Background/Aims Optimal small bowel (SB) preparation for video capsule endoscopy (VCE) is controversial. Our study aimed to support the use of a specified volume of 4 liters of clear liquids for bowel preparation for VCE. Methods A retrospective review of 284 patients who underwent SB preparation with 2 liters of polyethylene glycol (PEG) and 284 patients who had 4 liters of clear liquid preparation. We analyzed image quality, endoscopic findings, completion rate, and transit times. Results The 4-liter clear liquid group had significantly higher mean image quality scores when compared to the PEG group (2.908±0.77 to 2.669±0.64, p<0.0001), as well as more studies with adequate preparation (72% to 64%, p=0.0214). Although the PEG group had more endoscopic findings on VCE (40% to 23%, p<0.0001), there was a significant difference in the indications for the procedure between the groups. There was no difference in the capsule completion rate or SB transit time. Conclusions Our data demonstrate significantly higher mean image quality scores when using a specified volume of 4 liters of clear liquid compared to 2 liters of PEG. This study supports the growing evidence of the effectiveness of a 4-liter clear liquid SB preparation as opposed to PEG for VCE.

Background: We aimed to characterize the impact of antiretroviral therapy (ART) initiation on gastrointestinal-associated lymphoid tissue at various sites along the gastrointestinal site. Methodology: Peripheral blood and duodenal and rectal biopsies were obtained from 12 HIV- to 33 treatment-naive HIV+ participants at baseline and after 9 months ART. Tissue was digested for immunophenotyping. Inflammatory, bacterial translocation and intestinal damage markers were measured in plasma. Results: Twenty-six HIV+ patients completed follow-up. The lowest reconstitution of CD4(+) T cells and the lowest CD4(+)/CD8(+) ratio during ART compared with blood were observed in the duodenum with the rectum being either intermediate or approaching blood levels. Regulatory T cells were in higher proportions in the duodenum than the rectum and neither declined significantly during ART. Several correlations with biomarkers of microbial translocation were observed including increases in lipoteichoic acid levels, which reflects Gram-positive bacterial translocation, correlated with increases in %CD4(+) T cells in the duodenum (Rho 0.773, P = 0.033), and with decreases in duodenal regulatory T-cell populations (Rho -0.40, P = 0.045). Conclusion: HIV-mediated immunological disruption is greater in the duodenum than rectum and blood before and during ART. Small intestine damage may represent a unique environment for T-cell depletion, which might be attenuated by interaction with Gram-positive bacteria.

Background: An effective bowel cleanse can improve the imaging quality of video capsule endoscopy (VCE). We aimed to further investigate the optimal small bowel cleanse method by comparing the efficacy of 4 L of clear liquids, 2 L of polyethylene glycol (PEG), and 4 L of PEG on the image quality of VCE. Methods: A randomized controlled, non-inferiority trial was performed comparing 4 L of clear liquids (Group A), 2 L of PEG (Group B), and 4 L of PEG (Group C). The primary endpoint was image quality between the groups. The secondary endpoints included patient tolerability and side effects. Results: Eighty-one patients were analyzed in group A, 84 patients were analyzed in group B, and 80 patients were analyzed in group C. Image quality scores revealed 4 L of clear liquids to be non-inferior to 2 L of PEG, and 2 L of PEG to be non-inferior to 4 L of PEG (p < 0.0167). Group A had a lower difficulty of completion rate than Group B and Group C and a lower rate of side effects when compared to Group C (p < 0.0167). Conclusion: Four liters of clear liquids should be considered a routine method for small bowel preparation prior to VCE.

A 19-year-old, previously healthy woman presented with epigastric abdominal pain for 1 year. Radiograph of kidney, ureters, and bladder at that time showed ingested material filling a dilated stomach (Figure 1A), and gastric emptying study showed gastric retention of 78% and 71% at 2 and 4 hours, respectively. A few months later, the patient was seen in our clinic with persistent abdominal pain, with physical exam finding a firm, nontender mass in the epigastric region. She admitted to trichotillomania for the past 10 years, and underwent urgent computed tomography of the abdomen (Figure 1B and C). Endoscopic and chemical treatment were not possible as the entire stomach was filled with trichobezoar, and a surgical approach was indicated. The patient underwent urgent laparotomy, where a 1,466 g, 21 × 15 × 7 cm firm mass of hair was removed (Figure 1D). She recovered from surgery without any complication and followed closely with psychiatry thereafter. Trichobezoars are rare findings and form in patients with trichotillomania and trichophagia. Hair is retained between the gastric folds and becomes denatured by gastric acid, and subsequently turns black from oxidation. Once formed, bezoars continue to grow with ingestion of food rich in cellulose and other indigestible fiber, potentially forming a large mass within the stomach.

