The Use of Wireless Capsule Endoscopy in the Assessment of Small Bowel(SB) Disease

Fireman Z 1, Mahajna, E 1, Fich L1 , Kopelman Y 1 , Sternberg A1, Scapa E2

Departments of Gastroenterology, 1Hillel Yaffe, Hadera, & 2Asaf-Harofe, Zrifin, Israel

Background and aims: The SB is the most difficult part of the gastrointestinal (GI) tract to examine. Conventional endoscopic techniques for examining this portion are also limited by the length of the SB. The M2ATM Given Capsule procedure is a new system designed to aid the gastroenterologist in diagnosing SB diseases. This pilot study investigated its comparative value for various pathological conditions.

Materials and Methods: Study population – Patients with unexplained GI tract bleeding, with suspected pathology of the SB of an undisclosed nature and/or with unexplained abdominal pain lasting for more than one year were eligible for the study. They all had negative SB X-rays, no suspicion of intestinal obstruction, and none had undergone major abdominal surgery.

Results: 25 patients (13 males, mean age 51.8±15.7 years) ingested the capsule easily and evacuated it with no complications. They all had undergone 4.1±1.6 invasive procedures prior to study entry. The M2ATM Capsule diagnosed Crohn’s disease in 4/5 patients, pathological finding in 5/10 iron deficiency anemia patients, and yielded normal results in all 7 patients with chronic abdominal pain/irritable bowel syndrome (IBS) (Table 1).

Patients (n) Indication Pathological finding

10 Iron deficiency anemia 5

5 Suspected Crohn’s disease 4

7 Abdominal pain/ IBS 0

2 Malabsorption 2

1 Familial adenomatous polyposis 1

Conclusion: Wireless capsule endoscopy could be safely performed in all the patients. The diagnostic yield was 50% for IDA and 80% for suspected Crohn’s disease. It contributed no data of value in the investigation of either abdominal pain or IBS.

Endoscopic stapling of Zenker`s diverticulum

Boaz Sagi, Dani Zik and Amir Szold

Endoscopic Surgery Service, Department of Otolaryngology and the Department of Surgery B’, Tel Aviv Sourasky Medical Center

Background: Zenker`s diverticulum is an acquired condition affecting patients in the 5-9th decade. The diverticulum is a result of weakness in Killian`s triangle between the inferior pharyngeal constrictor and the cricopharyngeal muscle. The most common complains are dysphagia, regurgitation, chocking and recurrent aspirations. Presently, the most widely used methods for treatment of Zenker`s diverticulum are the standard open-neck diverticulectomy plus cricopharyngeal myotomy and endoscopic stapling of the common party wall between the diverticulum sac and the esophagus wall.

In the past 3 years we performed 9 endoscopic procedures of endoscopic stapling.

Methods: the procedure necessitates general anesthesia, endotracheal intubation and rigid esophagoscopy. Stapling of the common wall between the pouch and the esophagus is performed using Endo-GIA stapler.

Results: 9 patients underwent the endoscopic procedure (7 male, 2 female). The average age was 67.3 years (50-84). The average hospital stay was 1.8 days (1-4 days). 3 minor perioperative complications were noticed. In a follow-up of up to 2 years, no recurrences were noticed.

Conclusions: The endoscopic stapling technique for the treatment of Zenker`s diverticulum necessitates no skin incision and there is no need for naso-gastric tube. The procedure is shorter than the open-neck operation, as well as the time to oral intake and the hospital stay. The rate of complications and recurrence is low. Considering the old age and the high co-morbidity rate of the patients, we regard the endoscopic procedure for the treatment of Zenker`s diverticulum as the procedure of choice.

Adaptive versus maladaptive coping styles in non-ulcer dyspepsia versus peptic ulcer versus control patients: a fresh psychological evaluation of peptic patients.

Ron Shahory,  Jesse Lachter

Faculty of Medicine, Technion Israel Institute of Medicine, Haifa

Introduction: Coping, the way we respond to stress, is an integral part of quality of life. Coping can be reliably measured. Patterns which emphasize productive versus maladaptive coping strategies may be identified and quantified.

The aim of this work was to compare and contrast coping patterns between patients with two diseases, Peptic Ulcer Disease (PUD), vs. (NUD) Non Ulcer Dyspepsia

Patients and Methods: The Brief COPE 30 of Carver and Scheier and the Life Satisfaction questionnaires were administered to 200 consecutive consenting adults referred for suspected peptic ulcer disease. The questionnaires were filled just before undergoing diagnostic gastroscopy.

Results: After correcting for age and sex, the two test groups were found to respond as very similar subgroups. The significant differences between the NUD and PUD groups were in the categories of: 1-suppression of competing activities, 2-mental disengagement, and 3- regarding the patient’s will to change his or her lifestyle.

Discussion: This study’s findings support the notion that significant fractions of both PUD and NUD patients could benefit from coping-focused psychotherapy. Coping with PUD has differences compared to coping with NUD. We offer a new questionnaire with just five questions regarding the relevant coping patterns and regarding the will to change the current lifestyle. This questionnaire might help the clinician differentiate between these two entities (PUD & NUD), and help identify patients most likely to benefit from coping-focused therapy. Further study may elucidate whether this approach succeeds at improving the quality of life of dyspeptic patients.

