Sa1642. Effectiveness of Double Balloon Enteroscopy for Obscure. Gastrointestinal Bleeding : a Multicenter Retrospective Cohort. Study by Osaka Gut Forum.
Abstracts Sa1642 Effectiveness of Double Balloon Enteroscopy for Obscure Gastrointestinal Bleeding : a Multicenter Retrospective Cohort Study by Osaka Gut Forum Akira Maekawa*1, Masato Komori2, Satoshi Egawa3, Shinjirou Yamaguchi4, Kunio Suzuki5, Sachiko Nakajima6, Hiroyuki Ogawa7, Takashi Ueda8, Satoshi Hiyama1, Takahiro Inoue1, Takuya Yamada1, Shinichiro Shinzaki1, Tsutomu Nishida1, Hideki Iijima1, Masahiko Tsujii1, Tetsuo Takehara1 1 Department of Gastroenterology and Hepatology, Osaka University Graduate School of Medicine, Suita, Japan; 2Department of Gastroenterology, Osaka Rousai Hospital, Sakai, Japan; 3Department of Gastroenterology, Kansai Rousai Hospital, Amagasaki, Japan; 4 Department of Gastroenterology, Osaka Police Hospital, Osaka, Japan; 5 Department of Internal Medicine, Saiseikai Senri Hospital, Suita, Japan; 6Department of Gastroenterology, NTT-West Osaka Hospital, Osaka, Japan; 7Department of Gastroenterology, Nishinomiya Municipal Central Hospital, Nishinomiya, Japan; 8Department of Gastroenterology, Yao Municipal Hospital, Yao, Japan Background and Aim: Double-balloon enteroscopy (DBE) enabled endoscopic approaches to the small intestine and is useful to make accurate diagnosis of the responsible lesions of bleeding in patients with obscure gastrointestinal bleeding (OGIB). It is unknown, however, about the efficacy of DBE in association with bleeding condition. We aimed to investigate the efficacy of DBE for the diagnosis of occult and overt OGIB in a multi-center cohort. Methods: We analyzed 323 patients who underwent DBE due to OGIB between June 2004 and September 2012 in tertiary-care hospitals of Osaka Gut Forum. Overt OGIB was defined as with visible GI bleeding, while occult OGIB was with anemia or with a positive fecal occult blood test. Overt OGIB was further differentiated in terms of DBE findings in active overt (i.e., existence of endoscopic ongoing bleeding or bloody residue) and inactive overt bleeding. Results: We performed 430 DBE in 277 patients with overt OGIB (162 male, 115 female; mean age, 67 years; range, 15-91 years) and 46 DBE in 82 patients with occult OGIB (29 male, 17 female; mean age, 66 years; range, 17-84 years). Detection rate of the bleeding lesion was 55% (152/277) in patients with overt OGIB, including ulceration in 53 patients (35%), vascular lesions in 35 patients (23%), and neoplastic lesions in 18 patients (18%). Seventy lesions were diagnosed in oral DBE, while 82 were diagnosed in anal DBE. Detection rate of bleeding lesion was 49% (21/46) in patients with occult OGIB and was similar to that of overt OGIB. These lesions included ulceration in 8 patients (38%), vascular lesions in 4 patients (19%), and neoplastic lesions in 4 patients (19%). Nine lesions were diagnosed in oral DBE, while 12 were diagnosed in anal DBE. In 277 patients with overt OGIB, 49 patients showed endoscopically active bleeding by DBE and 228 did not. The shorter time from bleeding symptom till DBE, the more active bleeding was detected. The proportion of ulcer lesions was lower in active bleeding patients (26%) than in inactive patients (38%). In contrast, vascular lesions were significantly higher in patients with active bleeding (33%) than that of patients with inactive bleeding (19%). Conclusions: The detection rate of the bleeding lesions using DBE was similar between overt and occult OGIB and ulceration is most commonly observed in both overt and occult OGIB. Endoscopists should bear in mind that the types of lesions responsible for bleeding are different in terms of bleeding conditions.
Sa1643 Clinical Usefulness of New Classification of Intestinal Lymphangiectasia Inducing Protein-Losing Enteropathy (Superficial White Villi Type and Deep Non-White Villi Type) Naoki Ohmiya*1, Masanao Nakamura1, Takeshi Yamamura1, Taro Mizutani1, Makoto Ishihara1, Koji Yamada1, Asuka Nagura1, Toru Yoshimura1, Kohei Funasaka2, Ryoji Miyahara1, Eizaburo Ohno2, Hiroki Kawashima1, Akihiro Itoh1, Yoshiki Hirooka2, Osamu Watanabe1, Takafumi Ando1, Hidemi Goto1,2 1 Department of Gastroenterology and Hepatology, Nagoya University Graduate School of Medicine, Nagoya, Japan; 2Department of endoscopy, Nagoya University Hospital, Nagoya, Japan Background and Aims: Protein-losing enteropathy (PLE) is characterized by enteric loss of plasma proteins in abnormal amounts, resulting in hypoproteinemia. Although PLE is rare, it has many causes. Especially, intestinal lymphangiectasia (IL) is the primary etiology of PLE due to lymphatic obstruction. We classified IL enteroscopically and pathologically into two subgroups (i.e., superficial white villi type and deep non-white villi type), and evaluated their clinical characteristics and response to treatment. Patients and Methods: Of 929 patients who underwent double-balloon enteroscopy (DBE) between June 2003 and June 2012, 13 consecutive patients (7 male and 6 female, 40 ⫾ 23 years of age) with IL inducing PLE were enrolled. PLE was confirmed by fecal ␣1-AT clearance (C␣1AT) and/or technetium Tc 99m human serum albumin scintigraphy accompanied by hypoproteinemia (serum total protein
