helping families & friends find better ways Psychiatric medications finding the appropriate medication and • possible side effects and what should The experience of mental illness can have dosage, and in talking through concerns be done if they occur; a profound impact upon people's work, about side effects. • how long will it be necessary to take the family and social lives, as well as on
Global Technique Spotlight
Naveen Arya, M.D.
Halton Healthcare Services, Oakville, Ontario, Canada
Marco Carniel, M.D.
Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
Nestor Chopita, M.D.,
Bárbara Agustina Amendolara, M.D.,
Francisco Tufare, M.D. and Nelson Condado, M.D.
Hospital San Martín de La Plata, Buenos Aires, Argentina
Robert S. Dean, M.D.
Vassar Brothers Medical Center
Poughkeepsie, NY, USA
Robert D. Fanelli, M.D., F.A.C.S.
Berkshire Medical Center and Surgical
Specialists of Western New England, P.C., USA
David A. Florez, M.D.
Elms Endoscopy Center/ Trident Gastroenterology,
Charlestown, South Carolina, USA
Francisco Igea, M.D.
Hospital Rio Carrion, Palencia, Spain
Houssam Kharrat, M.D.
Covenant Medical Center, Lubbock, TX, USA
Luis F. Lara, M.D.
The University of Texas
Southwestern Medical Center at Dallas, USA
Adolfo Parra-Blanco, M.D.
Canarias University Hospital, Santa Cruz de Tenerife, Spain
CLOSURE OF A PERFORATION AFTER
CLOSURE OF AN IATROGENIC PERFORATION AFTER
A SALINE-ASSISTED POLYPECTOMY
AN ENDOSCOPIC MUCOSAL RESECTION
Naveen Arya, M.D.
Marco Carniel, M.D.
Gastroenterology and Therapeutic Endoscopy Department, Halton Healthcare Services, Oakville, Ontario, Canada Head of Endoscopy, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria An 87-year-old male presented with a three month history of rectal bleeding. The A 72-year-old female was referred to our centre for an endoscopic mucosal patient had no weight loss, change in bowel habit or abdominal pain. His past resection. The patient has a history of coronary heart disease, st.p. myocardial medical history was relevant for coronary artery disease with coronary bypass, infarction in 2000, arterial hypertension, hyperlipidaemia and osteoporosis.
hypertension and hyperlipidemia. He was on Coumadin™, Altace™, Lipitor™ and In February 2005, the referring hospital performed a partial rectal polypectomy. In Atenolol. Upon examination, the abdomen was found to be obese.
the last pre-colonoscopy examination, a recurrent flat polypoid formation wasdiscovered in the rectum.
The patient had a colonoscopy carried out by a general surgeon and was found to have an 8cm rectal mass. The biopsy proved to be a tublovillous adenoma with high An approximately 2.5cm flat adenoma could be seen in the rectum at 8cm. In the grade dysplasia and the patient was referred for a polypectomy. The risks of the centre of the lesion, scar tissue after the partial polypectomy in 2005 was readily procedure such as perforation, bleeding or serious side effects were discussed with distinguishable (Figure 1).
the patient and he consented to the procedure.
Fluid infiltration of the polyp revealed good lifting sign. Utilising a straight suction The polyp was endoscopically removed with saline-assisted injection in a piecemeal cap, the lesion was totally resected in four fragments using a piecemeal technique fashion (Figure 1). The edges were coagulated with Argon plasma coagulation at with a cautery snare.
40W (Figure 2). During the procedure it was noted that the middle of the A 12mm perforation was revealed upon retrieval of the last fragment (Figure 2). polypectomy base was open and the plane was obviously through the submucosa By applying 7 Resolution™ Clips, the perforation edges could be properly aligned (Figure 3). The base of the polyp was then clipped closed with 16 Resolution™ Clips step-by-step and the perforation successfully closed (Figures 3, 4 and 5).
(Figures 4, 5 and 6).
After the procedure the patient was taken to recovery, given antibiotics IV and three views of the abdomen were taken with no free air seen. The patient was stable andwanted to go home. He was put on PO antibiotics for seven days. The patient was Flat tubular partially tubulovillous adenoma with low to moderate grade intraep- seen within one week and had no symptoms or signs of perforation and was stable.
ithelial neoplasia, the muscularis mucosae overall intact – resection in toto.
The patient was kept under clinical observation for several days. There was no Six months later, the patient had a flexible sigmoidoscopy and there was no increase of inflammatory parameters upon serological examination and no clinical evidence of residual polyp. A scar was found and biopsies taken from it revealed signs of peritonitis. After two days, the patient was introduced to a dietary regimen normal mucosa.
which was well tolerated. A surgical intervention was not necessary and after This case demonstrates the utility of clips and gives endoscopists another modality four days the patient was discharged.
to increase their therapeutic arsenal.
