Objective: The goal of this review is to summarize and discuss the role of endoscopic ultrasound (EUS) in the staging and diagnosis of esophageal carcinoma. Background: EUS has a well-established role in the diagnosis and staging of esophageal carcinoma. Technological advancements over the last three decades have increased the ability and utility of EUS; it is a mainstay in the workup of esophageal carcinoma. Methods: Literature review and summary of the available information relating to the use of EUS in practice, along with a review of its limitations in practice. Conclusions: The technology that underlies EUS has evolved over the last three decades. In particular, EUS plays a vital role in determining the extent of local extension of the tumor, which is defined using the T-staging system. Furthermore, it can accurately identify metastases to nearby lymph nodes and liver, and provides the capability of tissue sampling of metastatic disease with fine needle aspiration (FNA), thereby expanding its diagnostic power. As EUS has developed, it has surpassed other modalities for the purposes of both T and N staging of esophageal cancers as delineated by the American Joint Committee on Cancer/ Union for International Cancer Control (AJCC/UICC). EUS is a cornerstone in the multimodal approach to the diagnosis and staging of esophageal cancer which also includes upper endoscopy, cross-sectional imaging, positron emission tomography (PET) scanning, mediastinoscopy and laparoscopy. Limitations of EUS include operator dependence, understaging of the disease in obstructing tumors, difficulty differentiating between T2 and T3 disease, and reduced yield in patients following chemoradiation therapy.

Zachary Daitch: NO financial relationship with a commercial interest | Shalini Gingipally: NO financial relationship with a commercial interest | Jun Song: NO financial relationship with a commercial interest | Saraswathi Cappelle: NO financial relationship with a commercial interest | Stephen Heller: YES financial relationship with a commercial interest;Olympus:Consulting | Adam Ehrlich: YES financial relationship with a commercial interest;Pfizer:Advisory Committees or Review Panels;Bristol Meyers Squibb:Advisory Committees or Review Panels;Level Ex:Consulting;Vindico:Consulting | Woo Jung Lee: YES financial relationship with a commercial interest;Olympus:Consulting

Introduction: Management of biliary leaks can involve nonsurgical interventions as part of the standard of care in hemodynamically stable patients. Studies indicate that endoscopic retrograde cholangiopancreatography (ERCP) is a beneficial nonsurgical procedure, as it reduces time to resolution of bile leak in iatrogenic injury and blunt hepatic trauma. Less research supports the role of ERCP in penetrating liver injuries, though studies suggest a benefit for these patients as well. Our aim was to examine patients with penetrating liver trauma who underwent ERCP to analyze if this was associated with clinical improvement, as manifested by decreased drain output. Methods: We conducted a retrospective study of patients with suspected bile leaks following penetrating liver injury from gunshot wounds. Our primary variable was relevant surgical drain output as determined by location. Other data collected included biliary stent size/location, degree of liver injury, and liver function tests (LFTs). Comparisons were assessed for 7 days pre and post ERCP with Wilcoxon Signed Rank tests. Results: We identified 10 male patients with suspected bile leaks following gunshot wounds who underwent ERCP with sphincterotomy and stenting of the biliary tree following surgery. For all, biliary injury was suspected due to bilious output from relevant surgical drains or bilothorax on chest tube drainage in one case. Mean combined drain output pre-ERCP was 112.03 mL/day and post-ERCP it was 63.97 mL/day. The difference was statistically significant (P=0.005). By day 7 post ERCP, 8 patients had at least a 25% reduction in output and 4 patients had at least a 50% reduction. 7 patients had sufficient LFT data for analysis. Post-ERCP mean total bilirubin levels decreased, while mean levels of aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase increased. Differences were not statistically significant, however. Conclusion: Our results show that ERCP correlates with decreased biliary drain output in the immediate post intervention period. The lack of significance with LFT trend analysis suggests that following relevant drain output may be a more useful prognostic factor than following post-ERCP LFTs in this patient population. Future directions include analyzing differences in ERCP interventions (i.e. stent size or location of stent placement), timing of ERCP, and comparison with surgery-only outcomes.