Resistance of Helicobacter pylori Isolates to Metronidazole, Clarithromycin, Tetracycline, Amoxicillin, and Cefixime in central Israel

1, 2Haim Shmuely , 1, 3 Zmira Samra , 1, 2Yaron Niv, 1Gabriel Dinari ,2Alex Geler, 2Eial Gal , 2Michal Fishman , 3Jacklin Bachor, 1Jacob Yahav

1Helicobacter Research Institute , 2Departement of Gastroenterology, 3Microbiology Laboratories, Rabin Medical Center, Campus Beilinson, Petach Tikva and

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv

Background: Antibiotic resistance of Helicobacter pylori differs according to geographical area and may have an important impact on the efficacy of therapy.

Aim: to determine the resistance of H. pylori isolates to metronidazole (MET), clarithromycin (CLR), tetracycline (TC), amoxicillin (AM) and cefixime (CEF) in central Israel.

Methods: One hundred thirty-eight isolates of H.pylori were isolated from specimens of 138 dyspeptic adults, including 28 patients previously treated for H.pylori infection. Antibiotic susceptibility was tested by E test method (AB Biodisc). Resistance was defined as follows: MIC ³ 0.5 mcg/ml for AM; ³1 mcg/ml for TC;

³2 mcg/ml for CLR and CEF; ³ 8 mcg/ml for MET. H. pylori ATCC 43526 strain was used for quality control.

Results: No resistance to tetracycline was detected. Resistance to amoxicillin was found in one isolate from an untreated patient. The prevalence of resistance to metronidazole, clarithromycin and cefixime was much higher in the isolates from the treated than the untreated patients: 60.7% and 38.2% for metronidazole (p=0.03); 46.4% and 8.2% for clarithromycin (p<0.001); and 7.2% and 1.87% for cefixime (p=0.18).

Conclusions: TC and CEF are potential alternative agents for the treatment of H.pylori infection. In vitro susceptibility testing may improve outcome especially after treatment failure.

INFLUENCE OF H.PYLORI ERADICATION ON GASTROESOPHAGEAL REFLUX SYMPTOMS IN CHILDREN AND ADOLESCENTS

A.Levine1, T Milo2,H. Shirin3, I.Dalal2, M.Boaz4, E Broide5

1Pediatric Gastroenterology Unit and 2Department of Pediatrics, 3Gastroenterology Divison, 4Epidemiology Unit, E. Wolfson Medical Center, and 5Pediatric Gastroenterology Unit, Assaf Harofe Medical Center, Israel

Background: Eradication of H.pylori has been reported to be associated with increased gastroesophageal reflux(GER) disease and esophagitis, though this is still controversial. We prospectively evaluated the role of eradication of H.pylori on symptoms of gastroesophageal reflux in a pediatric cohort.

Study Design: Patients referred for gastroscopy were evaluated for epigastric pain as well as frequency, severity, and nocturnal presence of symptoms related to reflux. Patients positive for H.pylori, received therapy. The patients were reevaluated at least 6 months after therapy and at subsequent follow-up visits. Patients with successful eradication (group 1) had symptoms compared to their pre eradication state, and were compared to those with unaltered H pylori status (group 2).

Results: 86 patients completed the study, with a mean follow-up of 11.7 months. Reflux symptoms worsened in 17% in both group 1 and group 2, irrespective of prior reflux presence, or severity. The distribution of outcomes for each symptom, ( better, worse, unchanged), was similar prior to and after eradication. Among patients with reflux and epigastric pain, improvement in epigastric pain was significantly correlated with the improvement in reflux but not with H.pylori eradication..

Conclusions: Eradication of H.pylori is not associated with increased symptoms of GER in children

THE PREVALENCE OF REFLUX-TYPE SYMPTOMS IN A REPRESENTATIVE POPULATION OF ISRAELI JEWISH ADULTS

1Ami D. Sperber, 2Zamir Halpern, 3Pesach Shvartzman, 4Michael Friger, 1Alex Fich

1Department of Gastroenterology, Soroka Medical Center, Beer-Sheva , 2Department of Gastroenterology, Tel-Aviv Medical Center, Tel-Aviv, 3Department of Family Medicine and 4Epidemiology Unit, Ben-Gurion University of the Negev, Beer-Sheva, Israel

Objective: There are no data concerning the prevalence of upper GI symptoms in Israel. We assessed the prevalence and associations of symptoms usually related to heartburn and/or reflux among Israeli Jewish adults. Methods: A questionnaire including heartburn and reflux-like symptoms was administered by telephone interview to a representative sample of the adult Israeli Jewish population provided to us by the Israel Ministry of the Interior. Results: The response rate among individuals successfully contacted was 81.9%. The final study population numbered 981 individuals with valid, complete data. 11.6% of the responders suffered from a retrosternal burning sensation, 10.4% from retrosternal pain, 19.4% from an acid taste in the mouth, and 17.9% from reflux of gastric content at some time over the past month. Of these, 6.4%, 5.3%, 11.8%, and 10.7% suffered these symptoms, respectively, on a weekly basis at least, and 2.0%, 1.8%, 2.4%, and 2.3% defined their symptoms as frequent and severe. Symptoms were more severe among women and lower income groups, and among individuals with a concomitant functional lower GI disorder. A logistic regression model showed that female gender (p=0.01) and the diagnosis of a functional lower GI disorder (p<0.0001) contributed significantly to the severity of upper GI reflux-like symptoms. Conclusions: The results suggest that symptoms commonly associated with gastroesophageal reflux are common and of substantial severity among Israeli Jewish adults. The apparent overlap with functional lower GI symptoms raises the possibility that in many cases the symptoms are functional.