BACKGROUND: Gallbladder masses can be identified endosongraphically, but FNA for cytologic diagnosis is not routine. This is a review of our experience with EUS-guided FNA of gallbladder masses. METHODS: Records of patients undergoing EUS were reviewed to identify cases in which FNA of the gallbladder was performed. Reports of EUS procedures, EUS images, cytology results, and clinical records were reviewed. OBSERVATIONS: Six cases were identified. The final diagnosis was gallbladder carcinoma in 5 and xanthogranulomatous cholecystitis in one. In each case, EUS revealed a hypoechoic mass within the gallbladder wall or gallbladder lumen. Gallbladder wall calcification was observed in 3 of the 5 cases of carcinoma. FNA yielded a specimen that was positive (n = 3) or raised a suspicion (n = 1) for adenocarcinoma in 4 of the 5 proven malignancies. FNA of regional lymph nodes demonstrated metastatic adenocarcinoma in 2 cases. FNA was negative for malignancy in the case of xanthogranulomatous cholecystitis and one case of proven carcinoma. There were no complications. CONCLUSIONS: EUS-guided FNA of gallbladder masses is safe and can provide a definitive diagnosis of malignancy. Gallbladder carcinoma appears endosonographically as a hypoechoic mass and may be associated with focal wall calcifications.

Aged↗

PubMed2003

Who is using chronic acid suppression therapy and why?

OBJECTIVES: Acid suppression medications have become one of the most commonly prescribed classes of therapeutic agents. Because little data exists describing the chronic use of these agents among a general population, we sought to determine the patterns of use of proton pump inhibitors (PPIs) and histamine type 2 receptor antagonists (H2RAs) in clinical practice, as well as the distribution and severity of symptoms in patients prescribed these therapies. METHODS: Pharmacy billing data from two insurers were used to identify all patients on chronic (>90 days) PPIs and H2RAs within a large, eastern Massachusetts provider network. Patient demographics, diagnoses, frequency of office visits, and information about diagnostic testing were obtained from billing databases. A questionnaire addressing recent upper GI symptoms, over-the-counter medication use, and gastroenterologist consultations was mailed to a 1,139 patient subset (35%) of eligible patients. We compared the diagnoses of patients on chronic therapy with those of the general population of the network. We also compared the frequency of symptoms and diagnostic testing between those prescribed H2RAs and PPIs. RESULTS: From a total population of 168,727 adult patients, we identified 4,684 (2.8%) prescribed chronic acid suppression therapy, with 47% taking H2RAs and 57% taking PPIs (4% filled prescriptions for both simultaneously). A relevant GI diagnosis was found using billing data for only 61% of patients, mainly for gastroesophageal reflux disease (38%) and dyspepsia (42%), with many patients carrying both diagnoses. Our survey (response rate 59%) revealed that more than 30% of responders experienced heartburn or reflux more than twice a week, and more than half experienced symptoms of dyspepsia at least once a week. Diagnostic testing was uncommon, with only 19% having undergone esophagogastroduodenoscopy within the prior 2 yr. CONCLUSIONS: Acid suppression medications were used chronically by a large number of patients within this population. A significant proportion of patients on chronic PPI or H2RA lacked definitive upper GI diagnoses in their billing data. The high symptom burden and low use of diagnostic testing indicates opportunities for improvement in the care of patients on chronic acid suppression therapy.

Adult↗

PubMed2003

Determinants of colorectal cancer screening in women undergoing mammography.

OBJECTIVES: Women who participate in screening for breast cancer are more likely to participate in screening for colorectal cancer. We studied such a motivated group of women to identify predictors of, and barriers to, participation in colorectal cancer screening by endoscopy. METHODS: We distributed surveys to 551 women > or = 50 yr of age while they were awaiting mammography at four sites in and around Boston, MA from June to September, 2000. The 40-question survey assessed knowledge, attitudes, and beliefs about, and behaviors toward, breast and colorectal cancer screening. Regression models were used to determine factors associated with having had sigmoidoscopy or colonoscopy. RESULTS: Seventy-nine percent of the women completed all or part of the survey. Half (221/438) reported ever having had sigmoidoscopy or colonoscopy. Of these, 93% did so at the recommendation of their primary care provider. Factors associated with participation in endoscopic screening included compliance with annual fecal occult blood testing, a family history of colorectal cancer, and indifference toward the gender of the doctor performing the endoscopy. CONCLUSIONS: Women undergoing mammography overwhelmingly cite the recommendation of their primary care provider as the reason for participating in colorectal cancer screening by endoscopy. Women who preferred a female endoscopist were less likely to have been screened. Whenever possible, primary care providers should offer women the choice of a female endoscopist for colorectal cancer screening.

Aged↗

PubMed2002

NAD(P)H and collagen as in vivo quantitative fluorescent biomarkers of epithelial precancerous changes.