Introduction: Diagnosis and evaluation of peptic ulcer disease (PUD) is one of the most common indications for upper endoscopy, and Helicobacter pylori (HP) infection and NSAID use are the most common etiologies of the disease. HP incidence has declined worldwide, with more pronounced decreases in developed countries. We investigated whether a decline in HP infection occurred in our cohort of patients compared with nationally available estimates and if patient demographics, including race, were associated with HP incidence. Prior studies have cited the prevalence of HP in African Americans to be as high as 50-60% compared to the national US prevalence of 30%. Using data from patients seen at an academic medical center in an underserved area, we aim to elucidate the relationship between demographics and HP incidence. Methods: We retrospectively queried our electronic health record for patients aged 18 or older diagnosed with PUD by endoscopy during a single year between 2019 and 2020. We collected information including age, gender, race, inpatient/outpatient diagnosis, Forrest classification of ulcer, location of ulcer, and HP status. We assessed association between these characteristics and HP status using Chi-squared analysis. Results: 303 patients met inclusion criteria. 216 had gastric ulcers and 122 had duodenal ulcers. Among those, 34 patients had both gastric and duodenal ulcers. HP tests were performed on 227 patients, with 24.2% positivity. African American patients were most likely to have HP associated ulcers and White patients were least likely to have them (33.6% vs 3.8%, P< 0.001). There was no significant difference between HP prevalence based on age or ulcer location. Males were more likely to have HP ulcers than females (30.5% vs 18.9%, P=0.042). Conclusion: Prevalence of HP has decreased nationally over the last several years. However, as seen in our data, there has been a significant difference in the rate of HP affecting males and African Americans. Specifically, our data shows that HP rates have impacted these groups at a significantly higher rate than Caucasians and females. This data is especially significant at an inner-city hospital, where patients experience disparities in healthcare access. We aim to supplement this analysis with prior years’ data to further understand the differential decrease in HP amongst populations in our community. By doing so, we can better provide a framework for screening, treatment, and education of our patients who are at increased risk for HP.Table 1.: Frequencies of Recorded Variables by H Pylori Status

The new EN-580T double balloon enteroscope (DBE) system from Fujifilm has improved image quality compared with its predecessor, the EN-450 DBE system which was introduced in 2004. Historically, the diagnostic yield of DBE approaches only 66%, depending on the procedure indication. Our goal was to compare the outcome of the new EN-580T enteroscope system to the EN-450T5 enteroscope system in terms of the diagnostic yield. 50 consecutive patients who underwent DBE with the new EN-580T system between September 2016 and June 2017 at our tertiary center were matched according to the procedure indication in a 1:2 ratio with 100 consecutive patents that underwent DBE with the EN-450T5 system between February 2015 and September 2016. The included procedure indications were overt and occult obscure gastrointestinal bleeding (OGIB), abnormal cross-sectional imaging and abnormal video capsule endoscopy. The primary outcome of interest was to compare the diagnostic yield of DBE. 50 patients underwent 62 DBE (46 anterograde, 16 retrograde) with the new EN-580T DBE system for overt OGIB (46%) and occult OGIB (30%). These patients were compared with 100 patients who underwent 119 DBE (90 upper, 29 lower) with the EN-450T5 DBE system for overt (46%) and occult (30%). There was no significant difference in the baseline characteristics age, gender, antiplatelet, anticoagulation, NSAID use and blood product transfusion requirement (Table 1). Both DBE scope systems achieved comparable intubation depth on anterograde and retrograde intubation (Table 1). Although there was no statistically significant difference between the proportion of the diagnostic findings and the diagnostic yield between both DBE systems, there was a trend of a higher diagnostic yield with the new EN-580T enteroscope system, particularly for detecting patients with angioectasia (NS). In our experience, the new EN-580T enteroscope is a valuable instrument given its improved image and color resolution, in addition to other advantages such as a larger working channel. Our initial evaluation did not show any improvement of DBE outcome with the EN-580T enteroscope. However, we cannot exclude a type II statistical error, as there was a trend towards an improved diagnostic yield.Tabled 1Table 1ENT-580T (n=50)EN-450T5 (n=100)p-valueAge, mean years (SD)70.3 (10.7)68.6 (14)0.4521Gender, % male31 (62%)50 (50%)0.2242Indication, n (%)Overt GI bleed23 (46%)46 (46%)Occult GI bleed15 (30%)30 (30%)Abnormal CT/MRI2 (4%)4 (4%)Abnormal video capsule10 (20%)20 (20%)DBE, n (%)0.5743Anterograde34 (68%)71 (71%)Retrograde4 (8%)10 (10%)Anterograde + Retrograde12 (24%)19 (19%)DBE anterograde, mean (SD)Intubation depth244.8 cm (77.4)223.4 cm (69.4)0.1381Scope time86.2 min (45)69.4 min (23)0.0071DBE retrograde, mean (SD)Intubation depth154.7 cm (63.4)141.3 cm (70.3)0.5311Scope time87.5 min (23.6)80 min (25)0.2511Total enteroscopy attempted, n1820Total enteroscopy achieved, n (%)8 (55.6%)18 (90%)0.0272Diagnostic findings on DBE, n (%)0.2643None / Normal17 (34%)45 (45%)Angioectasia22 (44%)29 (29%)Ulcer, Stricture3 (6%)1 (1%)Polyp, Tumor4 (8%)11 (11%)Other (e.g. Meckel)4 (8%)14 (14%)Diagnostic yield, n (%)All33 (66%)52 (52%)0.1181High confidence only30 (60%)44 (44%)0.18111. t-Test; 2. Chi-square; 3. ANOVA Open table in a new tab