Plasma, duodenal, and rectal tissue antiretroviral therapy (ART) drug concentrations, human immunodeficiency virus (HIV) RNA and HIV DNA copy numbers, and recovery of mucosal immunity were measured before and 9 months after initiation of 3 different ART regimens in 26 subjects. Plasma and tissue HIV RNA correlated at baseline and when 9-month declines were compared, suggesting that these compartments are tightly associated. Antiretroviral tissue:blood penetration ratios were above the 50% inhibitory concentration values in almost 100% of cases. There were no correlations between drug concentrations and HIV DNA/RNA. Importantly, no evidence was found for residual viral replication or deficient tissue drug penetration to account for delayed gastrointestinal-associated lymphoid tissue immune recovery.

[This corrects the article DOI: 10.1371/journal.ppat.1005381.].

Introduction: Video capsule endoscopy (VCE) is a relatively new technology and its use has been expanding. Current guidelines for VCE is for the evaluation of patients with obscure gastrointestinal bleeding (OGIB) or iron deficiency anemia (IDA) after negative standard endoscopy studies. However, this test may be ordered for other indications that may not reveal pathology. Our study was designed to determine which clinical indications were associated with a normal VCE and to examine if this test is being ordered appropriately. Methods: Data reviewed from June 3, 2010 to September 9, 2011 in a single-center university setting and 247 VCEs were studied and 100 VCEs were normal. Clinical indications for VCE were recorded and one patient could have multiple clinical indications. If the VCE was for anemia, the chart was reviewed, if available, to further characterize the type anemia. Other variables that were examined were age, gender, video capsule reader, small bowel passage time, and bowel preparation quality. Results: Anemia was the most common clinical indication with an overwhelming 80% of the normal VCEs (Table 1). OGIB was the second most common clinical indication (19%) followed by chronic diarrhea (8%), chronic abdominal pain (6%), evaluation or history of Crohn's disease (5%), and other (4%). Among the 80 patients whose clinical indication was anemia, 53 patients had VCEs ordered for IDA and/or microcytic anemia while 20 patients had VCEs ordered for normocytic anemia. Six out of the 80 patients did not have any corroborating information either from the available labs or chart to specify the type of anemia. Of the 100 patients, 62 were female and 38 were male with an average age of 60 years. Two video capsule readers read almost an equal number of cases (47 vs 53). The majority of the VCE were ordered in the outpatient rather than inpatient setting (90 vs 10) and ordered by providers specializing in Gastroenterology rather than non-Gastroenterology specialists (81 vs 19). Average small bowel transit time was 213 minutes and 92% of the bowel preparation was good.Table 1: Results of the Most Common Clinical IndicationsConclusion: Anemia of all causes was the most common clinical indication for VCE results that were normal, with IDA and/or microcytic anemia as the most common type of anemia. However, 25% these normal VCEs ordered for anemia had normocytic anemia and further studies are necessary to determine whether ordering VCE for normocytic anemia is helpful.

Background: Dieulafoy lesions account for approximately 5% of all gastrointestinal bleeds, with a mortality rate of 8.6%. Dieulafoy lesions are most commonly seen in the stomach, duodenum, and esophagus. Jejunal Dieulafoy's are exceedingly rare, accounting for approximately 1% of all lesions. We present two case reports of patients diagnosed with jejunal Dieulafoy lesions. Case Series: Case 1: A 78 year old male with CAD, atrial fibrillation, and ESRD on HD presented with melena. EGD/colonoscopy was nondiagnostic. Video capsule endoscopy (VCE) showed dark red blood from the mid small bowel up to the ileocecal valve. Anterograde double balloon enteroscopy (DBE) revealed a bleeding Dieulafoy's approximately 240 cm from the pylorus. Case 2: A 64 year old male with CHF, DM2, and HTN presented with melena. EGD/colonoscopy was non-diagnostic. VCE showed fresh red blood in the proximal jejunum. Anterograde DBE revealed a bleeding Dieulafoy's approximately 110 cm from the pylorus. Both patients were treated with multiple hemoclips followed by epinephrine injection, and successful hemostasis was achieved. Discussion: A Dieulafoy lesion is a dilated aberrant submucosal vessel that erodes through the overlying epithelium in the absence of a primary ulcer. Dieulafoy lesions are typically seen in patients with cardiovascular disease, chronic kidney disease, diabetes, hypertension, and in patients who use NSAIDs. Endoscopy is the procedure of choice for diagnosis and treatment of Dieulafoy lesions. Endoscopic treatment options include hemoclips, epinephrine injection, argon plasma coagulation (APC), or heater probe thermal coagulation. Endoscopic therapy is highly successful with a primary hemostasis rate over 90%. Studies have shown increased efficacy with the use of hemoclips and combined endoscopic therapies. Dulic-Lakovic et al, reviewed 284 patients referred to nine Austrian medical centers for small bowel enteroscopy. Small bowel Dieulafoy's were identified in ten patients (3.5%). All ten patients had successful primary hemostasis. Two patients, treated with APC and epinephrine injection, had re-bleeding events requiring surgical management. This case highlights the diagnostic and therapeutic challenges posed by small bowel Dieulafoy lesions.Figure 1Figure 2

