronic medical records, and were also included as a comparison cohort. The primary outcome was the comparison of the study groups with regard to incidence of metachronous ANLs during surveillance colonoscopy. RESULTS:A total of 185 patients had SSAs, of whom 75 with 101 resected polyps were finally included. The comparison cohort consisted of 564 patients: 140 LRAs (160 polyps), 87 HRAs (478 polyps), and 337 NICs. The overall mean colonoscopy follow-up was for 54.5 months (±s.d. 14). SSA patients with synchronous HRA on index colonoscopy presented a higher incidence rate of metachronous ANL (12.96 per 1,000 person-months) compared with patients with HRA (5.07 per 1,000 person-months), whereas those with synchronous LRA and without synchronous adenoma on index colonoscopy presented a low incidence rate of metachronous ANL (0 and 1.41 per 1,000 person-months, respectively) similar to LRA (1.47 per 1,000 person-months). Among patients with SSA the 3- and 5-year ANL free-cumulative probability was 64.3 and 32.1% in those with synchronous HRA, 100 and 100% in those with synchronous LRA, and 95.1 and 91.7% if no synchronous adenoma was found. CONCLUSIONS:Among patients with resected sporadic SSAs the risk of developing metachronous ANL is influenced by the presence of synchronous HRA on index colonoscopy. Patients with SSAs and synchronous HRA on index colonoscopy require closer surveillance, whereas those with synchronous LRA and those without synchronous adenomas may be followed up in the same way as those with LRAs.

Background: Barrett's esophagus (BE) is a premalignant condition that can progress to adenocarcinoma of the esophagus and gastroesophageal junction.The Prague C and M criteria was established to provide guidelines on the endoscopic characterization of BE through grading of continuous metaplastic extension from the top of the gastric folds.However, we have observed BE patients with metaplastic columnar 'islands' that would not be classified under the current criteria.The possibility of dysplasia within these islands and the potential for missed lesions during surveillance or through ablative therapy highlights the need for a revision of the Prague criteria.Aim: To identify and characterize Barrett's esophagus patients that develop metaplastic columnar islands and to assess the utility of a descriptive tool used in addition to the Prague criteria Methods: This retrospective review analyzed consecutive patients with BE referred for management of suspected dysplasia.All patients were assessed with endoscopes equipped with high definition white light, and narrow band imaging.All cases were classified using the Prague criteria for BE at a baseline, mapping upper endoscopy with 4 quadrant biopsies taken at 1 cm intervals from the gastroesophageal junction.After the "C" and "M" of the Prague scale were recorded, all additional islands of metaplastic columnar mucosa were mapped.An "I" designation was given to the most proximal island measured from the gastroesophageal junction.The Barrett's segment was represented as a CxMxIx where "x" is the number in cm from the gastroesophageal junction.Biopsied tissue was assessed for dysplasia, which was confirmed by an expert GI pathologist.Patients with and without islands were compared.Results: From June 2012 to October 2014, 73 patients (mean age 66.0, 61 male, 12 female) were referred for assessment of potential dysplastic BE. 49 (67%) patients did not have any observed islands (mean age 67.4,range 19-87).25 (33%) patients (mean age 63.6, range 37-84) had islands of Barrett's tissue; 11 with de novo islands and 14 with islands appearing after endoscopic ablation was administered.In the non-island BE group, the mean and range of C and M were 3.3 (0-11) and 4.8 (1-12) respectively.In the BE group with islands, the mean and range of C, M and I were 2.5 (0-11), 3.5 (0-10) and 5.2(1-10) respectively.2 patients in the island BE group had biopsy confirmed intramucosal carcinoma.All patients had regular surveillance with or without ablative therapy.Conclusion: The Prague criteria is well validated for endoscopic description of BE.However, we have observed that many patients assessed for BE have island configurations of Barrett's tissue that fall outside of classic Prague descriptors.The potential risk of missed dysplastic lesions warrants the need for a revision to the Prague Criteria.