Gastrointestinal endoscopy最新文献

Background and aims: An irregular z-line is characterized by a squamocolumnar junction (SCJ) that extends proximally above the gastroesophageal junction (GEJ) by < 1 centimeter (cm), while Barrett's esophagus (BE) is defined as a columnar lined esophagus (CLE) that extends proximally by ≥1 cm with the presence of specialized intestinal metaplasia (IM) on biopsy. Measurement of CLE is most accurate for lengths ≥1 cm, and as such, guidelines do not recommend biopsy of an irregular z-line when seen on endoscopy. However, a CLE is often estimated by visual inspection rather than direct measurement, making this characterization imprecise. In this study, we present methodology to standardize the characterization of the SCJ, hypothesizing that the shape of the z-line can be used as a surrogate classifier. We present a computer-generated algorithm capable of automated segmentation and shape complexity quantification of the z-line.

Methods: 849 images of the z-line were selected and manually segmented. We used the nnUNet framework to train a model to segment the z-line. An additional dataset of 58 videos containing the z-line were obtained from the Mayo Clinic Endoscopy video library. A high-quality image containing the z-line was selected from each video. Ten gastroenterologists (5 esophageal experts) rated each of the 58 video/image pairs containing the z-line as "regular" or "irregular," including their degree of confidence. Fleiss kappa statistics was used to determine interobserver variability. The "ground truth" classification was determined by the esophageal expert majority vote. A wavelet decomposition model was then used to determine the threshold of irregularity based on the ground truth. Heat maps were generated for each z-line to determine localized areas of complexity.

Results: Fair agreement, with a Fleiss' kappa of 0.39, was observed between the 10 endoscopists when rating the z-line as "regular" vs "irregular" using this dataset. Moderate agreement was observed between the 5 esophageal experts with a Fleiss' kappa statistic of 0.42, and fair agreement was observed between the 5 non-esophageal experts with a Fleiss' kappa statistic of 0.31. The wavelet energy coefficient optimal threshold to classify an SCJ as irregular was determined to be 1.53×10ˆ7 with an accuracy of 78%.

Conclusion: Our computer-generated model was capable of auto-segmentation and classification of the z-line. We established a threshold of complexity using wavelet energy coefficient to standardize the classification of the SCJ.

Background and aims: The pattern of inflammation in eosinophilic esophagitis (EoE) is patchy, necessitating multiple biopsies to optimize diagnostic yield. Current consensus-based guidelines recommend 6 total biopsies at two sites: distal and either middle or proximal esophagus, although based on limited data. We aimed to determine whether this biopsy protocol sufficiently captures EoE diagnoses by evaluating the distribution of eosinophilia in a large EoE cohort.

Methods: This was a retrospective study of consecutive, newly-diagnosed EoE patients with ≥2 esophageal segments biopsied. Demographics, clinical characteristics/history, endoscopic findings, and histologic results were manually reviewed. Distribution (proximal, middle, and/or distal) of eosinophilia (>15 eosinophils/hpf) was assessed. Predictors for non-distal disease (<15 eosinophils/hpf on distal biopsies) were evaluated using multivariable logistic regression.

Results: 511 newly-diagnosed EoE patients with ≥2 segments biopsied were included. All patients had distal esophageal biopsy. Overall, 286 (56.0%) had ≥1 site with <15 eosinophils/hpf, including 51 (10%) non-distal disease. Among patients with three segments biopsied (n=60), 19 (31.7%) had eosinophilia at only one site, including 6 (10%) isolated mid esophageal disease and no isolated proximal eosinophilia. Discordant mid and proximal biopsy results were found in 18 (30%) patients, with 17/18 (94.4%) mid esophageal eosinophilia. On multivariable analysis, increasing age (OR:1.02, CI:1.002-1.04, p=0.03) and male gender (OR:1.89, CI:1.002-3.55, p=0.049) independently predict non-distal disease.

Conclusions: Isolated segmental eosinophilia is common in EoE, including up to 10% non-distal disease. Discordant mid and proximal biopsy findings are prevalent, with no isolated proximal eosinophilia. Standard protocol should include routine biopsies of both distal and middle esophagus to maximize diagnostic yield.

Background and aims: Glucagon-like peptide-1 receptor agonists (GLP1RAs) can cause delayed gastric emptying, raising concern for retained gastric contents (RGCs) during endoscopy and adverse anesthesia events. We aimed to determine associations between GLP1RA and endoscopy and anesthesia outcomes.

Methods: This single-center retrospective cohort study examined patients prescribed GLP1RA who underwent outpatient endoscopy stratified by exposure at the time of endoscopy. The GLP1RA group had ≥6 weeks of exposure as confirmed by pharmacy dispensation reports. The control group were patients not on GLP1RA at the time of endoscopy (prescription never filled, discontinued ≥6 weeks prior, or started post-endoscopy). The outcomes were the presence of solid RGCs, aborted procedures or any adverse anesthesia events.

Results: 598 patients were included in the study with 360 on GLP1RA and 298 controls. Baseline characteristics including age, sex, chronic opiate use, gastroparesis and prior gastric surgery were similar, but diabetes mellitus was more prevalent in the GLP1RA group (68% vs. 57%, p=0.005). The odds of solid RGCs was significantly higher in the GLP1RA group in multivariate analysis (OR 3.80; 95% CI 1.57-9.21; p=0.003), but odds were not increased in patients undergoing concurrent colonoscopy. More patients in the GLP1RA group had procedures aborted (1.3% vs. 0%, p=0.021), but rates of hypoxia were similar (0.2% vs. 0.3%, p=0.341). There were no cases of pulmonary aspiration.

Conclusion: Patients on GLP1RAs have increased rates of solid RGCs during upper endoscopy, but not with concurrent colonoscopy, and higher rates of aborted procedures, but similar rates of adverse anesthesia events.