Local barrier dysfunction identified by confocal laser endomicroscopy predicts relapse in inflammatory bowel disease

Loss of intestinal barrier function plays an important role in the pathogenesis of inflammatory bowel disease (IBD). Shedding of intestinal epithelial cells is a potential cause of barrier loss during inflammation. The objectives of the study were (1) to determine whether cell shedding and barrier loss in humans can be detected by confocal endomicroscopy and (2) whether these parameters predict relapse of IBD

Confocal laser endomicroscopy is a new imaging modality for recognition of intramucosal bacteria in inflammatory bowel disease in vivo

Interaction of bacteria with the immune system within the intestinal mucosa plays a key role in the pathogenesis of inflammatory bowel disease (IBD). The aim of the current study was to develop a fluorescein-aided confocal laser endomicroscopy (CLE) method to visualise intramucosal enteric bacteria in vivo and to determine the involved mucosal area in the colon and ileum in patients with ulcerative colitis (UC) and Crohn's disease (CD)

Local barrier dysfunction identified by confocal laser endomicroscopy predicts relapse in inflammatory bowel disease

Objectives: Loss of intestinal barrier function plays an important role in the pathogenesis of inflammatory bowel disease (IBD). Shedding of intestinal epithelial cells is a potential cause of barrier loss during inflammation. The objectives of the study were (1) to determine whether cell shedding and barrier loss in humans can be detected by confocal endomicroscopy and (2) whether these parameters predict relapse of IBD. Methods: Confocal endomicroscopy was performed in IBD and control patients using intravenous fluorescein to determine the relationship between cell shedding and local barrier dysfunction. A grading system based on appearances at confocal endomicroscopy in humans was devised and used to predict relapse in a prospective pilot study of 47 patients with ulcerative colitis and 11 patients with Crohn's disease. Results: Confocal endomicroscopy in humans detected shedding epithelial cells and local barrier defects as plumes of fluorescein effluxing through the epithelium. Mouse experiments demonstrated inward flow through some leakage-associated shedding events, which was increased when luminal osmolarity was decreased. In IBD patients in clinical remission, increased cell shedding with fluorescein leakage was associated with subsequent relapse within 12 months after endomicroscopic examination (p<0.001). The sensitivity, specificity and accuracy for the grading system to predict a flare were 62.5% (95% CI 40.8% to 80.4%), 91.2% (95% CI 75.2 to 97.7) and 79% (95% CI 57.7 to 95.5), respectively. Conclusions: Cell shedding and barrier loss detected by confocal endomicroscopy predicts relapse of IBD and has potential as a diagnostic tool for the management of the disease

Confocal endomicroscopy identifies loss of local barrier function in the duodenum of patients with Crohn's disease and ulcerative colitis

Background: Increased cell shedding with gap formation and local barrier dysfunction can be identified endomicroscopically in the terminal ileum of patients with inflammatory bowel disease. We aim to evaluate whether these changes are also present in the duodenum of patients with inflammatory bowel disease. Methods: Fifteen patients with Crohn's disease (CD), 10 patients with ulcerative colitis (UC), and 10 controls underwent fluorescein-aided confocal laser endomicroscopy (CLE). CLE was performed on macroscopically normal antral and duodenal (D1, D2, D3, D4) mucosa. Representative CLE images were prospectively analyzed. Images were scored for the number of epithelial gaps, cell shedding, and the degree of fluorescein leakage into the intestinal lumen. Results: Both CD and UC patients had significantly more epithelial gaps, epithelial cell shedding, and leakage of fluorescein into the duodenal lumen than controls. The degree of cell shedding and epithelial gap formation was similar in CD and UC patients. In all cases, macroscopic endoscopic appearances of the duodenum were normal, and conventional histological analysis showed a mild nonspecific duodenitis in 7 of 15 patients with CD. Patients with UC had a histologically normal duodenum. Gap formation, cell shedding, and fluorescein leakage was similar in CD with active compared with inactive disease, except for D2 shedding. Conclusions: CLE can detect epithelial damage and barrier loss in the duodenum of CD and UC patients that is not apparent on conventional endoscopy or histology. Copyright © 2014 Crohn's & Colitis Foundation of America, Inc

