Variability in endoscopic assessment of Nissen fundoplication wrap integrity and hiatus herniation

Summary Background Upper endoscopy (EGD) is frequently performed in patients with esophageal complaints following anti-reflux surgery such as fundoplication. Endoscopic evaluation of fundoplication wrap integrity can be challenging. Our primary aim in this pilot study was to evaluate the accuracy and confidence of assessing Nissen fundoplication integrity and hiatus herniation among gastroenterology (GI) fellows, subspecialists, and foregut surgeons. Methods Five variations of post-Nissen fundoplication anatomy were included in a survey of 20 sets of EGD images that was completed by GI fellows, general GI attendings, esophagologists, and foregut surgeons. Accuracy, diagnostic confidence, and inter-rater agreement across providers were evaluated. Results There were 31 respondents in the final cohort. Confidence in pre-survey diagnostics significantly differed by provider type (mean confidence out of 5 was 1.8 for GI fellows, 2.7 for general GI attendings, 3.6 for esophagologists, and 3.6 for foregut surgeons, P = 0.01). The mean overall accuracy was 45.9%, which significantly differed by provider type with the lowest rate among GI fellows (37%) and highest among esophagologists (53%; P = 0.01). The accuracy was highest among esophagologists across all wrap integrity variations. Inter-rater agreement was low across wrap integrity variations (Krippendorf’s alpha <0.30), indicating low to no agreement between providers. Conclusion In this multi-center survey study, GI fellows had the lowest accuracy and confidence in assessing EGD images after Nissen fundoplication, whereas esophagologists had the highest. Diagnostic confidence varied considerably and inter-rater agreement was poor. These findings suggest experience may improve confidence, but highlight the need to improve the evaluation of fundoplication wraps.

P-EGS13 Risk Factors of Bleeding Gastroduodenal Ulcer Among Patient Undergo Emergency Upper Endoscopy in Hospital Melaka

Background Bleeding gastroduodenal ulcer has been one of the leading causes of admission in surgical or gastroenterology departments all over the world, requiring immediate intervention with high associated mortality exceeding 10%. We analyzed few important risk factors that lead to this potentially ill condition. Methods Data from a number of 548 patients who underwent emergency upper endoscopy were collected retrospectively from June 2020 till June 2021 in Hospital Melaka. Results From our data collection of emergency upper endoscopy performed, 111 patients had findings of high-risk ulcer (Forrest Ia, Ib, 2a and 2b). From these 111 patients, the most common presentation was low hemoglobin value (<10g/dL), with 43.6%. Presentation of melena encountered the second most common symptom (26.3%), while fresh per rectal bleeding counts the less common symptom (1%). Forrest Ib ulcer showed the commonest diagnosis found during endoscopy (45.5%), followed by Forrest IIa ulcer (34.5%), Forrest IIb ulcer (16.4%), and Forrest Ia ulcer (3.6%). There were 27 participants who undergo repetitive endoscopy. For Helicobacter Pylori infection, there were 367 patients (66.7%) underwent the test during endoscopy, which showed 187 patients detected (51%) with H.Pylori positive. We identify other risk factors which lead to this fatal condition such as, patient’s comorbidities including liver disease, renal disease and their medications, blood investigations including hemoglobin level, platelet count, total white cell count, total bilirubin, Alanine Transaminase (ALT), serum urea and creatinine. Conclusions It is a must to identify important risk factors for bleeding gastroduodenal ulcers to prevent morbidity and mortality, and to initiate emergency intervention medically and surgically. From this study, it was a great move for us to make further research on how these risk factors affecting our management of patients.

Gastric Cancers Missed at Upper Endoscopy in Central Norway 2007 to 2016—A Population-Based Study

Background: The rates of missed gastric cancers (MGC) at upper endoscopy (UE) has been reported at 5–10% in Western countries. We aimed to calculate the rate of MGC and identify factors associated with MGC. Methods: Retrospective population-based cohort study including 730 patients diagnosed with gastric adenocarcinoma in Central Norway 2007–2016. MGCs were incident gastric adenocarcinomas diagnosed 6–36 months after a previous UE. Factors associated with MGC were examined. Definitely missed (UE 6–12 months prior) and potentially missed (UE 12–36 months prior) MGCs were compared. Results: Sixty-seven (9.2%) of 730 gastric cancers were MGC. MGC were associated with localization (p = 0.009) and more frequent in the corpus, Lauren’s histological type (p = 0.028) and diffuse type more prevalent, and previous Billroth 2-operation (14.9% vs. 4.7%, p = 0.001). MGCs were diagnosed at earlier stages (p = 0.037). An ulceration was more common in patients with definitely missed than potentially MGC (40.9% vs. 17.8%, p = 0.041). Conclusions: MGC accounted for 9.2% of gastric cancers in Central Norway. MGC were associated with localization in the corpus, Lauren´s diffuse type and previous Billroth-2-operation. Intensified follow-up and adequate biopsy sampling of patients with gastric ulcerations could reduce the rate of missed gastric cancers.

Role of enteroscopy in the diagnosis of whipple’s disease

Whipple’s disease is a rare chronic systemic infection caused by Tropheryma whipplei. The widespread infection by this rod is responsible for the protean clinical manifestations of the disease, although its classical form is notable for the prevalence of abdominal symptoms such as chronic diarrhea and abdominal pain. Whitish-yellow patches, suggestive of lymphangiectasia, are typically observed in the duodenum during upper endoscopy. The diagnosis of this condition is supported by the identification in duodenal biopsies of Periodic acid-Schiff staining within lamina propria macrophages. Nevertheless, a significant portion of patients do not have lesions within the range of conventional upper endoscopy. Therefore, other endoscopic procedures such as video capsule endoscopy and enteroscopy may be useful to detect more distal lesions. The authors describe a case where the combined used of both techniques allowed the unmasking of this disease.