Coumadin™ is a trademark of Bristol-Myers Squibb. Altace™ is a trademark of King Pharmaceuticals. Lipitor™ is a trademark of Pfizer.
TREATMENT OF POST-EMR BLEEDING
PREVENTION OF POST-POLYPECTOMY
WITH ENDOSCOPIC CLIPS
HAEMORRHAGE USING THE RESOLUTION CLIP DEVICE
Nestor Chopita, M.D., Bárbara Agustina Amendolara, M.D., Robert S. Dean, M.D.
Francisco Tufare, M.D., Nelson Condado, M.D.
Vassar Brothers Medical Center, Poughkeepsie, NY Gastroenterology Department, Hospital San Martín de La Plata, Buenos Aires, Argentina A 62-year-old male with cirrhosis (Child B) and a history of variceal bleeding was A 91-year-old man presented with a history of anaemia and haematochezia. The admitted to our hospital for gastric polyposis resection.
patient was on chronic anticoagulation therapy with Coumadin™ due to porcine mitral valve replacement. Other past medical history includes a two vessel CABG, TIA, and seizure disorder. A colonoscopy was deemed necessary to explore potential sources of hematochezia. Concern was given in particular to the The endoscopy showed gastric polyposis and there was an abnormal area of need for continuing anticoagulation therapy. The patient was counselled to mucosa on the gastric incisura. Biopsy taken from the site revealed intra-mucosal discontinue his Coumadin therapy five days prior to the scheduled colonoscopy.
carcinoma and an endoscopic mucosal resection was performed (Figure 1).
Low-molecular-weight heparin was used to maintain anticoagulation until the The patient had haemodynamic instability, haematemesis and haematocrit evening prior to the procedure.
dropped at 22% 12 hours after the procedure. Another endoscopy showed active bleeding in the EMR site (Figure 2). The bleeding was successfully managed with the use of two Resolution™ Clips (Figures 3 and 4).
A colonoscopy was performed, during which time a 2cm polyp, on a thick stalk, was observed in the descending colon. This polyp was removed using a Captivator™ II Single - use Snare and cautery techniques. Reinspection of the During the follow up, the patient was in good condition and there were no resection margin revealed pooling of fresh blood at the polyp stalk base (Figure 1).
complications (Figure 5). Histological results confirmed early gastric cancer (EGC).
Two Resolution™ Clips were places at the polyp stalk base with good haemostasis (Figures 2 and 3).
Low-molecular-weight heparin was resumed the morning after the procedure.
There was no residual bleeding from the colon noted. Coumadin therapy was resumed 14 days post procedure and the patient has not had any Coumadin™ is a trademark of Bristol-Myers Squibb.
MANAGEMENT OF A LARGE GASTRIC POLYP
Robert D. Fanelli, M.D., F.A.C.S.
David A. Florez, M.D.
Director of Surgical Endoscopy, Berkshire Medical Center and Surgical Specialists of Western New England, P.C.
Medical Director, Elms Endoscopy Center/Trident Gastroenterology, Charlestown, South Carolina A 73-year-old man presented for outpatient consultation because of progressive An 81-year-old woman was referred for evaluation of weight loss and persistent dysphagia. During the consultation, it was discovered that he had not yet nausea. Prior attempts at managing her symptoms with proton pump inhibitor undergone screening colonoscopy. With his consent, he was scheduled for therapy and promotility agents by her primary physician had failed. An EGD sequential oesophagogastroduodenoscopy and colonoscopy in the outpatient demonstrated a large gastric polyp at the pylorus (Figure 1), causing a functional endoscopy unit.
gastric outlet obstruction. Radial Jaw™ 3 Standard Capacity Biopsy Forceps showed the polyp to be a benign hyperplastic inflammatory polyp. She was subsequently referred to me for endoscopic ultrasound evaluation (EUS) of the polyp and possible gastric polypectomy for definitive therapy.
The upper endoscopy revealed a distal oesophageal reflux-related stricture.
