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Biomedical subjects

Elizabeth Rajan

Publications and source records attributed to Elizabeth Rajan.

At least 37 records · Page 2Linked to original sources
PubMed2005

ASGE guideline: the role of endoscopy in the diagnosis, staging, and management of colorectal cancer.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Biopsy, Needle↗
PubMed2005

ASGE guideline: the management of low-molecular-weight heparin and nonaspirin antiplatelet agents for endoscopic procedures.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of expert consultants. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate use of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement, and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to these recommendations.

Clinical Trials as Topic↗
PubMed2005

ASGE guideline: complications of EUS.

This is one of a series of statements discussing the utilization of GI endoscopy in common clinical situations. The Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy prepared this text. In preparing this guideline, a MEDLINE literature search was performed, and additional references were obtained from the bibliographies of the identified articles and from recommendations of experts. When little or no data exist from well-designed prospective trials, emphasis is given to results from large series and reports from recognized experts. Guidelines for appropriate utilization of endoscopy are based on a critical review of the available data and expert consensus. Further controlled clinical studies are needed to clarify aspects of this statement and revision needed to clarify aspects of this statement and revision may be necessary as new data appear. Clinical consideration may justify a course of action at variance to the recommendations.

Autonomic Nerve Block↗
PubMed2005

Age-related changes in the pancreas identified by EUS: a prospective evaluation.

BACKGROUND: EUS is an important modality for the diagnosis of pancreatic disease. An understanding of normal pancreatic ductal and parenchymal variation in asymptomatic individuals is essential to improve EUS accuracy. The primary aim of this study was to determine age-related pancreatic parenchymal and ductular changes identifiable on EUS in individuals with no history or symptoms of pancreaticobiliary disease. Secondary aims were to define demographic and clinical factors associated with identifiable pancreatic parenchymal and ductular changes, and to determine the main pancreatic-duct diameter and pancreatic-gland width according to age. METHODS: Patients referred for either upper endoscopy or EUS for an indication unrelated to pancreaticobiliary disease were prospectively enrolled. Patients were stratified by age (<40, 40-60, >60 years). Each patient was assessed for the presence of EUS findings for chronic pancreatitis. Logistic regression was used to identify factors associated with an abnormality. RESULTS: A total of 120 patients (63 men, 57 women; median age, 52 years, interquartile range [IQR] 40-61 years) were prospectively evaluated. At least one parenchymal and/or ductular abnormality was identified in 28% of the patients, with a trend of increasing abnormality with age: <40 years (23%), 40 to 60 years (25%), and >60 years (39%); p = 0.13. No patient had more than 3 abnormal EUS features. Hyperechoic stranding (n = 22) was the most common finding in all age groups. The odds for any abnormality in men (relative to women) was significantly higher (OR 2.9: 95% CI[1.2, 6.8], p = 0.01), with 38% of men and 18% of women having an abnormality. Smoking, low alcohol intake, body mass index, and endoscopic finding were not significantly associated with an abnormal EUS. The overall median pancreatic-gland width and main pancreatic duct diameter were 15 mm (IQR 6-25 mm) and 1.7 mm (IQR 0.9-4.3 mm), respectively. CONCLUSIONS: The frequency of EUS abnormalities in patients without clinical evidence of chronic pancreatitis increases with age, particularly after 60 years of age. The threshold number of EUS criteria for the diagnosis of chronic pancreatitis is variable. However, the typically used standard of 3 or more criteria appears appropriate. A higher number of threshold criteria may be needed in males and to a lesser extent in patients over 40 years of age, which should be related to clinical history and other structural or functional studies. Ductal or parenchymal calculi, ductal narrowing, ductal dilatation, or more than 3 abnormalities appear to be more specific features for the EUS diagnosis of chronic pancreatitis at any age.

Adult↗
PubMed2005

EUS-guided trucut biopsy in establishing autoimmune pancreatitis as the cause of obstructive jaundice.

