Pediatric Gastrointestinal Endoscopy: European Society of Pediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) and European Society of Gastrointestinal Endoscopy (ESGE) Guidelines

ABSTRACT: This Guideline refers to infants, children and adolescents aged 0–18 years. The areas covered include: indications for diagnostic and therapeutic esophagogastroduodenoscopy and ileo-colonoscopy; endoscopy for foreign body ingestion; corrosive ingestion and stricture/stenosis endoscopic management; upper and lower gastrointestinal bleeding; endoscopic retrograde cholangio-pancreatography and endoscopic ultrasonography. Percutaneous endoscopic gastrostomy and endoscopy specific to inflammatory bowel disease (IBD) has been dealt with in other Guidelines [1–3] and are therefore not mentioned in this Guideline. Training and ongoing skill maintenance are to be dealt with in an imminent sister publication to this

Confocal laser endomicroscopy for diagnosis and therapy of gastrointestinal diseases

Die Endoskopie ist eine essentielle diagnostische und therapeutische Disziplin im Management verschiedener gastrointestinaler Erkrankungen. Moderne endoskopische Bildtechniken wie „magnifying endoscopy“, „narrow band imaging“ oder Autofluoreszenz Bildgebung haben dazu beigetragen, die diagnostische Ausbeute bei endoskopischen Untersuchungen zu steigern. Die konfokale Laser Endomikroskopie ist eine der neuesten Entwicklungen, die vielversprechende Ergebnisse gezeigt hat, die diagnostische Genauigkeit für eine Vielzahl unterschiedlicher gastrointestinaler Pathologien zu verbessern. Basierend auf einer umfassenden Erläuterung verschiedener diagnostischer und therapeutischer Endoskopieverfahren war es der Zweck dieser Arbeit, die Rolle der konfokalen Laser Endomikroskopie zur Diagnose und Therapie gastrointestinaler Erkrankungen zu untersuchen. Daher berichten wir über drei unterschiedliche Anwendungen dieser Technologie (Darstellung von Morbus Whipple, Etablierung und Evaluation diagnostischer Kriterien des „mucosa associated lymphatic tissue (MALT)-Lymphoms“ des Magens, gezielte endoskopische Resektion von Barrett-Ösophagus assoziierten Neoplasien), welche allesamt im Rahmen von klinischen Studien an unserer Abteilung untersucht wurden. Diese Studien zeigten sehr beeindruckende Ergebnisse, welche dann in Top-Journalen mit Fokus gastrointestinale Endoskopie publiziert wurden. Die Ergebnisse dieser drei Projekte werden im Rahmen dieser Arbeit im Detail diskutiert, besonders im Hinblick auf konkurrierende endoskopische Methoden und weitere Anwendungen des Endomikroskopiesystems. Zuletzt werden neue Entwicklungen der endomikroskopischen Technoloige in Bezug auf deren Vor- und Nachteile evaluiert, um die (zukünftige) Rolle der konfokalen Laser Endomikroskopie in Forschung und klinischer Praxis zu definieren.Endoscopy is an essential diagnostic and therapeutic discipline for the management of several gastrointestinal diseases. Modern endoscopic imaging techniques like magnifying endoscopy, narrow band imaging or autofluorescence imaging have helped to increase the diagnostic yield of endoscopic procedures. Confocal laser endomicroscopy is one of the most recent developments that showed very promising results to further improve the diagnostic accuracy for a variety of different gastrointestinal pathologies. Based on a comprehensive explanation of different diagnostic and therapeutic endoscopic modalities, the aim of this thesis was to investigate the role of confocal laser endomicroscopy for diagnosis and therapy of gastrointestinal diseases. Therefore, we report on three different applications of the technology (visualization of Whipples disease; establishment and evaluation of diagnostic criteria of gastric mucosa associated lymphatic tissue (MALT)-lymphoma; targeting endoscopic resection of Barretts esophagus associated neoplasia), all of which were investigated in the context of clinical studies at our department. These studies showed very impressive results which were then published in high-ranked peer-reviewed journals focused on gastrointestinal endoscopy. The results of these three projects are discussed in detail in this thesis, especially in view of concurrent endoscopic modalities as well as different applications of the endomicroscopy system. Finally, new developments of the confocal laser technology are evaluated regarding their advantages and disadvantages in order to determine the (future) role of confocal laser endomicroscopy for research as well as for clinical practice.submitted by Werner DolakAbweichender Titel laut Übersetzung der Verfasserin/des VerfassersMedizinische Universität Wien, Dissertation, 2017OeBB(VLID)235857

Rifaximin Reduces Number and Severity of Intestinal Lesions Associated With use of Non-steroidal Anti-inflammatory Drugs in Humans