Biopsies were taken using Radial Jaw™ 3 Large Capacity Forceps and then the stricture was dilated using an 18-19-20mm CRE™ Fixed Wire Balloon Dilator without incident. Screening colonoscopy revealed, what appeared to be, seven The patient underwent EUS examination. The gastric polyp was scanned with a adenomatous polyps distributed throughout the colon. One of the polyps was a radial echoendoscope, revealing a large mucosal based lesion (Figure 2). There long, slender, finger-like polyp in the proximal ascending colon (Figure 1). When were no significant blood vessels within the polyp. Additionally, there were no cautery snare polypectomy was performed, the substance of the polyp was malignant features and no evidence of invasion to deeper layers of the gastric stripped off of the underlying arterial structure that was central to its stalk (Figure wall. No significant celiac or peri-gastric lymphadenopathy was appreciated. 2). The vessel was not bleeding or visibly pulsing, but was turgid and standing A standard EGD scope was then passed and the polyp was removed in a piece- erect. It was felt that this vessel would definitely start bleeding at some point meal fashion with a Sensation™ Polypectomy Snare. The polyp fragments were soon (Figure 3). A single Resolution™ Clip was placed across the vessel at the then withdrawn through the mouth with a basket retrieval device.
base of the polyp, closing and reopening the clip until the perfect location was The polypectomy ulcer was then re-inspected. There was mild, persistent oozing identified to occlude the vessel. The Resolution Clip was then deployed. The of blood at the site. Given the patient's advanced age and the fact that she artery was immediately deflated and collapsed as the blood pressure within the lived in a rural area with considerable drive time to the nearest medical facility, structure was reduced to zero, virtually eliminating the risk of delayed I elected to attempt primary closure of the site with Resolution™ Clips. The defect polypectomy site haemorrhage. The shrivelled-up artery collapsed at the base of edges were reapproximated with three Resolution Clips achieving adequate the polyp, just above the Resolution Clip (Figure 4).
haemostasis. The patient tolerated the procedure well and there were no peri-operative complications. Twice daily proton pump inhibitor therapy was prescribed.
Pathologic inspection of the polyps removed during this screening colonoscopy revealed three tubular adenomas and four tubulovillous adenomas. No post-polypectomy haemorrhage occurred, and the patient's dysphagia was Final pathologic diagnosis of the polyp revealed a benign inflammatory completely abated after oesophageal dilation and the institution of proton pump polyp without dysphagia. On follow up, the patient's nausea had resolved and inhibitor therapy.
her weight had normalised.
CLOSURE OF AN IATROGENIC COLON
BLEEDING DIVERTICULUM CLOSURE
PERFORATION WITH ENDOSCOPIC CLIPS
Francisco Igea, M.D.
Houssam Kharrat, M.D.
Gastroenterology Department, Hospital Rio Carrion, Palencia, Spain Gastroenterologist, Covenant Medical Center, Lubbock, TX An 82-year-old woman with abdominal pain and change in bowel habits was An 83-year-old man presented with shortness of breath, generalised weakness remitted to our endoscopy unit for a total colonoscopy. The procedure was done and had been passing bright red blood from his rectum for 48 hours.
under continuous propofol sedation. A difficult and angulated sigma was noticed Past medical history was significant for Chronic Obstructive Pulmonary Disease and multiple attempts in different positions were done. During one advancing (COPD), Chronic Heart Failure (CHF) and Hypertension (HTN). Patient was treated manoeuvre, an iatrogenic perforation was noticed.
with blood pressure medication and ASA 81mg daily. Vital signs and physical exam appeared normal at the time of admission. Labs showed: WBC 7.3, Hgb 9.2, hematocrit 26.8, platelets 211 and an INR of 0.97. The patient had a negative A big hole showing mesenteric fat and vessels was seen (Figure 1). Immediate bleeding scan and was prepped for a colonoscopy the following day.
suction in order to minimise pneumoperitoneum and close the hole was applied (Figure 2). The first Resolution™ Clip was placed closing the lips of the hole (Figure 3). Then another two Resolution Clips were placed until complete suture of Patient prep was suboptimal. No active bleeding was seen, diverticulosis was the perforation was achieved (Figures 4 and 5).
observed up to the cecum, and bright red blood was found in the right colon. An EGD was performed, to rule out an upper-GI source of the bleeding, which was unremarkable. The patient was transfused and a repeat colonoscopy was done The patient was admitted to our hospitalisation unit and nil the following day.
per os and I.V. fluids and antibiotics (cefuroxime and A bleeding diverticulum was noted in the sigmoid colon (Figures 1 and 2). An metronidazol) were given, two hours later, an abdominal injection of epinephrine 1:10000 did not control the bleed. A Resolution™ Clip CT scan with contrast enema was done showing no was used to approximate the diverticulum edge. A total of six Resolution Clips leakage (Figures 6, 7 and 8). Pneumoperitoneum and (Figures 3 and 4) were deployed successfully to close the edge of the diverticulum.
retropneumoperitoneum was clearly demonstrated. Only slight pain was present during the first 48 hours.