BACKGROUND: The diagnosis of autoimmune pancreatitis can be difficult and often requires a larger specimen than can be provided by FNA alone to determine if the tissue sample obtained with EUS trucut biopsy (TCB) is sufficient to allow adequate histologic review to establish the diagnosis of autoimmune pancreatitis. METHODS: EUS TCB was performed in patients presenting with obstructive jaundice who were suspected of having autoimmune pancreatitis based on their clinical, laboratory and imaging studies. The charts were retrospectively reviewed to determine the feasibility of TCB. RESULTS: Between August 2002 and June 2004, 3 patients with obstructive jaundice and suspected autoimmune pancreatitis (AIP) underwent EUS TCB. In each case, a diagnosis of pancreatic cancer also was considered, and surgical resection was the planned therapy before the patient underwent EUS TCB. Histologic review of the TCB specimens established the diagnosis of AIP in two patients and identified nonspecific changes of chronic pancreatitis in the third patient. EUS-guided FNA was performed in two of the 3 patients and failed to establish the diagnosis in either patient. Other than mild transient abdominal pain (n = 1), no complications were identified. CONCLUSIONS: This preliminary study suggests that EUS TCB can safely establish the diagnosis of AIP. Doing so helps guide management and may help to avoid unnecessary surgery. Prospective studies are needed to verify these findings and to more clearly define the role of EUS TCB in these patients.

Aged↗
PubMed2005

Assessment of the impact of an educational course on knowledge of appropriate EUS indications.

BACKGROUND: The knowledge level of EUS among gastroenterologists likely influences the appropriateness of requested indications for EUS. It remains unknown what the impact is of a short EUS course, involving didactic teaching, on knowledge levels of EUS indications for EUS. The aim of this study was to assess the impact of a 3-day educational course on knowledge levels of attending gastroenterologists regarding the appropriateness of indications for EUS. METHODS: A questionnaire was designed that tested knowledge of indications for EUS in 4 anatomic sites: esophagus, gastroduodenum, hepatopancreatobiliary system, and colorectum. This questionnaire was distributed to all attendees of a 3-day EUS educational course. All attendees completed the survey before and immediately after the course. RESULTS: A total of 24 gastroenterologists completed the pre- and post-course survey. Before the course, respondents scored highest in questions on EUS applications in the gastroduodenum (94%) and the hepatopancreatobiliary system (88%) compared with the esophagus (72%) and the colorectum (74%). Statistically significant improvements in knowledge were recorded in all organ categories: gastroduodenum (100%, p = 0.002 vs. pretest score), hepatopancreatobiliary system (99%, p < 0.0001), esophagus (92%, p < 0.0001), and colorectum (93%, p = 0.0004). The biggest improvement was observed in knowledge levels for the esophagus (20%) and the colorectum (18%). CONCLUSIONS: There was a consistent improvement in the gastroenterologists' knowledge levels of EUS indications among all organ categories after an educational course. Our findings suggest that education enhances gastroenterologists' understanding of EUS. Future studies should seek to assess the impact of these improved knowledge levels on the appropriateness of EUS referral patterns.

Clinical Competence↗
PubMed2005

Endoscopic ultrasound-guided trucut biopsy of the cyst wall for diagnosing cystic pancreatic tumors.