Objective: To investigate the potential role of mucosal intestinal myofibroblasts (IMFs) in HIV and associated fibrosis in gut-associated lymphoid tissue. Design: Profibrotic changes within the secondary lymphoid organs and mucosa have been implicated in failed immune reconstitution following effective combination antiretroviral therapy (cART). Microbial translocation is believed to be sustaining these systemic inflammatory pathways. IMFs are nonprofessional antigen-presenting cells with both immunoregulatory and mesenchymal functions that are ideally positioned to respond to translocating microbial antigen. Methods: Duodenal biopsies, obtained from patients naive to cART, underwent trichrome staining and were examined for tissue growth factor-beta (TGF-β) expression. Combined immunostaining and second harmonic generation analysis were used to determine IMF activation and collagen deposition. Confocal microscopy was performed to examine IMF activation and Toll-like receptor (TLR)4 expression. Finally, primary IMF cultures were stimulated with lipopolysaccharide to demonstrate the expression of the inflammatory biomarkers. Results: The expression of the fibrosis-promoting molecule, TGF-β1, is significantly increased in duodenal biopsies from HIV patients naïve to cART, and negatively correlated with subsequent peripheral CD4+ recovery. The increase in TGF-β1 coincided with an increase in collagen deposition in the duodenal mucosa in the tissue area adjacent to the IMFs. We also observed that IMFs expressed TLR4 and had an activated phenotype since they were positive for fibroblast activation protein. Finally, stimulation of IMFs from HIV patients with TLR4 resulted in significantly increased expression of profibrotic molecules, TGF-β1, and interleukin-6. Conclusion: Our data support the hypothesis that activated IMFs may be among the major cells contributing to the profibrotic changes, and thus, the establishment and maintenance of systemic inflammation interfering with immune reconstitution in HIV patients.

Video capsule endoscopy (VCE) has emerged as the preferred method for small bowel (SB) evaluation in the workup of obscure gastrointestinal bleeding (OGIB). Efforts focusing on optimization of VCE have revealed a clear improvement in diagnostic yield (DY) when VCE is performed within 2 weeks of OGIB diagnosis. Additional studies dedicated to evaluating early use of VCE in OGIB are needed.

Introduction: The explanation for why insertion water exchange (WE) increases proximal colon adenoma detection rates compared to air insufflation (AI) is unknown. Our aim was to test the hypothesis that compared with AI, insertion WE significantly reduces the number of multitasking-related distractions from mucosal inspection. Methods: Prospectively recorded videos of screening colonoscopies comparing AI and WE were edited to remove the insertion phase of examination. Two reviewers blinded to insertion techniques evaluated recordings using a validated scoring system. Distractions from mucosal inspection were defined as water infusion, suctioning to clean the mucosa, and colonic spasms. The number of each distraction was analyzed by colonic segment. Withdrawal techniques, total withdrawal time, and bowel preparation quality scores were assessed. Intervention involving polypectomy and/or biopsy was considered yield of quality outcome.Table 1Results: When WE and AI were compared, no significant differences were noted for withdrawal techniques, total withdrawal and active inspection time, or bowel preparation scores. Compared with AI (n=42), insertion WE (n=24) consistently and significantly decreased the number of distractions of water infusion and suctioning during withdrawal in the right colon (cecum and ascending colon; p<0.0001). Yield of quality outcome was significantly increased in the right colon (p=0.01). Conclusion: Insertion WE is associated with fewer multitasking-related distractions during withdrawal inspection. Fewer multitasking-related distractions during colonoscope withdrawal may be a plausible explanation for the enhanced yield of quality outcomes in the right colon in earlier reports.