Double balloon enteroscopy (DBE) was introduced in 2004. Since then several technical limitations have been described, mainly relating to the small working channel and the image resolution below that of the most current high-definition endoscopes. Most recently Fujifilm introduced the new EN-580T double balloon enteroscope system with improved image quality and a 3.2 mm working channel size.

Eric O. Then, MD1, Jamil M. Shah, MD2, Tyler Grantham, MD3, Rajarajeshwari Ramachandran, MD1, Dustin J. Uhlenhopp, DO4, Tagore Sunkara, MD5, Madhavi Reddy, MD, FACG2, Vinaya Gaduputi, MD6. The Brooklyn Hospital Center, Brooklyn, NY; Brooklyn Hospital Center, Brooklyn, NY; St. Georges University, West Indies, Saint George, Grenada; University of Iowa Hospitals & Clinics, Iowa City, IA; MercyOne Des Moines Medical Center, Des Moines, IA; Blanchard Valley Health System, Findlay, OH.

Introduction: Gastric bypass with Roux-en-Y reconstruction is an increasingly common procedure for morbid obesity. Access to the Roux limb and excluded stomach is difficult endoscopically. This case highlights the use of double balloon enteroscopy to evaluate this anatomy. A 43-year-old female with a past medical history of morbid obesity and a strong family history of endometrial and ovarian cancer presented with complaints of severe right lower quadrant abdominal pain, nausea, and anorexia. She had a history of gastric bypass surgery with Roux-en-Y reconstruction performed 14 years prior to presentation. Initial evaluation by an outside gastroenterologist included a normal upper endoscopy of the esophagus and gastric pouch and a normal colonoscopy. Pelvic ultrasound and CT scan of the abdomen and pelvis revealed a right ovarian mass, abdominal and pelvic ascites, multiple liver nodules consistent with metastatic disease, and omental nodularity concerning for carcinomatosis. The patient was evaluated by a gynecologic oncologist at our institution. Ultrasound-guided core needle biopsy of one of the liver lesions revealed moderately differentiated adenocarcinoma with tumor cells positive for CK7, pCEA, CDX2, CK19, and CK20, suggesting a primary upper gastrointestinal or pancreaticobiliary neoplasm. Careful review of the patient’s CT scan suggested a mass in the portion of the stomach excluded as a result of her gastric bypass surgery. She was therefore referred to gastroenterology for upper double balloon enteroscopy (DBE) with the objective of examining the excluded stomach via a retrograde endoscopic approach and assessing for the presence of a primary gastric neoplasm. Upper DBE was performed under fluoroscopic guidance. The afferent Roux limb was intubated and the excluded stomach was reached via the retrograde approach. A large, fungating mass involving much of the gastric antrum and body was identified. Biopsies of the mass confirmed poorly-differentiated adenocarcinoma identical to the histology obtained by liver biopsy. The patient was diagnosed with metastatic gastric adenocarcinoma and palliative chemotherapy was instituted. Gastric cancer arising in a surgically excluded stomach is a rare entity. To our knowledge, this is the first reported case of the identification and diagnosis of gastric cancer in a surgically excluded stomach by DBE. This case underscores the importance of considering a neoplasm arising in a surgically excluded stomach in the differential diagnosis of upper gastrointestinal tumors, and the feasibility of the identification of such tumors by upper DBE.