BACKGROUND & AIMS: Nonoperative methods for diagnosis of pancreas cysts often lack sufficient accuracy. Accurate diagnosis is needed to determine prognosis and guide clinical management. The aim of this study was to determine whether the tissue obtained by endoscopic ultrasound-guided trucut biopsy (EUS TCB) is sufficient for histologic diagnosis of cystic pancreatic tumors (CPTs). METHODS: EUS TCB was performed in patients with a suspected CPT. A dedicated gastrointestinal pathologist reviewed the core biopsies. The final diagnosis was based on clinical, laboratory, imaging, and biopsy findings, and resected specimens when available. RESULTS: EUS TCB was performed in 10 patients with a suspected CPT. Final diagnoses included serous cystadenoma (SCA, n=5), islet cell tumor (n=2), mixed seromucinous lesion (n=1), polycystic disease of the pancreas (n=1), and pseudocyst (n=1). EUS TCB was nondiagnostic in 3 of 10 patients. Among the other 7 patients, TCB diagnosed 4 SCAs, obviating the need for planned surgery in 3 patients. In the fourth patient with an SCA, the TCB result ruled out metastatic disease from locally recurrent lung cancer, allowing a narrowed radiation field. EUS TCB confirmed the need for surgery in 2 patients with an islet cell tumor. In 1 patient, EUS TCB findings were "partially" diagnostic, leading to previously unplanned surgery. CONCLUSIONS: This report establishes the capability and safety of EUS TCB to collect sufficient tissue for diagnosing CPTs. The results might help guide clinical management.

Adenoma, Islet Cell↗
PubMed2005

Clinical implications of the extent of invasion of T3 esophageal cancer by endoscopic ultrasound.

BACKGROUND: Endoscopic ultrasound (EUS) is an accurate imaging modality for local staging of esophageal cancer. We aimed to determine if depth of tumor invasion beyond muscularis propria (MP), as determined by preoperative EUS, is predictive of tumor recurrence or survival (a positive change in mortality) in patients with T3 esophageal cancer. METHODS: Records and images of all patients with T3 N1 M0 esophageal cancer staged with EUS at our institution between January 1999 and October 2003 were reviewed. EUS images were independently reviewed by five blinded endosonographers and tumors were classified as minimally invasive (invasion < 3 mm beyond MP) or advanced (invasion > or = 3 mm beyond MP) T3 disease. RESULTS: One hundred and sixty-five patients with esophageal cancer underwent EUS for staging and 39 patients with T3 N1 esophageal cancer were identified; 17 patients had minimally invasive T3 disease and 22 had advanced disease. All patients underwent neoadjuvant chemoradiation therapy followed by esophagectomy. Median follow up was 13 months. Adjusting for age and sex, minimally invasive disease was not associated with a statistically significant improvement in recurrence-free survival (hazard ratio, 1.45; 95% CI, 0.88-2.41, P = 0.14) or mortality (hazard ratio, 0.96; 95% CI: 0.49-1.78, P = 0.91). CONCLUSIONS: The extent of invasion of T3 esophageal cancer beyond MP, as determined by EUS, is not a significant predictor of tumor recurrence or mortality.

Combined Modality Therapy↗
PubMed2004

Intestinal endometriosis: the great masquerader.

Chronic symptoms of abdominal pain and irregular bowel habits in women evoke a broad differential diagnosis including irritable bowel syndrome, infection, malabsorption, and inflammatory bowel disease. Endometriosis, a common disorder in young women that can involve the intestinal tract, deserves consideration as well. Intestinal endometriosis is typically asymptomatic; however, when symptoms occur, they can mimic those of irritable bowel syndrome. Identifying intestinal endometriosis can be challenging, but historical points and key clinical features aid in diagnosis.

Diagnosis, Differential↗
PubMed2004

Widespread EMR: a new technique for removal of large areas of mucosa.

BACKGROUND: Widespread EMR is a novel technique for resection of large areas of mucosa as a single bloc. Large lesion size (>2 cm) is a recognized limitation of current EMR techniques. This study assessed the technical feasibility, efficacy, and safety of widespread EMR in a porcine model. METHODS: Widespread EMR was performed in 6 pigs. A submucosal fluid cushion was created in the distal esophagus by using a 0.83% solution of hydroxypropyl methylcellulose. A mucosal strip 5 cm in length and including at least 50% of the luminal circumference was marginated by using a prototype cutting device. The proximal end of the mucosa was stripped from the submucosa by using a grasping forceps. The distal end was snare resected. Resected tissue was assessed histologically. Endoscopy was repeated at weeks 1 and 6. At week 6, a second widespread EMR of the mucosa on the wall opposite the initial resection was attempted to create a full circumferential resection. RESULTS: Widespread EMR was completed in all animals. The esophagus was denuded of mucosa in 5-cm lengths that included 50% of the circumference of the lumen. No procedure-related complication was observed. Histologic assessment demonstrated that the resection specimen included mucosa and submucosa but not muscularis propria. Endoscopy at 1 week revealed mucosal regrowth in two animals and ulceration in 4. At week 6, regrowth of mucosa was noted in all animals. The second wide EMR proved to be technically difficult and was associated with perforation, peri-esophageal abscess, and stricture formation. CONCLUSIONS: Wide EMR appears to be technically feasible for removal of large areas of mucosa. Mucosal strips 5 cm long that included over 50% of the luminal circumference were resected safely. Resection was followed by complete regrowth of the mucosa. However, a second wide EMR to create a circumferential resection proved to be technically difficult and unsafe.