BACKGROUND:Concerns over the hypothetical adverse effects of water absorption and the disturbance of serum sodium and potassium levels prompted a quality assurance evaluation of water exchange (WE) colonoscopy.AIM:The purpose of this study was to evaluate the balance of water infused and suctioned in WE colonoscopy, and to quantify the acute impact on serum levels of sodium and potassium.METHODS:Prospectively collected quality monitoring data of patients undergoing screening and surveillance colonoscopy at the Sacramento Veterans Affairs Medical Center were analyzed. Measurements were made of volume infused and suctioned during, and blood samples drawn 10 min before the start of and 10 min after completion of WE colonoscopy. Outcome measures included volume of water infused and suctioned, and serum levels of sodium and potassium.RESULTS:A total of 140 patients (134M:6F), mean age of 59, underwent WE colonoscopy. Mean total volume of water infused was 1,839 mL. A negative balance of an average of 22 mL was documented. The mean (standard deviation) values (in meq/L) of serum levels of sodium 139.33 (2.27) and 139.28 (2.32), and potassium 3.86 (0.36) and 3.91 (0.39), before and after colonoscopy, respectively, showed no significant change.CONCLUSION:The WE method allowed most of the water infused during colonoscopy to be recovered by suction at the completion of colonoscopy. Serum sodium and potassium levels did not change significantly within 10 min after completion. The WE method appears to be safe with minimal water retention and is devoid of acute fluctuations in serum levels of sodium and potassium.

Purpose: A 26-year-old woman presented with one-day history of hematochezia beginning shortly after undergoing dilation and evacuation for retained products of conception. On initial evaluation, the patient was hypotensive, tachycardic and acutely anemic (hemoglobin/hematocrit 8.6/25.5). An emergent CT scan with rectal contrast ruled out bowel or uterine injury. Urgent EGD and colonoscopy were performed, however, no sign or source of bleeding was identified. A tagged RBC scan showed only vaginal bleeding. The patient subsequently stabilized; however, two days later, she had recurrent hematochezia and worsening anemia with a hemoglobin of 6.4. She denied any vaginal bleeding at that time, having used a tampon to avoid confusion. Thus repeat EGD and colonoscopy were performed, which, again, did not identify a source of bleeding. However, a capsule endoscopy revealed fresh blood in the proximal to mid-small bowel. She thus underwent an urgent antegrade single balloon enteroscopy, where a 1.5-cm submucosal polyp with an ulcerated and necrotic surface was found at approximately 180 cm from the pylorus (Figure 1). The lesion was tattooed with India ink and injected with diluted epinephrine. A diagnostic laparoscopy with segmental small bowel resection removed the lesion and pathology of the polyp returned as intravascular papillary endothelial hyperplasia (Masson's tumor). Masson's tumors are benign vascular lesions that arise from intravascular endothelial proliferation in the setting of thrombus. They primarily affect the extremities, head and neck and have rarely been described within the abdominal cavity. To the best of our knowledge, only five other cases of Masson's tumor in the small bowel have been reported in the literature. When involving the GI tract, patients typically present with abdominal pain, melena, and anemia. The case described here is unique in that it is the only known instance of a patient with a Masson's tumor of the small bowel presenting with hematochezia.Figure 1: Submucosal ulcerated polyp found approximately 180 cm from the pylorus with antegrade single balloon enteroscopy.

Be. Results: examination of our experience showed obscure GI bleeding as the most common indication (77%), with angioectasias being the most common finding (47%). Our diagnostic yield (DY) was 79%. subgroup analysis showed a significantly higher DY when sBe was preceded by a positive video capsule endoscopy (V ce) exam (89% vs 59%, p=0.03). Of the Vce findings, fresh blood and angioectasias were significantly more likely to be confirmed on subsequent sBe (p=0.02). We recorded no significant adverse events. Our systematic review showed a significant positive correlation only between depth of insertion and procedure time. Two (0.2%) perforations were reported. Conclusions: sBe is a safe and effective method for sB evaluation, and has a significantly higher DY when preceded by a positive Vce exam showing fresh blood/angioectasias. Improvement of DY may not be dependent on procedure time, depth of insertion, or even procedure volume. prior sB evaluation by V ce and diligent examination during sBe may be the primary means to enhance DY.

