Serrated Lesions of the Colorectum: Review and Recommendations From an Expert Panel

わが国における成人市中肺炎の原因微生物の変遷(Meta‐analysis and systematic review)

Adverse events associated with ERCP

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE). It addresses the role of advanced endoscopic imaging for the detection and differentiation of colorectal neoplasia. Main recommendations
 1 ESGE suggests the routine use of high definition white-light endoscopy systems for detecting colorectal neoplasia in average risk populations (weak recommendation, moderate quality evidence). 2 ESGE recommends the routine use of high definition systems and pancolonic conventional or virtual (narrow band imaging [NBI], i-SCAN) chromoendoscopy in patients with known or suspected Lynch syndrome (strong recommendation, low quality evidence). 2b ESGE recommends the routine use of high definition systems and pancolonic conventional or virtual (NBI) chromoendoscopy in patients with known or suspected serrated polyposis syndrome (strong recommendation, low quality evidence). 3 ESGE recommends the routine use of 0.1 % methylene blue or 0.1 % – 0.5 % indigo carmine pancolonic chromoendoscopy with targeted biopsies for neoplasia surveillance in patients with long-standing colitis. In appropriately trained hands, in the situation of quiescent disease activity and adequate bowel preparation, nontargeted, four-quadrant biopsies can be abandoned (strong recommendation, high quality evidence). 4 ESGE suggests that virtual chromoendoscopy (NBI, FICE, i-SCAN) and conventional chromoendoscopy can be used, under strictly controlled conditions, for real-time optical diagnosis of diminutive (≤ 5 mm) colorectal polyps to replace histopathological diagnosis. The optical diagnosis has to be reported using validated scales, must be adequately photodocumented, and can be performed only by experienced endoscopists who are adequately trained and audited (weak recommendation, high quality evidence). 5 ESGE suggests the use of conventional or virtual (NBI) magnified chromoendoscopy to predict the risk of invasive cancer and deep submucosal invasion in lesions such as those with a depressed component (0-IIc according to the Paris classification) or nongranular or mixed-type laterally spreading tumors (weak recommendation, moderate quality evidence). Conclusion
 Advanced imaging techniques will need to be applied in specific patient groups in routine clinical practice and to be taught in endoscopic training programs.

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Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline.

Prophylaxis 1 ESGE recommends routine rectal administration of 100 mg of diclofenac or indomethacin immediately before endoscopic retrograde cholangiopancreatography (ERCP) in all patients without contraindications to nonsteroidal anti-inflammatory drug administration. Strong recommendation, moderate quality evidence. 2 ESGE recommends prophylactic pancreatic stenting in selected patients at high risk for post-ERCP pancreatitis (inadvertent guidewire insertion/opacification of the pancreatic duct, double-guidewire cannulation). Strong recommendation, moderate quality evidence. 3 ESGE suggests against routine endoscopic biliary sphincterotomy before the insertion of a single plastic stent or an uncovered/partially covered self-expandable metal stent for relief of biliary obstruction. Weak recommendation, moderate quality evidence. 4 ESGE recommends against the routine use of antibiotic prophylaxis before ERCP. Strong recommendation, moderate quality evidence. 5 ESGE suggests antibiotic prophylaxis before ERCP in the case of anticipated incomplete biliary drainage, for severely immunocompromised patients, and when performing cholangioscopy. Weak recommendation, moderate quality evidence. 6 ESGE suggests tests of coagulation are not routinely required prior to ERCP for patients who are not on anticoagulants and not jaundiced. Weak recommendation, low quality evidence. Treatment
 7 ESGE suggests against salvage pancreatic stenting in patients with post-ERCP pancreatitis. Weak recommendation, low quality evidence. 8 ESGE suggests temporary placement of a biliary fully covered self-expandable metal stent for post-sphincterotomy bleeding refractory to standard hemostatic modalities. Weak recommendation, low quality evidence. 9 ESGE suggests to evaluate patients with post-ERCP cholangitis by abdominal ultrasonography or computed tomography (CT) scan and, in the absence of improvement with conservative therapy, to consider repeat ERCP. A bile sample should be collected for microbiological examination during repeat ERCP. Weak recommendation, low quality evidence.