Animals↗
PubMed2004

Knowledge of indications for EUS among gastroenterologists and non-gastroenterologists.

BACKGROUND: The level of awareness among non-gastroenterologists of the indications for EUS is unknown. This study assessed knowledge of the indications and the utility of EUS among gastroenterologists and non-gastroenterologists in a large multispecialty academic practice. METHODS: A questionnaire was designed that tested knowledge of the indications for EUS with respect to 4 organ systems: esophagus, gastroduodenum, hepatopancreatobiliary system and colorectum. The questionnaire was distributed by electronic mail to gastroenterologists, general internists, non-gastroenterologist subspecialists, and surgeons in a large multispecialty practice. RESULTS: The survey was distributed to 659 attending physicians of whom 227 (34%) replied: gastroenterologists (53%), internists (30%), non-gastroenterologist specialists (33%), and surgeons (28%). Knowledge of appropriate indications was highest among gastroenterologists (84.3%) compared with internists (68.9%), non-gastroenterologist specialists (65.4%), and surgeons (65.3%) (p < 0.0001). Among all non-gastroenterologists, knowledge of indications for hepatopancreatobiliary (mean 66.3% correct responses) and colorectal applications (64.0%) was inferior to knowledge of esophageal (71.5%) and gastroduodenal (83.5%) applications. CONCLUSIONS: Internists, non-gastroenterologist specialists, and surgeons in a large multispeciality practice have moderate knowledge of the indications and the utility of EUS. Knowledge was at the lowest level for hepatopancreatobiliary and colorectal applications of EUS for all 3 groups of non-gastroenterologists. Future studies should focus on the education of non-gastroenterologists regarding the role of EUS and assess the impact of such education on the appropriateness of EUS referral patterns.

Bile Ducts↗
PubMed2003

Understanding endoluminal gastroplications: a histopathologic analysis of intraluminal suture plications.

BACKGROUND: Endoluminal gastroplication is used to treat GERD, with modest results. Little is known of the histologic reaction to endosutures. Thus, the histologic response to intraluminal plications at different penetration depths within the gastric wall was studied in an animal model. METHODS: Intraluminal gastroplications were performed through a laparotomy in 18 New Zealand rabbits. Three sets of everted plications were placed at different penetration depths in each stomach: submucosa (SMpl), muscularis propria (Mpl), and serosa (Spl). Animals were randomized to survival times of 3, 10, or 60 days (respectively, Groups I, II, and III). Plications were compared with a grade scale for each histologic healing phase and gross inspection. RESULTS: Fusion between folds was absent in all groups. Serosa differed from muscularis propria with respect to the proportion of samples with microscopic ischemia (67% vs. 8%; p = 0.015), remaining sutures in Group III (33% vs. 3%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance), and remaining plications in Group II (96% vs. 54%; p < 0.05 in a single test of significance, but correction for multiple testing removes this significance). All of the total and partial histologic scores for the corresponding healing phase in each group escalated with penetration depth. Overall comparison of the histologic scores showed a significant difference among the plications in the proliferation (Group II, p = 0.004) and maturation (Group II, p = 0.009) phases. Total scores also differed among the plications in Groups II (p < 0.001) and III (p < 0.001). Plications were absent in all of Group III, with Spl resulting only in a flat scar. CONCLUSION: Everted intraluminal gastroplications do not result in fusion between folds irrespective of suture-penetration depth. A flat scar is the final outcome and appears proportional to the amount of ischemia, foreign body reaction, and suture depth.