The intestinal microbiota might contribute to enteropathy associated with use of nonsteroidal anti-inflammatory drugs (NSAIDs), but there have been few human studies of this association. We performed a placebo-controlled study to determine whether a delayed-release antibiotic formulation (rifaximin-extended intestinal release [EIR]) prevents the development of intestinal lesions in subjects taking daily NSAIDs. Sixty healthy volunteers (median age, 26 y; 42% female) were given the NSAID diclofenac (75 mg twice daily) plus omeprazole (20 mg once daily), and either rifaximin-EIR (400 mg) or placebo, twice daily for 14 days. Subjects were assessed by videocapsule endoscopy at baseline and after 2 weeks of treatment. The primary end point was the proportion of subjects developing at least 1 small-bowel mucosal break at week 2. Secondary end points were the change in the mean number of mucosal lesions and the number of subjects with large erosions and/or ulcers after 14 days of exposure. We detected mucosal breaks in 20% of subjects given rifaximin and in 43% of subjects given placebo (P =.05 in the post hoc sensitivity analysis). None of the subjects in the rifaximin group developed large lesions, compared with 9 subjects in the placebo group (P <.001). Our findings indicate that intestinal bacteria contribute to the development of NSAID-associated enteropathy in human beings. Clinical trial no: EudraCT 2013-000730-36

Depth of Remission Following First-Line Treatment Is an Independent Prognostic Marker for Progression-Free Survival in Gastric Mucosa-Associated Lymphoid Tissue (MALT) Lymphoma

Gastric mucosa-associated lymphoid tissue (MALT) lymphoma responding to upfront treatment has an excellent outcome and no further therapy is recommended, even in the presence of residual disease. However, no data exist on the influence of initial depth of remission on progression-free survival (PFS). Methods: We investigated a correlation between PFS and depth of response, categorizing them as complete remission (CR), partial remission (PR) and stable disease (SD) in 137 consecutive patients at the Medical University Vienna. Results: All patients with Helicobacter pylori (H. pylori)-positive, localized disease received H. pylori eradication (70%, 96/137), while the remaining patients were treated with various modalities. The response rate was 67% for the entire collective and 58% for eradication only, with corresponding CR-rates of 48% and 38%. At a median follow-up of 56.2 months, the estimated PFS for the entire cohort was 34.2 months (95% Confidence Interval 16.0&ndash;52.4). Responding patients (=CR/PR) had a significantly longer PFS compared to SD (68.3 vs. 17.3 months, p &lt; 0.001). This was also applicable to the eradication only cohort (49.0 vs. 17.3 months, p &lt; 0.001) and remained significant after correction for MALT-IPI. Furthermore, CR significantly prolonged PFS over PR (p = 0.007 entire cohort, p = 0.020 eradication). Conclusions: Remission status correlated significantly with PFS, suggesting depth of remission as prognostic marker for long-term relapse-free survival

Successful Clarithromycin Monotherapy in a Patient with Primary Follicular Lymphoma of the Duodenum

Primary follicular lymphoma of the duodenum (FL-D) constitutes a rare subtype of extranodal follicular lymphoma with a usually indolent course. To date, no distinct treatment recommendations have been defined for those patients. We report the case of a 58-year-old male patient presenting with endoscopically assessed, symptomatic FL-D who was treated with clarithromycin monotherapy in analogy to recent data for mucosa-associated lymphoid tissue lymphoma. Each treatment cycle consisted of clarithromycin 500 mg twice daily for 3 weeks followed by a 2-week break. After four cycles of treatment, the patient showed a very good response with normal macroscopic findings confirmed by endosonographic examination and only focal minimal residual disease of lymphoma persisting in the histological assessment. The patient is currently asymptomatic and without treatment for 24+ months. As clarithromycin combines antimicrobial and direct antiproliferative effects mediated through a variety of pleiotropic mechanisms, this appears to be an interesting treatment approach for indolent lymphoma, particularly in those where a chronic infectious background cannot be completely ruled out, i.e., gastrointestinal manifestations. We suggest further investigation of this treatment approach.(VLID)471538

Prevalence of clarithromycin-resistant Helicobacter pylori strains in gastric mucosa-associated lymphoid tissue lymphoma patients

Gastric MALT lymphoma is closely associated with Helicobacter pylori infection. Bacterial eradication therapy comprising clarithromycin is the first-line treatment in gastric MALT lymphoma patients. However, antimicrobial resistance to clarithromycin has been increasing in Europe, and thus far, it has not been examined in gastric MALT lymphoma patients. Based upon histopathological investigation, 17 adult gastric MALT lymphoma patients were identified to be related with H. pylori infection between 1997 and 2014. Detection of H. pylori infection in these patients and clarithromycin susceptibility testing were performed by 23S rRNA gene real-time PCR. Twelve of the patients were confirmed with H. pylori infection by real-time PCR. Among these patients, only two were found to be infected with clarithromycin-resistant H. pylori strain. In one of them, both the clarithromycin-resistant and sensitive genotype were detected. The rate of clarithromycin resistance was 15.4 %. Clarithromycin resistance pattern in gastric MALT lymphoma patients is under the predictions since a previous study performed in Central Europe revealed a rate of 36.6 % in Austria. Considering the low antimicrobial resistance rate, clarithromycin is still an option in gastric MALT lymphoma management.(VLID)346788