Introduction: Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE-ERCP) is an effective method for interventions in the post-surgical patient. Most of the published experiences in DBE- ERCP have used conventional 200-cm double-balloon enteroscopes, which do not permit use of the standard ERCP accessories. The aim of this study was to explore the utility of the ‘short’ 152-cm DBE in patients with surgically altered anatomy. Methods: A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a ‘short’ DBE at 2 referral centers were performed. In patients who had multiple DBE-ERCP performed, only data from the first procedure was included. Enteroscopy success was defined as visualizing the pancreaticobiliary-enteric anastomosis or papilla. ERCP success was defined as completing the intended intervention. Results: From January 2011 through March 2014, we identified 37 patients in whom short DBEassisted ERCP was attempted (35% male, mean age 59 years). Anatomy was Roux-en-Y gastric bypass (n=21), hepaticojejunostomy (n=13), total gastrectomy (n=2), and Billroth 2 (n=1). Primary indications for the procedures were suspected biliary stone (n=10), dilated biliary system (n=7), surgical biliary leak (n=3), suspected anastomotic stricture (n=7), abnormal liver tests (n=6), and others (n=5). Enteroscopy was successful in 30 of 37 (81%), of whom 23 of 30 (82%) achieved ERCP success. Overall, the success rate of DBE-ERCP in all patients was 62% (23/37). The main reasons for enteroscopy failure were inability to reach afferent limb (n=3), inability to visualize anastomosis or ampulla (n=2), and jejunojejunal ulceration (n=1). The reasons for ERCP failure include inability to cannulate due to angulation (n=5), ampullary diverticulum (n=1), and separate pancreatic and biliary orifices (n=1). The following interventions were performed: biliary sphincterotomy (n=11), dilation (n=16), stent insertion (n=9), and stone removal (n=6). The mean duration of the procedures was 85 min (range: 30-236 min). ERCP success rates were similar between native papilla and pancreatobiliaryenteric anastomosis, 79% and 89%, respectively (p=0.51). There were no immediate procedure-related complications. Conclusion: ERCP is successful in nearly two-thirds of altered anatomy patients and in 82% when the papilla or pancreaticobiliary-enteric anastomosis is reached. Short DBEs offer an effective alternative to standard ‘long’ DBEs with the added benefit of the ability to use standard tools. Its use overcomes many of the technical limitations of long DBEs, resulting in reasonably high success rates for endoscopic therapy.

Nearly 140,000 Americans are diagnosed with colorectal cancer (CRC) each year. Colonoscopy has been shown to decrease the incidence and mortality from CRC. Despite this, many Americans remain without access to colonoscopy. Given current time constraints and increasing numbers of patients, it would be useful to improve colonoscopy time-efficiency while preserving safety and comfort.

Device-assisted enteroscopy (DAE) has a critical role in evaluation and treatment of small bowel disorders. It is unclear to what extent DAE is being performed by general gastroenterologists (GG) vs. advanced endoscopists (AE). Our aim was to identify who is being trained in these procedures (GG fellows, AE fellows or both), and what is the opinion of program directors (PD) in GG and AE fellowships as to whom should be performing these endoscopies.