Purpose: Colonoscopy led to a reduction in the incidence and mortality of colorectal cancer, a remarkable achievement when compared to other cancers. Interval cancers after screening colonoscopy drew attention to quality improvement. Missed small adenomas may be a contributing factor. The impact of adjunct measures (dye, cap, insertion polypectomy, retroflexion, NBI, water immersion) on ADR is mixed, suggesting usual insertion with air insufflation (AI) imposes unrecognized limitations. A new insertion platform may be needed. Hypothesis-generating retrospective studies show water exchange (WE) increases ADR. Pilot data of WE plus dye or cap vs AI show higher ADR. Since 2010, six RCTs have assessed the impact of WE on primary outcomes of insertion pain, cecal intubation rate and ADR. Hypothesis: Aggregate data of these RCTs show that WE enhances results of withdrawal inspection. Overall ADR in the entire colon and overall and <10 mm ADR in the proximal colon are increased significantly. Methods: Water exchange is a novel method based on modification of the widely used water immersion method. Its original goal was to minimize insertion pain in veterans who accepted scheduled unsedated colonoscopy without backup sedation in the U.S. It entails exclusion of air (air pump turned off and all residual luminal air removed by suction). Infusion of water coupled with removal of residual feces to clear the view is used to identify the lumen to aid insertion. Unique to the approach is that the infused water is removed predominantly during insertion to minimize distension. The approach avoids looping and pain during insertion; and minimizes distraction (need to remove large quantities of liquid) during withdrawal inspection. Mastery of the maneuvers after practice is reproducible. Six RCT compared WE to AI. During withdrawal, polyps were removed from the air filled colon. ADR was recorded based on intention-to-treat. Proper use of WE was ascertained by FWL via site-visits or by e-mail discussions. Uniform use of WE justifies merging ADR data for analyses. Results: (Tables 1 and 2): 797 and 805 subjects were randomized to the WE and AI arms. Data (not all shown) of each RCT confirm even randomization. Compared to AI, WE consistently (n=6 RCT; P=0.05; signed rank test) produces higher ADR, irrespective of ethnicity, site, sedation option, gender mix or bowel preparation regimen. The aggregate data of overall ADR in the entire colon (↑4-13%; mean 7%); overall and <10 mm ADR in the proximal colon (↑7-8%) show that WE is superior to AI. Limitation: Unblinded colonoscopists, included non-screening cases.Table 1: Demographic variables and procedural outcomesTable 2: Detection of adenomas in the entire colon and the proximal colonConclusion: The consistently higher ADR supports WE as a suitable insertion platform to replace AI in planned evaluation of new adjunct measures to improve ADR.

Purpose: In a randomized controlled trial (RCT; NCT01790425), we compared air insufflation vs. water infusion colonoscopy in female non-veteran patients presenting for colonoscopy. Water infusion in lieu of air insufflation for performing colonoscopy has been reported to have beneficial effects when studied in male veteran patients. These include significant reduction in discomfort with higher percentage (98% vs. 76%) of veterans successfully completing scheduled unsedated colonoscopy. The application of water infusion colonoscopy is less well-described in female than in male patients in the United States in a non-veteran setting. Methods: All patients received IV conscious sedation for the colonoscopy. In the conventional air (control) method, air is pumped gently (insufflation) into the colon to open the lumen and aid in colonoscope insertion. In the water (study) method, air button was turned off before scope insertion. Warm (body temperature) water was infused into the colon in place of air to distend the lumen and aid in colonoscope insertion until cecum was reached. Most of the infused water is suctioned during the scope insertion. Pain score was documented by the nurse during scope insertion and on withdrawal. Scope shortening, loop reduction, and suction removal of air or water were done when patient experienced pain/discomfort on scope insertion. For both methods, abdominal compression by the assistant or change in patient's position was performed to facilitate scope advancement in difficult cases. Air was used in both groups on scope withdrawal to facilitate biopsy and removal of lesions. Results: Demographic and baseline variables were comparable between the two groups except for signifi cantly more patients had abdominal surgery (excluding colon resection) in the water (study) group compared with the air (control) group (Table 1). There were no statistically significant differences in cecal intubation time and total procedure time between the two methods. Pain score was significantly higher on insertion with the air method, especially in the proximal colon before reaching the cecum, compared with the water method. There was significantly less need for abdominal compression or position change to facilitate scope insertion with water method. There was also less pain at discharge with a correspondingly better patient experience with the water method (Table 2).Table 1: Demographic and baseline dataTable 2: Primary and secondary outcomesConclusion: Despite having more patients with presumed difficult colonoscopy (prior abdominal surgery), water exchange colonoscopy offered a better patient outcome among non-veteran female patients with less need for abdominal compression for completion, lower pain scores, and better patient experience.