value ⬍ 6.0 g/dL or serum albumin value ⬍ 3.0 g/dL). These patients also underwent esophagogastroduodenoscopy, abdominal contrast-enhanced computed tomography (CECT), videocapsule endoscopy, and were clinically diagnosed with primary (n⫽9) and secondary IL (n⫽4; systemic lupus erythematosus, primary macroglobulinemia, post-radiation therapy, and post-liver transplantation) . Results: Enteroscopically, white plaques and white-tipped villi were observed in 7 patients and non-white swollen villi and folds were observed in 6 patients. Biopsy specimens at DBE revealed that white villi had D2-40positive lymphangiectasia in the lamina propria, and non-white swollen villi had D2-40-positive lymphangiectasia in the muscularis mucosa or submucosal layer. Snake skin appearance in the stomach was obseverd at 0% in superficial white villi type and at 67% in deep non-white villi type. Serum total protein, albumin, and C␣1AT levels in patients with superficial white villi type and deep non-white villi type were 3.7 ⫾ 0.6 g/dL vs. 3.4 ⫾ 0.6 g/dL (P ⫽ 0.570), 1.9 ⫾ 0.4 g/dL vs. 1.2 ⫾ 0.5 g/dL (P⫽0.026), and 140.0 ⫾ 81.4 mL/day vs. 284.6 ⫾ 165.9 mL/day (P⫽0.063), respectively. At CECT, enhanced small-bowel wall thickness, enhanced paraaortic fat density, and mesenteric lymph nodes were observed at 86%, 29%, and 57% in patients with superficial white villi type and at 83%, 33%, and 83% in deep non-white villi type, respectively. Response to corticosteroid treatment was observed at 20% (1/5) in patients with superficial white villi type and at 100% (5/5) in deep non-white villi type, respectively (P⫽0.048). Conclusions: Two distinct subgroups were found in IL. This classification was useful in predicting response to corticosteroid treatment.
Sa1644 Differences in Clinical Features and the Related Risk Factors Between Occult and Overt Cases of Obscure Gastrointestinal Bleeding Junichi Okamoto*, Satoshi Sugimori, Kazunari Tominaga, Tomoko Obayashi, Kunihiro Kato, Masaki Ominami, Shusei Fukunaga, Yasuaki Nagami, Mitsue Sogawa, Hirokazu Yamagami, Tetsuya Tanigawa, Masatsugu Shiba, Kenji Watanabe, Toshio Watanabe, Yasuhiro Fujiwara, Tetsuo Arakawa Gastroenterology, Osaka City University Graduate School of Medicine, Osaka city, Japan Background and Aim: Various studies have investigated the pathogenesis or etiology of obscure gastrointestinal bleeding (OGIB) in Japan. However, these studies were often performed without differentiating between occult and overt cases. We evaluated the differences in clinical features and the related risk factors of OGIB among occult, previously overt, and ongoing overt cases. Methods: We conducted a retrospective study of 446 patients with OGIB (occult, n ⫽ 107; previously overt, n ⫽ 286; and ongoing overt, n ⫽ 53) who underwent video capsule endoscopy (CE) or balloon-assisted endoscopy (BAE) in our hospital between January 2005 and January 2011. We compared the diagnostic ratio of ulcerative, vascular, and neoplastic lesions using these modalities after differentiating their respective OGIB etiologies. Furthermore, we evaluated their clinical features and related risk factors such as age; sex; hemoglobin (Hb); medications, including nonsteroidal anti-inflammatory drugs (NSAIDs), aspirin, and anticoagulants; and systemic comorbid diseases such as liver cirrhosis (LC), chronic renal failure (CRF) with hemodialysis (HD), cardiovascular, cerebrovascular, or hematologic diseases, rheumatoid arthritis, and diabetes mellitus using multivariate analysis. Results: There were no differences in overall diagnostic ratios between occult (55.1%) and overt (60.2%) OGIB cases (P ⫽ .06), but the diagnostic ratio significantly increased among occult (55.1%), previously overt (55.6%), and ongoing overt (84.9%) cases (P ⬍ .01). In particular, there was a remarkable difference in the diagnosis of vascular lesions. The diagnostic ratios of CE and BAE were similar. Multivariate analysis revealed that the use of NSAIDs was a risk factor related to ulcerative lesions of all OGIB cases and overt cases alone (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.30-4.00, P ⬍ .004 and OR, 2.87; 95% CI, 1.52-5.52, P ⬍ .001). Risk factors related to vascular lesions in OGIB included use of anticoagulants (OR, 2.81; 95% CI, 1.33-5.95, P ⬍ .007), CRF with HD (OR, 4.04; 95% CI, 1.78-9.19, P ⬍ .001), and LC (OR, 2.91; 95% CI, 1.40-6.08, P ⬍ .004). Risk factors related to neoplastic lesions in OGIB included male gender (OR, 3.10; 95% CI, 1.48-6.49, P ⬍ .003) and anemia (Hb levels ⬍ 8.1 g/dL) (OR, 0.87; 95% CI, 0.76-0.99, P ⬍ .048). Tertile classification of the minimum Hb levels in OGIB was reversely correlated with an increase in diagnostic ratio of some lesions (P for trend ⬍ .01), especially for vascular and neoplastic lesions. Conclusion: It may be critical to differentiate between bleeding patterns (occult or overt) and may be important to consider factors such as the use of NSAIDs or anticoagulants, systemic comorbid diseases such as CRF with HD or LC, and the minimum Hb levels for suspected bleeding lesions in the small intestine in OGIB cases.
AB278 GASTROINTESTINAL ENDOSCOPY Volume 77, No. 5S : 2013
www.giejournal.org