Anastomosis, Surgical↗
PubMed2003

Hydroxypropyl methylcellulose: A better submucosal fluid cushion for endoscopic mucosal resection.

BACKGROUND: Formation of a submucosal fluid cushion has become integral to endoscopic mucosal and polyp resection. Solutions available for injection into the submucosa of the GI tract create short-lasting submucosal fluid cushions or are costly. The feasibility, durability, and histologic response to submucosal fluid cushions created by injection of hydroxypropyl methylcellulose were studied in the esophagus of pigs. METHODS: Thirty-six esophageal submucosal fluid cushions created with hydroxypropyl methylcellulose were studied in 12 animals divided in 2 groups of 6 animals each. In Group I, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose followed by tattooing. In Group II, 18 submucosal fluid cushions were created by submucosal injection of hydroxypropyl methylcellulose, with sites marked by an endoscopically placed suture. In all cases, the duration of the submucosal fluid cushion was measured. After 7 days, submucosal fluid cushion sites were assessed by EGD, necropsy, and histologic evaluation. RESULTS: The mean submucosal fluid cushion duration was 36 minutes (3-45 minutes) and 38 minutes (5-45 minutes) for, respectively, Groups I and II. EGD and necropsy after 1 week showed normal-appearing mucosa at the site of all submucosal fluid cushions in both groups. Some Group I animals additionally had nodules at the tattoo sites. Histologic assessment demonstrated minimal alterations in 33 of 36 (92%) submucosal fluid cushion sites and localized mild inflammatory reaction in 3 of 36 (8%). In Group I, 8 of 18 (44%) tattoo sites exhibited a significant inflammatory reaction, including 3 abscesses. CONCLUSIONS: Hydroxypropyl methylcellulose creates a long-lasting submucosal fluid cushion with minimal tissue reaction and should be considered a low-cost option for creating submucosal fluid cushions. The use of tattooing with carbon black should be carefully considered when histologic study is required to assess potential inflammatory tissue responses to an invasive technique or instillation of foreign material in the GI tract.

Animals↗
PubMed2003

Is early colonoscopy after admission for acute diverticular bleeding needed?

OBJECTIVES: Urgent colonoscopy has been proposed for the diagnosis and management of acute colonic diverticular bleeding. Identification of active bleeding and nonbleeding stigmata facilitates diagnosis and endoscopic therapy, but it is unclear whether urgent colonoscopy after presentation increases the diagnostic yield. This study evaluated the association between timing of colonoscopy and diagnostic yield in patients admitted with acute colonic diverticular bleeding. METHODS: Patients admitted for hematochezia and receiving a diagnosis of diverticular hemorrhage were identified using the Mayo Clinic GI Bleeding Team and Emergency Room Admissions Databases for the years 1998-2000. Timing of colonoscopy was determined from the time of admission. Logistic regression analysis was used to assess whether the timing of colonoscopy was associated with an endoscopic finding of active bleeding or nonbleeding stigmata (or both). RESULTS: A diagnosis of definitive or presumptive diverticular bleeding was made in 78 patients (39 men and 39 women, mean age 78 yr, range 49-96 yr). Twelve patients (15%) had active bleeding or stigmata. Colonoscopies were performed a mean of 18 +/- 11 h after admission. The association between a definitive diagnosis of acute diverticular bleeding and the timing of colonoscopy was not significant (p > 0.46). CONCLUSIONS: No significant association is apparent between the timing of colonoscopy after admission and encountering active bleeding or nonbleeding stigmata. Based on these observations, urgent colonoscopy for these patients does not seem advantageous.

Acute Disease↗