Purpose/Objective(s)Radiation therapy (RT) is seldom considered an option for treating prostate cancer (PCa) in men with inflammatory bowel disease (IBD). We examined our experience in men with IBD who were treated with definitive RT for PCa.Materials/MethodsWe queried our prospective database and reviewed the charts of patients (pts) with a diagnosis of ulcerative colitis (UC), Crohn disease (CD) or IBD NOS treated definitively with RT for PCa. Endpoints were: acute and late > grade 2 (G2) GI toxicity (CTCAE v3.0), IBD flare after RT, biochemical failure (BCF), distant metastasis (DM) and overall survival (OS). Outcomes were compared to historical controls using propensity score matched 3-to-1. We matched controls to the IBD cohort according to: RT technique, RT dose, NCCN risk group, initial hormone use, year of treatment and age. We determined significant predictors of acute outcomes using Fisher's exact test. We compared time to outcomes between groups using the log-rank test.ResultsWe identified 21 pts treated from 1990-2010: 13 UC, 7 CD and 1 IBD NOS. Median age was 69, and median follow-up, 51 months. PCa risk groups were: 11 low, 3 intermediate, 5 high, 2 unknown. Four pts were treated with an I-125 implant, 17 with external beam RT (EBRT) - 6 pts 3D-conformal (3DCRT) and 11 IMRT. Median RT dose was 76 Gy. IMRT dose constraints were used and the median rectal V65 was 11.74% for the IMRT group. The median flare-free interval prior to RT was 10 years. Four pts had a prior colectomy for UC. 7 pts were taking prescribed IBD medications at the beginning of RT - 5ASA compounds, steroids, or infliximab. RT was halted after 10 Gy due to worsening GI symptoms in a patient who failed to disclose his history of IBD and was in the midst of an active flare at the start of RT and was removed from analysis. There was no difference in acute ≥G2 GI toxicity (25% vs 8.3%, p = 0.11) or late ≥G2 GI toxicity (at 36 months, 6.3% vs 10.2%, p = 0.83) in the IBD group vs controls. IBD medication use was the only predictor of acute ≥ G2 GI toxicity - 57.1% with medication vs 7.7% without (p = 0.03) - but did not affect late toxicity. Neither flare-free interval prior to RT, RT dose, nor modality (implant vs 3DCRT vs IMRT) predicted for GI toxicity or subsequent IBD flare. There was no difference in BCF, DM, or OS.ConclusionsWithin the limits of this population, definitive RT for PCa is safe and well tolerated when adhering to strict dosimetric guidelines in a group historically perceived to be at risk for RT complications when compared to matched controls. Acute GI toxicity is exacerbated in pts on concomitant medical therapy for IBD, but late toxicity and ability to complete RT appear to be unaffected. Additionally, patients should not receive RT while experiencing an active IBD flare. Purpose/Objective(s)Radiation therapy (RT) is seldom considered an option for treating prostate cancer (PCa) in men with inflammatory bowel disease (IBD). We examined our experience in men with IBD who were treated with definitive RT for PCa. Radiation therapy (RT) is seldom considered an option for treating prostate cancer (PCa) in men with inflammatory bowel disease (IBD). We examined our experience in men with IBD who were treated with definitive RT for PCa. Materials/MethodsWe queried our prospective database and reviewed the charts of patients (pts) with a diagnosis of ulcerative colitis (UC), Crohn disease (CD) or IBD NOS treated definitively with RT for PCa. Endpoints were: acute and late > grade 2 (G2) GI toxicity (CTCAE v3.0), IBD flare after RT, biochemical failure (BCF), distant metastasis (DM) and overall survival (OS). Outcomes were compared to historical controls using propensity score matched 3-to-1. We matched controls to the IBD cohort according to: RT technique, RT dose, NCCN risk group, initial hormone use, year of treatment and age. We determined significant predictors of acute outcomes using Fisher's exact test. We compared time to outcomes between groups using the log-rank test. We queried our prospective database and reviewed the charts of patients (pts) with a diagnosis of ulcerative colitis (UC), Crohn disease (CD) or IBD NOS treated definitively with RT for PCa. Endpoints were: acute and late > grade 2 (G2) GI toxicity (CTCAE v3.0), IBD flare after RT, biochemical failure (BCF), distant metastasis (DM) and overall survival (OS). Outcomes were compared to historical controls using propensity score matched 3-to-1. We matched controls to the IBD cohort according to: RT technique, RT dose, NCCN risk group, initial hormone use, year of treatment and age. We determined significant predictors of acute outcomes using Fisher's exact test. We compared time to outcomes between groups using the log-rank test. ResultsWe identified 21 pts treated from 1990-2010: 13 UC, 7 CD and 1 IBD NOS. Median age was 69, and median follow-up, 51 months. PCa risk groups were: 11 low, 3 intermediate, 5 high, 2 unknown. Four pts were treated with an I-125 implant, 17 with external beam RT (EBRT) - 6 pts 3D-conformal (3DCRT) and 11 IMRT. Median RT dose was 76 Gy. IMRT dose constraints were used and the median rectal V65 was 11.74% for the IMRT group. The median flare-free interval prior to RT was 10 years. Four pts had a prior colectomy for UC. 7 pts were taking prescribed IBD medications at the beginning of RT - 5ASA compounds, steroids, or infliximab. RT was halted after 10 Gy due to worsening GI symptoms in a patient who failed to disclose his history of IBD and was in the midst of an active flare at the start of RT and was removed from analysis. There was no difference in acute ≥G2 GI toxicity (25% vs 8.3%, p = 0.11) or late ≥G2 GI toxicity (at 36 months, 6.3% vs 10.2%, p = 0.83) in the IBD group vs controls. IBD medication use was the only predictor of acute ≥ G2 GI toxicity - 57.1% with medication vs 7.7% without (p = 0.03) - but did not affect late toxicity. Neither flare-free interval prior to RT, RT dose, nor modality (implant vs 3DCRT vs IMRT) predicted for GI toxicity or subsequent IBD flare. There was no difference in BCF, DM, or OS. We identified 21 pts treated from 1990-2010: 13 UC, 7 CD and 1 IBD NOS. Median age was 69, and median follow-up, 51 months. PCa risk groups were: 11 low, 3 intermediate, 5 high, 2 unknown. Four pts were treated with an I-125 implant, 17 with external beam RT (EBRT) - 6 pts 3D-conformal (3DCRT) and 11 IMRT. Median RT dose was 76 Gy. IMRT dose constraints were used and the median rectal V65 was 11.74% for the IMRT group. The median flare-free interval prior to RT was 10 years. Four pts had a prior colectomy for UC. 7 pts were taking prescribed IBD medications at the beginning of RT - 5ASA compounds, steroids, or infliximab. RT was halted after 10 Gy due to worsening GI symptoms in a patient who failed to disclose his history of IBD and was in the midst of an active flare at the start of RT and was removed from analysis. There was no difference in acute ≥G2 GI toxicity (25% vs 8.3%, p = 0.11) or late ≥G2 GI toxicity (at 36 months, 6.3% vs 10.2%, p = 0.83) in the IBD group vs controls. IBD medication use was the only predictor of acute ≥ G2 GI toxicity - 57.1% with medication vs 7.7% without (p = 0.03) - but did not affect late toxicity. Neither flare-free interval prior to RT, RT dose, nor modality (implant vs 3DCRT vs IMRT) predicted for GI toxicity or subsequent IBD flare. There was no difference in BCF, DM, or OS. ConclusionsWithin the limits of this population, definitive RT for PCa is safe and well tolerated when adhering to strict dosimetric guidelines in a group historically perceived to be at risk for RT complications when compared to matched controls. Acute GI toxicity is exacerbated in pts on concomitant medical therapy for IBD, but late toxicity and ability to complete RT appear to be unaffected. Additionally, patients should not receive RT while experiencing an active IBD flare. Within the limits of this population, definitive RT for PCa is safe and well tolerated when adhering to strict dosimetric guidelines in a group historically perceived to be at risk for RT complications when compared to matched controls. Acute GI toxicity is exacerbated in pts on concomitant medical therapy for IBD, but late toxicity and ability to complete RT appear to be unaffected. Additionally, patients should not receive RT while experiencing an active IBD flare.