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ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

What Level of Bowel Prep Quality Requires Early Repeat Colonoscopy: Systematic Review and Meta-Analysis of the Impact of Preparation Quality on Adenoma Detection Rate

Hypertriglyceridemia is an uncommon but a well-established etiology of acute pancreatitis leading to significant morbidity and mortality The risk and severity of acute pancreatitis increase with increasing levels of serum triglycerides It is crucial to identify hypertriglyceridemia as the cause of pancreatitis and initiate appropriate treatment plan Initial supportive treatment is similar to management of other causes of acute pancreatitis with additional specific therapies tailored to lower serum triglycerides levels This includes plasmapheresis, insulin, heparin infusion, and hemofiltration After the acute episode, diet and lifestyle modifications along with hypolipidemic drugs should be initiated to prevent further episodes Currently, there is paucity of studies directly comparing different modalities This article provides a comprehensive review of management of hypertriglyceridemia induced acute pancreatitis We conclude by summarizing our treatment approach to manage hypertriglyceridemia induced acute pancreatitis

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Management of Hypertriglyceridemia Induced Acute Pancreatitis

Background Although sessile serrated adenomas (SSAs) may represent a separate and important pathway for colorectal cancer (CRC), little is known about the risk factors for these lesions. Molecular abnormalities such as BRAF have been observed in SSA and smokers. Our hypothesis is that smoking may be associated with these lesions. Methods All patients diagnosed with an SSA from January 2007 to September 2010 were identified retrospectively based on a pathology database query. There were 2 sets of controls. One group had no adenomas, whereas another group had tubular adenomas. These groups were randomly identified from 2007 to 2010. Data collected included age, sex, ethnicity, height, weight, family history of CRC, diabetes mellitus, use of aspirin, statins, and calcium, and serum trigylcerides and cholesterol. We defined smokers as those patients who smoked at least 20 pack-years. Results We identified 90 patients with an SSA of any size, 90 patients with tubular adenomas, and 200 controls with no adenomas. Of the 90 SSAs, 42 were 6 mm or larger and 19 of them were ≥1 cm. Most of the SSAs was flat (76/90; 84.4%). After multivariate analyses, smokers with at least 20 pack-year exposure were found to have an increased risk [adjusted odds ratio (OR)=7.31; 95% confidence interval (CI), 3.92-13.63] of having any SSAs, SSAs ≥6 mm (adjusted OR=7.77; 95% CI, 3.48-17.35), and large SSAs (adjusted OR=10.20; 95% CI, 3.31-31.41) compared with nonsmokers. We also observed this relationship when comparing patients with SSAs to those with tubular adenomas. Conclusions Our data suggest that smoking at least 20 pack-years is strongly associated with any and large SSAs. In addition, diabetes mellitus and obesity seem to be associated with SSAs as well. Our data has implications for CRC screening.

Risk factors for sessile serrated adenomas.

Endoscopic Retrograde Cholangiopancreatography–Related Adverse Events: General Overview

Chronic radiation proctopathy occurs in 5%-20% of patients following pelvic radiotherapy. Although many cases resolve spontaneously, some lead to chronic symptoms including diarrhea, tenesmus, urgency and persistent rectal bleeding with iron deficiency anemia requiring blood transfusions. Treatments for chronic radiation proctitis remain unsatisfactory and the basis of evidence for various therapies is generally insufficient. There are very few controlled or prospective trials, and comparisons between therapies are limited because of different evaluation methods. Medical treatments, including formalin, topical sucralfate, 5-amino salicylic acid enemas, and short chain fatty acids have been used with limited success. Surgical management is associated with high morbidity and mortality. Endoscopic therapy using modalities such as the heater probe, neodymium:yttrium-aluminium-garnet laser, potassium titanyl phosphate laser and bipolar electrocoagulation has been reported to be of some benefit, but with frequent complications. Argon plasma coagulation is touted to be the preferred endoscopic therapy due to its efficacy and safety profile. Newer methods of endoscopic ablation such as radiofrequency ablation and cryotherapy have been recently described which may afford broader areas of treatment per application, with lower rate of complications. This review will focus on endoscopic ablation therapies, including such newer modalities, for chronic radiation proctitis.

Tarun Rustagi

Papers

What Level of Bowel Prep Quality Requires Early Repeat Colonoscopy: Systematic Review and Meta-Analysis of the Impact of Preparation Quality on Adenoma Detection Rate

Management of Hypertriglyceridemia Induced Acute Pancreatitis

Risk factors for sessile serrated adenomas.

Endoscopic Retrograde Cholangiopancreatography–Related Adverse Events: General Overview

Endoscopic management of chronic radiation proctitis.