The patient reintroduced oral intake 72 hours later and Good haemostasis was established at the end of the procedure. The patient was discharged seven days after without further did not require any additional transfusion and he was discharged shortly after. A three month follow up did not show any evidence of bleeding.
One month later the patient was doing fine without BLEEDING FROM A COLON TUMOUR AFTER
TREATMENT OF MUCOSAL TEARS IN THE
BIOPSY WITH FORCEPS
OESOPHAGUS WITH ENDOSCOPIC CLIPS
Luis F. Lara, M.D.
Adolfo Parra-Blanco, M.D.
Assistant Professor of Internal Medicine Department of Gastroenterology, Canarias University Hospital, Santa Cruz de Tenerife, Spain Division of Digestive and Liver Diseases, The University of Texas, Southwestern Medical Center at Dallas A 42-year-old white male diagnosed with cystic fibrosis, who had a bilateral lung A 73-year-old male underwent an upper endoscopy for the study of long-standing transplant in 1997 with a single previous episode of rejection and diabetes reflux symptoms. The examination was done under conscious sedation with poor mellitus, was referred to evaluate episodic mild haematochezia and new onset tolerance, in spite of the administration of 100 µg of fentanyl and 7 mg of constipation requiring intermittent laxative use. The patient had a previous Midazolam, and nausea occured repeatedly during the procedure.
spontaneous diverticular perforation for which he had a diverting colostomy that During the initial passage of the endoscope in the oesophagus, a long segment had been repaired three years earlier.
of Barrett's oesophagus was detected, with no other gross abnormalities. Onwithdrawal, two tears were found in the lower end of the columnar epithelium, proximally to the cardia: a shallow 1cm tear (located at 6 o'clock – Figure 1) and a The colonic anastomosis appeared normal. A circumferential, friable mass deep 3cm tear (located at 3 o'clock – Figure 1).
occluding the lumen to about 12mm and measuring 4cm in length was seen in the distal transverse colon. A standard biopsy forceps was used to biopsy the mass (Figure 1). Bleeding continued from one of the biopsy sites (estimated The affected area was flushed with water in order to have a clear view of the lesion.
to be 8mm in size), which did not stop after five minutes of irrigation and The bottom of the tear was inspected in detail and no signs of perforation were observation (Figure 2). A Resolution™ Clip was used to approximate the sides evident. There was some oozing from the tear and a decision was made to suture of the biopsy site, achieving haemostasis, which was confirmed before the mucosal defect in order to prevent further complications such as delayed scope withdrawal (Figure 3). Follow-up confirmed there was no further bleeding bleeding or perforation.
Five Resolution™ Clips were applied and attached consecutively in a distal toproximal order (Figure 2). The reason for this is that the clips initially applied may hamper the precise application of further clips, and it is easier to check the mucosal defect remaining to be sutured if the direction is from distal to proximal. This aspectis important, because although clipping is considered to be almost devoid of anyrisks, there is a possibility that a clip incorrectly placed at the bottom of a mucosaldefect instead of grasping normal mucosa at the edge of the lesion can result in a perforation.
The tear was successfully sutured with five Resolution Clips, which were placedeasily (Figure 3). The extent of the Barrett's oesophagus was C5M8 according to thePrague Classification. No biopsies were taken to confirm the diagnosis. The patientremained asymptomatic and was discharged after observation.
The patient was on high dose PPI. Four months later in a second endoscopy, no trace of the tear was found, but random biopsies revealed high-grade dysplasia in the Barrett's epithelium. A third endoscopy was performed in order to try to locate any dysplastic areas, and two small erosions were found in a Barrett's tongue (Figure 4). Biopsy taken from both areas revealed high-grade dysplasia and an endoscopic mucosectomy is planned.
Mucosal tears in the oesophagus may occur during diagnostic or therapeutic endoscopy, but they are very infrequent and underlying conditions such as eosinophilic oesophagitis should be ruled out. Resolution Clips are a valuable tool for the management of intraprocedural complications (bleeding, and perforations).
These cases reflect the opinion of and are the responsibility of their respective authors.
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"Medicinal crops" in Ethiopia - Current status and future potentials- Japan Association for International Collaboration of Agriculture and Forestry In response to the Development Initiative which was proposed by the then Prime Minister Koizumi on the occasion of the WTO ministerial conference in Hong Kong in December 2005, the Ministry of Agriculture, Forestry and Fisheries has announced "the Initiative by Ministry of