Since its inception nearly 40 years ago, endoscopic retrograde cholangiopancreatography (ERCP) has become the therapeutic cornerstone for removal of common bile duct (CBD) stones. Removal of the vast majority of stones with endoscopic sphincterotomy (EST), followed by sweeping the duct with either balloon or basket is successful in most cases, with an acceptable safety profile. Nevertheless, despite considerable refinements in ERCP over the last four decades, management of large, ‘‘difficult’’ CBD stones remains a therapeutic challenge. The definition of ‘‘large’’ CBD stones varies, ranging from[1 to[2 cm in diameter. Although the size of a stone is a prime determinant of its resistance to extraction, factors other than size are important. In a multivariate analysis, acute angulation of the distalmost aspect of the CBD and a shorter length of this distal CBD ‘‘arm’’ were associated with difficulty of ductal clearance [1]. Other factors inversely associated with stone clearance include very large stones such as those [3 cm, surgically altered anatomy, and firmness of the stones. The endoscopist must also consider not only the absolute stone size, but its diameter relative to the width of the distal duct through which it must be removed. Several different fragmentation modalities have been studied for the removal of difficult stones: extracorporeal shock wave lithotripsy (ESWL), mechanical lithotripsy (ML), electrohydraulic lithotripsy (EHL), and laser lithotripsy (LL) (Table 1). Each technique works reasonably well, albeit with significant drawbacks. ESWL achieved ductal clearance in 84 % of 283 patients with an acceptable minor complication profile [2]. However, this technique is notoriously cumbersome, requiring multiple treatment sessions: initial ERCP with placement of nasobiliary drain, ESWL with stone fragmentation, followed by at least one additional ERCP with removal of smaller stone fragments. A randomized study comparing LL with ESWL showed that LL cleared the duct with fewer fragmentation sessions and endoscopic procedures [3]. Mechanical lithotripsy (ML) has a long track record in the therapy of large stones. It utilizes a metal basket and overlying sheath, into which stone fragments become trapped and crushed. Its advantage is that it is a widely available accessory which can be deployed in the course of a ‘‘routine’’ ERCP without bringing in additional, expensive equipment. However, it can be challenging to set up and deploy; furthermore, its use does not entirely prevent the feared scenario of impacted basket and stone in the biliary tree, which transforms an endoscopic dilemma into a surgical emergency. Results are generally favorable, but not universally successful. In a review from a Canadian referral center, nearly one-quarter of patients treated with ML required more than one endoscopic treatment [4]. Electrohydraulic lithotripsy (EHL) relies upon the generation of shock waves, which under continuous saline irrigation of the bile duct are transmitted to stones, which then shatter. It has been traditionally performed using a dedicated smaller caliber cholangioscope which fits inside the working channel of a therapeutic duodenoscope, a so-called ‘‘mother–baby’’ scope arrangement. Unfortunately, this arrangement is extremely time-consuming, requires two endoscopists, and the cholangioscopes are extremely fragile. These formidable barriers have detracted from the appeal of EHL, even in tertiary referral centers. Laser lithotripsy (LL) works on a similar general principle to EHL. LL uses a high power light wavelength to deliver shockwaves to stones, thereby fragmenting them. S. J. Heller (&) Division of Gastroenterology, Fox Chase Cancer Center, Philadelphia, PA, USA e-mail: Stephen.Heller@fccc.edu