Hemostatic powder TC-325 treatment of malignancy-related upper gastrointestinal bleeds: International registry outcomes

BACKGROUND AND AIM: Upper gastrointestinal tumors account for 5% of upper gastrointestinal bleeds. These patients are challenging to treat due to the diffuse nature of the neoplastic bleeding lesions, high rebleeding rates, and significant transfusion requirements. TC-325 (Cook Medical, North Carolina, USA) is a hemostatic powder for gastrointestinal bleeding. The aim of this study was to examine the outcomes of upper gastrointestinal bleeds secondary to tumors treated with Hemospray therapy. METHODS: Data were prospectively collected on the use of Hemospray from 17 centers. Hemospray was used during emergency endoscopy for upper gastrointestinal bleeds secondary to tumors at the discretion of the endoscopist as a monotherapy, dual therapy with standard hemostatic techniques, or rescue therapy. RESULTS: One hundred and five patients with upper gastrointestinal bleeds secondary to tumors were recruited. The median Blatchford score at baseline was 10 (interquartile range [IQR], 7-12). The median Rockall score was 8 (IQR, 7-9). Immediate hemostasis was achieved in 102/105 (97%) patients, 15% of patients had a 30-day rebleed, 20% of patients died within 30 days (all-cause mortality). There was a significant improvement in transfusion requirements following treatment (P < 0.001) when comparing the number of units transfused 3 weeks before and after treatment. The mean reduction was one unit per patient. CONCLUSIONS: Hemospray achieved high rates of immediate hemostasis, with comparable rebleed rates following treatment of tumor-related upper gastrointestinal bleeds. Hemospray helped in improving transfusion requirements in these patients. This allows for patient stabilization and bridges towards definitive surgery or radiotherapy to treat the underlying tumor

Confocal Endomicroscopy of the Stomach: Gastritis, Intestinal Metaplasia, Adenoma, and Gastric Cancer

AbstractIn the stomach, neoplastic lesions often arise in the setting of precursor conditions such as gastritis, intestinal metaplasia, or adenomatous lesions. Biopsies may, therefore, underestimate disease severity or even miss the diagnosis (sampling error). Endomicroscopy is able to visualize typical features of such pathologies. It enables in vivo microscopy of gastritis with definition of enhanced vascularity and vascular leakage, but the typical cobblestone appearance of the gastric mucosa is preserved. The presence of intestinal metaplasia is confirmed by columnar absorptive cells with brush border and goblet cells within villiform foveolar epithelium. Gastric neoplasia is characterized by crowded glands with intraluminal folding and glandular budding and branching accompanied by increased density of dilated and distorted capillaries. Finally, in gastric cancer, gland and overall mucosal architecture is progressively lost. These features are shown side by side with white-light endoscopic findings. Endomicroscopy is used in such a setting to rapidly screen larger areas (optical biopsies) and subsequently target tissue sampling to areas with highly suspicious microscopic patterns. In experienced hands, it therefore constitutes an important part especially in the presence of neoplastic lesions within noncircumscript gastric premalignant conditions. This article is part of an expert video encyclopedia

In vivo histology with confocal endomicroscopy for diagnosing colorectal neoplasms

L'endomicroscopie confocale constitue un nouvel outil diagnostique destiné au diagnostic in vivo des modifications épithéliales constatées en cours de coloscopie. Après l'application d'agents fluorescents, la technique permet d'obtenir en temps réel, une imagerie de la surface muqueuse et de la couche sous-muqueuse sous microscopie à haute résolution. Sa haute précision diagnostique a été démontrée au cours de la coloscopie de dépistage et de surveillance des maladies inflammatoires. des lésions hyperplasiques et néoplasiques. Grâce à ce diagnostic histologique in vivo rapide, les procédures chirurgicales et endoscopiques ont pu être immédiatement réorientées en accord avec des biopsies optiques. Les indications de l'endomicroscopie sont certainement appelées à se développer dans un avenir proche et l'endomicroscopie confocale devrait ouvrir la porte à une technique d'imagerie moléculaire in vivo. Par conséquent, cette technique devrait avoir un impact important dans différents domaines médicaux