During the development of neoplasia, epithelial tissues undergo biochemical and structural changes that can manifest in tissue fluorescence. There have been several reports on different in vivo fluorescence characteristics between normal and precancerous (dysplastic) tissues. However, it has been difficult to identify and quantify the origins of these changes, mainly because of distortions introduced in measured tissue fluorescence spectra by tissue scattering and absorption. Such distortions can be removed by combining information in simultaneously measured fluorescence and reflectance spectra. Thus, we can recover the intrinsic (undistorted) tissue fluorescence. In this report, we show that extraction of the intrinsic fluorescence allows us: (a) to determine the fluorescence spectra of NAD(P)H and collagen in an in vivo environment, and (b) to use these NAD(P)H and collagen spectra to describe, quantitatively, diagnostically significant biochemical changes between normal and dysplastic tissues. Specifically, by analyzing intrinsic fluorescence of human epithelial tissue as it becomes deoxygenated in vivo, we can resolve the fluorescence spectra of NAD(P)H and collagen, two of the major tissue fluorophores. This is important because fluorescence depends on the local environment of the chromophore. Then, we extract the intrinsic fluorescence spectra of sites from 35 patients with suspected cervical lesions and 7 patients with Barrett's esophagus and describe them accurately as a linear combination of NAD(P)H and collagen contributions. In both tissue cases, we find that low collagen and high NAD(P)H fluorescence characterizes the high-grade dysplastic lesions when compared with nondysplastic tissues. These data present evidence for the presence of detectable levels of NAD(P)H fluorescence in human epithelial tissues in an in vivo setting and demonstrate that NAD(P)H and collagen may be used as quantitative fluorescence biomarkers for in vivo detection of dysplasia in the cervix and the esophagus.

Barrett Esophagus↗

PubMed2002

Guidelines for the use of deep sedation and anesthesia for GI endoscopy.

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Adjuvants, Anesthesia↗

PubMed2002

Enhanced endoscopy in inflammatory bowel disease.

Spectroscopy and OCT are two new methods for imaging the gastrointestinal mucosa. They both rely on the interaction of light within a tissue and have been adapted for use with endoscopes. It is unlikely that any one type of imaging modality will be able to reliably diagnose the presence of microscopic dysplasia. However, combining different methods may prove to be extremely accurate for detecting dysplasia and may therefore obviate a need for taking tissue biopsies. For instance, LSS may be most helpful in detecting early dysplasia because it is sensitive to changes in nuclear size and crowding. As more cells become dysplastic, fluorescence may play a role in defining changes in content of collagen or markers of metabolism (i.e. NADH). Finally, reflectance spectroscopy becomes useful in detecting characteristic changes in the tissue architecture as dysplasia progresses to invasive cancer. Using all three types of spectroscopy at once ("tri-modal spectroscopy") has proven to be extremely accurate for classifying Barrett's mucosa as either dysplastic or nondysplastic [9]. Our current method for detecting microscopic dysplasia relies upon random biopsies and interpretation of histology by pathologists. Interobserver agreement among even experienced pathologists regarding the presence or absence and degree of dysplasia in histologic specimens is not consistent [50]. Spectroscopy and OCT may ultimately provide new methods for accurately diagnosing dysplasia in real-time, without the need for tissue processing, and without the interobserver variations of histologic interpretation.

Endoscopy, Gastrointestinal↗

PubMed2002

Acute pancreatitis associated with rofecoxib.

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Acute Disease↗

PubMed2002

Endoscopic ultrasound-guided gallbladder bile aspiration in idiopathic pancreatitis carries a significant risk of bile peritonitis.

BACKGROUND: Direct microscopic examination of bile for the presence of microlithiasis is often performed during the evaluation of patients with idiopathic pancreatitis. Bile sampled from the duodenum and/or the common bile duct may not represent gallbladder bile, and thus may be inadequate for the diagnosis of microlithiasis. AIM: We sought to determine the safety and efficacy of endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) of gallbladder bile in patients with idiopathic pancreatitis. METHODS: Patients with idiopathic pancreatitis underwent EUS with a linear echoendoscope. After excluding potential causes of pancreatitis such as common bile duct stones or pancreatic lesions, the gallbladder was identified. The gallbladder lumen was entered using a 22-gauge FNA needle via the duodenal wall. Bile was aspirated and analyzed for the presence of cholesterol monohydrate crystal, calcium bilirubinate granules, calcium carbonate microspheroliths and mucin gel strands. RESULTS: Three patients underwent EUS-guided FNA of gallbladder bile. Two of these patients developed bile peritonitis within one hour of the procedure prompting us to discontinue the study. One patient's gallbladder bile contained microlithiasis. This patient had bile aspirated from the common bile duct via ERCP 3 weeks prior to EUS. However, analysis of that bile sample failed to show microlithiasis. CONCLUSION: Unfortunately, transduodenal EUS-guided FNA of gallbladder bile using a 22-gauge needle carries a significant risk of bile peritonitis.

Acute Disease↗