Double-balloon enteroscopy-assisted endoscopic retrograde cholangiopancreaticography (DBE–ERCP) is an effective method for interventions in the pancreaticobiliary system in the post-surgical patient. However, use of currently available endoscopic accessories during this procedure is limited due of the length of the conventional instrument (200 cm). The aim of this study was to explore the utility of the short DBE (152 cm) for the management of pancreaticobiliary disorders in patients with surgically altered anatomies.

Purpose: Meckel's diverticula (MD) are typically found in the ileum and > 50% contain heterotopic gastric or pancreatic mucosa. MD may present with gastrointestinal hemorrhage, intussusception, obstruction, diverticulitis, or perforation. Most MD are diagnosed via technetium-99 scintigraphy or at surgical exploration. Double balloon enteroscopy (DBE) permits direct endoscopic visualization and therapy for lesions in the distal small bowel. We sought to characterize our experience with the diagnosis of MD via DBE. Methods: We retrospectively reviewed DBE performed at two tertiary care centers from 2004-2012 for the diagnosis of MD. Results: We report 8 cases of MD diagnosed via retrograde DBE at two tertiary referral centers (Table 1). All 8 patients had prior negative endoscopic and/or radiologic evaluation and were subsequently referred for device-assisted enteroscopy.Table 1: No Caption available.Conclusion: Retrograde DBE readily detects the presence of MD. While prior series have emphasized MD in the differential diagnosis of obscure bleeding in the young, the median age in our series was 57 years. MD should remain in the differential diagnosis in older patients with bleeding. The endoscopic identification of ectopic gastric mucosa and adjacent ulceration presumably increase the likelihood that MD is the source of obscure bleeding. Further, the ability to tattoo the site facilitates laparoscopic surgical intervention. These cases illustrate that MD can be easily identified via retrograde DBE and should be considered in the differential diagnosis of obscure bleeding in adult patients. Disclosure: Dr. Oleh Haluszka - Consultant Fujinon.Figure: Mucosal ulceration within a MD.Figure: Heterotopic mucosa in the base of a MD.

A 55 year old woman was referred to us for double balloon enteroscopy (DBE) for obscure-occult gastrointestinal bleeding. Her past medical history included non-alcoholic steatosis without clinical evidence of advanced hepatic fibrosis, HTN, hypercholesterolemia, GERD and chronic iron deficiency anemia. She denied any history of bleeding diatheses, alcohol use, malignancy, or use of non-steroidal anti-inflammatory, antiplatelet, or anticoagulant medications. Following an extensive but unrevealing diagnostic workup, she was referred to our institution for DBE.

The small bowel is a relatively infrequent site of malignancy in the gastrointestinal tract. The most common primary tumors of the small bowel are adenocarcinoma, lymphoma, neuroendocrine tumors, and gastrointestinal stromal tumors. However, as many as half of all small bowel tumors are metastatic. In general, the best chance for cure in patients with localized primary small bowel malignancy is surgical resection. The incidence of primary small bowel cancer is strikingly elevated in the genetic syndromes of familial adenomatous polyposis, hereditary nonpolyposis colorectal cancer, and Peutz–Jeghers syndrome. In the hope of prevention or early detection of cancer in patients with these disorders, experts have recommended surveillance of the small bowel in affected individuals. Historically, surveillance has been performed with small bowel radiography. However, in the past decade, video capsule endoscopy has largely replaced x-ray studies. Device-assisted enteroscopy, most notably double-balloon enteroscopy, has assumed an expanding role in the surveillance of these patients and in the endoscopic removal of premalignant lesions of the small bowel, such as adenomas and hamartomas.

Purpose: A 69-year-old female was referred to our institution for upper double balloon enteroscopy (DBE). She had been diagnosed by her primary physician with microcytic anemia and referred to a gastroenterologist for endoscopic evaluation. No melena, hematochezia, nausea or weight loss was noted. No blood transfusion was required. The patient denied the use of NSAID drugs, anti-platelet agents or anticoagulants. The patient's hemoglobin was 9.4 g/dl with a mean corpuscular volume (MCV) of 66 FL. Upper endoscopy and colonoscopy were unremarkable. A wireless video capsule endoscopy revealed “a friable mid-jejunal polyp.” No angiodysplasias were seen. Based upon these findings, we performed an upper double DBE, which demonstrated a 15 mm pedunculated polyp with a hemorrhagic appearance in the mid-jejunum, approximately 200 cm distal to the ligament of Treitz. The polyp was removed in toto with snare electrocautery following the injection of 5 cc of 1:40,000 epinephrine at the base and two hemostatic clips placement at the polypectomy site to preserve hemostasis. The patient recovered uneventfully from the procedure and was discharged home. Pathology demonstrated large, dilated, blood-filled vessels lined by flattened endothelium consistent with cavernous hemangioma. Conventional endoscopy can detect tumors as far distal as the proximal jejunum. In the last decade, the introduction of deep enteroscopy using device-assisted methods (e.g. DBE) has enabled endoscopists to directly visualize, sample, and potentially treat small bowel (SB) polyps and neoplasms. SB hemangioma is a rare disease, accounts for only 0.05% of intestinal neoplasms and up to 10% of the benign tumors of the SB. These lesions are more frequently located in the jejunum. SB hemangiomas most commonly present with symptoms such as acute or chronic gastrointestinal bleeding, anemia, malabsorption and occasionally platelet sequestration. Rarely, these lesions present more acutely with intussusception, small bowel obstruction or perforation. Diagnosis is usually made with biopsy or resection of the lesion. With the advent of deep SB enteroscopy, gastroenterologists have a new tool to deeply intubate the SB, visualize these neoplasms directly and perform endoscopic therapy including polypectomy. Conclusion: SB hemangioma is a rare neoplasm and an uncommon cause of obscure GI blood loss. Here we describe the detection and successful removal of a jejunal hemangioma using DBE and standard polypectomy technique. Clinicians should be aware of SB hemangiomas on the differential diagnosis of polypoid lesions of the SB, and the feasibility of removal of these lesions by DBE.